ATI RN
Introduction to Nursing Questions
Question 1 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 2 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.
Question 3 of 5
The nurse is performing an assessment on a patient who will begin taking propranolol (Inderal) to treat hypertension. The nurse learns that the patient has a history of asthma and diabetes. The nurse will take which action?
Correct Answer: B
Rationale: Step 1: Identify contraindications - Propranolol is contraindicated in patients with asthma due to its potential to exacerbate bronchospasm. Step 2: Recognize patient history - The patient has a history of asthma. Step 3: Assess for comorbidities - The patient also has diabetes, which is another consideration in selecting appropriate antihypertensive medication. Step 4: Consider safer alternatives - Given the contraindications and comorbidities, contacting the provider to discuss an alternative antihypertensive medication is the best course of action. Step 5: Monitor for adverse effects - Administering the medication without addressing the contraindications could lead to serious complications. Summary: Option B is correct as it addresses the contraindications and comorbidities, ensuring patient safety. Options A, C, and D are incorrect as they do not address the potential risks associated with propranolol in this specific
Question 4 of 5
The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective?
Correct Answer: C
Rationale: The correct answer is C because having the spouse sleep in another room reduces the risk of transmitting TB through close contact. This step indicates understanding of the need to prevent close contact with others to prevent the spread of TB. A, B, and D are incorrect: A: Taking the bus instead of driving does not relate to TB transmission. B: Staying indoors whenever possible does not address the issue of close contact with others. D: Keeping windows closed at home does not directly impact the transmission of TB through close contact with an infected individual.
Question 5 of 5
A patient with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is accurate?
Correct Answer: C
Rationale: The correct answer is C. Lovenox (enoxaparin) is a low molecular weight heparin that works immediately to prevent further clot formation. Warfarin (Coumadin) takes several days to reach therapeutic levels and inhibit clotting factors. Therefore, the combination of both medications ensures immediate anticoagulant effects from Lovenox while waiting for Coumadin to take full effect. Explanation of other choices: A: Incorrect. Using two anticoagulants does not necessarily reduce the risk for recurrent venous thrombosis. B: Incorrect. Lovenox and Coumadin have different mechanisms of action and do not function solely in clot dissolution and prevention. D: Incorrect. The presence of a VTE does not inherently indicate an increased risk for pulmonary embolism.