ATI RN
Nursing a Concept Based Approach to Learning Test Bank Free Questions
Question 1 of 5
What increases after an embolus has become trapped in the pulmonary microvasculature?
Correct Answer: C
Rationale: After an embolus becomes trapped in the pulmonary microvasculature, dead space increases. Dead space refers to the portion of the lung that is ventilated but not perfused, resulting in reduced gas exchange. When a pulmonary embolus blocks blood flow within a pulmonary vessel, it leads to a mismatch between ventilation and perfusion in the affected lung region. This mismatch results in increased dead space, as ventilation continues in areas that are not effectively perfused. As dead space increases, the overall efficiency of gas exchange in the lung is impaired, potentially leading to hypoxemia.
Question 2 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 3 of 5
A client diagnosed with cardiomyopathy reports having to rest between activities during the day. The client asks the nurse why this is occurring. Which reason should the nurse include in the response to the client?
Correct Answer: B
Rationale: The client with cardiomyopathy may experience decreased cardiac output, which is a common manifestation of this condition. Cardiomyopathy is a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body. Reduced cardiac output means that less blood is being pumped out by the heart with each beat, leading to symptoms such as fatigue, weakness, and the need to rest between activities. This is why the client is experiencing the need to rest between activities during the day.
Question 4 of 5
Which action should the nurse carry out for the laboring client who has been diagnosed with preeclampsia?
Correct Answer: B
Rationale: When caring for a laboring client diagnosed with preeclampsia, it is important to be mindful of certain considerations to ensure the safety and well-being of both the mother and the baby. Placing the client in left lateral position when she feels the urge to push is crucial in cases of preeclampsia as it helps to optimize maternal and fetal oxygenation. This position can help improve blood flow to the placenta and reduce the risk of decreased perfusion due to the elevated blood pressure associated with preeclampsia. By maintaining the client in the left lateral position during pushing, it can help prevent potential complications and support better outcomes for both the mother and baby.
Question 5 of 5
An older adult client receiving medication for hypertension had a recent fall at home. Which intervention should the nurse include in this client's plan of care?
Correct Answer: B
Rationale: Assessing postural blood pressures is important in determining if the client may be experiencing orthostatic hypotension, which could have contributed to the fall. Orthostatic hypotension is a sudden drop in blood pressure that can occur when a person stands up from a sitting or lying position. Older adults on antihypertensive medications are at increased risk for orthostatic hypotension. By monitoring postural blood pressures, the nurse can identify fluctuations in blood pressure that may put the client at risk for falls and implement appropriate interventions to prevent future falls. Monitoring serum sodium levels and creatinine levels are important for detecting electrolyte imbalances or kidney dysfunction but do not directly address the issue of orthostatic hypotension related to falls. Monitoring blood pressure every 2 hours may not provide valuable information on postural blood pressure changes that are associated with orthostatic hypotension.