ATI RN
Nursing a Concept Based Approach Test Bank Questions
Question 1 of 5
A client diagnosed with disseminated intravascular coagulation (DIC) is currently bleeding through the gastrointestinal tract. Which does the nurse anticipate administering to this client as a first line treatment?
Correct Answer: C
Rationale: Disseminated intravascular coagulation (DIC) is a serious condition characterized by widespread clot formation in the small blood vessels, leading to bleeding tendencies. In DIC, the body consumes clotting factors and platelets faster than they can be replaced, resulting in both bleeding and clotting. Because of this complex pathophysiology, the first line treatment for DIC-related bleeding is to provide replacement of the consumed clotting factors and platelets. Fresh frozen plasma contains clotting factors, and platelets help in stopping bleeding by aiding in clot formation. Therefore, the administration of fresh frozen plasma and platelets helps to correct the coagulopathy in DIC and manage the bleeding episodes effectively. Aspirin, Warfarin (Coumadin), and Heparin are anticoagulants and would not be appropriate in the treatment of DIC-related bleeding as they can exacerbate the bleeding tendency in this condition.
Question 2 of 5
A nurse working on an antepartum unit is providing care for a client with preeclampsia. Which laboratory value does the nurse anticipate for this client?
Correct Answer: D
Rationale: In a client with preeclampsia, one of the laboratory values that the nurse might anticipate is an increased serum creatinine level. Preeclampsia is a hypertensive disorder of pregnancy characterized by high blood pressure and involvement of multiple organ systems, including the kidneys. An elevated serum creatinine level indicates impaired kidney function, as creatinine is a waste product that is normally filtered by the kidneys and excreted in the urine. In preeclampsia, reduced kidney perfusion due to the high blood pressure can lead to decreased glomerular filtration rate, resulting in elevated serum creatinine levels. Monitoring serum creatinine is essential in assessing kidney function and guiding management in clients with preeclampsia.
Question 3 of 5
The nurse is planning care for an older adult client with chronic venous insufficiency. Which will the nurse include in the client's teaching plan?
Correct Answer: B
Rationale: Elastic compression therapy, such as wearing elastic hose (compression stockings), is an essential component of managing chronic venous insufficiency. Compression stockings help improve venous return, reduce edema, and alleviate symptoms such as pain and swelling. They work by applying external pressure to the legs, promoting better circulation and preventing blood from pooling in the veins. The nurse should ensure that the client wears the compression stockings as prescribed to maximize their effectiveness in managing the condition.
Question 4 of 5
The nurse is caring for a client who develops dyspnea and chest pain. Which diagnostic finding is consistent with a pulmonary embolism (PE)?
Correct Answer: D
Rationale: Tachycardia and nonspecific T-wave changes on the EKG are consistent with a pulmonary embolism (PE). Tachycardia is a common finding in PE, as the body tries to compensate for the decreased oxygenation due to the blockage in the pulmonary artery. Nonspecific T-wave changes, such as ST-segment abnormalities or inverted T-waves, can also be seen in patients with PE. These EKG findings, along with symptoms like dyspnea and chest pain, raise the suspicion for pulmonary embolism and warrant further diagnostic workup. Options A, B, and C are not specific findings related to a pulmonary embolism.
Question 5 of 5
While teaching a wellness class on the warning signs of stroke, a participant asks the nurse, "What's the most important thing for me to remember?" What is an appropriate response by the nurse?
Correct Answer: A
Rationale: The most important thing to remember regarding the warning signs of stroke is to "be alert for sudden weakness or numbness." This is crucial because sudden weakness or numbness in the face, arm, or leg, especially on one side of the body, is one of the hallmark symptoms of a stroke. It is essential to recognize these signs promptly and seek immediate medical attention to minimize the potential damage caused by a stroke. Being aware of these sudden symptoms can help individuals receive timely treatment and improve their chances of recovery.