ATI RN
Fundamental Concepts and Skills for Nursing Test Questions Questions
Question 1 of 5
A client with disseminated intravascular coagulation (DIC) has a nursing diagnosis of Ineffective Peripheral Tissue Perfusion. Which actions interventions are appropriate for this diagnosis? Select all that apply.
Correct Answer: B
Rationale: In the context of a client with disseminated intravascular coagulation (DIC) and a nursing diagnosis of Ineffective Peripheral Tissue Perfusion, elevating the client's knees on the bed or with a pillow is the most appropriate intervention. Elevating the knees promotes venous return and helps improve circulation to the peripheral tissues, thereby aiding in perfusion. Monitoring the client's level of consciousness and mental status (Option A) is important but not directly related to improving peripheral tissue perfusion in this case. Minimizing the use of tape on the client's skin (Option C) is a good practice to prevent skin damage but is not a priority for addressing ineffective peripheral tissue perfusion. Assessing extremity pulses, warmth, and capillary refill (Option D) is essential for evaluating perfusion status, but it is an assessment rather than an intervention to directly improve perfusion. In an educational context, understanding the rationale behind interventions for ineffective peripheral tissue perfusion in clients with DIC is crucial for nurses to provide effective care. Elevating the knees is a practical, evidence-based intervention that directly addresses the issue of poor perfusion in the extremities, highlighting the importance of targeted nursing interventions based on a thorough understanding of the client's condition.
Question 2 of 5
A nurse is caring for a pregnant client who is hypertensive. Which additional clinical manifestations leads the nurse to believe that the client is experiencing early preeclampsia?
Correct Answer: D
Rationale: Early preeclampsia is a condition characterized by high blood pressure and signs of damage to another organ system, commonly the liver and kidneys. Severe epigastric pain is a common symptom of this organ involvement. It is caused by liver distention due to the breakdown of red blood cells and platelets, which can lead to a condition known as HELLP syndrome. This manifestation is a significant indicator of early preeclampsia and requires prompt evaluation and intervention to prevent complications for both the mother and the baby. While the other options may be present in preeclampsia, severe epigastric pain is a more specific and concerning symptom requiring immediate attention.
Question 3 of 5
A client with peripheral vascular disease (PVD) is experiencing pain. Which nursing intervention addresses the client's pain?
Correct Answer: B
Rationale: Keeping the extremities warm (Choice B) is the appropriate nursing intervention for a client with peripheral vascular disease (PVD) experiencing pain. Maintaining warmth helps promote vasodilation and improve blood flow to the affected areas, reducing pain and discomfort. Cold temperatures can exacerbate vasoconstriction and worsen symptoms in individuals with PVD. Elevating the legs in bed (Choice A) may be beneficial in some cases to improve circulation, but in the context of pain management for PVD, keeping the extremities warm is more pertinent. Encouraging ambulation (Choice C) can also help improve circulation, but it may not be suitable during episodes of pain. Applying cool compresses (Choice D) is contraindicated for PVD-related pain as it can further exacerbate vasoconstriction and discomfort.
Question 4 of 5
The nurse is caring for a pregnant woman with a suspected pulmonary embolism without DVT. With regard to diagnostic tests to confirm the diagnosis what should the nurse anticipate being ordered for the client? Select all that apply.
Correct Answer: A
Rationale: In the context of caring for a pregnant woman with a suspected pulmonary embolism without deep vein thrombosis (DVT), the nurse should anticipate that a ventilation-perfusion (V/Q) scan would likely be ordered to confirm the diagnosis. A V/Q scan is a preferred diagnostic test in pregnant patients due to its safety and the avoidance of ionizing radiation to the fetus. A chest x-ray may not be sufficient to confirm a pulmonary embolism as it may not show definitive signs. A computerized tomography pulmonary angiography (CTPA) is contraindicated in pregnancy due to the risk of radiation exposure to the fetus. A non-stress test is used to evaluate fetal well-being and is not directly related to diagnosing a pulmonary embolism in the mother. In an educational context, understanding the appropriate diagnostic tests for specific conditions in pregnant patients is crucial for nursing practice. It is essential to consider the safety of both the mother and the fetus when selecting diagnostic procedures, making the V/Q scan the most appropriate choice in this scenario.
Question 5 of 5
A client with a suspected transient ischemic attack (TIA) presents to the emergency department with aphasia. Based on this data, the nurse plans care based on ischemia to which portion of the brain?
Correct Answer: C
Rationale: Aphasia, which is the inability to understand or express speech, is typically associated with damage to the left hemisphere of the brain. In a client with suspected transient ischemic attack (TIA) presenting with aphasia, the nurse would plan care based on ischemia affecting the left hemisphere of the brain. The left hemisphere is responsible for language processing in most individuals, so damage in this area can result in communication deficits such as aphasia.