ATI RN
Nursing a Concept Based Approach to Learning Test Bank Free Questions
Question 1 of 5
What is a good way for a nurse to prepare the environment for teaching?
Correct Answer: C
Rationale: Evaluating client abilities to perform skills with return demonstrations is a good way for a nurse to prepare the environment for teaching. By observing the clients' abilities to perform the necessary skills, the nurse can tailor the teaching to meet the specific needs of each individual. Return demonstrations allow for immediate feedback and correction if needed, ensuring that the clients understand and can perform the skills accurately. This interactive approach to teaching promotes active learning and enhances retention of information.
Question 2 of 5
The nurse is caring for a child who has just been diagnosed with an atrial septal defect (ASD). Which manifestations would the nurse expect upon assessment? Select all that apply.
Correct Answer: B
Rationale: In caring for a child diagnosed with an atrial septal defect (ASD), understanding the expected manifestations is crucial for effective nursing care. The correct answer is B) Midsystolic murmur at lower right sternal border. This is because an ASD typically presents with a midsystolic murmur due to increased blood flow across the defect during systole, which can be auscultated at the lower right sternal border. Option A) Pulmonary artery hypotension is incorrect because ASD can lead to increased pulmonary blood flow and, subsequently, pulmonary artery hypertension rather than hypotension. Option C) Mitral valve regurgitation with cleft on mitral valve is incorrect as ASD does not directly cause mitral valve abnormalities. Option D) S1 heart tone may be split due to forceful left ventricular contraction is incorrect as S1 splitting is not a common finding in ASD. Educationally, understanding the specific clinical manifestations associated with ASD helps nurses in early identification, appropriate management, and effective communication with healthcare providers. This knowledge enhances the quality of care provided to pediatric patients with congenital heart defects.
Question 3 of 5
The nurse is completing an assessment on a newly admitted client. What finding would alert the nurse that the client may be experiencing a deep venous thrombosis (DVT)?
Correct Answer: C
Rationale: Swelling in one leg with edema is a classic sign of deep venous thrombosis (DVT). DVT occurs when a blood clot forms in one or more of the deep veins in the body, usually in the legs. This can lead to swelling in the affected leg due to the impaired venous return caused by the blood clot. It is important for the nurse to recognize this sign because if left untreated, DVT can lead to serious complications such as pulmonary embolism. Therefore, the nurse should further assess the client and notify the healthcare provider for appropriate management.
Question 4 of 5
A nurse caring for a client with suspected disseminated intravascular coagulation (DIC). Which test result is common in DIC?
Correct Answer: C
Rationale: Disseminated intravascular coagulation (DIC) is a condition characterized by widespread activation of clotting factors throughout the body, leading to both excessive clot formation and consumption of clotting factors. As a result, one of the common features of DIC is a decreased level of fibrinogen, which is an essential protein for blood clot formation. In DIC, fibrinogen is consumed in the formation of multiple small blood clots throughout the circulation, causing a decrease in its levels. This decrease in fibrinogen can contribute to the increased risk of bleeding that is seen in DIC. Therefore, a decreased fibrinogen level is a characteristic laboratory finding in DIC.
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.