ATI RN
Fundamental Concepts and Skills for Nursing Test Questions Questions
Question 1 of 9
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: - Elevating the client's knees on the bed or with a pillow can help improve venous return and promote circulation, ultimately enhancing peripheral tissue perfusion in a client with DIC.
Question 2 of 9
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: - Elevating the client's knees on the bed or with a pillow can help improve venous return and promote circulation, ultimately enhancing peripheral tissue perfusion in a client with DIC.
Question 3 of 9
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 4 of 9
The nurse is assessing the musculoskeletal status of a 70-year-old patient. What findings should the nurse consider as expected age-related changes in this body system? Select all that apply.
Correct Answer: A
Rationale: A. Decreased muscle mass: As individuals age, there is a natural decline in muscle mass known as sarcopenia. This can lead to overall decreased muscle strength and functional ability.
Question 5 of 9
The nurse is caring for an infant diagnosed with hypoplastic left heart syndrome. The client has recently been scheduled for surgery to repair the defect. Which procedure does the nurse anticipate needing to provide client teaching about to the client's family?
Correct Answer: A
Rationale: The Norwood procedure is a surgical technique used to treat hypoplastic left heart syndrome, a congenital heart defect where the left side of the heart is underdeveloped. In this procedure, the surgeon creates a new functional aorta and reconstructs the right ventricle to take over pumping blood to both the lungs and the body. This procedure is typically performed in 3 stages, with the first stage usually done in the first week of life. Providing client teaching about the Norwood procedure is important for the family to understand the surgery, postoperative care, and potential complications. It helps prepare them for what to expect and how to best support their infant through the surgical and recovery process.
Question 6 of 9
The nurse is caring for a client with hypertension. Which diagnostic tests should the nurse anticipate being ordered to rule out secondary causes? Select all that apply.
Correct Answer: A
Rationale: A. Cerebral angiogram: This diagnostic test may be ordered to assess the blood vessels in the brain and rule out potential causes of hypertension related to the central nervous system.
Question 7 of 9
The nurse is caring for a breastfeeding client recovering from a cesarean section. The physician diagnoses her with superficial venous thrombosis. Which intervention should the nurse anticipate carrying out first?
Correct Answer: C
Rationale: Superficial venous thrombosis is a condition characterized by the formation of a blood clot in a superficial vein. The initial intervention for this condition is to apply warm, moist compresses to the affected area. The warmth can help to increase blood flow and promote the resolution of the clot. It also helps to reduce pain and inflammation in the area. Encouraging ambulation, taking aspirin, or administering methylergonovine are not appropriate interventions for superficial venous thrombosis and could potentially worsen the condition or lead to complications.
Question 8 of 9
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 9 of 9
A patient admitted with possible kidney stones suddenly experiences acute crampy pain on the left side that radiates into the groin. The patient is nauseated, vomits clear fluid, and voids pink urine. What should the nurse do first?
Correct Answer: B
Rationale: The patient's symptoms are indicative of kidney stones causing obstruction and possibly renal colic. The sudden onset of severe crampy pain on the left side radiating into the groin, along with nausea, vomiting clear fluid, and passing pink urine (hematuria) are classic signs of kidney stones. Given the severity of the symptoms and the potential for complications, it is crucial to notify the physician immediately for further evaluation and management. Straining all urine, administering analgesics, and obtaining a bladder scan may be necessary interventions but should be done after informing the physician and following their recommendations.