ATI RN
Introduction to Professional Nursing Questions
Question 1 of 5
You are currently inserting an IV line into a client. While you were inserting it, which of the following signs should you stop advancing the catheter?
Correct Answer: D
Rationale: Correct answer: D. The blood return shows in the backflash chamber of the catheter. Rationale: When inserting an IV line, the appearance of blood return in the backflash chamber indicates proper placement within the vein. This signifies that the catheter tip is in the vein, and further advancement should be stopped to prevent complications like infiltration. Options A, B, and C do not provide direct indications of proper catheter placement and do not offer concrete guidance on when to stop advancing the catheter.
Question 2 of 5
A nurse is caring for a client with a chest tube attached to a Pleurevac drainage system. Which of the following actions should the nurse avoid to prevent a tension pneumothorax?
Correct Answer: A
Rationale: Correct Answer: A: Clamping the chest tube Rationale: Clamping the chest tube can lead to a tension pneumothorax by preventing air from escaping the pleural space. This can cause a buildup of pressure, leading to lung collapse and potential life-threatening complications. Summary of other choices: B: Taping the connection can prevent air leaks and maintain the system's integrity. C: Adding water to the suction chamber is necessary to maintain suction and prevent air leaks. D: Maintaining the collection chamber below the client's waist helps with proper drainage and prevents backflow of fluid.
Question 3 of 5
A client is to be discharged from an acute care facility after treatment for right leg thrombophlebitis. The nurse notes that the client's leg is pain-free, without redness or edema. The nurse's actions reflect which step of the nursing process?
Correct Answer: D
Rationale: The correct answer is D: Evaluation. In the nursing process, evaluation is the final step where the nurse determines if the goals and outcomes of care have been achieved. In this scenario, the nurse is assessing the client's condition before discharge to ensure there are no signs of thrombophlebitis. The absence of pain, redness, and edema indicates successful treatment. This step aligns with the evaluation phase as the nurse is assessing the client's response to treatment. A: Assessment is incorrect because the nurse has already assessed the client's leg and is now determining the effectiveness of the treatment. B: Analysis is incorrect as this step involves interpreting the data collected during assessment to identify problems and make nursing diagnoses. C: Implementation is incorrect as this step involves carrying out the nursing interventions to achieve the established goals. The nurse has already implemented the treatment plan in this scenario.
Question 4 of 5
A client is admitted to the health care facility with bowel obstruction secondary to colon cancer. The nurse obtains a health history, measures vital signs, and auscultates for bowel sounds. Which step of the nursing process is the nurse performing?
Correct Answer: B
Rationale: The correct answer is B: Assessment. In this scenario, the nurse is collecting data by obtaining the health history, measuring vital signs, and auscultating for bowel sounds. Assessment is the first step in the nursing process, where data is gathered to identify the client's health status. Planning (A) involves setting goals and outcomes, Evaluation (C) involves determining the effectiveness of interventions, and Implementation (D) involves carrying out the planned interventions. In this case, the nurse is still in the data collection phase, making Assessment the correct choice.
Question 5 of 5
The nurse is performing a breast assessment to a client. Which of the following findings is a deviation from normal?
Correct Answer: C
Rationale: The correct answer is C: Retraction or dimpling. This finding is a deviation from normal as it can indicate possible breast cancer or other abnormalities. Retraction or dimpling can be a sign of tissue distortion or fibrosis, which should be further evaluated. Presence of striae (A) is common and not a cause for concern. Breasts that are rounded (B) and slightly unequal in size are considered normal variations. Simply being round (D) does not necessarily indicate a deviation from normal.