ATI RN
Dewits Fundamental Concepts and Skills for Nursing Test Bank Questions
Question 1 of 5
A urine dipstick test reveals a trace amount of protein. The nurse identifies which nursing diagnosis as appropriate for the client at this time?
Correct Answer: A
Rationale: A trace amount of protein in the urine dipstick test can indicate proteinuria, which can be a sign of kidney dysfunction. The presence of protein in the urine may lead to fluid retention and potential imbalances in fluid volume. Therefore, the appropriate nursing diagnosis in this situation would be "Risk for Imbalanced Fluid Volume," as monitoring and management of fluid balance would be crucial for the client's overall health and prevention of further complications related to kidney function.
Question 2 of 5
The nurse is planning care for a client with a pulmonary embolism. Which nursing action would assist with the client's decrease in cardiac output?
Correct Answer: A
Rationale: Providing oxygen will help increase the oxygen supply to the tissues, thus supporting the heart in maintaining cardiac output. A decrease in cardiac output is a concern with pulmonary embolism as it can lead to inadequate tissue perfusion and possible complications. Oxygen therapy can improve oxygenation and support the heart in meeting the body's demands, helping to stabilize cardiac output. Monitoring and assessing pulmonary arterial pressures would be important in managing a pulmonary embolism but would not directly assist in increasing cardiac output. Keeping protamine sulfate at the bedside is more relevant for managing heparin overdose, not specifically for addressing a decrease in cardiac output. Assessing for bleeding is important in monitoring for potential complications of anticoagulant therapy but does not directly address the decrease in cardiac output seen in pulmonary embolism.
Question 3 of 5
What type of shock is characterized by increased pulse and respirations, normal blood pressure, elevated body temperature, and warm and flushed skin?
Correct Answer: C
Rationale: Neurogenic shock is characterized by decreased vascular resistance due to loss of sympathetic tone. In this type of shock, there is widespread vasodilation leading to pooling of blood in the peripheral vessels, resulting in decreased venous return to the heart. The decreased vascular resistance results in relative hypovolemia despite normal blood volume, leading to compensatory mechanisms such as increased pulse and respirations to maintain tissue perfusion. The warm and flushed skin in neurogenic shock is a result of peripheral vasodilation, while the normal blood pressure is maintained due to the compensatory mechanisms and the lack of actual blood volume loss. Additionally, the elevated body temperature is a possible manifestation due to the systemic response to the shock state.
Question 4 of 5
The nurse is preparing to assess a patient’s thyroid gland. For which criteria is the nurse assessing this gland?
Correct Answer: B
Rationale: When assessing the thyroid gland, the nurse primarily focuses on evaluating its size and consistency. The size of the thyroid can give indications of potential abnormalities such as enlargement (goiter) or nodules. Consistency refers to the feel of the gland, which can vary depending on conditions such as inflammation or malignancy. Monitoring size and consistency helps the nurse in detecting common thyroid issues and determining appropriate interventions for the patient. Pain, pulse rate, character, texture, edema, and movement are not the primary criteria used to assess the thyroid gland.
Question 5 of 5
During a health history interview, a patient reports having to get up to void several times during the night and there is burning when passing urine. Which terms should the nurse use when documenting this patient’s manifestations? Select all that apply.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.