Medical Surgical Nursing Concepts and Practice Test Bank

Questions 14

ATI RN

ATI RN Test Bank

Medical Surgical Nursing Concepts and Practice Test Bank Questions

Question 1 of 5

While completing a health history with an older adult client, the nurse learns that the client experienced a transient ischemic attack (TIA) several months ago. The nurse should recognize that:

Correct Answer: A

Rationale: A transient ischemic attack (TIA) is often considered a warning sign that the individual is at an increased risk for a future ischemic stroke. TIAs are brief episodes of neurological dysfunction caused by a temporary disruption in blood supply to the brain. While the symptoms of a TIA typically resolve within 24 hours, they should not be ignored as they indicate an underlying vascular issue that needs to be addressed to prevent a more severe stroke in the future. Therefore, the client is at risk for an ischemic thrombotic stroke and should receive appropriate interventions and follow-up care to manage this risk.

Question 2 of 5

The nurse is providing care to several clients on a medical-surgical unit. Which client is at highest risk for a nonthrombotic pulmonary embolism (PE)?

Correct Answer: B

Rationale: The client who is postoperative from a major surgery, such as femur fracture repair, is at the highest risk for a nonthrombotic pulmonary embolism (PE). Postoperative clients are at an increased risk due to factors such as immobility, surgical trauma, and possible venous stasis. Additionally, major orthopedic surgeries involving the lower extremities carry a higher risk of developing a PE because of the potential for blood clots to form in the veins of the legs (deep vein thrombosis) and then travel to the lungs, leading to a pulmonary embolism. Close monitoring and preventative measures, such as early ambulation, compression devices, and anticoagulant therapy, are crucial in preventing this serious complication in postoperative clients.

Question 3 of 5

A baby will be having surgery to correct a congenital heart defect. On which topic should the parents be instructed regarding the care of the child before surgery?

Correct Answer: B

Rationale: It is crucial for parents to be instructed on preventing exposure to infection before their baby's surgery to correct a congenital heart defect. Infections can pose a serious risk to individuals, especially those with preexisting medical conditions like a congenital heart defect. Infection control measures, such as handwashing, avoiding sick contacts, and keeping the environment clean, can help reduce the risk of postoperative complications due to infections. This instruction is important to help ensure the successful outcome of the baby's surgery and recovery process. It is essential for parents to be vigilant in maintaining a hygienic environment and taking necessary precautions to prevent their baby from getting sick prior to the surgery.

Question 4 of 5

The nurse is reviewing objective data obtained during the assessment of a pregnant woman in her 34th week of gestation. Which finding would be cause for concern?

Correct Answer: C

Rationale: In a pregnant woman, a hematocrit level of 24% is cause for concern as it is lower than the normal range during pregnancy. A lower than normal hematocrit level may indicate anemia in the pregnant woman, which can lead to complications for both the mother and the baby. Anemia during pregnancy can result in inadequate oxygen reaching the tissues, fatigue, increased risk of preterm birth, and low birth weight for the baby. Therefore, this finding should be further evaluated and managed promptly to ensure the well-being of the pregnant woman and her baby.

Question 5 of 5

The day following a below-the-knee amputation, the patient complains of toes cramping in the amputated foot. What should the nurse realize the patient is experiencing?

Correct Answer: D

Rationale: Phantom limb sensation is a common phenomenon where a patient perceives sensations such as cramping, itching, or pain in the limb that has been amputated. This occurs because the brain continues to receive signals from the nerves that originally innervated the amputated limb, leading to the perception of sensation in the absent body part. In this case, the patient's complaint of toes cramping in the amputated foot is indicative of phantom limb sensation rather than contractures, attention-seeking behavior, or chronic stump pain. It is important for the nurse to educate the patient about this phenomenon and provide appropriate support and reassurance.

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