Concepts for Nursing Practice Test Bank

Questions 14

ATI RN

ATI RN Test Bank

Concepts for Nursing Practice Test Bank Questions

Question 1 of 5

A client diagnosed with a pulmonary embolism has a reduction in arterial oxygen saturation level and dyspnea. Which is the priority nursing diagnosis for this client?

Correct Answer: C

Rationale: In a client diagnosed with a pulmonary embolism experiencing a reduction in arterial oxygen saturation level and dyspnea, the priority nursing diagnosis would be Impaired Gas Exchange. This is because a pulmonary embolism can obstruct blood flow and prevent proper gas exchange in the lungs. Dyspnea and reduced oxygen saturation levels indicate inadequate gas exchange, which can lead to hypoxia. Prioritizing this nursing diagnosis will ensure that interventions are focused on improving oxygenation and respiratory function to prevent further complications.

Question 2 of 5

The nurse is performing an assessment of a client. Which should the nurse recognize as a noncardiac risk factor for heart failure?

Correct Answer: C

Rationale: Hyperthyroidism is a noncardiac risk factor for heart failure because it can lead to increased heart rate, palpitations, and ultimately strain on the heart. When a person has hyperthyroidism, the thyroid gland produces too much thyroid hormone, which can impact the cardiovascular system by affecting heart function. This increased workload on the heart can contribute to the development of heart failure. It is important for the nurse to recognize hyperthyroidism as a potential risk factor for heart failure during the assessment of the client.

Question 3 of 5

The nurse is preparing to conduct a cardiac assessment for a pediatric client. Which location will the nurse use when auscultating the apical pulse?

Correct Answer: A

Rationale: When auscultating the apical pulse in pediatric clients, the nurse should place the stethoscope at the fifth intercostal space at the midclavicular line. This location is where the apex of the heart is located in pediatric clients and provides the most accurate assessment of the apical pulse. Placing the stethoscope at the left nipple (B) or right nipple (C) would not provide an accurate assessment of the apical pulse location. Auscultating at the eighth intercostal space (D) would be too low and not capture the apical pulse accurately.

Question 4 of 5

A client with hemophilia is at increased risk for what type of shock?

Correct Answer: D

Rationale: Hemophilia is a genetic disorder that impairs the blood's ability to clot properly, leading to prolonged bleeding. This makes individuals with hemophilia particularly susceptible to hemorrhagic shock, which is a type of distributive shock. Distributive shock occurs when there is widespread vasodilation and increased vascular permeability, leading to inadequate tissue perfusion and oxygen delivery. In the case of hemophilia, excessive bleeding can result in a significant loss of blood volume and impaired circulation, eventually leading to distributive shock due to the body's inability to maintain adequate perfusion to vital organs. Therefore, individuals with hemophilia are at an increased risk of developing distributive shock, specifically hemorrhagic shock, if they experience severe bleeding events.

Question 5 of 5

A client diagnosed with a pulmonary embolism has a reduction in arterial oxygen saturation level and dyspnea. Which is the priority nursing diagnosis for this client?

Correct Answer: C

Rationale: In a client diagnosed with a pulmonary embolism experiencing a reduction in arterial oxygen saturation level and dyspnea, the priority nursing diagnosis would be Impaired Gas Exchange. This is because a pulmonary embolism can obstruct blood flow and prevent proper gas exchange in the lungs. Dyspnea and reduced oxygen saturation levels indicate inadequate gas exchange, which can lead to hypoxia. Prioritizing this nursing diagnosis will ensure that interventions are focused on improving oxygenation and respiratory function to prevent further complications.

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