ATI RN
Introduction to Nursing Pdf Questions
Question 1 of 5
Which safeguard should the nurse take to ensure accuracy with a telephone order?
Correct Answer: A
Rationale: The correct answer is A because repeating the order to the prescriber ensures accurate communication and allows for verification of the order. This step helps prevent errors due to misinterpretation. Option B is incorrect as the nursing supervisor is not the prescriber. Option C is incorrect as waiting for the physician's signature delays timely administration. Option D is incorrect as the nursing supervisor's role is not to monitor telephone orders.
Question 2 of 5
A nurse in the ICU is caring for a patient with PEEP. The patient suddenly called the nurse, and said: “Nurse, my leg is severely aching!” What is your priority nursing action?
Correct Answer: C
Rationale: The correct answer is C: Check the balloon of the ET tube. This is the priority nursing action because PEEP (Positive End-Expiratory Pressure) is a mechanical ventilation setting that can lead to accidental migration of the endotracheal (ET) tube, causing pressure on surrounding structures like the vocal cords or trachea, leading to referred pain in the leg. Checking the balloon of the ET tube ensures proper placement and prevents complications. Choice A: Checking the condition of the leg is not the priority as the patient's complaint is likely related to the mechanical ventilation. Choice B: Checking for pain scale is not the priority as addressing the source of the pain is more critical. Choice D: Giving analgesic is not appropriate until the cause of the leg pain is identified.
Question 3 of 5
What is the priority of care after the urinary catheter is removed?
Correct Answer: C
Rationale: The correct answer is C because after urinary catheter removal, priority is to evaluate the client for normal voiding to ensure proper bladder function. Encouraging fluid intake (A) is important for hydration. Documenting catheter size and client tolerance (B) is relevant but not a priority post-catheter removal. Documenting client teaching (D) is important but not the immediate priority.
Question 4 of 5
The nurse is reviewing the report of a client's routine urinalysis. Which value should the nurse consider abnormal?
Correct Answer: B
Rationale: The correct answer is B: Urine pH of 3.0 is abnormal. Normal urine pH ranges from 4.6 to 8.0. A pH of 3.0 indicates highly acidic urine, which may be indicative of certain health conditions. Specific gravity of 1.03 is within the normal range (1.005-1.030). Absence of protein and glucose in urine is normal. Proteinuria and glucosuria are typically abnormal findings.
Question 5 of 5
When admitting a patient with stage 3 pressure injuries on both heels, which information obtained by the nurse will have the most impact on wound healing?
Correct Answer: B
Rationale: The correct answer is B because oral hypoglycemic agents are important in managing blood sugar levels. High blood sugar can impair wound healing and increase the risk of infection. Controlling blood sugar levels is crucial for optimal wound healing. A: The duration of injury does not directly impact wound healing compared to managing underlying conditions. C: Pain management is important but does not directly affect wound healing. D: Keloids are unrelated to pressure injuries and do not impact wound healing.