ATI RN
Concepts for Nursing Practice 3rd Edition Test Bank Questions
Question 1 of 5
A client is prescribed enalapril (Vasotec) for treatment of heart failure. Which adverse effect should the nurse assess for following the initial administration of this drug?
Correct Answer: C
Rationale: Enalapril is an angiotensin-converting enzyme (ACE) inhibitor commonly used in the treatment of heart failure. One of the potential adverse effects of ACE inhibitors, including enalapril, is hypotension or low blood pressure. This is especially a concern following the initial administration of the drug, as it can cause a significant drop in blood pressure. Nurses should assess the patient for signs and symptoms of hypotension, such as dizziness, light-headedness, weakness, or fainting, after starting enalapril therapy. Monitoring blood pressure regularly and educating the patient about the possibility of low blood pressure is important to ensure patient safety and optimal outcomes.
Question 2 of 5
A nurse is caring for a client who was involved in a motor vehicle accident and has lost approximately 1,550 mL of blood. The nurse should recognize that the client's shock will be classified as:
Correct Answer: C
Rationale: Class III hemorrhagic shock typically involves the loss of 1,500-2,000 mL of blood, which aligns closely with the approximately 1,550 mL of blood lost by the client in this scenario. Class III shock is considered severe and can lead to significant physiological consequences, including decreased blood pressure, increased heart rate, altered mental status, and potential organ dysfunction.
Therefore, based on the amount of blood loss and severity of symptoms, the client's shock would be classified as Class III.
Question 3 of 5
A client with sepsis has a temperature of 40°C. Which dysrhythmia is most likely to occur in this client?
Correct Answer: B
Rationale: A client with sepsis and a temperature of 40°C is likely experiencing a systemic inflammatory response, which can lead to a variety of dysrhythmias. In this case, the client is more likely to develop a tachydysrhythmia (fast heart rate) due to the body's response to the infection. Sepsis can result in an increase in heart rate as the body tries to maintain adequate perfusion to vital organs in response to the inflammatory process. Tachydysrhythmias such as supraventricular tachycardia or atrial fibrillation are commonly observed in septic patients with high fevers.
Question 4 of 5
The nurse is concerned that a client admitted for a total hip replacement is at risk for thrombus formation. Which assessment finding caused the nurse to draw this conclusion?
Correct Answer: B
Rationale: A former cigarette smoker is at increased risk for thrombus formation due to the damage smoking causes to the blood vessels, increasing the likelihood of blood clots. Smoking can also contribute to inflammation and increased platelet activation, further promoting clot formation. This risk factor is particularly concerning in a client undergoing a total hip replacement surgery, as immobility and surgery itself can also increase the risk of blood clots forming. Monitoring and addressing this risk factor is important in preventing potential complications such as deep vein thrombosis or pulmonary embolism in this client population. While the other assessment findings are important to consider for overall health, the former cigarette smoking status is specifically associated with thrombus formation in this scenario.
Question 5 of 5
After being diagnosed with polycystic kidney disease, an adult patient asks if current children are at risk for developing the disorder. How should the nurse respond?
Correct Answer: B
Rationale: Polycystic kidney disease (PK
D) is a genetic disorder that can be inherited by children if one or both parents have the gene mutation responsible for the condition. In cases where a parent has been diagnosed with PKD, their children are at risk of inheriting the faulty gene. As such, it is recommended for the children to undergo genetic testing and screening to identify any evidence of the disease early on. By identifying the gene mutation in the children, appropriate monitoring and management can be initiated, potentially leading to better outcomes and quality of life for the affected individuals.
Therefore, genetic testing and screening are crucial in cases where there is a known genetic component to a disorder like PKD.