ATI RN
Fundamental Concepts and Skills for Nursing 6th Edition Test Bank Questions
Question 1 of 5
The nurse is caring for a client who has recently received a permanent colostomy. The client will be going home in several days and requires discharge teaching. What should the nurse do when organizing the teaching experience?
Correct Answer: D
Rationale: Breaking the information into small sessions to enhance learning is the most effective approach when organizing the teaching experience for a client with a new permanent colostomy. This allows for better retention of information as the client can focus on a few key points at a time and then progressively build upon that knowledge. By breaking the information into smaller sessions, the nurse can ensure that the client fully understands each aspect of colostomy care before moving on to the next topic. This method promotes better understanding, leads to improved compliance with care instructions, and ultimately contributes to better outcomes for the client.
Question 2 of 5
The nurse is planning care for a pediatric client recovering from surgery to repair a congenital heart defect. Which intervention should the nurse include to support the client's fluid status?
Correct Answer: A
Rationale: Encouraging oral intake of fluids when permitted is the most appropriate intervention to support the pediatric client's fluid status post-surgery. Adequate hydration is essential for the recovery process, and oral intake of fluids helps maintain fluid balance. Limiting oral and intravenous intake of fluids (option B) would not be beneficial in promoting hydration and recovery. Continuing normal saline administration even after oral intake is normal (option C) may lead to fluid overload. Converting the intravenous line to a saline lock immediately after surgery (option D) may not be ideal as the client may still need intravenous fluids to support hydration until they can tolerate oral intake effectively.
Question 3 of 5
The nurse is providing care to a female client who is diagnosed with coronary artery disease. The client states to the nurse, "I don't know how this happened." Which response by the nurse is the most appropriate?
Correct Answer: A
Rationale: Option A is the most appropriate response by the nurse because it provides accurate information related to the client's concern about developing coronary artery disease. Studies have shown that women who take oral contraceptives have an increased risk of developing cardiovascular issues, including coronary artery disease. By providing this information, the nurse addresses the client's statement and educates her about a potential risk factor for the disease. This empowers the client with knowledge that can help her understand the possible reasons behind her diagnosis and make informed decisions about her health moving forward.
Question 4 of 5
The nurse is caring for a client with disseminated intravascular coagulation (DIC). Which should the nurse identify as a priority intervention for this client?
Correct Answer: B
Rationale: In disseminated intravascular coagulation (DIC), the client experiences widespread clotting throughout the body's small blood vessels, leading to organ damage and bleeding. Maintaining skin integrity is a priority intervention because DIC can cause hemorrhage and increased risk of skin breakdown due to impaired blood circulation. Preventing pressure ulcers and promoting skin health in a client with DIC is crucial to prevent further complications. Frequent ambulation may not be safe for a client with DIC due to the risk of bleeding from compromised blood vessels. Preparation for radiograph procedures and fluid restriction may be necessary interventions depending on the client's condition, but they are not the priority in the immediate care of a client with DIC.
Question 5 of 5
A client with heart failure is admitted to the hospital for the placement of an implantable defibrillator. The client appears comfortable at rest, but displays dyspnea with activities of daily living (ADLs). Which stage of heart failure does the nurse recognize when reading the client's health record?
Correct Answer: C
Rationale: In stage III of heart failure, the client displays symptoms such as dyspnea, fatigue, and other symptoms with ordinary physical activity, known as NYHA Class III. This is consistent with the client's presentation of dyspnea with activities of daily living, indicating a moderate level of heart failure. The need for the placement of an implantable defibrillator also suggests a more advanced stage of heart failure compared to stage I or II. Stage IV is characterized by severe symptoms at rest, which the client does not exhibit based on the information provided.