ATI RN
Professional Nursing Concepts and Challenges Test Bank Questions
Question 1 of 9
The nurse identifies that a patient with immobility is at risk for the development of urolithiasis. What should the nurse include when planning this patient’s care?
Correct Answer: D
Rationale: Immobility can contribute to the development of urolithiasis (the formation of urinary calculi or stones) due to decreased mobility leading to stagnant urine flow, which can result in the concentration of crystal-forming substances in the urine. Increasing fluid intake helps prevent urinary stasis and dilutes the urine, reducing the risk of stone formation. Adequate hydration can also help flush out any existing crystals or small stones before they grow larger. Therefore, increasing fluid intake to 3000 mL/day is essential in preventing urolithiasis in patients with immobility. Monitoring urine pH, administering calcium supplements, or maintaining an indwelling urinary catheter are not appropriate interventions for preventing urolithiasis in this situation.
Question 2 of 9
The nurse identifies that a patient with immobility is at risk for the development of urolithiasis. What should the nurse include when planning this patient’s care?
Correct Answer: D
Rationale: Immobility can contribute to the development of urolithiasis (the formation of urinary calculi or stones) due to decreased mobility leading to stagnant urine flow, which can result in the concentration of crystal-forming substances in the urine. Increasing fluid intake helps prevent urinary stasis and dilutes the urine, reducing the risk of stone formation. Adequate hydration can also help flush out any existing crystals or small stones before they grow larger. Therefore, increasing fluid intake to 3000 mL/day is essential in preventing urolithiasis in patients with immobility. Monitoring urine pH, administering calcium supplements, or maintaining an indwelling urinary catheter are not appropriate interventions for preventing urolithiasis in this situation.
Question 3 of 9
The nurse is planning care for a group of clients. Which client should the nurse identify as having the greatest risk for developing deep venous thrombosis (DVT)?
Correct Answer: D
Rationale: The client recovering from knee replacement surgery has the greatest risk for developing deep venous thrombosis (DVT). Knee replacement surgery is a major orthopedic procedure that involves prolonged immobility and disruption of the normal blood flow in the lower extremities, which increases the risk of developing DVT. Postoperative patients are at a higher risk for developing blood clots due to reduced mobility, surgical trauma, and alterations in blood flow. Therefore, it is essential for healthcare providers to implement preventive measures to reduce the risk of DVT, such as early mobilization, compression stockings, and pharmacological prophylaxis.
Question 4 of 9
A client admitted with the diagnosis of cardiomyopathy becomes short of breath with ambulation and eating and fatigued with routine care activities. Which nursing diagnosis does the nurse include in the client's plan of care?
Correct Answer: C
Rationale: Activity intolerance is the most appropriate nursing diagnosis for a client with cardiomyopathy who becomes short of breath with ambulation and eating and fatigued with routine care activities. Cardiomyopathy is a condition where the heart muscle becomes weakened, affecting its ability to pump blood effectively. As a result, the client may experience symptoms such as shortness of breath, fatigue, and decreased tolerance for physical activity. By identifying activity intolerance as a nursing diagnosis, the nurse can focus on addressing the client's limitations in performing activities and developing a plan of care to help improve the client's endurance and functional ability.
Question 5 of 9
The nurse is caring for a child with a fractured femur who complains of sudden chest pain and difficulty breathing. Which test would the nurse question if it was ordered by the physician?
Correct Answer: A
Rationale: The nurse would question the order for a D-dimer test in this case. A D-dimer test is a blood test used to help rule out or diagnose blood clots. However, in a child with a fractured femur complaining of sudden chest pain and difficulty breathing, the symptoms suggest the possibility of a pulmonary embolism (PE). In this scenario, a D-dimer test may not be necessary because the clinical presentation warrants more advanced imaging studies such as V/Q scans, CT pulmonary angiography, or MR pulmonary angiography to definitively diagnose or rule out a PE. Therefore, the focus should be on imaging studies rather than a D-dimer test in this situation.
Question 6 of 9
The nurse is reviewing laboratory values for a patient with an acute attack of gout. Which laboratory value should the nurse expect to be increased?
Correct Answer: A
Rationale: In a patient with an acute attack of gout, the nurse should expect the uric acid level to be increased. Gout occurs due to the buildup of uric acid crystals in the joints, leading to inflammation and pain. Monitoring the uric acid level is important in diagnosing and managing gout, as elevated levels indicate an increased risk of crystal formation and gout attacks. Therefore, an increased uric acid level is a key laboratory finding in patients experiencing gout flares.
Question 7 of 9
The nurse is providing teaching to the parents of a child born with tetralogy of Fallot (TOF). Which statement should the nurse include in her teaching regarding this defect?
Correct Answer: B
Rationale: Tetralogy of Fallot (TOF) involves four cardiac defects, as described in option B: pulmonic stenosis, right ventricular hypertrophy, ventricular septal defect, and an overriding aorta. These four defects result in mixing of oxygen-poor and oxygen-rich blood in the heart, leading to decreased oxygen levels in the blood that is pumped to the body. This characteristic results in cyanosis (blue discoloration of the skin). Providing accurate information about the specific defects involved in TOF helps parents understand the complexity and potential complications associated with their child's condition. This knowledge can aid in their ability to recognize symptoms and seek timely medical intervention when needed.
Question 8 of 9
The nurse is instructing the spouse of a client with a stroke on how to do passive range-of- motion exercises to the affected limbs. Which rationale for this intervention will the nurse include in the teaching session?
Correct Answer: D
Rationale: Passive range-of-motion exercises are beneficial in maintaining joint flexibility in clients with stroke. These exercises involve moving the client's limbs through a full range of motion, which helps prevent joint contractures and stiffness. Joint flexibility is crucial for maintaining mobility and preventing secondary complications such as pressure ulcers. While passive range-of-motion exercises may indirectly impact muscle strength, cardiorespiratory function, and endurance, the primary rationale for this intervention is to maintain joint flexibility.
Question 9 of 9
A patient with inflammatory bowel disease is prescribed sulfasalazine (Azulfidine). What should the nurse teach the patient about taking this medication?
Correct Answer: C
Rationale: Sulfasalazine can cause photosensitivity, making the patient more prone to sunburn. Therefore, it is important for patients taking sulfasalazine to use sunscreen to protect their skin from harmful UV rays. This can help prevent sunburn and skin damage while on the medication. It is not necessary to take vitamin C with this drug, take it on an empty stomach, or limit fluid intake to 1500 mL per day.