ATI RN
Introduction to Nursing Questions
Question 1 of 5
Which information will be most important for the nurse to communicate to the health care provider about an older patient who has influenza?
Correct Answer: B
Rationale: The correct answer is B: Diffuse crackles in the lungs. This is the most important information to communicate because it indicates a potential complication like pneumonia in older patients with influenza. Crackles suggest fluid accumulation in the lungs, requiring prompt medical attention. Fever (A) and myalgia/headache (D) are common symptoms of influenza but may not indicate severe complications. Sore throat and cough (C) are typical symptoms and do not directly point to a serious issue like lung involvement.
Question 2 of 5
A nurse cares for a client who has packing inserted for posterior nasal bleeding. What action would the nurse take first?
Correct Answer: D
Rationale: The correct answer is D: Assess the client's airway. This is the priority action because airway patency is always the top priority in any emergency situation. In this case, the packing for posterior nasal bleeding could potentially obstruct the client's airway, leading to respiratory distress or compromise. By assessing the client's airway first, the nurse can ensure that the client is able to breathe effectively. Choice A: Assessing the client's pain level is important but not the first priority in this situation. Choice B: Keeping the client's head elevated may be beneficial, but it is not the immediate priority over assessing the airway. Choice C: Teaching the client about the causes of nasal bleeding is important for education but not urgent in this situation.
Question 3 of 5
While assessing an older adult patient, the nurse notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. What does this finding indicate?
Correct Answer: C
Rationale: The correct answer is C: Increased right atrial pressure. Jugular venous distention (JVD) with the head of the bed elevated indicates increased pressure in the right atrium, leading to backflow and distention of the jugular veins. This is commonly seen in conditions like heart failure or fluid overload. Incorrect choices: A: Decreased fluid volume - This is incorrect because JVD is typically associated with volume overload, not decreased fluid volume. B: Jugular vein atherosclerosis - This is incorrect as atherosclerosis is a condition of the arteries, not the veins. D: Incompetent jugular vein valves - This is incorrect as incompetent valves may lead to venous reflux but are not directly related to JVD seen in this scenario.
Question 4 of 5
The nurse is assessing the client who presented to the emergency department with a serum sodium level of 114 mEg/L. Which findings would the nurse relate to the serum sodium level? Select all that do not apply.
Correct Answer: D
Rationale: The correct answer is D: Warm, flushed skin. A serum sodium level of 114 mEg/L indicates hyponatremia. Hyponatremia causes water to move into cells, leading to cellular swelling and potential neurological symptoms. Muscle weakness, headache, and confusion are all associated with hyponatremia due to neurological effects. However, warm, flushed skin is not typically related to hyponatremia; instead, it may be seen in conditions like hyperthermia or vasodilation. Therefore, the nurse would not relate warm, flushed skin to the low serum sodium level in this case.
Question 5 of 5
A patient has administered regular insulin 30 minutes prior but has not received a breakfast tray. The patient is experiencing nervousness and tremors. What is the nurse's first action?
Correct Answer: D
Rationale: The correct answer is D: Perform bedside glucose testing. The patient is likely experiencing hypoglycemia due to insulin administration without food intake. Performing bedside glucose testing will confirm hypoglycemia and guide appropriate interventions. Administering glucagon (choice A) is not the first-line action for mild hypoglycemia. Giving orange juice (choice B) could be considered, but confirming hypoglycemia first is crucial. Notifying the kitchen to deliver the tray (choice C) delays immediate assessment and intervention.