ATI RN
Nursing a Concept Based Approach to Learning Test Bank Questions
Question 1 of 9
A patient with osteoporosis is prescribed the bisphosphonate alendronate (Fosamax). What should the nurse include when teaching the patient about this medication? Select all that apply.
Correct Answer: A
Rationale: A. Take the medication as directed with clear water only: Alendronate should be taken with a full glass of plain water on an empty stomach in the morning at least 30 minutes before consuming any food, drink, or other medications. Avoid taking it with any other liquids besides plain water, as other beverages can interfere with the absorption of the drug.
Question 2 of 9
A client with disseminated intravascular coagulation (DIC) is experiencing joint pain. Which nursing intervention is appropriate for this client?
Correct Answer: C
Rationale: In disseminated intravascular coagulation (DIC), the client is experiencing joint pain due to the formation of microthrombi which can lead to ischemia and inflammation within the joints. Heat application is appropriate as it can help improve circulation, reduce pain, and promote relaxation of the joints. Heat helps to increase blood flow to the affected area, which can aid in reducing pain and stiffness in the joints. Additionally, heat can also help to soothe the inflamed tissues and promote comfort for the client. Splints, cool compresses, and ice are not appropriate interventions for joint pain in DIC and may not provide the same level of relief as heat therapy.
Question 3 of 9
The nurse is caring for a patient with an epiphyseal fracture. What bone classification should the nurse keep in mind when planning this patient’s care?
Correct Answer: B
Rationale: An epiphyseal fracture involves the distal or proximal epiphysis of a long bone, such as the femur, tibia, or humerus. Long bones are characterized by having a long shaft with distinct ends (epiphyses). The epiphysis is the site of bone growth and plays a crucial role in bone development. Therefore, understanding the classification of the bone as long helps the nurse in providing appropriate care for the patient with an epiphyseal fracture, such as monitoring growth plate involvement and ensuring proper immobilization for healing.
Question 4 of 9
A pregnant client is diagnosed with HELLP syndrome. Based on this diagnosis, which laboratory findings are consistent with diagnosis of HELLP?
Correct Answer: B
Rationale: HELLP syndrome is a serious complication of pregnancy characterized by Hemolysis (H), Elevated Liver enzymes (EL), and a Low Platelet count (LP). Therefore, the correct laboratory finding consistent with the diagnosis of HELLP syndrome is hemolysis. This can be indicated by an elevated lactate dehydrogenase (LDH) level, low haptoglobin, elevated bilirubin, and the presence of schistocytes on a blood smear. The other options (A, C, and D) do not align with the classic presentation of HELLP syndrome.
Question 5 of 9
The nurse is caring for a client who has been diagnosed with diabetes mellitus. The client must learn how to independently perform fingerstick blood sugar analysis as part of the plan of care. The client says, "I already know what you are attempting to teach because I looked everything up on the internet." Which is the best action by the nurse based on the client's statement?
Correct Answer: D
Rationale: While it is positive that the client has taken the initiative to research the procedure online, it is essential for the nurse to assess the client's actual understanding and ability to perform the fingerstick blood sugar analysis correctly. The best course of action would be for the nurse to watch the client perform a return demonstration of the skill. This will allow the nurse to provide real-time feedback, correct any errors, and ensure that the client is performing the procedure accurately and safely. Watching a return demonstration is a critical step in the client's learning process, as it confirms their comprehension and ability to apply the information effectively. It also enables the nurse to address any misconceptions or gaps in knowledge that may not have been evident from the client's statement alone.
Question 6 of 9
A patient has been experiencing diarrhea for the past week. What should the nurse do first when caring for this patient?
Correct Answer: A
Rationale: The first action that the nurse should take when caring for a patient experiencing diarrhea is to ask the patient to describe the number and character of daily stools. This assessment is crucial in determining the severity and possible cause of the diarrhea. By understanding the frequency and consistency of the stools, the nurse can evaluate if the diarrhea is due to an infection, a reaction to medications, dietary factors, or other underlying health issues. Based on this assessment, appropriate interventions can then be implemented, which may include further diagnostic tests, fluid replacement therapy, dietary modifications, or medication administration. It is essential to gather this information first before considering other interventions such as abstaining from oral intake or using over-the-counter antidiarrheal medications.
Question 7 of 9
The nurse is planning care for a client admitted with a stroke. Which intervention would support the client's sensorimotor needs?
Correct Answer: A
Rationale: Supporting a stroke client's sensorimotor needs involves encouraging independence and rehabilitation of the affected side. By encouraging the use of the nonaffected arm for self-care activities like feeding, bathing, and dressing, the nurse is promoting sensorimotor development and function in the affected arm. This intervention will help the client regain strength, coordination, and functionality in the affected arm, which is crucial for their overall recovery and independence. Encouraging the client to actively engage the affected arm promotes neuroplasticity and can improve motor function over time.
Question 8 of 9
The nurse is caring for a client who has not been adhering to treatment with anti-hypertension medication. Which approach to addressing this issue should the nurse use?
Correct Answer: B
Rationale: When addressing a client's non-adherence to treatment, a nonjudgmental approach is most effective. This involves showing empathy, understanding, and support without criticizing or condemning the client. By adopting a nonjudgmental attitude, the nurse can create a safe environment for open communication and collaboration to explore the reasons behind the client's non-adherence. This approach helps build trust and rapport, which are essential for promoting positive behavior change and improving treatment adherence. In contrast, being indifferent, demanding, or confrontational can lead to defensiveness, resistance, and further non-adherence in the client.
Question 9 of 9
The nurse is planning care for a client with peripheral vascular disease (PVD) who is at risk for Impaired Skin Integrity. Which intervention is appropriate for the nurse to include in the plan of care?
Correct Answer: B
Rationale: For a client with peripheral vascular disease (PVD) who is at risk for Impaired Skin Integrity, keeping the skin clean and dry, and moisturizing areas of dryness is crucial. Patients with PVD often have compromised circulation to the extremities, which can lead to decreased oxygen and nutrient delivery to tissues, increasing the risk of skin breakdown and impaired wound healing. Proper skin care helps prevent skin breakdown, decreases the risk of infection, and promotes overall skin health. Keeping the skin clean and dry helps prevent skin breakdown, while moisturizing areas of dryness helps maintain skin integrity. This intervention focuses on maintaining skin health and preventing complications associated with compromised circulation in patients with PVD.