ATI RN
Concepts for Nursing Practice Test Bank Questions
Question 1 of 9
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.
Question 2 of 9
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 9
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.
Question 4 of 9
A home health nurse is working with a client who has chronic obstructive pulmonary disease. Which nursing diagnosis will take the highest priority for implementing client education?
Correct Answer: A
Rationale: Impaired Gas Exchange is the nursing diagnosis that should take the highest priority for implementing client education in a client with chronic obstructive pulmonary disease (COPD). Since COPD directly affects the ability of the lungs to take in oxygen and eliminate carbon dioxide, impaired gas exchange is a critical concern for these patients. By educating the client on proper breathing techniques, medication adherence, smoking cessation, and environmental triggers, the nurse can help in improving gas exchange and overall respiratory function. Addressing Impaired Gas Exchange as a priority can significantly impact the client's quality of life and prevent respiratory complications.
Question 5 of 9
The client's vital signs include P 119, R 24, BP 98/63, T 1°F, and SpO2 89%. Which actions would the nurse implement at this time? Select all that apply.
Correct Answer: B
Rationale: B. Coach in nonpharmacologic pain management techniques: The client's vital signs indicate they may be experiencing pain as evidenced by an elevated heart rate (P 119), which can be addressed initially with nonpharmacologic pain management techniques. This approach can help reduce pain and anxiety without the immediate need for medication.
Question 6 of 9
The nurse is preparing instructional materials for a patient recovering from a fractured leg. What mineral should the nurse teach as being essential in bone healing?
Correct Answer: B
Rationale: Calcium is essential in bone healing as it is a major component of bone tissue. Adequate calcium intake is crucial for maintaining bone density and strength, which is particularly important during the healing process of a fractured bone. Calcium plays a key role in the mineralization of bone tissue, helping in the formation of new bone and repair of the fractured area. Therefore, teaching the patient about the importance of sufficient calcium intake is vital for promoting bone healing and recovery.
Question 7 of 9
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 8 of 9
The nurse is preparing to conduct a cardiac assessment for a pediatric client. Which location will the nurse use when auscultating the apical pulse?
Correct Answer: A
Rationale: When auscultating the apical pulse in pediatric clients, the nurse should place the stethoscope at the fifth intercostal space at the midclavicular line. This location is where the apex of the heart is located in pediatric clients and provides the most accurate assessment of the apical pulse. Placing the stethoscope at the left nipple (B) or right nipple (C) would not provide an accurate assessment of the apical pulse location. Auscultating at the eighth intercostal space (D) would be too low and not capture the apical pulse accurately.
Question 9 of 9
The nurse is conducting a health history with a patient that focuses on the endocrine system. Which question should the nurse include in this assessment?
Correct Answer: B
Rationale: The nurse should include the question "Have you noticed a change in your thirst?" in the health history focusing on the endocrine system because changes in thirst can be indicative of conditions such as diabetes insipidus or diabetes mellitus that affect the endocrine system. Thirst can be altered due to changes in hormone levels, particularly those related to water balance and blood sugar regulation. Monitoring changes in thirst can provide important information about potential endocrine imbalances in the body. Asking about changes in thirst is relevant to assessing the patient's endocrine health in this context.