ATI RN
Chapter 1 Introduction to Nursing Quizlet Questions
Question 1 of 5
When giving an I.M. injection, the nurse should insert the needle into the muscle at an angle of:
Correct Answer: D
Rationale: The correct angle for an I.M. injection is 90 degrees (straight in). This angle ensures proper medication absorption and minimizes tissue damage. Inserting the needle at 15, 30, or 45 degrees can lead to suboptimal drug delivery or cause pain and discomfort. It is crucial to follow evidence-based guidelines to administer injections safely and effectively.
Question 2 of 5
A client is admitted with frequent, loose stools. Prior to implementing orders to insert a Foley catheter, the nurse would first:
Correct Answer: A
Rationale: Step 1: Assess the client's condition and potential causes of frequent, loose stools. Step 2: Apply a fecal incontinence bag to contain and monitor stool output. Step 3: Monitor the effectiveness of the bag in managing stool output. Step 4: If necessary, implement further interventions based on assessment findings. Summary: - Option B: Performing perineal care is important for hygiene but does not directly address the issue of managing stool output. - Option C: Administering an antidiarrheal agent may mask symptoms without addressing the underlying cause. - Option D: Inserting a rectal tube is invasive and not typically indicated before trying less invasive interventions like a fecal incontinence bag.
Question 3 of 5
In obtaining the cerebrospinal fluid, the needle is inserted:
Correct Answer: B
Rationale: The correct answer is B: Between L3 and L4. The cerebrospinal fluid is obtained via a procedure called lumbar puncture, commonly known as a spinal tap. The needle is inserted between the third and fourth lumbar vertebrae to avoid the spinal cord itself. This location provides access to the subarachnoid space where the cerebrospinal fluid circulates. Choosing A, C, or D would result in potential damage to the spinal cord or improper collection of cerebrospinal fluid.
Question 4 of 5
To prepare a patient for a paracentesis, it is essential for the nurse to:
Correct Answer: D
Rationale: Correct Answer: D - Have the patient empty his bladder Rationale: 1. Emptying the bladder prevents discomfort during the procedure. 2. A full bladder may increase the risk of injury during paracentesis. 3. It ensures accurate measurement of fluid output post-procedure. 4. Administering enema and restricting fluids are unnecessary and unrelated. 5. Pre-medicating with a narcotic analgesic is not routine practice for paracentesis.
Question 5 of 5
A nurse is assessing clients on a medical-surgical unit. Which adult client does the nurse identify as being at greatest risk for insensible water loss?
Correct Answer: B
Rationale: The correct answer is B. Anxious clients with tachypnea are at greatest risk for insensible water loss due to increased respiratory rate leading to increased water evaporation from the lungs. This results in higher water loss compared to other options. Clients taking furosemide (A) may experience increased urine output but it is not considered insensible water loss. Clients on fluid restrictions (C) would have decreased water intake but it is not insensible loss. Constipated clients (D) may have fluid imbalance but it is not related to insensible water loss.