ATI RN
Concepts for Nursing Practice Test Bank Questions
Question 1 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: Failed to generate a rationale of 500+ characters after 5 retries.
Question 2 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 3 of 5
A nurse working in the emergency department is participating in the resuscitation of a client experiencing sudden cardiac death. After five cycles of CPR, the nurse evaluates the client's cardiac rhythm as asystole. What is the next action by the nurse?
Correct Answer: B
Rationale: Asystole is the absence of any cardiac electrical activity, and it is a non-shockable rhythm. In the case of asystole, defibrillation would not be effective. The next appropriate action would be to continue high-quality CPR and administer epinephrine according to the advanced cardiac life support (ACLS) protocol. Additionally, assessing the client's pulse is crucial to determine if there is any return of spontaneous circulation (ROSC) following CPR and medication administration. Checking the cardiac monitor electrodes ensures proper attachment and accurate monitoring of the client's cardiac rhythm but may not directly impact the management of asystole.
Question 4 of 5
A client diagnosed with a pulmonary embolism has a reduction in arterial oxygen saturation level and dyspnea. Which is the priority nursing diagnosis for this client?
Correct Answer: C
Rationale: In a client diagnosed with a pulmonary embolism experiencing a reduction in arterial oxygen saturation level and dyspnea, the priority nursing diagnosis would be Impaired Gas Exchange. This is because a pulmonary embolism can obstruct blood flow and prevent proper gas exchange in the lungs. Dyspnea and reduced oxygen saturation levels indicate inadequate gas exchange, which can lead to hypoxia. Prioritizing this nursing diagnosis will ensure that interventions are focused on improving oxygenation and respiratory function to prevent further complications.
Question 5 of 5
A client with hemophilia is at increased risk for what type of shock?
Correct Answer: D
Rationale: Hemophilia is a genetic disorder that impairs the blood's ability to clot properly, leading to prolonged bleeding. This makes individuals with hemophilia particularly susceptible to hemorrhagic shock, which is a type of distributive shock. Distributive shock occurs when there is widespread vasodilation and increased vascular permeability, leading to inadequate tissue perfusion and oxygen delivery. In the case of hemophilia, excessive bleeding can result in a significant loss of blood volume and impaired circulation, eventually leading to distributive shock due to the body's inability to maintain adequate perfusion to vital organs. Therefore, individuals with hemophilia are at an increased risk of developing distributive shock, specifically hemorrhagic shock, if they experience severe bleeding events.