ATI RN
Introduction to Nursing Pdf Questions
Question 1 of 5
Which action will the nurse take to evaluate the effectiveness of IV nitroglycerin for a patient with a myocardial infarction (MI)?
Correct Answer: B
Rationale: The correct answer is B: Ask about chest pain. This is because assessing the presence or absence of chest pain is a critical indicator of the effectiveness of IV nitroglycerin in managing myocardial infarction. Chest pain is a cardinal symptom of MI, and the relief or reduction of chest pain indicates that the nitroglycerin is working to improve blood flow to the heart muscle. Monitoring heart rate, checking blood pressure, and observing for dysrhythmias are important assessments in managing MI, but they do not directly reflect the effectiveness of nitroglycerin therapy.
Question 2 of 5
Which finding by the nurse most specifically indicates that a patient is not able to effectively clear the airway?
Correct Answer: A
Rationale: The correct answer is A: Weak cough effort. A weak cough effort indicates ineffective airway clearance as coughing helps clear secretions and foreign particles from the airway. Profuse green sputum (B) indicates infection but not necessarily inability to clear the airway. Respiratory rate of 28 breaths/min (C) and low SpO2 (D) suggest respiratory distress but do not specifically indicate inability to clear the airway. Weak cough effort directly relates to the airway's ability to clear, making it the most specific finding.
Question 3 of 5
A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that do not apply.)
Correct Answer: D
Rationale: The correct answer is D because fluorescent light bulbs can pose a fire hazard when used near oxygen due to their high energy output. Oxygen supports combustion, and fluorescent bulbs can generate heat and sparks. A, B, and C are incorrect because they are factors that the nurse should assess for safe oxygen use in the home. Smoking prohibition prevents fire risks, functional electrical cords prevent electrical hazards, and storing flammable liquids away from oxygen reduces the risk of explosions.
Question 4 of 5
After 2 months of tuberculosis (TB) treatment with isoniazid, rifampin (Rifadin), pyrazinamide, and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next?
Correct Answer: C
Rationale: The correct answer is C: Ask the patient whether medications have been taken as directed. This is the next appropriate action because the patient is still testing positive for AFB despite being on the appropriate TB treatment regimen for 2 months. By assessing medication adherence, the nurse can determine if the lack of improvement is due to non-compliance. If the patient has been taking the medications as prescribed, then further evaluation for drug-resistant TB or other factors may be necessary. Choice A is incorrect because assuming drug resistance without confirming adherence could lead to unnecessary treatment changes. Choice B is not the immediate priority as ensuring medication adherence should come first. Choice D is premature without first confirming adherence and evaluating other possible reasons for treatment failure.
Question 5 of 5
A patient who has heart failure has recently started taking digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril. Which finding by the home health nurse is a priority to communicate to the health care provider?
Correct Answer: C
Rationale: The correct answer is C. A serum potassium level of 3.0 mEq/L after 1 week of therapy is a priority finding to communicate to the healthcare provider because digoxin, furosemide, and captopril can all cause electrolyte imbalances, especially hypokalemia, which can increase the risk of digoxin toxicity leading to life-threatening dysrhythmias. It is crucial to address and monitor potassium levels closely in patients taking these medications. A: Presence of 1+ to 2+ edema in the feet and ankles is a common finding in heart failure patients and may not be an immediate concern unless it worsens. B: Palpable liver edge 2 cm below the ribs may indicate hepatic congestion, which can occur in heart failure, but it is not as urgent as monitoring potassium levels. D: A weight increase of 2 pounds over 3 days can be a sign of fluid retention, which is important to monitor but