ATI RN
Concepts for Nursing Practice Test Bank Questions
Question 1 of 5
The nurse identifies assessment findings for a client with preeclampsia. Blood pressure is 158/100 mmHg; urinary output 50 mL/hour; crackles in the lungs on auscultation; urine protein 1+; 1+ edema hands, feet, ankles. On the next hourly assessment, which new assessment finding would indicate worsening of the condition?
Correct Answer: B
Rationale: A decreased urinary output from 50 mL/hour to 40 mL/hour indicates a worsening of the client's condition with preeclampsia. A decreased urinary output can be a sign of reduced kidney function, which is a serious complication in preeclampsia. Monitoring urinary output is crucial in assessing kidney function and overall fluid balance in clients with preeclampsia. It is important to promptly address any reduction in urinary output to prevent further deterioration in the client's condition. The other options do not specifically indicate a worsening of the condition in this context.
Question 2 of 5
During the health history of an older male patient, the nurse focuses on the gland that encircles the male urethra at the base of the bladder. On which organ is the nurse focusing?
Correct Answer: B
Rationale: The gland that encircles the male urethra at the base of the bladder is the prostate gland. The prostate is an important organ in the male reproductive system that produces fluid to nourish and protect sperm. It also plays a role in ejaculation. A nurse focusing on the prostate gland during the health history of an older male patient is particularly important because issues related to the prostate, such as benign prostatic hyperplasia (BPH) or prostate cancer, commonly affect older men. Regular assessment and screening of the prostate gland are crucial for early detection and management of any potential prostate problems.
Question 3 of 5
The nurse is preparing to conduct a cardiac assessment for a pediatric client. Which location will the nurse use when auscultating the apical pulse?
Correct Answer: A
Rationale: When auscultating the apical pulse in pediatric clients, the nurse should place the stethoscope at the fifth intercostal space at the midclavicular line. This location is where the apex of the heart is located in pediatric clients and provides the most accurate assessment of the apical pulse. Placing the stethoscope at the left nipple (
B) or right nipple (
C) would not provide an accurate assessment of the apical pulse location. Auscultating at the eighth intercostal space (
D) would be too low and not capture the apical pulse accurately.
Question 4 of 5
A client is admitted to the intensive care unit with disseminated intravascular coagulation (DIC). Which clinical manifestations does the nurse anticipate? Select all that apply.
Correct Answer: A
Rationale: 1. Tachycardia: Disseminated intravascular coagulation (DI
C) can lead to widespread clotting within the blood vessels, which can result in tissue ischemia and subsequent compensatory mechanisms such as tachycardia to increase cardiac output and maintain perfusion.
Question 5 of 5
The client's vital signs include P 119, R 24, BP 98/63, T 1°F, and SpO2 89%. Which actions would the nurse implement at this time? Select all that apply.
Correct Answer: B
Rationale: B. Coach in nonpharmacologic pain management techniques: The client's vital signs indicate they may be experiencing pain as evidenced by an elevated heart rate (P 119), which can be addressed initially with nonpharmacologic pain management techniques. This approach can help reduce pain and anxiety without the immediate need for medication.
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