ATI RN
Nursing a Concept Based Approach Test Bank Questions
Question 1 of 9
Following a kidney transplant, the nurse notes that a patient’s urine is cloudy. What should the nurse do about this finding?
Correct Answer: A
Rationale: Cloudy urine following a kidney transplant may be a common occurrence and could be due to various factors such as dehydration, medication side effects, or the presence of mucus, cells, or proteins in the urine. The nurse should first record the finding and then further assess the patient by checking for other signs and symptoms like pain, fever, or abnormal odors in the urine. If the cloudy urine is persistent or accompanied by other concerning symptoms, then the nurse should notify the physician for further evaluation. However, initially recording the finding allows for documentation and monitoring of the patient's condition, providing a baseline for further assessment and intervention if necessary. It is important to remember that cloudy urine alone may not always indicate a serious issue, but thorough assessment and documentation are essential steps in ensuring the patient's well-being.
Question 2 of 9
The nurse is caring for a client diagnosed with dilated cardiomyopathy. Which clinical manifestations does the nurse anticipate during the physical assessment? Select all that apply.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 3 of 9
The nurse is planning care for an older adult client with chronic venous insufficiency. Which will the nurse include in the client's teaching plan?
Correct Answer: B
Rationale: Elastic compression therapy, such as wearing elastic hose (compression stockings), is an essential component of managing chronic venous insufficiency. Compression stockings help improve venous return, reduce edema, and alleviate symptoms such as pain and swelling. They work by applying external pressure to the legs, promoting better circulation and preventing blood from pooling in the veins. The nurse should ensure that the client wears the compression stockings as prescribed to maximize their effectiveness in managing the condition.
Question 4 of 9
The nurse is preparing an educational session for employees of a manufacturing plant regarding emergency care of amputated digits. What should the nurse include when teaching about the type of injury?
Correct Answer: C
Rationale: When teaching about the type of injury of an amputated digit, the nurse should include the proper handling of the amputated part. The correct method is to wrap the amputated digit in a clean towel, place it in a sealed plastic bag to prevent direct contact with ice, and then place the bag on ice. Placing the amputated digit directly on ice can cause frostbite and further damage to the tissue. By following this method, the amputated digit can be preserved properly until medical help is received. Transporting the person to the hospital is important but proper handling of the amputated digit is critical to increase the chances of successful reattachment. Placing the amputated digit in warm water or taping it to the hand are not recommended methods for preserving an amputated digit.
Question 5 of 9
The nurse is assessing a patient’s deep tendon reflexes. For which endocrine disorder is this nurse assessing?
Correct Answer: C
Rationale: The nurse is assessing the deep tendon reflexes of the patient to evaluate for signs of hyperthyroidism. In hyperthyroidism, there is an excessive production of thyroid hormones, which can lead to symptoms such as hyperactivity of the nervous system. Patients with hyperthyroidism may exhibit brisk deep tendon reflexes, along with other signs such as tremors, weight loss, heat intolerance, and tachycardia. Therefore, the nurse's assessment of deep tendon reflexes is particularly relevant in identifying signs of hyperthyroidism.
Question 6 of 9
The nurse is caring for a client who develops dyspnea and chest pain. Which diagnostic finding is consistent with a pulmonary embolism (PE)?
Correct Answer: D
Rationale: Tachycardia and nonspecific T-wave changes on the EKG are consistent with a pulmonary embolism (PE). Tachycardia is a common finding in PE, as the body tries to compensate for the decreased oxygenation due to the blockage in the pulmonary artery. Nonspecific T-wave changes, such as ST-segment abnormalities or inverted T-waves, can also be seen in patients with PE. These EKG findings, along with symptoms like dyspnea and chest pain, raise the suspicion for pulmonary embolism and warrant further diagnostic workup. Options A, B, and C are not specific findings related to a pulmonary embolism.
Question 7 of 9
The nurse teaches a client about lifestyle modifications to help manage hypertension. Which client statement indicates teaching has been effective?
Correct Answer: B
Rationale: This client statement indicates that they understand the importance of making lifestyle modifications to manage hypertension. Giving up cigarettes and alcohol can significantly improve blood pressure control and overall health for someone with hypertension. It demonstrates that the client is willing to make necessary changes to help manage their condition effectively.
Question 8 of 9
The nurse is conducting a physical examination of a patient’s renal system. What assessment would the nurse use to assess the hydration status of a patient?
Correct Answer: A
Rationale: Palpation for skin turgor is used to assess the hydration status of a patient. Skin turgor is a measure of the skin's elasticity and hydration level. When a patient is well-hydrated, their skin will have good turgor, meaning it will return to its normal position quickly after being pinched. On the other hand, in a dehydrated patient, the skin will have poor turgor and will not return to its normal position promptly. Therefore, assessing skin turgor is a valuable tool for determining a patient's hydration status during a physical examination of the renal system. Palpation of both kidneys, auscultation of renal arteries, and percussion for dullness over the bladder are not specifically related to assessing hydration status.
Question 9 of 9
A client diagnosed with disseminated intravascular coagulation (DIC) is currently bleeding through the gastrointestinal tract. Which does the nurse anticipate administering to this client as a first line treatment?
Correct Answer: C
Rationale: Disseminated intravascular coagulation (DIC) is a serious condition characterized by widespread clot formation in the small blood vessels, leading to bleeding tendencies. In DIC, the body consumes clotting factors and platelets faster than they can be replaced, resulting in both bleeding and clotting. Because of this complex pathophysiology, the first line treatment for DIC-related bleeding is to provide replacement of the consumed clotting factors and platelets. Fresh frozen plasma contains clotting factors, and platelets help in stopping bleeding by aiding in clot formation. Therefore, the administration of fresh frozen plasma and platelets helps to correct the coagulopathy in DIC and manage the bleeding episodes effectively. Aspirin, Warfarin (Coumadin), and Heparin are anticoagulants and would not be appropriate in the treatment of DIC-related bleeding as they can exacerbate the bleeding tendency in this condition.