ATI RN
Introduction to Maternity and Pediatric Nursing Test Bank Questions
Question 1 of 5
A 39-year old male client underwent Transurethral Resection of the Prostate (TURP) eight hours ago and asks the nurse, "Why is my urine in the bag clotting like blood?" The nurse's best interpretation of this finding is that:
Correct Answer: A
Rationale: After undergoing Transurethral Resection of the Prostate (TURP), it is normal for a client's urine to contain blood and form clots initially. This is because the surgery involves removing prostate tissue, which can lead to bleeding. The presence of blood clots in the urine collection bag is expected within the first 24 hours post-op. It is necessary to monitor for excessive bleeding or signs of a clot blocking the catheter, but seeing blood clots is not alarming in the immediate post-operative period.
Question 2 of 5
Mr. Go had a post-kidney transplant. What should the nurse immediately assess?
Correct Answer: A
Rationale: After a kidney transplant, it is essential for the nurse to immediately assess for fluid and electrolyte imbalances in the recipient. The transplanted kidney may take some time to start functioning optimally, and during this period, the body may not be able to regulate fluid and electrolyte balance effectively. Monitoring for signs of fluid overload, electrolyte disturbances, and kidney function is crucial to prevent complications such as dehydration, electrolyte abnormalities, and organ rejection. Early detection of these imbalances allows for prompt intervention and prevention of potential complications.
Question 3 of 5
On the third day after a partial thyroidectomy, a client exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life- threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?
Correct Answer: A
Rationale: Hypocalcemia is the most common electrolyte disturbance that follows thyroid surgery, particularly after a partial thyroidectomy. This occurs due to inadvertent injury or removal of the parathyroid glands, which are responsible for regulating calcium levels in the body. The symptoms of hypocalcemia, such as muscle twitching, hyperirritability of the nervous system, numbness, and tingling, align with the client's presentation in this scenario. Prompt recognition and treatment of hypocalcemia are crucial to prevent life-threatening complications like tetany or seizures. Therefore, the nurse's decision to notify the surgeon immediately is appropriate to address this electrolyte imbalance.
Question 4 of 5
The nurse is explaining the action of insulin to a newly diagnosed diabetic client. During the teaching, the nurse reviews the process of insulin secretion in the body. The nurse is correct when stating that insulin is secreted from the:
Correct Answer: C
Rationale: Insulin is secreted from the beta cells of the pancreas. These specialized cells are located in the islets of Langerhans within the pancreas. When blood glucose levels rise after eating, beta cells release insulin into the bloodstream to help regulate glucose levels by allowing cells to take in glucose for energy or storage. Insulin also helps lower blood sugar by promoting the conversion of glucose to glycogen in the liver and muscles. Therefore, the nurse is correct in stating that insulin is secreted from the beta cells of the pancreas.
Question 5 of 5
The nurse should expect a client with hypothyroidism to report which health concerns?
Correct Answer: C
Rationale: Hypothyroidism is characterized by an underactive thyroid gland that does not produce enough thyroid hormone. This hormonal imbalance can lead to symptoms such as slow metabolism, weight gain, fatigue, cold intolerance, constipation, and puffiness of the face and hands. The slowed metabolic rate can also cause fluid retention, resulting in the characteristic puffiness associated with hypothyroidism. Increased appetite and weight loss are not typical symptoms of hypothyroidism, as the condition is more commonly associated with weight gain. Nervousness and tremors are more indicative of hyperthyroidism, where the thyroid gland is overactive. Thyroid gland swelling, known as goiter, can occur in various thyroid disorders but is not specific to hypothyroidism.