ATI RN
Pharmacology and the Nursing Process 9th Edition Test Bank Questions
Question 1 of 5
In an individual with Sjogren’s syndrome, nursing care should focus on:
Correct Answer: A
Rationale: The correct answer is A: Moisture replacement. Sjogren's syndrome is an autoimmune disorder that primarily affects the moisture-producing glands, leading to dryness in the eyes, mouth, and other mucous membranes. Nursing care should focus on managing these symptoms by providing moisture replacement through artificial tears, lubricating eye drops, and hydrating mouthwashes. This helps prevent complications such as corneal damage and dental issues. Nutritional supplementation (
B) may be needed if there are difficulties in eating due to dry mouth, but it is not the primary focus. Electrolyte balance (
C) and arrhythmia management (
D) are not directly related to the symptoms of Sjogren's syndrome and are therefore not the main priorities in nursing care for this condition.
Question 2 of 5
For the first 72 hours thyroidectomy surgery, the nurse would assess the client for Chvostek’s sign and Trousseau’s sign because they indicate which of the following?
Correct Answer: A
Rationale: The correct answer is A: Hypocalcemia. Chvostek's sign and Trousseau's sign are both indicators of hypocalcemia, which is a common complication following thyroidectomy surgery due to potential damage to the parathyroid glands. Chvostek's sign is elicited by tapping the facial nerve and observing facial muscle twitching, while Trousseau's sign involves carpal spasm induced by inflating a blood pressure cuff above systolic pressure. Both signs are sensitive indicators of hypocalcemia due to their association with neuromuscular irritability. Hypercalcemia (option
C) and hyperkalemia (option
D) are not typically associated with thyroidectomy surgery and would not present with these specific signs. Hypokalemia (option
B) is not related to Chvostek's sign and Trousseau's sign.
Question 3 of 5
Which question would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea?
Correct Answer: B
Rationale: The correct answer is B because asking about the frequency of bowel movements is crucial in assessing diarrhea, a common symptom. This information helps determine the severity and duration of the condition, guiding the nurse in identifying potential causes and appropriate interventions.
Choice A focuses on the cause of upset stomach, not specifically diarrhea.
Choice C is more related to incontinence rather than diarrhea.
Choice D is important but not directly related to establishing a nursing diagnosis for diarrhea.
Therefore,
Choice B is the most appropriate question to assist in accurately assessing and diagnosing diarrhea.
Question 4 of 5
The nurse is caring for a client with bronchogenic carcinoma. Which nursing diagnosis takes highest priority?
Correct Answer: B
Rationale: The correct answer is B: Ineffective airway clearance related to obstruction by a tumor or secretions. This is the highest priority because compromised airway clearance can lead to life-threatening complications such as respiratory distress or hypoxia. Ensuring effective airway clearance is crucial in preventing respiratory compromise and maintaining oxygenation.
Choices A, C, and D are not the highest priority because they do not directly address the immediate risk to the client's physiological well-being. Treating disturbed body image, anxiety, or imbalanced nutrition are important but can be addressed after ensuring the client's airway is clear and they are able to breathe effectively.
Question 5 of 5
A few minutes after beginning a blood transfusion, the nurse notes that the client has chills, dyspnea, and urticaria. The nurse reports this to the physician immediately because the client probably is experiencing which problem?
Correct Answer: A
Rationale: The correct answer is A: A hemolytic reaction to mismatched blood. Chills, dyspnea, and urticaria are indicative of a hemolytic transfusion reaction, which occurs when the recipient's immune system attacks the donor's red blood cells. This can lead to various symptoms, including fever, chills, difficulty breathing, and hives. This type of reaction is most commonly seen with mismatched blood types.
Option B (A hemolytic reaction to Rh-incompatible blood) is incorrect because Rh incompatibility typically leads to hemolytic disease of the newborn, not an immediate transfusion reaction. Option C (A hemolytic allergic reaction caused by bacterial contamination of donor blood) is incorrect as bacterial contamination would present with symptoms such as fever and sepsis, not chills, dyspnea, and urticaria. Option D (None of the above) is incorrect as the symptoms presented align with a hemolytic transfusion reaction.