ATI RN
Test Bank Pharmacology and the Nursing Process Questions
Question 1 of 5
Why should the nurse closely monitor a client to ensure that the venous access device remains in the vein during a transfusion?
Correct Answer: B
Rationale: The correct answer is B: It minimizes the risk of circulatory overload. When a venous access device dislodges during a transfusion, there is a risk of the infusion going into the surrounding tissues instead of the vein, leading to circulatory overload. This can result in fluid overload and potentially lead to serious complications such as heart failure. Monitoring the device ensures that the medication is delivered safely and effectively into the bloodstream.
Choices A, C, and D are incorrect:
A: Monitoring the device does not directly minimize the risk of phlebitis, which is inflammation of the vein.
C: Monitoring the device does not directly minimize the risk of pulmonary complications, which are not typically associated with a dislodged venous access device.
D: Monitoring the device does not directly minimize the risk of localized edema embolism, which is a blockage caused by a blood clot, air bubble, or other material in a blood vessel.
Question 2 of 5
What part of the nursing diagnosis statement suggests the nursing interventions to be included in the plan of care?
Correct Answer: C
Rationale: The correct answer is C: Etiology of the problem. In a nursing diagnosis statement, the etiology describes the underlying cause or contributing factors to the identified problem. This is crucial as it guides the selection of appropriate nursing interventions aimed at addressing the root cause of the issue. By addressing the etiology, nurses can implement interventions that will effectively treat the problem.
Choice A (Problem statement) simply identifies the issue without providing insight into its cause.
Choice B (Defining characteristics) lists the signs and symptoms of the problem but doesn't directly inform the interventions needed.
Choice D (Outcomes criteria) outlines the expected results of the interventions but doesn't directly suggest which interventions to implement. Thus, C is the correct choice as it directly influences the selection of appropriate nursing interventions.
Question 3 of 5
Which of the ff instructions should a nurse give a client with Hodgkin’s disease who is at risk of impaired skin integrity? Choose all that apply
Correct Answer: B
Rationale:
Step 1: Keeping the neck in midline helps prevent compression of the lymphatic vessels in the neck, reducing the risk of impaired skin integrity in Hodgkin's disease.
Step 2: This position also helps maintain proper blood flow and lymphatic drainage in the neck area.
Step 3: Trimming nails short, using mild soap, and supporting bony prominences are not directly related to preventing impaired skin integrity in Hodgkin's disease.
Summary:
Choice B is correct as it directly addresses the specific risk factor of impaired skin integrity in Hodgkin's disease, while the other choices are not as relevant to this particular concern.
Question 4 of 5
Which of the ff nursing interventions is taken as a precautionary measure if shock develops when a client with a spinal cord injury is hospitalized?
Correct Answer: A
Rationale: The correct answer is A: An IV line is inserted to provide access to a vein. In shock, adequate intravenous access is crucial to administer fluids and medications rapidly. This helps stabilize the client's condition by restoring blood volume and improving circulation.
Choice B is incorrect as immobilization is not a primary intervention for shock in this scenario.
Choice C, traction, is not appropriate for managing shock but rather for stabilizing spinal cord injuries.
Choice D, using a turning frame, is not relevant to managing shock and does not address the immediate need for fluid resuscitation.
Question 5 of 5
Which of the ff. actions would the nurse include in the plan of care to reduce the symptoms of the patient who has vertigo?
Correct Answer: C
Rationale: The correct answer is C: Avoid sudden movements. Vertigo is a type of dizziness where a person feels like they're spinning or the world around them is spinning. Sudden movements can worsen vertigo symptoms. By avoiding sudden movements, the nurse can help reduce the patient's vertigo symptoms.
Avoiding noises (
A) may help with other conditions like migraines, but it is not specifically helpful for vertigo. Encouraging fluid intake (
B) is important for overall health but does not directly address vertigo symptoms. Administering analgesics (
D) may help with pain but will not address the underlying cause of vertigo.
Therefore, choosing option C is the most appropriate action to include in the plan of care for reducing vertigo symptoms.