Concepts for Nursing Practice 3rd Edition Test Bank

Questions 14

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Concepts for Nursing Practice 3rd Edition Test Bank Questions

Question 1 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 2 of 5

The nurse is caring for a client admitted to the hospital with lower extremity edema and shortness of breath. Which electrocardiogram finding indicates the client is at risk for an alteration in perfusion?

Correct Answer: D

Rationale: An isoelectric ST segment on an electrocardiogram can indicate myocardial ischemia or injury, which can lead to a decrease in perfusion to the heart muscle. This finding suggests an increased risk of inadequate blood flow to the heart, potentially resulting in further complications such as a myocardial infarction or altered perfusion to other organs. In a client with lower extremity edema and shortness of breath, identifying this ECG finding is crucial for early intervention and monitoring to prevent further deterioration in perfusion status.

Question 3 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 4 of 5

The nurse is providing care to a client who has experienced several episodes of angina. Which agent does the nurse anticipate being ordered to reduce the intensity and frequency of an angina episode?

Correct Answer: C

Rationale: Nitrates are commonly prescribed for the management of angina. These agents work by dilating blood vessels, which leads to improved blood flow to the heart muscle and decreased workload on the heart. This results in reduced intensity and frequency of angina episodes by increasing oxygen supply to the heart and decreasing its demand. Nitrates can be administered sublingually, orally, or topically to provide prompt relief of chest pain during an angina episode. Thorough patient education should be provided regarding the proper use of nitrates and potential side effects.

Question 5 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.

Similar Questions

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:
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?
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