ATI RN
Fundamental Concepts and Skills for Nursing Test Questions Questions
Question 1 of 5
A nurse is preparing to discharge a client who experienced a myocardial infarction. The client will have to make many lifestyle changes, and the nurse is providing instruction on how to implement a heart-healthy lifestyle. Which is the best description of the client education the nurse is presenting to this client?
Correct Answer: B
Rationale: The best description of the client education the nurse is presenting in this scenario is an important independent nursing function. Nurses are responsible for educating clients on how to make lifestyle changes to promote heart health, such as following a heart-healthy diet, engaging in regular exercise, and managing stress. This education is a crucial aspect of nursing care and falls under the independent function of nurses, as it does not require a healthcare provider's order to implement. Nurses play a key role in empowering clients to take control of their health and well-being through education and support.
Question 2 of 5
The nurse identifies the diagnosis of Excess Fluid Volume as appropriate for a client with cardiomyopathy. Which interventions should the nurse emphasize when planning this client's care? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A) Monitor B-type natriuretic peptide (BNP) level. In a client with cardiomyopathy and Excess Fluid Volume, monitoring BNP levels is crucial as it is a biomarker for heart failure. Elevated BNP levels indicate heart failure exacerbation and fluid overload, guiding treatment and assessing response to interventions. Option B, providing oxygen, is important in heart failure but not specific to Excess Fluid Volume. Option C, assessing respiratory status and lung sounds, is relevant for heart failure management but does not directly address Excess Fluid Volume. Option D, providing information about activity, is not a priority when addressing fluid volume excess in cardiomyopathy. Educationally, understanding the rationale behind monitoring BNP levels in heart failure patients not only reinforces the importance of biomarker monitoring but also highlights the significance of tailored interventions for specific patient conditions, contributing to optimal nursing care delivery.
Question 3 of 5
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 4 of 5
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 5 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.