ATI RN
Nursing a Concept Based Approach to Learning Test Bank Free Questions
Question 1 of 9
A nurse caring for a client with suspected disseminated intravascular coagulation (DIC). Which test result is common in DIC?
Correct Answer: C
Rationale: Disseminated intravascular coagulation (DIC) is a condition characterized by widespread activation of clotting factors throughout the body, leading to both excessive clot formation and consumption of clotting factors. As a result, one of the common features of DIC is a decreased level of fibrinogen, which is an essential protein for blood clot formation. In DIC, fibrinogen is consumed in the formation of multiple small blood clots throughout the circulation, causing a decrease in its levels. This decrease in fibrinogen can contribute to the increased risk of bleeding that is seen in DIC. Therefore, a decreased fibrinogen level is a characteristic laboratory finding in DIC.
Question 2 of 9
The nurse is preparing teaching for a patient with mild osteoarthritis of the knees. Which medication treatments should the nurse include in these instructions? Select all that apply.
Correct Answer: B
Rationale: A. Opioids are not typically indicated for mild osteoarthritis of the knees. They are usually reserved for more severe cases or when other pain management options have failed due to the potential for addiction and side effects.
Question 3 of 9
What is a good way for a nurse to prepare the environment for teaching?
Correct Answer: C
Rationale: Evaluating client abilities to perform skills with return demonstrations is a good way for a nurse to prepare the environment for teaching. By observing the clients' abilities to perform the necessary skills, the nurse can tailor the teaching to meet the specific needs of each individual. Return demonstrations allow for immediate feedback and correction if needed, ensuring that the clients understand and can perform the skills accurately. This interactive approach to teaching promotes active learning and enhances retention of information.
Question 4 of 9
A patient comes into the emergency department with manifestations of appendicitis. What is the highest priority when caring for this patient?
Correct Answer: C
Rationale: The highest priority when caring for a patient with manifestations of appendicitis is to provide pain relief. By inserting a saline lock for intravenous pain medication, the patient can receive immediate pain relief to alleviate their discomfort. Pain management is crucial in appendicitis as it can help in improving the patient's overall well-being and reduce the risk of complications. While other options such as withholding food and fluids, performing preoperative skin preparation, or teaching postoperative exercises are important aspects of care, addressing the patient's pain is the top priority to ensure their comfort and well-being.
Question 5 of 9
Which action should the nurse carry out for the laboring client who has been diagnosed with preeclampsia?
Correct Answer: B
Rationale: When caring for a laboring client diagnosed with preeclampsia, it is important to be mindful of certain considerations to ensure the safety and well-being of both the mother and the baby. Placing the client in left lateral position when she feels the urge to push is crucial in cases of preeclampsia as it helps to optimize maternal and fetal oxygenation. This position can help improve blood flow to the placenta and reduce the risk of decreased perfusion due to the elevated blood pressure associated with preeclampsia. By maintaining the client in the left lateral position during pushing, it can help prevent potential complications and support better outcomes for both the mother and baby.
Question 6 of 9
A perimenopausal patient is experiencing frequency, urgency, nocturia, dysuria, and cloudy, rust- colored urine for the third time in the past 2 years. What should the nurse include when teaching this patient? Select all that apply.
Correct Answer: B
Rationale: B. Recommendations for perineal cleansing: Proper perineal hygiene is important in preventing urinary tract infections (UTIs). Teaching the patient to cleanse the perineal area properly can help reduce the risk of UTIs.
Question 7 of 9
A client diagnosed with a stroke is going to receive treatment with fibrinolytic therapy using the recombinant tissue plasminogen activator alteplase (rt-PA). Which information should the nurse include when performing medication teaching for the client's family?
Correct Answer: D
Rationale: When performing medication teaching for the client's family about fibrinolytic therapy with alteplase (rt-PA), the nurse should include information that this medication is administered to break up existing clots and increase cerebral blood flow. rt-PA works by converting plasminogen to plasmin, which helps dissolve clots and restore blood flow to the brain. It is used specifically for ischemic strokes, not hemorrhagic strokes, and is most effective when administered within 3 hours (up to 4.5 hours in some cases) of the stroke symptoms starting. It is associated with potential serious complications, including an increased risk of bleeding, which the nurse should also educate the family about.
Question 8 of 9
During an assessment, the nurse asks the patient to move an extremity away from the body midline. What movement is the nurse assessing?
Correct Answer: C
Rationale: When the nurse asks the patient to move an extremity away from the body midline, they are assessing the movement of abduction. Abduction refers to the movement of a body part away from the midline of the body. In this case, moving the extremity away from the body midline represents abduction, as the limb is being moved outward or away from the center of the body. Flexion and extension involve bending and straightening movements, respectively, along a joint axis, while adduction involves moving a body part towards the midline of the body.
Question 9 of 9
An older adult client receiving medication for hypertension had a recent fall at home. Which intervention should the nurse include in this client's plan of care?
Correct Answer: B
Rationale: Assessing postural blood pressures is important in determining if the client may be experiencing orthostatic hypotension, which could have contributed to the fall. Orthostatic hypotension is a sudden drop in blood pressure that can occur when a person stands up from a sitting or lying position. Older adults on antihypertensive medications are at increased risk for orthostatic hypotension. By monitoring postural blood pressures, the nurse can identify fluctuations in blood pressure that may put the client at risk for falls and implement appropriate interventions to prevent future falls. Monitoring serum sodium levels and creatinine levels are important for detecting electrolyte imbalances or kidney dysfunction but do not directly address the issue of orthostatic hypotension related to falls. Monitoring blood pressure every 2 hours may not provide valuable information on postural blood pressure changes that are associated with orthostatic hypotension.