ATI RN
Test Bank Pharmacology and the Nursing Process Questions
Question 1 of 5
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 2 of 5
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 3 of 5
The nurse is explaining the action of insulin to a newly diagnosed diabetic client. During the teaching, the nurse reviews the process of insulin secretion in the body. The nurse is correct when stating that insulin is secreted from the:
Correct Answer: C
Rationale: Rationale: 1. Insulin is a hormone produced by beta cells of the pancreas. 2. Beta cells are responsible for monitoring blood glucose levels and secreting insulin in response to high glucose levels. 3. Insulin helps regulate blood glucose by facilitating glucose uptake into cells. 4. Adenohypophysis secretes other hormones, not insulin. 5. Alpha cells of the pancreas secrete glucagon, not insulin. 6. Parafollicular cells of the thyroid secrete calcitonin, not insulin. Summary: Choice C is correct because insulin is indeed secreted from the beta cells of the pancreas. Choices A, B, and D are incorrect as they do not secrete insulin or are related to other hormones.
Question 4 of 5
The nurse is assigned to care for a postoperative client who has diabetes mellitus. During the assessment interview, the client reports that he’s impotent and says he’s concerned about its effect on his marriage. In planning this client’s care, the most appropriate intervention would be to:
Correct Answer: D
Rationale: The correct answer is D: Suggest referral to a sex counselor or other appropriate professional. This is the most appropriate intervention as it addresses the client's concern about impotence affecting his marriage by offering specialized help from a professional who can provide counseling and guidance on managing sexual issues related to diabetes. Referring the client to a sex counselor ensures that he receives expert support in addressing his specific concerns and helps improve his overall well-being and quality of life. A: Encouraging the client to ask questions about personality sexuality may not address the underlying issue of impotence and its impact on the marriage. B: Providing time for privacy is important but may not directly address the client's concerns about impotence. C: Providing support for the spouse or significant other is beneficial, but the primary focus should be on addressing the client's specific concerns about impotence.
Question 5 of 5
The Glasgow coma scale is used to .evaluate the level of consciousness in the neurological and neurological patients. The three assessment factors included in this scale are:
Correct Answer: C
Rationale: The correct answer is C: Eye opening, verbal response, motor response. The Glasgow Coma Scale assesses a patient's level of consciousness using these three factors. Eye opening measures arousal, verbal response assesses communication abilities, and motor response evaluates motor function. In the case of J.E., since he is alert and oriented, his eye opening is intact. His ability to communicate verbally and move his limbs appropriately would be crucial in determining his neurological status. Choices A and B are incorrect as they do not include the necessary assessment factor of eye opening. Choice D is incorrect as it mentions "response to pain" instead of verbal response, which is a key component of the Glasgow Coma Scale.