ATI RN
Introduction to Community Health Nursing Questions
Question 1 of 5
Which action should the nurse plan to prevent aspiration in a high-risk patient?
Correct Answer: B
Rationale: The correct answer is B: Place a patient with altered consciousness in a side-lying position. This position helps prevent aspiration by reducing the risk of regurgitated material entering the airway. Patients with altered consciousness are at higher risk of aspiration due to impaired protective airway reflexes. Placing them in a side-lying position helps maintain an open airway and facilitates drainage of secretions. Incorrect choices: A: Turning and repositioning an immobile patient every 2 hours is important for preventing pressure ulcers, not aspiration. C: Inserting a nasogastric tube for feeding does not directly prevent aspiration; it is a method of providing nutrition. D: Monitoring respiratory symptoms in an immunosuppressed patient is important for detecting infections but does not directly prevent aspiration.
Question 2 of 5
A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes that the client’s face is puffy and the eyelids are swollen. What action by the nurse takes best?
Correct Answer: B
Rationale: The correct answer is B: Notify the Rapid Response Team. Puffy face and swollen eyelids can indicate a potential airway obstruction, which is a medical emergency. Notifying the Rapid Response Team ensures prompt intervention and appropriate management. Assessing oxygen saturation (A) may be important but addressing the potential obstruction takes priority. Oxygenating with a bag-valve-mask (C) may worsen the obstruction. Palpating the skin of the upper chest (D) is not directly related to addressing the potential airway issue.
Question 3 of 5
A young adult patient tells the health care provider about experiencing cold, numb fingers and Raynaud's phenomenon is suspected. What type of testing should the nurse anticipate explaining to the patient?
Correct Answer: C
Rationale: The correct answer is C: Autoimmune disorders. Raynaud's phenomenon is often associated with autoimmune conditions, such as systemic lupus erythematosus or scleroderma. Testing for autoimmune disorders may involve blood tests to check for specific antibodies or inflammatory markers. Hyperglycemia (A) is high blood sugar levels, not directly related to Raynaud's. Hyperlipidemia (B) is high levels of fats in the blood, not typically associated with Raynaud's. Coronary artery disease (D) involves the narrowing of the arteries that supply blood to the heart, which is not directly related to Raynaud's phenomenon.
Question 4 of 5
The nurse is admitting a patient who has chest pain. Which assessment data suggest that the pain is from an acute myocardial infarction?
Correct Answer: B
Rationale: The correct answer is B because chest pain lasting longer than 30 minutes is a common characteristic of an acute myocardial infarction (heart attack). This prolonged duration indicates cardiac tissue damage. Choices A, C, and D are incorrect. Choice A, pain increasing with deep breathing, is more indicative of musculoskeletal pain. Choice C, pain relieved by nitroglycerin, is suggestive of angina rather than a heart attack. Choice D, reproducible pain with arm movement, is more consistent with musculoskeletal or nerve-related pain rather than a heart attack.
Question 5 of 5
While assessing an older adult patient, the nurse notes jugular venous distention (JD) with the head of the patient's bed elevated 45 degrees. What does this finding indicate?
Correct Answer: C
Rationale: Step 1: Jugular venous distention (JD) indicates increased pressure in the right atrium. Step 2: When the head of the bed is elevated, gravity helps blood return to the right side of the heart. Step 3: If JD is present with head elevation, it suggests that the right atrial pressure is elevated. Step 4: Elevated right atrial pressure often indicates heart failure or fluid overload. Step 5: Therefore, the correct answer is C: Increased right atrial pressure. Summary: A: Decreased fluid volume is incorrect because JD suggests fluid overload, not decreased volume. B: Jugular vein atherosclerosis is incorrect as JD is not typically associated with atherosclerosis. D: Incompetent jugular vein valves is incorrect as JD is more likely due to increased pressure than valve incompetence.