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 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 3 of 9
Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient? The nurse determines to remove a wound dressing when the patient reveals the time
Correct Answer: A
Rationale: The correct answer is A because the nurse is using data validation by comparing the time of the last dressing change with the appearance of old and new drainage. This process ensures that the decision to remove the wound dressing is based on accurate and relevant information. By assessing both the time of the last dressing change and the characteristics of the drainage, the nurse is validating the need for the intervention. Option B is incorrect because administering pain medicine based solely on a patient's report of increased pain without further validation does not demonstrate data validation. Option C is incorrect as the nurse immediately requesting an order of potassium without further assessment of the patient's condition is not an example of data validation. Option D is incorrect as elevating a leg cast based solely on a patient's report of decreased mobility without further assessment does not involve data validation.
Question 4 of 9
Which of the following BP changes alerts the nurse to increasing ICP, and should be reported immediately?
Correct Answer: B
Rationale: The correct answer is B, Widening pulse pressure. This indicates increasing intracranial pressure (ICP) as it signifies a significant difference between systolic and diastolic blood pressure. A widening pulse pressure is a key sign of impending herniation and requires immediate intervention. A: Gradual increase does not provide a clear indication of acute changes in ICP. C: Rapid drop followed by gradual increase may suggest other conditions and is not specific to increasing ICP. D: Rapid fluctuations may occur in various scenarios and do not specifically point to increasing ICP. In summary, a widening pulse pressure is the most critical and specific indicator of increasing ICP among the choices provided.
Question 5 of 9
The nurse assesses the motor functions during a neurologic examination of a client. Which of the ff steps will help the nurse perform the examination effectively? Choose all that apply
Correct Answer: A
Rationale: Step-by-step rationale: 1. Allowing the client to grasp the nurse's hand firmly assesses grip strength and motor coordination. 2. This step helps evaluate the client's ability to follow instructions and perform a coordinated motor task accurately. 3. Assessing grip strength is essential in determining any muscle weakness or neurological deficits. 4. It also provides insight into the client's motor function and coordination abilities. Summary: - Choice B is incorrect because it focuses on sensory functions rather than motor functions. - Choice C assesses fine motor skills, not grip strength and coordination. - Choice D evaluates cognition and logic, which are not directly related to motor function assessment.
Question 6 of 9
Which nursing intervention is appropriate for the nurse to take when setting up supplies for a client who requires a blood transfusion?
Correct Answer: C
Rationale: The correct answer is C because priming the tubing of the blood administration set with 0.9% NS solution ensures that there are no air bubbles in the tubing, preventing air embolism when the blood transfusion starts. This step also ensures that the blood flows smoothly and prevents clotting in the tubing. Choice A is incorrect because adding IV medication in the blood bag can lead to incompatibility issues and should not be done without proper verification and approval. Choice B is incorrect because leaving the blood bag at room temperature for an hour can lead to bacterial growth in the blood, increasing the risk of infection when transfused. Choice D is unrelated to setting up supplies for a blood transfusion and does not address the immediate nursing intervention required in this situation.
Question 7 of 9
At 1400, the nurse notices that the dressing is saturated and leaking. What is the nurse’s next action?
Correct Answer: B
Rationale: The correct answer is B because a saturated and leaking dressing indicates a potential infection risk and compromised wound healing. The nurse should revise the plan of care and change the dressing immediately to prevent complications. Waiting until 1800 (choice A) could lead to further contamination and delay in treatment. Reassessing in 2 hours (choice C) might worsen the condition. Discontinuing the plan of care (choice D) is not appropriate without addressing the immediate issue.
Question 8 of 9
For which of the ff conditions would the use of salt tablets be considered?
Correct Answer: A
Rationale: Rationale: - Salt tablets are used for mild deficits of serum sodium to help restore electrolyte balance. - Sodium is crucial for fluid balance, nerve function, and muscle contraction. - Severe deficits of serum magnesium, potassium, and calcium require specific electrolyte replacement therapy, not salt tablets. Summary: - Choice A is correct because salt tablets are used for mild deficits of serum sodium. - Choices B, C, and D are incorrect because they involve severe deficits of different electrolytes that require specific replacement therapy.
Question 9 of 9
Just as the nurse was entering the room, the patient who was sitting on his chair begins to have a seizure. Which of the following must the nurse do first?
Correct Answer: A
Rationale: The correct answer is A: Ease the patient to the floor. This is the first step because it helps prevent injury during a seizure. Lowering the patient to the floor prevents falls and protects the patient's head. Choices B, C, and D are incorrect. Choice B can cause injury or obstruct the airway, choice C involves unnecessary movement, and choice D can lead to further harm or injury. It is crucial to prioritize safety and prevent harm during a seizure episode.