ATI RN
Nursing a Concept Based Approach Test Bank Questions
Question 1 of 9
The nurse is conducting a physical examination of a patient’s renal system. What assessment would the nurse use to assess the hydration status of a patient?
Correct Answer: A
Rationale: Palpation for skin turgor is used to assess the hydration status of a patient. Skin turgor is a measure of the skin's elasticity and hydration level. When a patient is well-hydrated, their skin will have good turgor, meaning it will return to its normal position quickly after being pinched. On the other hand, in a dehydrated patient, the skin will have poor turgor and will not return to its normal position promptly. Therefore, assessing skin turgor is a valuable tool for determining a patient's hydration status during a physical examination of the renal system. Palpation of both kidneys, auscultation of renal arteries, and percussion for dullness over the bladder are not specifically related to assessing hydration status.
Question 2 of 9
A nurse is caring for a child who is hospitalized for an exacerbation of asthma. The nurse is preparing discharge teaching, as the client will be going home on nebulizer treatments and an inhaler. The client and her family members, who are recent immigrants to the United States, speak little English. In addition to enlisting an interpreter to help with the language barrier, what should be a priority for the nurse in developing a teaching plan?
Correct Answer: D
Rationale: Addressing any healing beliefs the family has should be a priority for the nurse in developing a teaching plan for the child with asthma. The family's cultural beliefs and practices may influence their understanding and acceptance of medical treatments. By understanding and respecting the family's beliefs, the nurse can tailor the teaching plan to align with the family's values and ensure better adherence to the treatment plan. This approach promotes effective communication, trust, and collaboration between the healthcare team and the family, which is essential for the child's recovery and ongoing management of asthma. Providing culturally sensitive care is crucial in improving health outcomes and promoting family-centered care in a diverse healthcare setting.
Question 3 of 9
The nurse is caring for a client who develops dyspnea and chest pain. Which diagnostic finding is consistent with a pulmonary embolism (PE)?
Correct Answer: D
Rationale: Tachycardia and nonspecific T-wave changes on the EKG are consistent with a pulmonary embolism (PE). Tachycardia is a common finding in PE, as the body tries to compensate for the decreased oxygenation due to the blockage in the pulmonary artery. Nonspecific T-wave changes, such as ST-segment abnormalities or inverted T-waves, can also be seen in patients with PE. These EKG findings, along with symptoms like dyspnea and chest pain, raise the suspicion for pulmonary embolism and warrant further diagnostic workup. Options A, B, and C are not specific findings related to a pulmonary embolism.
Question 4 of 9
A nurse working on an antepartum unit is providing care for a client with preeclampsia. Which laboratory value does the nurse anticipate for this client?
Correct Answer: D
Rationale: In a client with preeclampsia, one of the laboratory values that the nurse might anticipate is an increased serum creatinine level. Preeclampsia is a hypertensive disorder of pregnancy characterized by high blood pressure and involvement of multiple organ systems, including the kidneys. An elevated serum creatinine level indicates impaired kidney function, as creatinine is a waste product that is normally filtered by the kidneys and excreted in the urine. In preeclampsia, reduced kidney perfusion due to the high blood pressure can lead to decreased glomerular filtration rate, resulting in elevated serum creatinine levels. Monitoring serum creatinine is essential in assessing kidney function and guiding management in clients with preeclampsia.
Question 5 of 9
The nurse is assessing a toddler diagnosed with tetralogy of Fallot (TOF). Which clinical manifestations does the nurse anticipate during the physical assessment? Select all that apply.
Correct Answer: A
Rationale: 1. A palpable thrill in the pulmonic area is a common finding in children with tetralogy of Fallot (TOF). This sensation is caused by turbulent blood flow across the pulmonic valve due to the structural abnormalities present in TOF.
Question 6 of 9
While teaching a wellness class on the warning signs of stroke, a participant asks the nurse, "What's the most important thing for me to remember?" What is an appropriate response by the nurse?
Correct Answer: A
Rationale: The most important thing to remember regarding the warning signs of stroke is to "be alert for sudden weakness or numbness." This is crucial because sudden weakness or numbness in the face, arm, or leg, especially on one side of the body, is one of the hallmark symptoms of a stroke. It is essential to recognize these signs promptly and seek immediate medical attention to minimize the potential damage caused by a stroke. Being aware of these sudden symptoms can help individuals receive timely treatment and improve their chances of recovery.
Question 7 of 9
The nurse is caring for a client diagnosed with dilated cardiomyopathy. Which clinical manifestations does the nurse anticipate during the physical assessment? Select all that apply.
Correct Answer: A
Rationale: Dilated cardiomyopathy is a condition characterized by an enlarged and weakened heart muscle, leading to decreased heart function. Common clinical manifestations of dilated cardiomyopathy include:
Question 8 of 9
The nurse is preparing an educational session for employees of a manufacturing plant regarding emergency care of amputated digits. What should the nurse include when teaching about the type of injury?
Correct Answer: C
Rationale: When teaching about the type of injury of an amputated digit, the nurse should include the proper handling of the amputated part. The correct method is to wrap the amputated digit in a clean towel, place it in a sealed plastic bag to prevent direct contact with ice, and then place the bag on ice. Placing the amputated digit directly on ice can cause frostbite and further damage to the tissue. By following this method, the amputated digit can be preserved properly until medical help is received. Transporting the person to the hospital is important but proper handling of the amputated digit is critical to increase the chances of successful reattachment. Placing the amputated digit in warm water or taping it to the hand are not recommended methods for preserving an amputated digit.
Question 9 of 9
The nurse is planning care for an older adult client with chronic venous insufficiency. Which will the nurse include in the client's teaching plan?
Correct Answer: B
Rationale: Elastic compression therapy, such as wearing elastic hose (compression stockings), is an essential component of managing chronic venous insufficiency. Compression stockings help improve venous return, reduce edema, and alleviate symptoms such as pain and swelling. They work by applying external pressure to the legs, promoting better circulation and preventing blood from pooling in the veins. The nurse should ensure that the client wears the compression stockings as prescribed to maximize their effectiveness in managing the condition.