ATI RN
Professional Nursing Concepts and Challenges Test Bank Questions
Question 1 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 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 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 4 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 5 of 9
A client with peripheral vascular disease (PVD) asks the nurse what types of exercise would improve the client's condition and overall health. Which type of exercise will the nurse include in the response to the client?
Correct Answer: C
Rationale: For a client with peripheral vascular disease (PVD), the nurse would recommend low-impact exercises that promote circulation and improve overall health without overstressing the cardiovascular system. Yoga is a beneficial form of exercise for individuals with PVD because it involves gentle movements, controlled breathing, and mindfulness practices that can help improve flexibility, strength, and blood flow. Additionally, yoga can help reduce stress and improve relaxation, which can be beneficial for managing symptoms associated with PVD. Weight lifting and team sports may be too strenuous for individuals with PVD, and passive ROM exercises may not provide the cardiovascular benefits needed for this condition.
Question 6 of 9
A home health nurse is admitting a new client to the agency who was recently discharged from the hospital with a new diagnosis of pulmonary fibrosis. What is the best way for the nurse to evaluate whether the client is able to set up and administer a nebulizer treatment?
Correct Answer: A
Rationale: Direct observation of behavior is the best way for the nurse to evaluate whether the client is able to set up and administer a nebulizer treatment. By directly observing the client, the nurse can assess the client's understanding and ability in performing the necessary steps correctly and safely. This approach allows for real-time evaluation and correction if needed, ensuring that the client can effectively manage their nebulizer treatment at home. Written or oral descriptions may not accurately reflect the client's actual competency in performing the task, and relying on the client's self-report during a follow-up appointment may not provide a complete picture of their ability.
Question 7 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 8 of 9
Which is believed to be the cause of preeclampsia?
Correct Answer: A
Rationale: Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to other organ systems, most often the liver and kidneys. Placental dysfunction is believed to be the main cause of preeclampsia. In a normal pregnancy, blood vessels in the placenta develop to supply the fetus with nutrients and oxygen. In preeclampsia, these blood vessels don't develop or function properly, leading to inadequate blood flow and reduced supply of nutrients to the placenta. This can result in high blood pressure and affect the function of other organs.
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.