ATI RN
Introduction to Nursing Final Exam Quizlet Questions
Question 1 of 5
Which nursing diagnosis is in PES format?
Correct Answer: D
Rationale: The correct answer is D because it follows the PES format, which stands for Problem (nursing diagnosis), Etiology (related factor), and Signs/Symptoms (defining characteristics). In this case, the Problem is "Self-esteem disturbance," the Etiology is "related to rejection by the husband," and the Signs/Symptoms are "manifested by crying and isolation." The other options do not follow the PES format correctly. A lacks defining characteristics, B does not have a clear related factor, and C does not have a problem clearly identified. Thus, D is the correct choice as it adheres to the PES structure for nursing diagnosis formulation.
Question 2 of 5
What does a lab report showing RBC 5M/mm3, WBC 12,000/mm3, Platelet 200,000/mm3, and prothrombin time of 11 seconds suggest?
Correct Answer: D
Rationale: The lab values indicate a high WBC count (12,000/mm3) suggesting an elevated immune response, typical in infections. The RBC count (5M/mm3) and platelet count (200,000/mm3) are within normal range ruling out dehydration and polycythemia. The prothrombin time of 11 seconds is also normal. Therefore, the most likely interpretation is an infection. Dehydration would show high RBC count and high platelet count, polycythemia would show high RBC count, and leukopenia would show low WBC count.
Question 3 of 5
0.9 normal saline solution had been infusing at 100 mL/hour via a central line catheter in the right internal jugular for approximately 12 hours to increase urine output and maintain the client's blood pressure. Upon entering the Justine’s room, the you noted that the client is breathing rapidly and coughing. For which additional signs of a complication should the nurse assess based on the previously known data?
Correct Answer: B
Rationale: The correct answer is B: Crackles in the lungs. Rapid breathing and coughing can indicate fluid overload, a potential complication of infusing 0.9% saline solution. Crackles in the lungs suggest pulmonary edema, a serious consequence of fluid overload. Assessing for crackles in the lungs is crucial for early detection and intervention. Incorrect Choices: A: Excessive bleeding is not directly related to infusing saline solution. C: Incompatibility of the infusion is unlikely as 0.9% saline is a standard solution. D: Chest pain radiating to the left arm is more indicative of cardiac issues like a heart attack, not fluid overload.
Question 4 of 5
Mrs. Sales also tells the nurse that she is often constipated. Because she is aging, what physical changes predispose her to constipation?
Correct Answer: C
Rationale: The correct answer is C: Loss of tone of the smooth muscles of the colon. As individuals age, the smooth muscles of the colon can lose their tone, resulting in slower peristalsis and decreased bowel movements, leading to constipation. This physical change is a common factor contributing to constipation in older adults. A: Inhibition of the parasympathetic reflex is not directly related to constipation in aging individuals. Parasympathetic stimulation usually promotes bowel movements. B: Esophageal emptying hastening is not relevant to constipation. Esophageal emptying refers to the movement of food from the esophagus into the stomach, not the colon. D: Decreased ability to absorb fluids in the lower intestines is not a typical physical change associated with aging that predisposes individuals to constipation. Constipation is more commonly linked to issues with colonic motility rather than fluid absorption.
Question 5 of 5
To reduce risk of airborne disease transmission from a client with infectious status in a private room, the nurse should do which of the following control measures?
Correct Answer: D
Rationale: The correct answer is D: Provide special ventilation. Special ventilation systems help to control and reduce the concentration of airborne pathogens in the room, decreasing the risk of disease transmission. This measure is necessary for infection control in private rooms. A: Using a face mask when entering the room may provide some protection, but it is not as effective as special ventilation in reducing airborne pathogen concentration. B: Keeping the door closed can help contain the pathogens within the room but does not address the need for proper ventilation. C: Limiting visitors can help reduce the spread of infection, but it does not directly address airborne transmission control like special ventilation does.