ATI RN
Introduction to Professional Nursing Questions
Question 1 of 5
When assessing Frank for chest percussion or chest vibration and postural drainage, Mario would focus on the following, EXCEPT:
Correct Answer: C
Rationale: The correct answer is C because when assessing for chest percussion or chest vibration and postural drainage, Mario should focus on the client's respiratory status, not breath sounds and location of congestion. Breath sounds and congestion assessment are important for lung auscultation, not for the actual treatment techniques. A: Monitoring food and fluid intake is important to prevent aspiration during treatment. B: Respiratory rate indicates the client's respiratory effort and response to treatment. D: Teaching relatives to perform the procedure ensures continuity of care and client support. Therefore, C is the correct answer as it is not directly related to the assessment for these specific treatments.
Question 2 of 5
A client is to be discharged from an acute care facility after treatment for right leg thrombophlebitis. The nurse notes that the client's leg is pain-free, without redness or edema. The nurse's actions reflect which step of the nursing process?
Correct Answer: D
Rationale: The correct answer is D: Evaluation. In the nursing process, evaluation is the final step where the nurse determines if the goals and outcomes of care have been achieved. In this scenario, the nurse is assessing the client's condition before discharge to ensure there are no signs of thrombophlebitis. The absence of pain, redness, and edema indicates successful treatment. This step aligns with the evaluation phase as the nurse is assessing the client's response to treatment. A: Assessment is incorrect because the nurse has already assessed the client's leg and is now determining the effectiveness of the treatment. B: Analysis is incorrect as this step involves interpreting the data collected during assessment to identify problems and make nursing diagnoses. C: Implementation is incorrect as this step involves carrying out the nursing interventions to achieve the established goals. The nurse has already implemented the treatment plan in this scenario.
Question 3 of 5
A client is admitted to the health care facility with bowel obstruction secondary to colon cancer. The nurse obtains a health history, measures vital signs, and auscultates for bowel sounds. Which step of the nursing process is the nurse performing?
Correct Answer: B
Rationale: The correct answer is B: Assessment. In this scenario, the nurse is collecting data by obtaining the health history, measuring vital signs, and auscultating for bowel sounds. Assessment is the first step in the nursing process, where data is gathered to identify the client's health status. Planning (A) involves setting goals and outcomes, Evaluation (C) involves determining the effectiveness of interventions, and Implementation (D) involves carrying out the planned interventions. In this case, the nurse is still in the data collection phase, making Assessment the correct choice.
Question 4 of 5
The nurse is performing a breast assessment to a client. Which of the following findings is a deviation from normal?
Correct Answer: C
Rationale: The correct answer is C: Retraction or dimpling. This finding is a deviation from normal as it can indicate possible breast cancer or other abnormalities. Retraction or dimpling can be a sign of tissue distortion or fibrosis, which should be further evaluated. Presence of striae (A) is common and not a cause for concern. Breasts that are rounded (B) and slightly unequal in size are considered normal variations. Simply being round (D) does not necessarily indicate a deviation from normal.
Question 5 of 5
The nurse attached a pulse oximeter to a client. She knows that the purpose of this is to:
Correct Answer: C
Rationale: Rationale: Choice C is correct because a pulse oximeter measures oxygen saturation in arterial blood, providing crucial information on the client's oxygen levels. This helps monitor respiratory status and determine the need for supplemental oxygen. Choice A is incorrect as tissue perfusion is not directly assessed by a pulse oximeter. Choice B is incorrect as it measures hemoglobin indirectly. Choice D is incorrect as anti-hypertensive medications do not impact oxygen saturation directly.