ATI RN
Nursing a Concept Based Approach to Learning Test Bank Free Questions
Question 1 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 2 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 3 of 5
A client diagnosed with a stroke is going to receive treatment with fibrinolytic therapy using the recombinant tissue plasminogen activator alteplase (rt-PA). Which information should the nurse include when performing medication teaching for the client's family?
Correct Answer: D
Rationale: When performing medication teaching for the client's family about fibrinolytic therapy with alteplase (rt-PA), the nurse should include information that this medication is administered to break up existing clots and increase cerebral blood flow. rt-PA works by converting plasminogen to plasmin, which helps dissolve clots and restore blood flow to the brain. It is used specifically for ischemic strokes, not hemorrhagic strokes, and is most effective when administered within 3 hours (up to 4.5 hours in some cases) of the stroke symptoms starting. It is associated with potential serious complications, including an increased risk of bleeding, which the nurse should also educate the family about.
Question 4 of 5
A patient comes into the emergency department with manifestations of appendicitis. What is the highest priority when caring for this patient?
Correct Answer: C
Rationale: The highest priority when caring for a patient with manifestations of appendicitis is to provide pain relief. By inserting a saline lock for intravenous pain medication, the patient can receive immediate pain relief to alleviate their discomfort. Pain management is crucial in appendicitis as it can help in improving the patient's overall well-being and reduce the risk of complications. While other options such as withholding food and fluids, performing preoperative skin preparation, or teaching postoperative exercises are important aspects of care, addressing the patient's pain is the top priority to ensure their comfort and well-being.
Question 5 of 5
A perimenopausal patient is experiencing frequency, urgency, nocturia, dysuria, and cloudy, rust- colored urine for the third time in the past 2 years. What should the nurse include when teaching this patient? Select all that apply.
Correct Answer: B
Rationale: In this scenario, the correct option is B) Recommendations for perineal cleansing. Perimenopausal women are at an increased risk for urinary tract infections (UTIs) due to hormonal changes affecting the genitourinary tract. Teaching the patient about proper perineal hygiene, including front-to-back wiping after using the restroom, can help prevent the introduction of bacteria into the urinary tract, reducing the risk of UTIs. Option A) Pre-procedure instruction for an IVP is incorrect as it is not relevant to the patient's current symptoms of a possible UTI. Option C) Recommendations for screening cystoscopy is unnecessary at this point as the patient's symptoms are indicative of a UTI rather than a need for further invasive diagnostic procedures. Option D) Potential benefits of estrogen vaginal cream is not appropriate as the patient's symptoms are more indicative of a UTI rather than a hormonal issue. Option E) Return to the office in 10 days for a follow-up culture is premature without addressing the immediate need for perineal hygiene education to prevent recurrent UTIs. Educationally, this rationale highlights the importance of teaching patients about preventive measures to reduce the risk of UTIs, especially in perimenopausal women who may be more susceptible to these infections due to hormonal changes. It emphasizes the role of patient education in promoting self-care and preventing recurrent UTIs.