ATI RN
Fundamental Concepts and Skills for Nursing 6th Edition Test Bank Questions
Question 1 of 9
The nurse is providing teaching about long-term anticoagulant therapy to a client recovering from a pulmonary embolism. Which client statement indicates that instruction has been effective?
Correct Answer: B
Rationale: The correct answer is B. The statement "I need to use a soft toothbrush and an electric razor to avoid injuries" indicates that the client understands the importance of preventive measures to minimize bleeding risks while on anticoagulant therapy. Using a soft toothbrush and an electric razor can help prevent accidental cuts that may lead to bleeding complications. It shows the client's understanding of the need to take precautions to avoid potential harm while on long-term anticoagulant therapy. The other statements do not directly address safety measures to prevent bleeding complications associated with anticoagulant therapy.
Question 2 of 9
The nurse is providing teaching about long-term anticoagulant therapy to a client recovering from a pulmonary embolism. Which client statement indicates that instruction has been effective?
Correct Answer: B
Rationale: The correct answer is B. The statement "I need to use a soft toothbrush and an electric razor to avoid injuries" indicates that the client understands the importance of preventive measures to minimize bleeding risks while on anticoagulant therapy. Using a soft toothbrush and an electric razor can help prevent accidental cuts that may lead to bleeding complications. It shows the client's understanding of the need to take precautions to avoid potential harm while on long-term anticoagulant therapy. The other statements do not directly address safety measures to prevent bleeding complications associated with anticoagulant therapy.
Question 3 of 9
The nurse is planning care to reduce the risk of a patient in the intensive care unit from developing acute kidney injury. Which intervention should the nurse implement for this patient?
Correct Answer: C
Rationale: Acute kidney injury (AKI) is a common complication in critically ill patients in the intensive care unit (ICU). One of the primary interventions to reduce the risk of AKI is to maintain adequate fluid volume and cardiac output. Adequate hydration and adequate perfusion pressure are essential for renal function. Maintaining fluid volume and adequate cardiac output ensure that the kidneys receive enough blood flow and oxygen to function optimally. Conversely, inadequate fluid volume or low cardiac output can lead to decreased renal perfusion, predisposing the patient to AKI. Monitoring and optimizing fluid status and cardiac output are crucial in preventing AKI in high-risk patients in the ICU.
Question 4 of 9
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 9
Which statements are correct regarding the various layers of the heart? Select all that apply.
Correct Answer: C
Rationale: The epicardium is the outermost layer of the heart and is also known as the visceral layer of the serous pericardium. It is a thin layer that covers the surface of the heart and is composed of connective tissue and fat. The epicardium helps to protect the heart and provides a smooth outer surface for the heart to move within the pericardial cavity.
Question 6 of 9
The community nurse is caring for a client who is 32 weeks pregnant and diagnosed with preeclampsia. Which statement indicates that the client requires additional teaching?
Correct Answer: A
Rationale: This statement indicates a need for additional teaching because in a client with preeclampsia, dark and reduced urine output could be a sign of kidney involvement and impaired kidney function. In preeclampsia, monitoring urine output, particularly for signs of proteinuria, is crucial as it can indicate worsening of the condition and potential damage to the kidneys. Therefore, the client should be educated that changes in urine color and amount should be reported to the healthcare provider promptly.
Question 7 of 9
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.
Question 8 of 9
The nurse is caring for a patient with a deep venous thrombosis of the left lower extremity. What additional body system should the nurse carefully monitor in this patient?
Correct Answer: C
Rationale: Patients with deep venous thrombosis (DVT) are at risk for developing a complication known as pulmonary embolism, which is a potentially life-threatening condition. A pulmonary embolism occurs when a blood clot dislodges from the veins, typically in the legs, and travels to the lungs, blocking blood flow. This can lead to respiratory symptoms such as shortness of breath, chest pain, and in severe cases, respiratory failure. Therefore, it is essential for the nurse to carefully monitor the respiratory system in a patient with DVT to promptly identify any signs of pulmonary embolism and initiate appropriate interventions to prevent further complications.
Question 9 of 9
The nurse notes that the patient has a low calcium level and plans to assess for Chvostek’s sign. How will the nurse conduct this assessment?
Correct Answer: C
Rationale: Chvostek’s sign is an assessment technique used to detect hypocalcemia. The nurse will tap lightly over the facial nerve, just in front of the patient’s ear. A positive Chvostek’s sign is indicated by a twitching of the facial muscles on the same side of the face as the area that was tapped. This twitching is due to the hyperexcitability of the facial nerve, which can be a sign of low calcium levels. Therefore, option C is the correct way to conduct the assessment for Chvostek’s sign.