ATI RN
Pharmacology and the Nursing Process 10th Edition Test Bank Questions
Question 1 of 9
A client who is receiving a blood transfusion begins to experience chills, shortness of breath, nausea, excessive perspiration, and a vague sense of uneasiness. What is the nurse’s first best action?
Correct Answer: D
Rationale: The correct answer is D: Stop the infusion. This is the best action because the client is likely experiencing a transfusion reaction. Stopping the infusion immediately is crucial to prevent further complications. Reporting the signs and symptoms to the healthcare provider (A) can cause a delay in addressing the reaction. While monitoring vital signs (B) and assessing respiratory status (C) are important, stopping the infusion takes precedence to ensure the client's safety and prevent a severe reaction.
Question 2 of 9
On a visit to the gynecologist, a client complains of urinary frequency, pelvic discomfort, and weight loss. After a complete physical examination, blood studies, and a pelvic examination with a Papanicolaou test, the physician diagnoses stage IV ovarian cancer. The nurse expects to prepare the client for which initial treatment?
Correct Answer: C
Rationale: The correct initial treatment for stage IV ovarian cancer is major surgery (Choice C). This is because at this advanced stage, surgery is typically performed to debulk the tumor and remove as much cancerous tissue as possible, followed by chemotherapy to target any remaining cancer cells. Radiation therapy (Choice A) is not typically the initial treatment for ovarian cancer. Chemotherapy (Choice B) is often used in combination with surgery, but surgery is usually the first line of treatment for stage IV disease. Choosing no treatment (Choice D) would be detrimental as the cancer is advanced and requires immediate intervention.
Question 3 of 9
A 17-year-old student enters the emergency department with a nosebleed that won’t quit. Which of the following positions is recommended for the patient with a nosebleed?
Correct Answer: D
Rationale: The correct answer is D: Sitting up leaning slightly forward. This position helps prevent blood from flowing back into the throat, reducing the risk of choking and aspiration. It also allows for better drainage of blood out of the nose. Lying down with feet elevated (choice A) can increase blood flow to the head and worsen the nosebleed. Sitting up with neck extended (choice B) can lead to blood flowing into the throat. Lying down with a small pillow under the head (choice C) may cause blood to flow backward.
Question 4 of 9
Bacterial meningitis alters intracranial physiology, causing:
Correct Answer: D
Rationale: The correct answer is D. Bacterial meningitis alters intracranial physiology by causing cerebral edema, raised intracranial pressure, and increased permeability of the blood-brain barrier. Cerebral edema is the accumulation of fluid in the brain tissue, leading to increased pressure. Raised intracranial pressure occurs due to the inflammation and swelling caused by the infection. Increased permeability of the blood-brain barrier allows substances to pass through that would normally be blocked, contributing to the inflammatory response. Therefore, all of these changes are interconnected and commonly observed in bacterial meningitis cases. Choices A, B, and C individually describe specific alterations seen in bacterial meningitis but do not encompass the full spectrum of changes that occur, making them incorrect options.
Question 5 of 9
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.
Question 6 of 9
A nurse adds a nursing diagnosis to a patient’s care plan. Which information did the nurse document?
Correct Answer: A
Rationale: The correct answer is A because it follows the correct format of a nursing diagnosis: "Problem related to Etiology." In this case, "Decreased cardiac output" is the problem, and "altered myocardial contractility" is the cause. This format helps identify the specific issue and its underlying cause, allowing for targeted interventions. Choice B is incorrect as it doesn't follow the problem-etiology format and lacks specificity. Choice C is also incorrect as it lacks a clear nursing diagnosis and specific etiology. Choice D is incorrect as it presents a symptom rather than a nursing diagnosis with an associated cause. Overall, choice A is the best option as it provides a clear, specific nursing diagnosis that guides appropriate nursing interventions.
Question 7 of 9
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 8 of 9
In which of the ff clients will an MRI scan be contraindicated?
Correct Answer: B
Rationale: The correct answer is B: Clients with metal implants in their body. An MRI uses strong magnetic fields, which can interact with metal implants, causing movement or heating of the metal and potential harm to the client. This could lead to serious injuries or complications during the scan. Overweight clients (choice A), clients over the age of 60 (choice C), and clients with brain tumors (choice D) do not have contraindications for an MRI scan.
Question 9 of 9
A client with cancer is scheduled for radiation therapy. The nurse knows that radiation at any treatment site may cause a certain adverse effect. Therefore, the nurse should prepare the client to expect:
Correct Answer: A
Rationale: The correct answer is A: Hair loss. Radiation therapy targets fast-growing cancer cells, which can also affect healthy cells such as those in hair follicles, leading to hair loss. This adverse effect occurs commonly with radiation therapy due to its impact on rapidly dividing cells. Hair loss is a well-known side effect that clients undergoing radiation therapy are often prepared for. The other choices, B: Fatigue, C: Stomatitis, and D: Vomiting, are also potential side effects of radiation therapy, but hair loss is specifically associated with radiation treatment due to its effect on hair follicles. Fatigue is a common side effect of cancer treatment in general, stomatitis is more commonly associated with chemotherapy, and vomiting can be a side effect of radiation but is not as directly linked as hair loss.