ATI RN
Dewits Fundamental Concepts and Skills for Nursing Test Bank Questions
Question 1 of 5
The nurse is caring for a client who has been admitted to labor and delivery. What should the nurse recognize as risk factors for disseminating intravascular coagulation (DIC)? Select all that apply.
Correct Answer: B
Rationale: Disseminated intravascular coagulation (DI
C) is a serious condition characterized by widespread activation of the clotting cascade and consumption of clotting factors, leading to both thrombosis and bleeding. Risk factors for DIC include conditions that cause significant tissue injury, which can trigger the coagulation pathway.
Question 2 of 5
A urine dipstick test reveals a trace amount of protein. The nurse identifies which nursing diagnosis as appropriate for the client at this time?
Correct Answer: A
Rationale: A trace amount of protein in the urine dipstick test can indicate proteinuria, which can be a sign of kidney dysfunction. The presence of protein in the urine may lead to fluid retention and potential imbalances in fluid volume.
Therefore, the appropriate nursing diagnosis in this situation would be "Risk for Imbalanced Fluid Volume," as monitoring and management of fluid balance would be crucial for the client's overall health and prevention of further complications related to kidney function.
Question 3 of 5
The nurse is caring for a client who is scheduled to receive metoprolol (Lopressor). What should the nurse teach the client about this medication?
Correct Answer: B
Rationale: Metoprolol (Lopressor) is a beta-blocker medication used to treat high blood pressure, angina, and heart failure. One common side effect of beta-blockers is orthostatic hypotension, which can cause a drop in blood pressure when changing positions from lying down to sitting or standing.
To prevent dizziness or fainting due to this side effect, clients taking metoprolol should be advised to change positions slowly to allow their body to adjust and minimize the risk of falls or injury.
Question 4 of 5
The nurse is planning care for a client with a pulmonary embolism. Which nursing action would assist with the client's decrease in cardiac output?
Correct Answer: A
Rationale: Providing oxygen will help increase the oxygen supply to the tissues, thus supporting the heart in maintaining cardiac output. A decrease in cardiac output is a concern with pulmonary embolism as it can lead to inadequate tissue perfusion and possible complications. Oxygen therapy can improve oxygenation and support the heart in meeting the body's demands, helping to stabilize cardiac output. Monitoring and assessing pulmonary arterial pressures would be important in managing a pulmonary embolism but would not directly assist in increasing cardiac output. Keeping protamine sulfate at the bedside is more relevant for managing heparin overdose, not specifically for addressing a decrease in cardiac output. Assessing for bleeding is important in monitoring for potential complications of anticoagulant therapy but does not directly address the decrease in cardiac output seen in pulmonary embolism.
Question 5 of 5
What type of shock is characterized by increased pulse and respirations, normal blood pressure, elevated body temperature, and warm and flushed skin?
Correct Answer: C
Rationale: Neurogenic shock is characterized by decreased vascular resistance due to loss of sympathetic tone. In this type of shock, there is widespread vasodilation leading to pooling of blood in the peripheral vessels, resulting in decreased venous return to the heart. The decreased vascular resistance results in relative hypovolemia despite normal blood volume, leading to compensatory mechanisms such as increased pulse and respirations to maintain tissue perfusion. The warm and flushed skin in neurogenic shock is a result of peripheral vasodilation, while the normal blood pressure is maintained due to the compensatory mechanisms and the lack of actual blood volume loss. Additionally, the elevated body temperature is a possible manifestation due to the systemic response to the shock state.