ATI RN
Pharmacology and the Nursing Process 10th Edition Test Bank Questions
Question 1 of 5
A client is admitted with a serum glucose of 618mg/dl. The client is awake and oriented, with hot, dry skin; a temperature of 100.6F (38.1 C); a heart rate of 116beats/min; and a blood pressure of 108/70mmHg. Based on these findings, which nursing diagnosis takes highest priority?
Correct Answer: A
Rationale: The correct answer is A: Deficient fluid volume related to osmotic diuresis. With a serum glucose level of 618mg/dl, the client is likely experiencing diabetic ketoacidosis, leading to excessive urination (osmotic diuresis) and dehydration. The priority is to address fluid volume deficit to prevent hypovolemic shock. The other options are not the priority because: B: Decreased cardiac output is a result of the increased heart rate, not the primary issue. C: Imbalanced nutrition is important but not as urgent as fluid volume deficit. D: Ineffective thermoregulation is a concern but not the priority in this scenario.
Question 2 of 5
Mr. Dela Isla said he cannot comprehend what the nurse was saying. He suffers from:
Correct Answer: D
Rationale: The correct answer is D: Aphasia. Aphasia is a language disorder that affects a person's ability to communicate and understand speech. In this case, Mr. Dela Isla's difficulty in comprehending what the nurse was saying indicates a problem with language processing, which aligns with the symptoms of aphasia. Insomnia (A) is a sleep disorder, not related to language comprehension. Agnosia (B) is a perception disorder where someone cannot recognize objects or people, not related to language. Apraxia (C) is a motor disorder affecting the ability to perform purposeful movements, not related to language comprehension.
Question 3 of 5
While completing an admission database, the nurse is interviewing a patient who states “I am allergic to latex.” Which action will the nurse take first?
Correct Answer: B
Rationale: The correct answer is B: Ask the patient to describe the type of reaction. This is the first action the nurse should take because it helps determine the severity of the allergy and how to best proceed with care. By understanding the specific type of reaction the patient experiences, the nurse can implement appropriate precautions and interventions to prevent any adverse reactions during the patient's stay. Choice A is incorrect because placing the patient in isolation is not necessary for a latex allergy. Choice C is incorrect as terminating the interview is premature and does not address the patient's allergy. Choice D is also incorrect as documenting the allergy is important but not the first action to take when assessing a patient's allergic reaction.
Question 4 of 5
While completing an admission database, the nurse is interviewing a patient who states “I am allergic to latex.” Which action will the nurse take first?
Correct Answer: B
Rationale: The correct answer is B: Ask the patient to describe the type of reaction. This is the first action the nurse should take because it is essential to assess the severity of the latex allergy to determine the appropriate precautions and interventions. By asking the patient to describe the type of reaction, the nurse can gather crucial information to ensure patient safety. Choice A is incorrect because placing the patient in isolation is not necessary for a latex allergy. Choice C is incorrect as terminating the interview prematurely is not appropriate without gathering important information about the allergy. Choice D is incorrect because documenting the allergy is important, but assessing the type of reaction should be the initial priority.
Question 5 of 5
While completing an admission database, the nurse is interviewing a patient who states “I am allergic to latex.” Which action will the nurse take first?
Correct Answer: B
Rationale: The correct answer is B: Ask the patient to describe the type of reaction. This is the first action the nurse should take to assess the severity of the latex allergy and determine appropriate interventions. By gathering more information about the reaction, the nurse can better understand the potential risks and provide safe care. Summary of other choices: A: Immediately placing the patient in isolation is unnecessary and not indicated based solely on the patient's latex allergy. C: Proceeding to the termination phase of the interview is premature without fully assessing the patient's allergy. D: Documenting the allergy is important but should not be the first action without assessing the reaction itself.