ATI RN
Concepts for Nursing Practice 3rd Edition Test Bank Questions
Question 1 of 5
The nurse is assessing a client who is in the third trimester of pregnancy. Which finding would require immediate intervention by the nurse?
Correct Answer: A
Rationale: A blood pressure of 142/92 mmHg in a client in the third trimester of pregnancy is elevated and could indicate the development of preeclampsia, a serious hypertensive disorder that can have adverse effects on both the mother and the fetus. Preeclampsia is characterized by high blood pressure accompanied by signs of organ damage, such as proteinuria and changes in other laboratory values. Immediate intervention is required in this situation, as preeclampsia can lead to complications such as seizures (eclampsia), stroke, and placental abruption. It is essential for the nurse to further assess the client and notify the healthcare provider promptly for appropriate management.
Question 2 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 3 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 4 of 5
During an assessment, the nurse decides to assess a patient’s calcium level. Which action will the nurse take to identify a low calcium level?
Correct Answer: C
Rationale: The Trousseau’s sign test is used to identify low calcium levels in a patient. This test involves inflating a blood pressure cuff on the patient's arm above systolic pressure for a few minutes, which can trigger a carpal spasm (wrist and hand flexion) in patients with low calcium levels (hypocalcemia). This is due to increased neuromuscular irritability caused by low calcium levels. Therefore, conducting a Trousseau’s sign test is the appropriate action to identify a low calcium level in a patient. Palpating turgor of skin, observing the color of the skin, and saving urine to measure 17-ketosteroids are not relevant actions for assessing calcium levels.
Question 5 of 5
A patient has been vomiting for 4 hours. Which hormone will increase secretion in response to the physiologic changes caused by the vomiting?
Correct Answer: D
Rationale: Vomiting can lead to dehydration and electrolyte imbalances due to the loss of fluids and electrolytes. In response to these physiologic changes caused by vomiting, aldosterone secretion will increase. Aldosterone is a hormone produced by the adrenal glands that acts on the kidneys to increase reabsorption of sodium and water, helping to maintain blood pressure and electrolyte balance. By increasing aldosterone secretion, the body aims to retain more sodium and water to counteract the effects of vomiting and prevent dehydration.