ATI RN
Pharmacology and the Nursing Process 10th Edition Test Bank Questions
Question 1 of 5
Nurse Raymond is giving instructions to an elderly client on diabetic foot care. Which teaching is not part of foot care?
Correct Answer: C
Rationale: The correct answer is C because washing feet in hot water can lead to burns or skin damage for those with diabetes. A: Proper footwear is essential for preventing foot injuries. B: Trimming toenails straight across helps prevent ingrown nails. D: Wearing shoes on hot surfaces prevents burns or blisters. Overall, C is incorrect due to the potential harm it can cause to diabetic feet.
Question 2 of 5
Which of the following nursing interventions will help prevent a further increase in ICP?
Correct Answer: C
Rationale: Elevating the head of the bed is the correct answer because it helps to promote venous drainage, reduce cerebral edema, and decrease intracranial pressure (ICP). By positioning the patient with the head elevated, gravity assists in preventing further increases in ICP. Encouraging fluids may lead to fluid overload and exacerbate cerebral edema. Providing physical therapy and frequent repositioning may increase ICP by causing unnecessary movement and potential strain on the patient's head and neck.
Question 3 of 5
A patient was diagnosed with hiatal hernia. She frequently has regurgitation and a sour taste on his mouth especially after eating large meals. Which action by the client shows understanding of her treatment regimen?
Correct Answer: D
Rationale: The correct answer is D: avoid caffeine, alcohol, and chocolate. This helps to reduce acid reflux symptoms associated with hiatal hernia. Caffeine, alcohol, and chocolate can relax the lower esophageal sphincter, leading to increased reflux. Elevating legs (choice
A) does not address the underlying issue. Drinking more fluids (choice
B) can exacerbate symptoms by increasing stomach volume. Increasing roughage (choice
C) may worsen symptoms due to increased gastric distension. By avoiding triggers like caffeine, alcohol, and chocolate, the client can effectively manage her symptoms.
Question 4 of 5
A nurse is collecting information from a client with dementia. The client’s daughter accompanies the client. Which of the following statements by the nurse would recognize the client’s value as an individual?
Correct Answer: C
Rationale: The correct answer is C because it acknowledges the client's value as an individual by directly addressing them and asking about their own self-care practices, which respects their autonomy and personhood.
Choice A focuses on the client's father rather than the client themselves.
Choice B addresses the daughter, not the client, and implies a lack of prioritization of the client's needs.
Choice D is dismissive and does not recognize the client's capacity to communicate, undermining their dignity.
Question 5 of 5
A client is admitted with a serum glucose of 618mg/dl. The client is awake and oriented, with hot, dry skin; a temperature of 100.6F (38.1 C); a heart rate of 116beats/min; and a blood pressure of 108/70mmHg. Based on these findings, which nursing diagnosis takes highest priority?
Correct Answer: A
Rationale: The correct answer is A: Deficient fluid volume related to osmotic diuresis. With a serum glucose level of 618mg/dl, the client is likely experiencing diabetic ketoacidosis, leading to excessive urination (osmotic diuresis) and dehydration. The priority is to address fluid volume deficit to prevent hypovolemic shock. The other options are not the priority because: B: Decreased cardiac output is a result of the increased heart rate, not the primary issue. C: Imbalanced nutrition is important but not as urgent as fluid volume deficit. D: Ineffective thermoregulation is a concern but not the priority in this scenario.