ATI RN
Introduction to Critical Care Nursing 8th Edition Questions
Question 1 of 5
When using a cane for maximal support, the nurse is aware that the client should:
Correct Answer: A
Rationale: The correct answer is A: Hold the cane on the weaker side. This is correct because it provides maximal support and stability for the client. By holding the cane on the weaker side, the client can shift weight off the weaker leg, reducing strain and improving balance. Choice B is incorrect because weight should be shifted to the stronger side, not evenly distributed. Choice C is incorrect as keeping the elbow stiff can lead to discomfort and limited mobility. Choice D is incorrect as the stronger foot should advance ahead of the cane for stability.
Question 2 of 5
A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next?
Correct Answer: C
Rationale: The correct answer is C: Rising body temperature. When a patient with a systemic bacterial infection experiences a shaking chill, it indicates that the body is trying to generate heat to combat the infection. The next assessment finding the nurse would expect is a rising body temperature as the body's immune response kicks in to fight off the infection. Skin flushing (choice A) is less likely as the patient is feeling cold initially. Muscle cramps (choice B) are not typically associated with this scenario. Decreasing blood pressure (choice D) may be a later complication but is not the immediate next assessment finding after a shaking chill.
Question 3 of 5
A new nurse reads a client has a wound “healing by second intention” and asks what that means. Which description by the charge nurse is most accurate?
Correct Answer: C
Rationale: The correct answer is C because healing by second intention refers to a wound that is left open to fill in with granulation tissue. This process allows for the wound to heal from the inside out, promoting tissue regeneration. Explanation: 1. Option A is incorrect because healing by second intention does not involve approximating or stitching wound edges together. 2. Option B is incorrect because stapling a wound after an infection does not necessarily relate to healing by second intention. 3. Option D is incorrect because although the wound may be contaminated, healing by second intention does not mean it cannot be closed at all. In summary, the correct answer is C because it accurately describes the process of healing by second intention, which involves allowing an open wound to fill in with granulation tissue.
Question 4 of 5
A nurse is learning about the types of different cells involved in the inflammatory response. Which principles does the nurse learn? (Select the one that does not apply.)
Correct Answer: A
Rationale: The correct answer is A because basophils are not only involved in the general inflammatory process but are primarily associated with allergic reactions. Basophils release histamine and other chemicals that contribute to allergic responses. Choice B is incorrect because eosinophils do increase during allergic reactions and parasitic invasion. Choice C is correct as macrophages are known to participate in multiple episodes of phagocytosis, clearing pathogens and debris. Choice D is also correct as monocytes do differentiate into macrophages once they enter body tissues to perform their immune functions.
Question 5 of 5
The nurse will monitor a patient for signs and symptoms of hyperkalemia if the patient is taking which of these diuretics?
Correct Answer: D
Rationale: The correct answer is D: Spironolactone (Aldactone). Spironolactone is a potassium-sparing diuretic that can lead to hyperkalemia due to its mechanism of action, which inhibits aldosterone. Aldosterone promotes potassium excretion, so inhibiting it can lead to potassium retention and hyperkalemia. Hydrochlorothiazide (A) is a thiazide diuretic that can actually cause hypokalemia. Furosemide (B) is a loop diuretic that also can lead to hypokalemia by increasing potassium excretion. Acetazolamide (C) is a carbonic anhydrase inhibitor diuretic and is not associated with significant effects on potassium levels.