ATI RN
Giddens Concepts for Nursing Practice Test Bank Questions
Question 1 of 9
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 9
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 9
The nurse is planning care for a patient beginning hemodialysis. What should be included in this patient’s plan of care? Select all that apply.
Correct Answer: A
Rationale: A. Restrict fluid and protein intake: Patients undergoing hemodialysis typically have restrictions on their fluid and protein intake to prevent fluid overload and minimize the buildup of waste products in the blood that can occur with impaired kidney function.
Question 4 of 9
A community health nurse is providing education to a group of adults regarding myocardial infarction (MI). When discussing ways to prevent the number of MI-related deaths, which statement by the nurse is inappropriate?
Correct Answer: B
Rationale: While taking a baby aspirin daily can be beneficial for some individuals at increased risk of heart attacks or strokes, it is not a general recommendation for everyone to prevent myocardial infarction (MI). There are potential risks associated with aspirin use, such as gastrointestinal bleeding, which could outweigh the benefits for individuals at low risk of a heart attack. It is important for individuals to consult with their healthcare provider before starting any regimen of daily aspirin therapy. The other statements (A, C, D) focus on increasing awareness, knowledge, and prompt action in response to a suspected MI, which are appropriate measures for prevention and improving outcomes.
Question 5 of 9
A nurse is providing a series of educational workshops for caregivers of older clients interested in promoting the health and well-being of their clients. Which would be appropriate topics for this group? Select all that apply.
Correct Answer: A
Rationale: 1. Fall prevention: One of the common risks for older clients is falling, which can lead to serious injuries. Educating caregivers on fall prevention strategies can help them create a safe environment for their clients and reduce the risk of falls.
Question 6 of 9
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 7 of 9
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: A. Limit the use of over-the-counter medications: This is important because some over-the-counter medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin, can increase the risk of bleeding in individuals taking anticoagulants for the treatment of pulmonary embolism.
Question 8 of 9
The nurse is caring for a patient recovering from a below-the-knee amputation. What should be included in this patient’s plan of care? Select all that apply.
Correct Answer: A
Rationale: A. Elevate the stump: Elevation of the stump helps to reduce swelling and improve blood circulation, aiding in the healing process after the amputation.
Question 9 of 9
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.