ATI RN
Concepts for Nursing Practice Test Bank Questions
Question 1 of 9
A nurse working in the emergency department is participating in the resuscitation of a client experiencing sudden cardiac death. After five cycles of CPR, the nurse evaluates the client's cardiac rhythm as asystole. What is the next action by the nurse?
Correct Answer: B
Rationale: Asystole is the absence of any cardiac electrical activity, and it is a non-shockable rhythm. In the case of asystole, defibrillation would not be effective. The next appropriate action would be to continue high-quality CPR and administer epinephrine according to the advanced cardiac life support (ACLS) protocol. Additionally, assessing the client's pulse is crucial to determine if there is any return of spontaneous circulation (ROSC) following CPR and medication administration. Checking the cardiac monitor electrodes ensures proper attachment and accurate monitoring of the client's cardiac rhythm but may not directly impact the management of asystole.
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
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 4 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 5 of 9
A client is admitted to the intensive care unit with disseminated intravascular coagulation (DIC). Which clinical manifestations does the nurse anticipate? Select all that apply.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 6 of 9
The nurse is evaluating the teaching provided to a patient with acute glomerulonephritis. Which patient action indicates that additional teaching is not necessary?
Correct Answer: B
Rationale: Option B, "Demonstrates care of the vascular access device for dialysis," indicates that the patient understands how to care for their vascular access device, which is important for receiving dialysis treatment. This action shows adequate comprehension and competency in managing this aspect of their care. Therefore, additional teaching is not necessary in this area. On the other hand, options A, C, and D present actions that may require further clarification or reinforcement in the teaching provided to the patient with acute glomerulonephritis.
Question 7 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 8 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 9 of 9
The mother of a baby born with a congenital heart defect is upset, as no one else in the family has been born with this condition. To determine the cause of the defect, which question is appropriate for the nurse to ask the mother?
Correct Answer: A
Rationale: The appropriate question for the nurse to ask the mother in this scenario is "Did you consume any alcohol before you knew you were pregnant?" This is because maternal alcohol consumption during pregnancy is a known risk factor for congenital heart defects. By asking this question, the nurse can gather crucial information to determine a potential cause for the baby's condition. It is important to address this potential risk factor to provide appropriate care and support to the mother and baby.