ATI RN
Concepts for Nursing Practice Test Bank Questions
Question 1 of 5
The nurse is performing an assessment of a client. Which should the nurse recognize as a noncardiac risk factor for heart failure?
Correct Answer: C
Rationale: Hyperthyroidism is a noncardiac risk factor for heart failure because it can lead to increased heart rate, palpitations, and ultimately strain on the heart. When a person has hyperthyroidism, the thyroid gland produces too much thyroid hormone, which can impact the cardiovascular system by affecting heart function. This increased workload on the heart can contribute to the development of heart failure. It is important for the nurse to recognize hyperthyroidism as a potential risk factor for heart failure during the assessment of the client.
Question 2 of 5
A nurse working in the emergency department is participating in the resuscitation of a client experiencing sudden cardiac death. After five cycles of CPR, the nurse evaluates the client's cardiac rhythm as asystole. What is the next action by the nurse?
Correct Answer: B
Rationale: Asystole is the absence of any cardiac electrical activity, and it is a non-shockable rhythm. In the case of asystole, defibrillation would not be effective. The next appropriate action would be to continue high-quality CPR and administer epinephrine according to the advanced cardiac life support (ACLS) protocol. Additionally, assessing the client's pulse is crucial to determine if there is any return of spontaneous circulation (ROSC) following CPR and medication administration. Checking the cardiac monitor electrodes ensures proper attachment and accurate monitoring of the client's cardiac rhythm but may not directly impact the management of asystole.
Question 3 of 5
A client diagnosed with a pulmonary embolism has a reduction in arterial oxygen saturation level and dyspnea. Which is the priority nursing diagnosis for this client?
Correct Answer: C
Rationale: In a client diagnosed with a pulmonary embolism experiencing a reduction in arterial oxygen saturation level and dyspnea, the priority nursing diagnosis would be Impaired Gas Exchange. This is because a pulmonary embolism can obstruct blood flow and prevent proper gas exchange in the lungs. Dyspnea and reduced oxygen saturation levels indicate inadequate gas exchange, which can lead to hypoxia. Prioritizing this nursing diagnosis will ensure that interventions are focused on improving oxygenation and respiratory function to prevent further complications.
Question 4 of 5
A client with hemophilia is at increased risk for what type of shock?
Correct Answer: D
Rationale: Hemophilia is a genetic disorder that impairs the blood's ability to clot properly, leading to prolonged bleeding. This makes individuals with hemophilia particularly susceptible to hemorrhagic shock, which is a type of distributive shock. Distributive shock occurs when there is widespread vasodilation and increased vascular permeability, leading to inadequate tissue perfusion and oxygen delivery. In the case of hemophilia, excessive bleeding can result in a significant loss of blood volume and impaired circulation, eventually leading to distributive shock due to the body's inability to maintain adequate perfusion to vital organs. Therefore, individuals with hemophilia are at an increased risk of developing distributive shock, specifically hemorrhagic shock, if they experience severe bleeding events.
Question 5 of 5
The nurse is conducting a health history with a patient that focuses on the endocrine system. Which question should the nurse include in this assessment?
Correct Answer: B
Rationale: The nurse should include the question "Have you noticed a change in your thirst?" in the health history focusing on the endocrine system because changes in thirst can be indicative of conditions such as diabetes insipidus or diabetes mellitus that affect the endocrine system. Thirst can be altered due to changes in hormone levels, particularly those related to water balance and blood sugar regulation. Monitoring changes in thirst can provide important information about potential endocrine imbalances in the body. Asking about changes in thirst is relevant to assessing the patient's endocrine health in this context.