ATI RN
Giddens Concepts for Nursing Practice Test Bank Questions
Question 1 of 5
The nurse has identified Ineffective Peripheral Tissue Perfusion as a nursing diagnosis for a client with disseminated intravascular coagulation (DIC). What intervention would be appropriate for the client?
Correct Answer: B
Rationale: In the context of Ineffective Peripheral Tissue Perfusion in a client with disseminated intravascular coagulation (DIC), administering oxygen is the most appropriate intervention. DIC is a serious condition characterized by widespread clotting in small blood vessels throughout the body, leading to tissue ischemia and inadequate perfusion. Administering oxygen can support tissue oxygenation and improve perfusion to the peripheral tissues, helping to alleviate the effects of decreased blood flow and oxygen delivery caused by DIC. Oxygen therapy can help optimize oxygen levels in the blood and tissues, promoting better tissue perfusion and overall patient outcomes. Monitoring oxygen saturation and ensuring adequate oxygen delivery are crucial aspects of managing tissue perfusion in clients with DIC.
Question 2 of 5
A client with preeclampsia begins to demonstrate manifestations of seizure activity. Which intervention by the nurse is most likely to protect the client and fetus from injury?
Correct Answer: B
Rationale: Placing the client on the left side and protecting the airway is the most appropriate intervention to protect the client and the fetus from injury during a seizure. This position helps to prevent aspiration of vomitus and maintains an open airway. Placing the client on the left side also enhances maternal and fetal perfusion by reducing pressure on the vena cava, improving blood flow to the placenta, and decreasing the risk of supine hypotensive syndrome. Elevating the client's legs (Option A) and placing the client in the supine position (Option C) are contraindicated as they may worsen the client's condition in the context of preeclampsia and seizure activity. Elevating the head of the bed (Option D) does not address the immediate need to protect the airway and maintain proper positioning during a seizure.
Question 3 of 5
A client admitted with chronic venous insufficiency has an infected wound of the left lower extremity. Which clinical manifestations does the nurse anticipate during the client's assessment? Select all that apply.
Correct Answer: A
Rationale: 1. Pulses absent in the extremity with the wound (Option A): In chronic venous insufficiency, damaged valves in the veins result in blood pooling in the lower extremities. This can lead to decreased arterial perfusion and impaired circulation, causing weakened or absent pulses in the affected extremity.
Question 4 of 5
The nurse is preparing to discharge a client recovering from a pulmonary embolism (PE). Which topics should the nurse to include in the teaching session? Select all that apply.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 5 of 5
A 67-year-old client with a history of type II diabetes mellitus and chronic hypertension is admitted to the emergency department after a myocardial infarction. Which type of shock should the nurse be prepared to treat in this client?
Correct Answer: A
Rationale: Given the client's history of type II diabetes mellitus, chronic hypertension, and recent myocardial infarction, the most likely type of shock for the nurse to be prepared to treat in this client is cardiogenic shock. Cardiogenic shock occurs when the heart is unable to pump effectively, leading to inadequate perfusion of vital organs. This can be a complication of myocardial infarction, as damage to the heart muscle can impair its ability to pump blood effectively. Patients with a history of diabetes and hypertension are at increased risk for cardiovascular diseases, such as myocardial infarction, which can lead to cardiogenic shock. Symptoms of cardiogenic shock include hypotension, tachycardia, cool and clammy skin, and altered mental status. Treatment may involve medications to support cardiac function, such as inotropes, and interventions to improve oxygen delivery, such as oxygen therapy and fluid administration.