ATI RN
Nursing a Concept Based Approach to Learning Test Bank Free Questions
Question 1 of 5
The nurse is evaluating teaching provided to a client with peripheral vascular disease (PVD). Which client observation indicates teaching has been effective?
Correct Answer: B
Rationale: Option B, washing the lower extremities with mild soap, drying the legs, and applying a light moisturizer, indicates effective teaching for a client with peripheral vascular disease (PVD). Proper hygiene, including gentle washing with mild soap, thorough drying to prevent moisture-related skin breakdown, and moisturizing to prevent dry skin and promote circulation, are key components of self-care for individuals with PVD. Option A is incorrect because sitting with a pillow behind the knees does not specifically address PVD self-care. Option C is incorrect because crossing the left leg over the right while sitting does not relate to appropriate PVD management. Option D is incorrect because smoking in any form is detrimental to vascular health and should be discouraged in PVD management.
Question 2 of 5
A client diagnosed with a stroke is going to receive treatment with fibrinolytic therapy using the recombinant tissue plasminogen activator alteplase (rt-PA). Which information should the nurse include when performing medication teaching for the client's family?
Correct Answer: D
Rationale: When performing medication teaching for the client's family about fibrinolytic therapy with alteplase (rt-PA), the nurse should include information that this medication is administered to break up existing clots and increase cerebral blood flow. rt-PA works by converting plasminogen to plasmin, which helps dissolve clots and restore blood flow to the brain. It is used specifically for ischemic strokes, not hemorrhagic strokes, and is most effective when administered within 3 hours (up to 4.5 hours in some cases) of the stroke symptoms starting. It is associated with potential serious complications, including an increased risk of bleeding, which the nurse should also educate the family about.
Question 3 of 5
A patient comes into the emergency department with manifestations of appendicitis. What is the highest priority when caring for this patient?
Correct Answer: C
Rationale: The highest priority when caring for a patient with manifestations of appendicitis is to provide pain relief. By inserting a saline lock for intravenous pain medication, the patient can receive immediate pain relief to alleviate their discomfort. Pain management is crucial in appendicitis as it can help in improving the patient's overall well-being and reduce the risk of complications. While other options such as withholding food and fluids, performing preoperative skin preparation, or teaching postoperative exercises are important aspects of care, addressing the patient's pain is the top priority to ensure their comfort and well-being.
Question 4 of 5
A perimenopausal patient is experiencing frequency, urgency, nocturia, dysuria, and cloudy, rust- colored urine for the third time in the past 2 years. What should the nurse include when teaching this patient? Select all that apply.
Correct Answer: B
Rationale: In this scenario, the correct option is B) Recommendations for perineal cleansing. Perimenopausal women are at an increased risk for urinary tract infections (UTIs) due to hormonal changes affecting the genitourinary tract. Teaching the patient about proper perineal hygiene, including front-to-back wiping after using the restroom, can help prevent the introduction of bacteria into the urinary tract, reducing the risk of UTIs. Option A) Pre-procedure instruction for an IVP is incorrect as it is not relevant to the patient's current symptoms of a possible UTI. Option C) Recommendations for screening cystoscopy is unnecessary at this point as the patient's symptoms are indicative of a UTI rather than a need for further invasive diagnostic procedures. Option D) Potential benefits of estrogen vaginal cream is not appropriate as the patient's symptoms are more indicative of a UTI rather than a hormonal issue. Option E) Return to the office in 10 days for a follow-up culture is premature without addressing the immediate need for perineal hygiene education to prevent recurrent UTIs. Educationally, this rationale highlights the importance of teaching patients about preventive measures to reduce the risk of UTIs, especially in perimenopausal women who may be more susceptible to these infections due to hormonal changes. It emphasizes the role of patient education in promoting self-care and preventing recurrent UTIs.
Question 5 of 5
During an assessment, the nurse asks the patient to move an extremity away from the body midline. What movement is the nurse assessing?
Correct Answer: C
Rationale: When the nurse asks the patient to move an extremity away from the body midline, they are assessing the movement of abduction. Abduction refers to the movement of a body part away from the midline of the body. In this case, moving the extremity away from the body midline represents abduction, as the limb is being moved outward or away from the center of the body. Flexion and extension involve bending and straightening movements, respectively, along a joint axis, while adduction involves moving a body part towards the midline of the body.