ATI RN
Fundamental Concepts and Skills for Nursing Test Bank Questions
Question 1 of 5
How would this blood pressure be categorized for this client?
Correct Answer: C
Rationale: Based on the blood pressure categories defined by the American Heart Association, hypertension is classified as having a systolic blood pressure (top number) of 130 mm Hg or higher and/or a diastolic blood pressure (bottom number) of 80 mm Hg or higher. The client's blood pressure reading of 150/90 mm Hg falls within the range of hypertension, indicating elevated blood pressure levels that may require monitoring and/or intervention to reduce the risk of cardiovascular complications.
Question 2 of 5
The nurse caring is caring for a client who is recovering from a hysterectomy. Which clinical manifestation supports that the client is experiencing a pulmonary embolism (PE)?
Correct Answer: C
Rationale: Pulmonary embolism (PE) is a serious condition where a blood clot travels to the lungs and blocks blood flow, which can be life-threatening. Common clinical manifestations of PE include sudden onset of dyspnea (difficulty breathing), chest pain (sharp, stabbing pain that may worsen with deep breaths), tachypnea (rapid breathing), tachycardia (rapid heart rate), and possibly cough or hemoptysis (coughing up blood). In the context of a client recovering from a hysterectomy, it is crucial to recognize the signs of PE as early intervention is essential to prevent serious complications. Nausea, decreased urine output, and activity intolerance are not typical clinical manifestations of a pulmonary embolism and should not be the primary focus when suspecting a PE in this scenario.
Question 3 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 4 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 5 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.