ATI RN
Concept Based Nursing Practice Questions Questions
Question 1 of 5
A client with disseminated intravascular coagulation (DIC) has a nursing diagnosis of Impaired Gas Exchange. Which action is appropriate when providing care based on this nursing diagnosis?
Correct Answer: B
Rationale: Monitoring the client's oxygen saturation intermittently is the most appropriate action when providing care for a client with disseminated intravascular coagulation (DIC) who has a nursing diagnosis of Impaired Gas Exchange. DIC can lead to a variety of complications, including inadequate oxygenation of tissues due to abnormal clotting and bleeding. By monitoring the client's oxygen saturation levels, the healthcare team can assess the effectiveness of gas exchange and adjust interventions as needed to optimize oxygenation. This action helps in early detection of worsening gas exchange and guides appropriate interventions to address any respiratory issues promptly. Placing the client in a low-Fowler position may not be suitable for all patients with DIC, encouraging frequent ambulation could be risky due to the increased bleeding tendency, and using continuous endotracheal suctioning is not recommended as it can lead to aggravation of respiratory issues and increase the risk of further complications.
Question 2 of 5
During a blood pressure screening, an older adult client tells the nurse about chest fluttering while doing yard work. The client reports no other symptoms and the frequency is intermittent. Which action is correct by the nurse?
Correct Answer: C
Rationale: The correct action for the nurse in this situation would be to ensure the client is evaluated by his/her medical provider. Chest fluttering, also known as palpitations, can sometimes be related to cardiac arrhythmias, which can be a concern in older adults. Even though the client reports no other symptoms and the frequency is intermittent, it is essential for the medical provider to assess and determine the cause of the fluttering to rule out any serious underlying cardiac issues. Taking appropriate action promptly can help prevent any potential complications and ensure the client's well-being.
Question 3 of 5
A client with peripheral vascular disease (PVD) has symptoms of intermittent claudication. Which should the nurse include when teaching the client about intermittent claudication?
Correct Answer: C
Rationale: Intermittent claudication is a symptom of peripheral vascular disease (PVD) characterized by cramping or aching pain in the lower extremities and buttocks that occurs with a predictable level of activity, such as walking a certain distance. This pain typically resolves with rest. The pain is due to inadequate blood flow to the muscles during activity, causing a buildup of lactic acid, which leads to muscle pain. This symptom is an important indicator of decreased arterial blood flow and is a common presentation in individuals with PVD. Therefore, when teaching the client about intermittent claudication, the nurse should emphasize the predictable nature of the pain related to activity and the relief experienced with rest.
Question 4 of 5
Which assessment findings support the nurse's concern that a client is experiencing hypovolemic shock? Select all that apply.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 5 of 5
The community nurse is teaching a class at the community center regarding the cultural and ethnic risk factors for stroke. Which statement should nurse include in this presentation?
Correct Answer: B
Rationale: The correct statement that should be included in the presentation is that African Americans have almost twice the number of first-ever strokes compared with Whites. This is based on research and statistics that show African Americans have a higher incidence of stroke compared to other ethnic groups in the United States. It is important for healthcare providers to be aware of these disparities in order to address them effectively through targeted prevention and management strategies. Moreover, raising awareness about these risk factors can help promote early intervention and reduce the burden of stroke within the African American community.