ATI RN
Transcultural Concepts in Nursing Care Test Bank Questions
Question 1 of 5
The nurse identifies the diagnosis of Deficient Fluid Volume as appropriate for a patient with a nasogastric tube for gastric decompression. Which actions should the nurse perform to support this diagnosis? Select all that apply.
Correct Answer: A
Rationale: A. Measuring abdominal girth every 4 to 8 hours is important to monitor for signs of fluid accumulation in the abdominal cavity, indicating potential fluid volume deficit.
Question 2 of 5
The nurse monitors vital signs and laboratory values for a patient recovering from a total knee replacement. For which reason is the nurse implementing these actions?
Correct Answer: C
Rationale: The nurse is monitoring vital signs and laboratory values for the patient recovering from a total knee replacement to ensure adequate circulation to the involved extremity. After a total knee replacement surgery, there is a risk of developing complications such as deep vein thrombosis (DVT) or impaired circulation to the surgical site. Monitoring vital signs and laboratory values allows the nurse to assess for any signs of compromised circulation, which could indicate the development of complications requiring immediate intervention. By closely monitoring these parameters, the nurse can ensure that the patient's recovery is progressing smoothly and without any major complications impacting the circulation to the involved extremity.
Question 3 of 5
The nurse is caring for a pregnant woman with congenital heart disease. The woman asks if she will be able to have a vaginal delivery. Which answer by the nurse is correct?
Correct Answer: C
Rationale: A vaginal birth is preferred over a Cesarean section for women who have aortic stenosis. Aortic stenosis is a type of congenital heart disease that restricts blood flow from the heart to the rest of the body due to a narrowing of the aortic valve. In women with aortic stenosis, the increased blood volume and heart rate during labor and delivery can put extra strain on the heart. However, in most cases, vaginal delivery is preferred over a Cesarean section to avoid the risks associated with major abdominal surgery, such as bleeding, infection, and thrombophlebitis. A vaginal birth allows for a more gradual and controlled increase in cardiac output compared to the more sudden changes that can occur during a Cesarean section. Additionally, the stress of labor may mimic the stress test for some patients, providing valuable information about their heart function. However, each case is unique and must be evaluated by the healthcare team
Question 4 of 5
At a local health fair, a male participant remarks to the nurse about urine occasionally being pink and wonders if this should be a concern. How should the nurse respond?
Correct Answer: C
Rationale: Instructing the participant to track the relationship between urine color and activities would be the most appropriate response in this situation. Occasionally having pink urine can be caused by various factors, such as certain foods, medications, strenuous exercise, or even dehydration. By tracking when the urine appears pink in relation to these activities, the participant can gather valuable information to share with a healthcare provider if needed. This approach can help identify any patterns and determine the underlying cause, guiding further evaluation or management if necessary. It allows for a proactive and informative approach before seeking medical attention, as long as there are no other concerning symptoms present.
Question 5 of 5
The nurse is providing discharge teaching to a client recovering from deep venous thrombosis (DVT). Which instructions are appropriate for the nurse to include in the teaching session? Select all that apply.
Correct Answer: A
Rationale: A. Avoid crossing the legs: Crossing the legs can impede blood flow and increase the risk of developing blood clots, so it is important for the client recovering from DVT to avoid this position.