ATI RN
Test Bank Pharmacology and the Nursing Process Questions
Question 1 of 9
A 16 y.o. girl is diagnosed with genital herpes. She is tearful and as she asks what she can do to prevent complications of the disease. Based on the data provided, which nursing diagnosis is appropriate for her plan of care?
Correct Answer: A
Rationale: The correct answer is A: Risk for transmission of infection. This is appropriate because the girl has genital herpes, which is a sexually transmitted infection (STI) that can be transmitted to others through sexual contact. Therefore, the main concern is preventing the spread of the infection to others. Pain (B) is a symptom of herpes but not the primary concern here. Health-seeking behaviors (C) may be relevant for education and prevention, but not the immediate focus. Ineffective sexuality pattern (D) is not directly related to the risk of transmission of infection in this case.
Question 2 of 9
A 39-year old male client underwent Transurethral Resection of the Prostate (TURP) eight hours ago and asks the nurse, “Why is my urine in the bag clotting like blood?” The nurse’s best interpretation of this finding is that:
Correct Answer: A
Rationale: The correct answer is A: after the surgery, bleeding is normal. This is because after a TURP procedure, it is common for some bleeding to occur, leading to blood clots in the urine bag. The surgical site undergoes trauma, causing bleeding as a part of the healing process. Choice B is incorrect because while irrigation may be done post-surgery, blood clots in the urine bag are expected due to the surgery itself, not just irrigation. Choice C is incorrect as it is normal for some bleeding to occur after TURP, and immediate physician intervention is not necessary unless excessive bleeding is observed. Choice D is incorrect as tugging on the catheter may cause bleeding, but in this case, the presence of blood clots is likely due to the surgery itself, not catheter irritation.
Question 3 of 9
A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data?
Correct Answer: D
Rationale: The correct answer is D because "Unable to palpate femoral pulse in left leg" is an objective finding that can be measured or observed without interpretation or bias. It provides concrete, measurable information about the patient's condition. Choices A, B, and C are subjective data as they rely on the patient's feelings, emotions, and perceptions, which can vary and are open to interpretation. Objective data is crucial in making accurate assessments and decisions in healthcare.
Question 4 of 9
The nurse is instructing a premenopausal woman about breast self-examination. The nurse should tell the client to do her self-examination:
Correct Answer: C
Rationale: Correct Answer: C - The nurse should tell the client to do her self-examination on the same day each month to establish a routine, making it easier to remember and detect any changes. This consistency helps in early detection of abnormalities. Incorrect Choices: A: Doing it at the end of the menstrual cycle may not be consistent due to varying cycle lengths. B: Doing it on the 1st day of the menstrual cycle may not be practical and could lead to missing potential abnormalities. D: Doing it immediately after her menstrual period may not provide a consistent schedule for self-examination.
Question 5 of 9
On the third day after a partial thyroidectomy, a client exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life- threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?
Correct Answer: A
Rationale: Rationale: 1. Following thyroid surgery, there is a risk of damaging the parathyroid glands, leading to hypocalcemia. 2. Symptoms of hypocalcemia include muscle twitching, hyperirritability, numbness, and tingling. 3. These symptoms align with the client's presentation, indicating a probable electrolyte imbalance. 4. Hypocalcemia is a common complication post-thyroidectomy due to parathyroid gland damage. 5. Prompt recognition and treatment of hypocalcemia are essential to prevent severe complications. Summary: B: Hyperkalemia - Not typically associated with thyroid surgery, symptoms differ. C: Hyponatremia - Unlikely post-thyroidectomy, symptoms don't match presentation. D: Hypermagnesemia - Rare post-thyroidectomy, symptoms and electrolyte disturbance don't align.
Question 6 of 9
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.
Question 7 of 9
A client is admitted to the ICU, which laboratory result must be reported immediately to the physician?
Correct Answer: C
Rationale: The correct answer is C: platelets 18,000. A critically low platelet count can lead to life-threatening bleeding in the ICU. Normal platelet count ranges from 150,000 to 450,000. A count of 18,000 indicates severe thrombocytopenia. Immediate reporting is crucial for prompt intervention. Rationale for why other choices are incorrect: A: Hematocrit of 48% is within normal range (male: 42-52%, female: 37-47%). B: paCO2 of 38 mm Hg is within normal range (35-45 mm Hg). D: WBC count of 8000 is within normal range (4000-11000/uL). In critical care settings, it is vital to prioritize and address life-threatening conditions promptly, hence the urgent need to report the critically low platelet count.
Question 8 of 9
A nurse is providing education to a client with newly diagnosed hypertension about the importance of adhering to prescribed medications. Which phase of the nursing process does this activity represent?
Correct Answer: C
Rationale: The correct answer is C: Implementation. In the nursing process, implementation involves carrying out the care plan, interventions, and education that were determined during the planning phase. Providing education to a client about the importance of adhering to prescribed medications falls under this phase as it involves putting the plan into action to promote positive health outcomes. Assessment (A) involves collecting data about the client's condition, Planning (B) involves developing a care plan based on the assessment findings, and Evaluation (D) involves assessing the effectiveness of the interventions implemented.
Question 9 of 9
A patient is admitted for a splenectomy. Why is an injection of Vit. K ordered before surgery?
Correct Answer: A
Rationale: Step 1: Vitamin K is essential for the synthesis of clotting factors in the liver. Step 2: A splenectomy increases the risk of bleeding due to decreased platelet sequestration. Step 3: Preoperative Vitamin K injection helps correct any clotting deficiencies. Summary: - Choice B is incorrect as Vitamin K does not prevent infection. - Choice C is incorrect as Vitamin K does not directly promote healing. - Choice D is incorrect as Vitamin K does not dry secretions.