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
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 3 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 4 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: 1. Tachycardia: Disseminated intravascular coagulation (DIC) can lead to widespread clotting within the blood vessels, which can result in tissue ischemia and subsequent compensatory mechanisms such as tachycardia to increase cardiac output and maintain perfusion.
Question 5 of 9
The nurse is performing an assessment of a client. Which should the nurse recognize as a noncardiac risk factor for heart failure?
Correct Answer: C
Rationale: Hyperthyroidism is a noncardiac risk factor for heart failure because it can lead to increased heart rate, palpitations, and ultimately strain on the heart. When a person has hyperthyroidism, the thyroid gland produces too much thyroid hormone, which can impact the cardiovascular system by affecting heart function. This increased workload on the heart can contribute to the development of heart failure. It is important for the nurse to recognize hyperthyroidism as a potential risk factor for heart failure during the assessment of the client.
Question 6 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 7 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 8 of 9
During the health history of an older male patient, the nurse focuses on the gland that encircles the male urethra at the base of the bladder. On which organ is the nurse focusing?
Correct Answer: B
Rationale: The gland that encircles the male urethra at the base of the bladder is the prostate gland. The prostate is an important organ in the male reproductive system that produces fluid to nourish and protect sperm. It also plays a role in ejaculation. A nurse focusing on the prostate gland during the health history of an older male patient is particularly important because issues related to the prostate, such as benign prostatic hyperplasia (BPH) or prostate cancer, commonly affect older men. Regular assessment and screening of the prostate gland are crucial for early detection and management of any potential prostate problems.
Question 9 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.