ATI RN
Fundamental Concepts and Skills for Nursing Test Bank Questions
Question 1 of 5
A client is scheduled for temporary pacemaker insertion. What instruction will this client need prior to discharge?
Correct Answer: D
Rationale: The correct instruction for a client who is scheduled for temporary pacemaker insertion is to use battery-powered equipment. This is because temporary pacemakers are powered by an external power source, typically a battery pack worn by the client. Therefore, it is important for the client to be aware of this and ensure that they have access to the necessary battery-powered equipment at home for the pacemaker to function properly. The other options are not appropriate instructions for a client with a temporary pacemaker.
Question 2 of 5
A client is receiving intravenous nitroprusside (Nipride) for shock. Which adverse reactions will the nurse assess this client for when administering the infusion? Select all that apply.
Correct Answer: A
Rationale: Intravenous nitroprusside (Nipride) is a potent vasodilator commonly used in the treatment of acute hypertensive emergencies like shock. Muscle spasms are a common adverse reaction to nitroprusside infusion due to its potential to deplete intracellular thiamine stores, leading to lactic acidosis and muscle irritability. Tachycardia is not a typical adverse effect of nitroprusside; in fact, it often causes reflex bradycardia due to its vasodilatory effects. Confusion is also not a direct adverse effect of nitroprusside and is more commonly associated with medications that affect the central nervous system. Gastrointestinal bleeding is not a known adverse reaction of nitroprusside therapy. In an educational context, understanding the potential adverse reactions of medications is crucial for nurses to provide safe and effective care. By knowing the expected side effects of drugs like nitroprusside, nurses can anticipate and monitor for these reactions, intervene promptly, and ensure positive patient outcomes.
Question 3 of 5
A patient is being treated for a condition where the pituitary gland is producing an increased amount of antidiuretic hormone (ADH). What finding would the nurse most likely assess in this patient?
Correct Answer: B
Rationale: An increased amount of antidiuretic hormone (ADH) leads to the condition known as syndrome of inappropriate antidiuretic hormone (SIADH). This condition results in the kidneys absorbing more water, which leads to decreased urine output (oliguria) and concentrated urine. The increased ADH levels cause the body to retain fluid, leading to a decrease in urine output and potential complications such as hyponatremia (low sodium levels), which can be harmful. Increased facial hair growth or decreased testosterone production are not directly related to an overproduction of ADH.
Question 4 of 5
The nurse suspects that an older female patient has a health problem affecting the renal system. Which statement did the patient make that caused the nurse to come to this conclusion?
Correct Answer: D
Rationale: The statement "My doctor told me I have a slight amount of protein in my urine" suggests that the patient has proteinuria, which is a condition where abnormal amounts of protein are found in the urine. Proteinuria can be an indication of a health problem affecting the renal system, such as kidney disease or dysfunction. This made the nurse suspect that the older female patient may have an issue with her renal system. Statements A, B, and C are common experiences related to urinary habits but do not specifically point towards a renal health problem like proteinuria does.
Question 5 of 5
An older patient with heart failure is prescribed digoxin (Lanoxin) 125 mg by mouth three times a week. What action should the nurse take regarding this prescribed medication?
Correct Answer: C
Rationale: For an older patient with heart failure prescribed digoxin (Lanoxin) 125 mcg by mouth three times a week, the nurse should administer the drug as prescribed while monitoring for manifestations of toxicity. Digoxin is a medication commonly used in heart failure, but it has a narrow therapeutic index, meaning that the difference between a therapeutic dose and a toxic dose is small. Older patients are more susceptible to digoxin toxicity due to age-related changes in pharmacokinetics and pharmacodynamics, as well as potential comorbidities. Therefore, close monitoring for signs and symptoms of digoxin toxicity, such as nausea, vomiting, visual disturbances, and cardiac arrhythmias, is essential. It is important for the nurse to be vigilant for any early signs of toxicity and communicate any concerns to the healthcare provider promptly.