ATI RN
Transcultural Concepts in Nursing Care Test Bank Questions
Question 1 of 5
A school-age client with a history of multiple allergies is prescribed epinephrine (EpiPen™) for prevention of anaphylactic shock. The client's mother says to the nurse, "I thought shock was about heart failure." Which response by the nurse is the most appropriate?
Correct Answer: A
Rationale: The most appropriate response by the nurse is Option A, "Allergic response is the most fatal type of shock; other types involve loss of blood, heart failure, and liver failure." This response is accurate because anaphylactic shock, which is caused by severe allergic reactions, can be life-threatening if not treated promptly with epinephrine (EpiPen™). While heart failure is a serious type of shock, anaphylactic shock is specifically related to severe allergic reactions and not heart failure. The nurse's response educates the mother about the seriousness of anaphylactic shock in relation to allergic responses and highlights that other types of shock can involve different organ system failures.
Question 2 of 5
The nurse identifies the diagnosis of Deficient Fluid Volume as appropriate for a patient with a nasogastric tube for gastric decompression. Which actions should the nurse perform to support this diagnosis? Select all that apply.
Correct Answer: A
Rationale: In this scenario, the correct action for the nurse to perform to support the diagnosis of Deficient Fluid Volume in a patient with a nasogastric tube for gastric decompression is to measure abdominal girth every 4 to 8 hours (Option A). This is because a decrease in abdominal girth may indicate fluid volume deficit, which can be caused by gastric suctioning through the nasogastric tube. Providing the patient with generous amounts of oral fluids (Option B) may exacerbate the fluid volume deficit due to the ongoing gastric decompression. Keeping an accurate record of intake and output every 2 to 4 hours (Option C) is important but does not directly address the specific issue of fluid volume deficit related to gastric decompression. Documenting the amount and color of nasogastric tube drainage every shift (Option D) is relevant for monitoring the patient's condition but does not directly address fluid volume status. Listening to bowel sounds before checking the placement of the nasogastric tube (Option E) is important for ensuring proper tube placement but does not specifically address fluid volume deficits. Educationally, it is crucial for nurses to understand the rationale behind each nursing action to provide safe and effective patient care. Understanding the signs and symptoms of fluid volume deficits and appropriate interventions in patients with nasogastric tubes is essential for delivering optimal nursing care in various clinical settings.
Question 3 of 5
At a local health fair, a male participant remarks to the nurse about urine occasionally being pink and wonders if this should be a concern. How should the nurse respond?
Correct Answer: C
Rationale: Instructing the participant to track the relationship between urine color and activities would be the most appropriate response in this situation. Occasionally having pink urine can be caused by various factors, such as certain foods, medications, strenuous exercise, or even dehydration. By tracking when the urine appears pink in relation to these activities, the participant can gather valuable information to share with a healthcare provider if needed. This approach can help identify any patterns and determine the underlying cause, guiding further evaluation or management if necessary. It allows for a proactive and informative approach before seeking medical attention, as long as there are no other concerning symptoms present.
Question 4 of 5
The nurse is assessing muscle strength. What should the nurse ask the patient to do to assess facial muscle strength?
Correct Answer: A
Rationale: Asking the patient to clench their teeth is a common way to assess muscle strength in the face, particularly the muscles involved in the jaw. Clenching the teeth engages the muscles responsible for this action, such as the masseter muscle. Assessing the ability to clench the teeth provides insight into the strength and function of these facial muscles.
Question 5 of 5
The nurse monitors vital signs and laboratory values for a patient recovering from a total knee replacement. For which reason is the nurse implementing these actions?
Correct Answer: C
Rationale: The nurse is monitoring vital signs and laboratory values for the patient recovering from a total knee replacement to ensure adequate circulation to the involved extremity. After a total knee replacement surgery, there is a risk of developing complications such as deep vein thrombosis (DVT) or impaired circulation to the surgical site. Monitoring vital signs and laboratory values allows the nurse to assess for any signs of compromised circulation, which could indicate the development of complications requiring immediate intervention. By closely monitoring these parameters, the nurse can ensure that the patient's recovery is progressing smoothly and without any major complications impacting the circulation to the involved extremity.