ATI RN
Nursing a Concept Based Approach to Learning Test Bank Free Questions
Question 1 of 9
During an assessment, the nurse asks the patient to move an extremity away from the body midline. What movement is the nurse assessing?
Correct Answer: C
Rationale: When the nurse asks the patient to move an extremity away from the body midline, they are assessing the movement of abduction. Abduction refers to the movement of a body part away from the midline of the body. In this case, moving the extremity away from the body midline represents abduction, as the limb is being moved outward or away from the center of the body. Flexion and extension involve bending and straightening movements, respectively, along a joint axis, while adduction involves moving a body part towards the midline of the body.
Question 2 of 9
During an assessment, the nurse asks the patient to move an extremity away from the body midline. What movement is the nurse assessing?
Correct Answer: C
Rationale: When the nurse asks the patient to move an extremity away from the body midline, they are assessing the movement of abduction. Abduction refers to the movement of a body part away from the midline of the body. In this case, moving the extremity away from the body midline represents abduction, as the limb is being moved outward or away from the center of the body. Flexion and extension involve bending and straightening movements, respectively, along a joint axis, while adduction involves moving a body part towards the midline of the body.
Question 3 of 9
The nurse is completing an assessment on a newly admitted client. What finding would alert the nurse that the client may be experiencing a deep venous thrombosis (DVT)?
Correct Answer: C
Rationale: Swelling in one leg with edema is a classic sign of deep venous thrombosis (DVT). DVT occurs when a blood clot forms in one or more of the deep veins in the body, usually in the legs. This can lead to swelling in the affected leg due to the impaired venous return caused by the blood clot. It is important for the nurse to recognize this sign because if left untreated, DVT can lead to serious complications such as pulmonary embolism. Therefore, the nurse should further assess the client and notify the healthcare provider for appropriate management.
Question 4 of 9
A perimenopausal patient is experiencing frequency, urgency, nocturia, dysuria, and cloudy, rust- colored urine for the third time in the past 2 years. What should the nurse include when teaching this patient? Select all that apply.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 5 of 9
The nurse is evaluating teaching provided to a client with peripheral vascular disease (PVD). Which client observation indicates teaching has been effective?
Correct Answer: B
Rationale: Option B, washing the lower extremities with mild soap, drying the legs, and applying a light moisturizer, indicates effective teaching for a client with peripheral vascular disease (PVD). Proper hygiene, including gentle washing with mild soap, thorough drying to prevent moisture-related skin breakdown, and moisturizing to prevent dry skin and promote circulation, are key components of self-care for individuals with PVD. Option A is incorrect because sitting with a pillow behind the knees does not specifically address PVD self-care. Option C is incorrect because crossing the left leg over the right while sitting does not relate to appropriate PVD management. Option D is incorrect because smoking in any form is detrimental to vascular health and should be discouraged in PVD management.
Question 6 of 9
An older adult client receiving medication for hypertension had a recent fall at home. Which intervention should the nurse include in this client's plan of care?
Correct Answer: B
Rationale: Assessing postural blood pressures is important in determining if the client may be experiencing orthostatic hypotension, which could have contributed to the fall. Orthostatic hypotension is a sudden drop in blood pressure that can occur when a person stands up from a sitting or lying position. Older adults on antihypertensive medications are at increased risk for orthostatic hypotension. By monitoring postural blood pressures, the nurse can identify fluctuations in blood pressure that may put the client at risk for falls and implement appropriate interventions to prevent future falls. Monitoring serum sodium levels and creatinine levels are important for detecting electrolyte imbalances or kidney dysfunction but do not directly address the issue of orthostatic hypotension related to falls. Monitoring blood pressure every 2 hours may not provide valuable information on postural blood pressure changes that are associated with orthostatic hypotension.
Question 7 of 9
A nurse caring for a client with suspected disseminated intravascular coagulation (DIC). Which test result is common in DIC?
Correct Answer: C
Rationale: Disseminated intravascular coagulation (DIC) is a condition characterized by widespread activation of clotting factors throughout the body, leading to both excessive clot formation and consumption of clotting factors. As a result, one of the common features of DIC is a decreased level of fibrinogen, which is an essential protein for blood clot formation. In DIC, fibrinogen is consumed in the formation of multiple small blood clots throughout the circulation, causing a decrease in its levels. This decrease in fibrinogen can contribute to the increased risk of bleeding that is seen in DIC. Therefore, a decreased fibrinogen level is a characteristic laboratory finding in DIC.
Question 8 of 9
A patient comes into the emergency department with manifestations of appendicitis. What is the highest priority when caring for this patient?
Correct Answer: C
Rationale: The highest priority when caring for a patient with manifestations of appendicitis is to provide pain relief. By inserting a saline lock for intravenous pain medication, the patient can receive immediate pain relief to alleviate their discomfort. Pain management is crucial in appendicitis as it can help in improving the patient's overall well-being and reduce the risk of complications. While other options such as withholding food and fluids, performing preoperative skin preparation, or teaching postoperative exercises are important aspects of care, addressing the patient's pain is the top priority to ensure their comfort and well-being.
Question 9 of 9
What is a good way for a nurse to prepare the environment for teaching?
Correct Answer: C
Rationale: Evaluating client abilities to perform skills with return demonstrations is a good way for a nurse to prepare the environment for teaching. By observing the clients' abilities to perform the necessary skills, the nurse can tailor the teaching to meet the specific needs of each individual. Return demonstrations allow for immediate feedback and correction if needed, ensuring that the clients understand and can perform the skills accurately. This interactive approach to teaching promotes active learning and enhances retention of information.