ATI RN
Dewits Fundamental Concepts and Skills for Nursing Test Bank Questions
Question 1 of 5
The nurse is analyzing data collected after assessing a child with a congenital heart defect that decreases pulmonary blood flow. Which nursing diagnosis would be applicable for this client?
Correct Answer: C
Rationale: A congenital heart defect that decreases pulmonary blood flow can lead to reduced cardiac output. Cardiac output is the amount of blood pumped by the heart per minute, and a decrease in pulmonary blood flow can affect the heart's ability to effectively pump blood to the body. Therefore, the appropriate nursing diagnosis for this client would be Decreased Cardiac Output. This diagnosis reflects the underlying physiological issue caused by the congenital heart defect and guides the nurse in planning appropriate interventions to support and optimize the child's cardiac function.
Question 2 of 5
The nurse is planning care for a client with a pulmonary embolism. Which nursing action would assist with the client's decrease in cardiac output?
Correct Answer: A
Rationale: Providing oxygen will help increase the oxygen supply to the tissues, thus supporting the heart in maintaining cardiac output. A decrease in cardiac output is a concern with pulmonary embolism as it can lead to inadequate tissue perfusion and possible complications. Oxygen therapy can improve oxygenation and support the heart in meeting the body's demands, helping to stabilize cardiac output. Monitoring and assessing pulmonary arterial pressures would be important in managing a pulmonary embolism but would not directly assist in increasing cardiac output. Keeping protamine sulfate at the bedside is more relevant for managing heparin overdose, not specifically for addressing a decrease in cardiac output. Assessing for bleeding is important in monitoring for potential complications of anticoagulant therapy but does not directly address the decrease in cardiac output seen in pulmonary embolism.
Question 3 of 5
The nurse is caring for a client who has been admitted to labor and delivery. What should the nurse recognize as risk factors for disseminating intravascular coagulation (DIC)? Select all that apply.
Correct Answer: B
Rationale: Disseminated intravascular coagulation (DIC) is a serious condition characterized by widespread activation of the clotting cascade and consumption of clotting factors, leading to both thrombosis and bleeding. Risk factors for DIC include conditions that cause significant tissue injury, which can trigger the coagulation pathway.
Question 4 of 5
The nurse is analyzing data collected after assessing a child with a congenital heart defect that decreases pulmonary blood flow. Which nursing diagnosis would be applicable for this client?
Correct Answer: C
Rationale: A congenital heart defect that decreases pulmonary blood flow can lead to reduced cardiac output. Cardiac output is the amount of blood pumped by the heart per minute, and a decrease in pulmonary blood flow can affect the heart's ability to effectively pump blood to the body. Therefore, the appropriate nursing diagnosis for this client would be Decreased Cardiac Output. This diagnosis reflects the underlying physiological issue caused by the congenital heart defect and guides the nurse in planning appropriate interventions to support and optimize the child's cardiac function.
Question 5 of 5
The nurse reviews documentation on a patient with a long leg cast for a fracture in which the pulses in the foot were decreased and the patient was experiencing a pain rating of 8 on a scale of 0 to 10 during the previous shift. Which additional findings should the nurse immediately report to the healthcare provider? Select all that apply.
Correct Answer: C
Rationale: Cyanosis in the foot indicates poor circulation or decreased blood flow to the area, which is concerning in a patient with a long leg cast and decreased pulses. This could signify a significant decrease in oxygenated blood reaching the foot, which could lead to serious complications if not addressed promptly. The nurse should report this finding immediately to the healthcare provider for further assessment and intervention.