ATI RN
Introduction to Nursing Final Exam Quizlet Questions
Question 1 of 5
When auscultating a client's chest, the nurse assesses a second heart sound (S2). This sound results from:
Correct Answer: D
Rationale: The second heart sound (S2) occurs during the closing of the aortic and pulmonic valves. This closure marks the end of systole and the beginning of diastole. The closure of these valves produces a characteristic "dub" sound. The opening of the mitral and tricuspid valves occurs during diastole, while the opening of the aortic and pulmonic valves happens during systole. Therefore, the correct answer is D, as it accurately reflects the physiological basis of S2. The other choices (A, B, C) are incorrect as they do not align with the specific cardiac events associated with the second heart sound.
Question 2 of 5
Which of the following is a priority nursing action when administering oral care to a dependent client?
Correct Answer: B
Rationale: The correct answer is B: Wear disposable gloves. This is a priority nursing action to prevent the spread of infection and protect both the client and the caregiver. By wearing disposable gloves, the nurse maintains proper infection control practices and reduces the risk of transmitting pathogens during oral care procedures. A: Assisting the client to a dorsal recumbent position is not specifically related to oral care and is not a priority action. C: Using a firm toothbrush may cause injury to the client's gums and oral tissues, so it is not the best choice for oral care. D: Irrigating the mouth with hydrogen peroxide is not a recommended practice for routine oral care, as it can be harmful if ingested and may cause irritation to the oral mucosa.
Question 3 of 5
Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students?
Correct Answer: D
Rationale: The correct answer is D because whitish oval specks sticking to the hair are nits, which are eggs of head lice, confirming pediculosis capitis. Nits are firmly attached to the hair shaft close to the scalp. A: Scratching the head more than usual can be a symptom but not confirmatory. B: Flakes on shoulders could be dandruff. C: Oval pattern occipital hair loss is not specific to head lice.
Question 4 of 5
Nurse De Silva knows he can perform chest physiotherapy:
Correct Answer: B
Rationale: Correct Answer: B (One hour after meals) Rationale: Performing chest physiotherapy one hour after meals helps prevent aspiration during the procedure. Waiting allows food to move from the stomach to the small intestine, reducing the risk of aspiration. Performing chest physiotherapy immediately before meals (A) or during meals (C) could increase the risk of aspiration. Similarly, performing it before bedtime (D) may also increase the risk of aspiration as the patient lies down after the procedure.
Question 5 of 5
A client is admitted to the Emergency Department after a motorcycle accident that resulted in the client's skidding across a cement parking lot. Since the client was wearing shorts, there are large areas on the legs where the skin is ripped off. This wound is best described as:
Correct Answer: A
Rationale: The correct answer is A: Abrasion. An abrasion is a wound caused by friction, resulting in the removal of the superficial layers of skin. In this scenario, the client skidding across a cement parking lot caused the skin to be ripped off, which aligns with the definition of an abrasion. Choice B: Unapproximated, is incorrect because it refers to wound edges that are not brought together for healing, which is not the primary characteristic of the described wound. Choice C: Laceration, is incorrect as lacerations are typically caused by sharp objects cutting through the skin, rather than by friction as in the case of the motorcycle accident. Choice D: Eschar, is incorrect as eschar refers to a thick, hard, blackened crust that forms over a burn or necrotic tissue, which is not the case in this scenario.