ATI RN
Introduction to Nursing Chapter 1 Quizlet Questions
Question 1 of 5
While caring for a client who's immobile, the nurse documents the following information in the client's chart: Turned client from side to back every 2 hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." This nursing diagnosis accurately reflects the potential of:"
Correct Answer: A
Rationale: The correct answer is A: Risk for impaired skin integrity related to immobility. The nurse's documentation indicates preventive measures taken to maintain skin integrity due to immobility, such as turning the client every 2 hours. The absence of redness and improved skin turgor show proactive skin assessment and care. Choice B is incorrect as there is no evidence of actual skin breakdown. Constipation (choice C) and disturbed body image (choice D) are not supported by the information provided. Therefore, choice A is the most appropriate nursing diagnosis based on the documented care and assessment findings.
Question 2 of 5
All of the following are correct methods in the assessment of blood pressure except:
Correct Answer: D
Rationale: The correct answer is D because pumping the cuff to around 50 mmHg above the point where the pulse is obliterated is incorrect. The correct method is to pump the cuff to about 30 mmHg above the point where the pulse disappears. Pumping too high can lead to inaccurate readings. Observing procedures for infection control (A), taking BP on both arms for comparison (B), and listening to identify Korotkoff sounds (C) are all correct methods in the assessment of blood pressure, ensuring accuracy and reliability.
Question 3 of 5
A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers?
Correct Answer: A
Rationale: The correct answer is A: A 79 year-old malnourished client on bed rest. This client is at highest risk for decubitus ulcers due to malnourishment causing poor tissue healing, and immobility leading to pressure ulcers. The other choices are less likely: B may have increased pressure but obesity does not directly correlate with ulcer risk, C's incontinence may increase risk of skin breakdown but not as high as malnutrition and immobility, and D's ambulatory status reduces the risk compared to bed rest.
Question 4 of 5
After a lumbar puncture, the nurse should place the client in:
Correct Answer: A
Rationale: The correct answer is A: Supine position with a pillow. Placing the client in a supine position with a pillow helps prevent post-lumbar puncture headache by aiding in the restoration of normal cerebrospinal fluid pressure. The pillow supports the head and neck, reducing strain on the puncture site. Choice B: Supine with neck hyperextended is incorrect as it can increase the risk of complications and discomfort for the client. Choice C: Prone for 24 hours is incorrect as it can lead to increased pressure on the puncture site and hinder the recovery process. Choice D: Orthopneic is incorrect as this position is typically used for respiratory distress and not indicated post-lumbar puncture.
Question 5 of 5
You have safely inserted an indwelling catheter to Mr. Edward Cullen. To secure the catheter in place and prevent its dislodgment you should tape the catheter tubing in the client’s:
Correct Answer: B
Rationale: The correct answer is B, lower abdomen. Securing the catheter tubing in the lower abdomen helps prevent dislodgment by reducing movement and tension on the catheter. This area allows for easy monitoring of the catheter site and minimizes the risk of accidental removal. Taping the catheter tubing on the inner thigh or lower thigh may lead to increased friction and movement, increasing the risk of dislodgment. Choosing "All of these" is incorrect because taping the catheter tubing in multiple areas can cause unnecessary discomfort and potential complications for the client.