UNRS 107 Quiz2_Prep_Rationale - ATI Quiz #2 Prep
Questions With Complete Solutions
1. A nurse is preparing an in-service for an annual skills fair at a
community medical facility about fire safety. Place the steps in
the order in which they should be performed in the case of a fire
emergency. (Move the steps into the box on the right, placing
them in the selected order of performance. Use all the steps.)
A. Pull the fire alarm.
B. Confine the fire.
C. Extinguish the fire.
D. Rescue the clients. - The correct order for responding to a
fire emergency is typically referred to as "RACE," which stands
for:
R. Rescue the clients.
A. Activate the fire alarm (pull the fire alarm).
C. Confine the fire.
E. Extinguish the fire.
10. A nurse is caring for a child who has asthma and a
prescription for montelukast granules. Which of the following
instructions should the nurse provide the client's parent on
administering the medication?
A. Give the medication in the morning daily.
,B. Administer the medication 2 hr before exercise.
C. Give the medication at the onset of wheezing.
D. Administer the granules mixed with 20 oz of water. - B.
Administer the medication 2 hr before exercise.
Rationale: Montelukast should be given daily during the
evening, except when being used for exercise-induced
bronchospasm. It should then be given 2 hr before exercise, and
not given again for 24 hr.
11. A nurse in the post-anesthesia care unit is caring for a client
who is postoperative following a thoracotomy and lobectomy.
Which of the following postoperative assessments should the
nurse give highest priority to?
A. Arterial blood gases.
B. Urinary output.
C. Chest tube drainage.
D. Pain level. - A. Arterial blood gases
Rationale: According to the ABC priority-setting framework, the
postoperative surgical client may need supplemental oxygen in
order to maintain normal blood oxygen levels. The effectiveness
of oxygenation is monitored using pulse oximetry and arterial
blood gases.
,12. A nurse is caring for four hospitalized clients. Which of the
following clients should the nurse identify as being at risk for
fluid volume deficit?
A. The client who has been NPO since midnight for endoscopy.
B. The client who has left-sided heart failure and has a brain
natriuretic peptide (BNP) level of 600 pg/mL.
C. The client who has end-stage renal failure and is scheduled
for dialysis today.
D. The client who has gastroenteritis and is febrile. - D. The
client who has gastroenteritis and is febrile.
Rationale: This client has two risk factors for the development
of fluid volume deficit, or dehydration. Gastroenteritis is
characterized by diarrhea and may also be associated with
vomiting, so it can be a significant source of fluid loss. The
client who has a fever can also lose fluid via diaphoresis, and
fever raises the metabolic rate, further putting the client at
increased risk for dehydration. Consequently, this is the client at
greatest risk for fluid volume deficit.
13. A nurse is attending a social event when another guest
coughs weakly once, grasps his throat with his hands, and
cannot talk. Which of the following actions should the nurse
should take?
A. Observe the client before taking further action.
, B. Perform the Heimlich maneuver.
C. Assist the client to the floor and begin mouth-to-mouth
resuscitation.
D. Slap the client on the back several times. - B. Perform the
Heimlich maneuver.
Rationale: The client cannot talk, coughs only once, and is
demonstrating the universal choking sign: grasping at the throat
with the hands. Choking requires immediate intervention. The
Heimlich maneuver is the most effective method for clearing the
obstruction in the airway of a choking
person
14. A nurse is caring for a toddler who has acute
laryngotracheobronchitis and has been placed in a cool mist tent.
Which of the following findings indicates that the treatment has
been effective?
A. Barking cough.
B. Improved hydration.
C. Decreased stridor.
D. Decreased temperature. - C. Decreased stridor
Rationale: Laryngotracheobronchitis, or croup, is a condition
caused by an infection of the upper airway (larynx, trachea, and
bronchus) and is characterized by a barking cough. Edema and
Questions With Complete Solutions
1. A nurse is preparing an in-service for an annual skills fair at a
community medical facility about fire safety. Place the steps in
the order in which they should be performed in the case of a fire
emergency. (Move the steps into the box on the right, placing
them in the selected order of performance. Use all the steps.)
A. Pull the fire alarm.
B. Confine the fire.
C. Extinguish the fire.
D. Rescue the clients. - The correct order for responding to a
fire emergency is typically referred to as "RACE," which stands
for:
R. Rescue the clients.
A. Activate the fire alarm (pull the fire alarm).
C. Confine the fire.
E. Extinguish the fire.
10. A nurse is caring for a child who has asthma and a
prescription for montelukast granules. Which of the following
instructions should the nurse provide the client's parent on
administering the medication?
A. Give the medication in the morning daily.
,B. Administer the medication 2 hr before exercise.
C. Give the medication at the onset of wheezing.
D. Administer the granules mixed with 20 oz of water. - B.
Administer the medication 2 hr before exercise.
Rationale: Montelukast should be given daily during the
evening, except when being used for exercise-induced
bronchospasm. It should then be given 2 hr before exercise, and
not given again for 24 hr.
11. A nurse in the post-anesthesia care unit is caring for a client
who is postoperative following a thoracotomy and lobectomy.
Which of the following postoperative assessments should the
nurse give highest priority to?
A. Arterial blood gases.
B. Urinary output.
C. Chest tube drainage.
D. Pain level. - A. Arterial blood gases
Rationale: According to the ABC priority-setting framework, the
postoperative surgical client may need supplemental oxygen in
order to maintain normal blood oxygen levels. The effectiveness
of oxygenation is monitored using pulse oximetry and arterial
blood gases.
,12. A nurse is caring for four hospitalized clients. Which of the
following clients should the nurse identify as being at risk for
fluid volume deficit?
A. The client who has been NPO since midnight for endoscopy.
B. The client who has left-sided heart failure and has a brain
natriuretic peptide (BNP) level of 600 pg/mL.
C. The client who has end-stage renal failure and is scheduled
for dialysis today.
D. The client who has gastroenteritis and is febrile. - D. The
client who has gastroenteritis and is febrile.
Rationale: This client has two risk factors for the development
of fluid volume deficit, or dehydration. Gastroenteritis is
characterized by diarrhea and may also be associated with
vomiting, so it can be a significant source of fluid loss. The
client who has a fever can also lose fluid via diaphoresis, and
fever raises the metabolic rate, further putting the client at
increased risk for dehydration. Consequently, this is the client at
greatest risk for fluid volume deficit.
13. A nurse is attending a social event when another guest
coughs weakly once, grasps his throat with his hands, and
cannot talk. Which of the following actions should the nurse
should take?
A. Observe the client before taking further action.
, B. Perform the Heimlich maneuver.
C. Assist the client to the floor and begin mouth-to-mouth
resuscitation.
D. Slap the client on the back several times. - B. Perform the
Heimlich maneuver.
Rationale: The client cannot talk, coughs only once, and is
demonstrating the universal choking sign: grasping at the throat
with the hands. Choking requires immediate intervention. The
Heimlich maneuver is the most effective method for clearing the
obstruction in the airway of a choking
person
14. A nurse is caring for a toddler who has acute
laryngotracheobronchitis and has been placed in a cool mist tent.
Which of the following findings indicates that the treatment has
been effective?
A. Barking cough.
B. Improved hydration.
C. Decreased stridor.
D. Decreased temperature. - C. Decreased stridor
Rationale: Laryngotracheobronchitis, or croup, is a condition
caused by an infection of the upper airway (larynx, trachea, and
bronchus) and is characterized by a barking cough. Edema and
