ATI RN
Introduction to Professional Nursing Questions
Question 1 of 5
Where should the aortic valve be assessed?
Correct Answer: B
Rationale: The correct answer is B: 2nd ICS to the right. The aortic valve is best assessed at the 2nd intercostal space (ICS) to the right of the sternum. This is where the aortic valve can be auscultated most accurately due to its anatomical positioning. Assessing at the 3rd ICS to the left (choice A) would be incorrect as it is more indicative of the pulmonic valve. Choices C and D are also incorrect as they do not align with the accurate anatomical location of the aortic valve.
Question 2 of 5
You are currently inserting an IV line into a client. While you were inserting it, which of the following signs should you stop advancing the catheter?
Correct Answer: D
Rationale: Correct answer: D. The blood return shows in the backflash chamber of the catheter. Rationale: When inserting an IV line, the appearance of blood return in the backflash chamber indicates proper placement within the vein. This signifies that the catheter tip is in the vein, and further advancement should be stopped to prevent complications like infiltration. Options A, B, and C do not provide direct indications of proper catheter placement and do not offer concrete guidance on when to stop advancing the catheter.
Question 3 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 4 of 5
A nurse is caring for a client with a chest tube attached to a Pleurevac drainage system. Which of the following actions should the nurse avoid to prevent a tension pneumothorax?
Correct Answer: A
Rationale: Correct Answer: A: Clamping the chest tube Rationale: Clamping the chest tube can lead to a tension pneumothorax by preventing air from escaping the pleural space. This can cause a buildup of pressure, leading to lung collapse and potential life-threatening complications. Summary of other choices: B: Taping the connection can prevent air leaks and maintain the system's integrity. C: Adding water to the suction chamber is necessary to maintain suction and prevent air leaks. D: Maintaining the collection chamber below the client's waist helps with proper drainage and prevents backflow of fluid.
Question 5 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.