ATI RN
Fundamentals of Nursing Care Concepts, Connections & Skills Test Bank Questions
Question 1 of 5
A client with disseminated intravascular coagulation (DIC) is anxious and has decreased oxygen saturation. Which is the priority nursing diagnosis for this client?
Correct Answer: B
Rationale: In a client with disseminated intravascular coagulation (DIC) who is anxious and has decreased oxygen saturation, the priority nursing diagnosis is Impaired Gas Exchange. DIC can lead to microvascular thrombosis and bleeding, which can affect oxygenation at the cellular level. The client's decreased oxygen saturation indicates a problem with gas exchange, which is crucial for the delivery of oxygen to tissues and the removal of carbon dioxide. Prioritizing this issue is essential to prevent complications related to poor tissue oxygenation, such as organ dysfunction. Addressing the client's anxiety would also be important, but ensuring adequate gas exchange takes precedence to maintain tissue perfusion and oxygenation.
Question 2 of 5
The nurse is providing postpartum care for a client who gave birth by cesarean section several hours ago. The client had preeclampsia during the last 3 weeks of pregnancy. Which interventions are appropriate for this client within the first 48 hours after birth? Select all that apply.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 3 of 5
The nurse is caring for a 6-year-old child when the child goes into cardiac arrest. When performing compressions for CPR, what should the nurse do?
Correct Answer: A
Rationale: When performing CPR on a 6-year-old child, the nurse should place thumbs side by side and perform compressions below the nipple line. For children ages 1 to 8 years old, it is recommended to use the two-thumb encircling hands technique for chest compressions. This involves placing both thumbs on the lower half of the child's breastbone below the nipple line. This technique helps provide effective chest compressions that are appropriate for a child's size and physiology. It is important to follow these guidelines to ensure proper care and maximize the chances of a successful outcome when providing CPR to a child in cardiac arrest.
Question 4 of 5
A client scheduled for surgery is being instructed in leg exercises and the pneumatic compression device. The nurse includes these instructions to decrease which postoperative complication?
Correct Answer: D
Rationale: The client is being instructed in leg exercises and the pneumatic compression device to decrease the risk of developing deep vein thrombosis (DVT) postoperatively. DVT is a serious complication that can occur due to decreased mobility, venous stasis, and hypercoagulability associated with surgery. Leg exercises help promote circulation and prevent blood stasis in the veins, while pneumatic compression devices can also assist in improving blood flow and preventing the formation of blood clots in the deep veins of the legs. By reducing the risk of DVT, the client can avoid potential complications such as pulmonary embolism, which can be life-threatening.
Question 5 of 5
The nurse is caring for a child who was burned in a house fire. The child has burns on 30% of his body, particularly his legs. The child suddenly goes into shock and needs CPR. What is the first step the nurse should take based on pediatric advanced life support (PALS) guidelines?
Correct Answer: B
Rationale: In pediatric advanced life support (PALS) guidelines, the first step in CPR for a child in shock is to begin chest compressions, not ventilations. This is because the priority is to maintain blood flow to vital organs, especially in cases where the child's heart is not effectively pumping due to shock. By performing chest compressions immediately, the nurse can help circulate oxygenated blood throughout the child's body, increasing the chances of survival. Once chest compressions are initiated, ventilations can be added to support oxygenation and ventilation. Obtaining a defibrillator and establishing vascular access are important steps in advanced resuscitation but are not the initial actions in this scenario of a child in shock needing CPR.