ATI RN
Nursing a Concept Based Approach to Learning Test Bank Free Questions
Question 1 of 5
The nurse is completing an assessment on a newly admitted client. What finding would alert the nurse that the client may be experiencing a deep venous thrombosis (DVT)?
Correct Answer: C
Rationale: Swelling in one leg with edema is a classic sign of deep venous thrombosis (DVT). DVT occurs when a blood clot forms in one or more of the deep veins in the body, usually in the legs. This can lead to swelling in the affected leg due to the impaired venous return caused by the blood clot. It is important for the nurse to recognize this sign because if left untreated, DVT can lead to serious complications such as pulmonary embolism.
Therefore, the nurse should further assess the client and notify the healthcare provider for appropriate management.
Question 2 of 5
A patient comes into the emergency department with manifestations of appendicitis. What is the highest priority when caring for this patient?
Correct Answer: C
Rationale: The highest priority when caring for a patient with manifestations of appendicitis is to provide pain relief. By inserting a saline lock for intravenous pain medication, the patient can receive immediate pain relief to alleviate their discomfort. Pain management is crucial in appendicitis as it can help in improving the patient's overall well-being and reduce the risk of complications. While other options such as withholding food and fluids, performing preoperative skin preparation, or teaching postoperative exercises are important aspects of care, addressing the patient's pain is the top priority to ensure their comfort and well-being.
Question 3 of 5
A perimenopausal patient is experiencing frequency, urgency, nocturia, dysuria, and cloudy, rust- colored urine for the third time in the past 2 years. What should the nurse include when teaching this patient? Select all that apply.
Correct Answer: B
Rationale: B. Recommendations for perineal cleansing: Proper perineal hygiene is important in preventing urinary tract infections (UTIs). Teaching the patient to cleanse the perineal area properly can help reduce the risk of UTIs.
Question 4 of 5
During an assessment, the nurse asks the patient to move an extremity away from the body midline. What movement is the nurse assessing?
Correct Answer: C
Rationale: When the nurse asks the patient to move an extremity away from the body midline, they are assessing the movement of abduction. Abduction refers to the movement of a body part away from the midline of the body. In this case, moving the extremity away from the body midline represents abduction, as the limb is being moved outward or away from the center of the body. Flexion and extension involve bending and straightening movements, respectively, along a joint axis, while adduction involves moving a body part towards the midline of the body.
Question 5 of 5
A client diagnosed with cardiomyopathy reports having to rest between activities during the day. The client asks the nurse why this is occurring. Which reason should the nurse include in the response to the client?
Correct Answer: B
Rationale: The client with cardiomyopathy may experience decreased cardiac output, which is a common manifestation of this condition. Cardiomyopathy is a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body. Reduced cardiac output means that less blood is being pumped out by the heart with each beat, leading to symptoms such as fatigue, weakness, and the need to rest between activities. This is why the client is experiencing the need to rest between activities during the day.