ATI RN
Concept Based Nursing Practice Questions Questions
Question 1 of 5
The nurse is planning care for a client with deep venous thrombosis (DVT). Which problem would be a priority for this client?
Correct Answer: C
Rationale: In a client with deep venous thrombosis (DVT), the priority problem would be peripheral perfusion. DVT is a condition where a blood clot forms in a vein deep within the body, usually in the lower extremities. This clot can impede blood flow in the affected vein, leading to compromised circulation to the surrounding tissues. Poor peripheral perfusion can result in tissue ischemia and potential tissue necrosis. Monitoring and ensuring adequate peripheral perfusion is crucial to prevent tissue damage and further complications such as pulmonary embolism. Therefore, addressing and improving peripheral perfusion would be the priority in caring for a client with DVT.
Question 2 of 5
A client has a blood pressure of 142/92 mmHg. Which classification is appropriate for the nurse to use when documenting this data?
Correct Answer: D
Rationale: A blood pressure reading of 142/92 mmHg falls into the category of Hypertension Stage II based on the guidelines from the American Heart Association. In this classification, systolic blood pressure is 140-159 mmHg and diastolic blood pressure is 90-99 mmHg. Stage II hypertension indicates that the individual has a significantly elevated blood pressure level that requires prompt management and monitoring. It is crucial for the nurse to document this accurately to ensure appropriate interventions are provided to the client.
Question 3 of 5
During a blood pressure screening, an older adult client tells the nurse about chest fluttering while doing yard work. The client reports no other symptoms and the frequency is intermittent. Which action is correct by the nurse?
Correct Answer: C
Rationale: The correct action for the nurse in this situation would be to ensure the client is evaluated by his/her medical provider. Chest fluttering, also known as palpitations, can sometimes be related to cardiac arrhythmias, which can be a concern in older adults. Even though the client reports no other symptoms and the frequency is intermittent, it is essential for the medical provider to assess and determine the cause of the fluttering to rule out any serious underlying cardiac issues. Taking appropriate action promptly can help prevent any potential complications and ensure the client's well-being.
Question 4 of 5
A client with peripheral vascular disease (PVD) has symptoms of intermittent claudication. Which should the nurse include when teaching the client about intermittent claudication?
Correct Answer: C
Rationale: Intermittent claudication is a symptom of peripheral vascular disease (PVD) characterized by cramping or aching pain in the lower extremities and buttocks that occurs with a predictable level of activity, such as walking a certain distance. This pain typically resolves with rest. The pain is due to inadequate blood flow to the muscles during activity, causing a buildup of lactic acid, which leads to muscle pain. This symptom is an important indicator of decreased arterial blood flow and is a common presentation in individuals with PVD. Therefore, when teaching the client about intermittent claudication, the nurse should emphasize the predictable nature of the pain related to activity and the relief experienced with rest.
Question 5 of 5
Which assessment findings support the nurse's concern that a client is experiencing hypovolemic shock? Select all that apply.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.