ATI RN
Introduction to Nursing Questions
Question 1 of 5
Which nursing diagnosis would comply with guidelines set forth by NANDA?
Correct Answer: D
Rationale: The correct answer is D: Risk for injury related to generalized weakness. This diagnosis complies with NANDA guidelines as it is specific, measurable, and based on clinical judgment. It focuses on the potential harm a patient may experience due to their weakness, aligning with NANDA's criteria for nursing diagnoses. The other choices lack specificity and do not directly address the patient's actual health problem. Choice A assumes the cause of ineffective airway clearance without assessment data. Choice B involves psychological factors not directly related to a physiological condition. Choice C implies a behavioral issue rather than a potential health risk.
Question 2 of 5
After a few hours in the emergency room, the client is admitted to the ward with an order of hourly monitoring of BP. The nurse finds that the cuff is too narrow and this will cause the BP reading to be:
Correct Answer: B
Rationale: The correct answer is B: Higher than what the reading should be. A narrow cuff will result in inaccurate BP readings because it can cause increased pressure on the artery, leading to artificially elevated readings. When the cuff is too narrow, it can compress the artery more than necessary, resulting in a higher BP reading. This is why it is important to use the correct cuff size based on the client's arm circumference to obtain an accurate reading. Choices A and C are incorrect because a narrow cuff would not result in a lower or the same BP reading, respectively. Choice D, inconsistent, is also incorrect because the incorrect cuff size will consistently produce higher readings due to increased pressure on the artery.
Question 3 of 5
While caring for a client, the nurse notes a pulsating mass in the client's periumbilical area. Which of the following assessments is appropriate for the nurse to perform?
Correct Answer: B
Rationale: The correct answer is B: Auscultate the mass. Auscultation can help identify the nature of the pulsating mass, such as detecting bruits, which may indicate an underlying vascular issue. Measuring the length (A) is not relevant for assessing a pulsating mass. Percussion (C) is used to assess underlying structures, not the nature of a mass. Palpation (D) can provide information on the size, shape, and consistency of the mass but auscultation is essential to detect potential abnormalities like bruits.
Question 4 of 5
The best position for a client for thoracentesis is:
Correct Answer: A
Rationale: The correct answer is A: Upright leaning sideward. This position allows for better access to the pleural space between the ribs, minimizing the risk of injury to surrounding structures. The upright position helps to expand the lung and diaphragm, making it easier to locate the fluid pocket for thoracentesis. Leaning sideways helps to ensure gravity assists in pooling the fluid away from the needle insertion site. Choice B: Orthopneic is not the best position for thoracentesis as the patient is sitting upright and leaning forward, which may not be as effective in accessing the fluid pocket. Choice C: Prone position is incorrect because the patient is lying face down, making it difficult to access the pleural space in the back. Choice D: Supine position is also incorrect as the patient is lying flat on their back, making it challenging to access the pleural space effectively.
Question 5 of 5
What statement by a nurse to a new nurse, orienting to the unit, is correct regarding seizure precautions?
Correct Answer: C
Rationale: Correct Answer: C Rationale: 1. Forcing a tongue depressor between the teeth can cause injury during a seizure. 2. It is important to maintain a patent airway during a seizure. 3. Placing an object in the mouth can increase the risk of aspiration or damage to the teeth. 4. The nurse should protect the client from harm by ensuring a safe environment during a seizure. Summary: A: Not all seizures lead to status epilepticus; it depends on the individual. B: Oxygen may be needed, but it is not the priority over maintaining a clear airway. D: Administering anticonvulsant drugs is beneficial for seizure management.