ATI RN
Fundamental Concepts and Skills for Nursing Test Bank Questions
Question 1 of 5
What characteristic of veins increases the risk for the development of a thrombus?
Correct Answer: A
Rationale: Low blood flow in veins increases the risk for the development of a thrombus. When blood flow is slow or stagnant in veins, it can lead to the formation of blood clots or thrombi. This risk is further heightened in individuals who have conditions that affect blood flow, such as being sedentary or having a condition that impairs circulation. Thrombi can pose serious health risks if they break off and travel to other parts of the body, potentially causing blockages or even life-threatening complications like pulmonary embolism. Thus, low blood flow in veins is a key characteristic that increases the risk for thrombus formation.
Question 2 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 3 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 4 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 5 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.