ATI RN
Pharmacology and the Nursing Process 9th Edition Test Bank Questions
Question 1 of 9
A client with ascites has a paracentesis, and 1500 ml of fluid is removed. Immediately following the procedure it is most important for the nurse to observe for:
Correct Answer: A
Rationale: The correct answer is A: A rapid, thready pulse. After paracentesis, rapid removal of ascitic fluid can lead to a decrease in intravascular volume, causing hypovolemia and subsequent compensatory mechanisms like tachycardia (rapid pulse). This is a crucial sign that the nurse should monitor for early detection of hypovolemia. B: Decreased peristalsis is not directly related to paracentesis and is not an immediate concern post-procedure. C: Respiratory congestion is not a common complication of paracentesis and is not the most immediate concern. D: An increased temperature is not a typical response to paracentesis and is not a priority observation post-procedure.
Question 2 of 9
Which of the following is a discharge criterion from the PACU for a patient following surgery?
Correct Answer: A
Rationale: The correct answer is A: Oxygen saturation above 90%. This is a discharge criterion because adequate oxygen saturation indicates the patient is breathing well and there is no immediate respiratory compromise. Oxygen saturation below 90% (choice C) would indicate hypoxemia and would not be safe for discharge. IV narcotics given less than 15 minutes ago (choice B) can still be in effect and may impair the patient's ability to function post-surgery. IV narcotics given less than 30 minutes ago (choice D) is a longer timeframe but still not ideal for discharge as the effects of the narcotics may not have fully worn off.
Question 3 of 9
Miss OB’s malignant tumor in her left breast was discovered to be spreading all over the surrounding and adjacent tissue and not entering the blood stream, it would be:
Correct Answer: A
Rationale: The correct answer is A: Malignant. A malignant tumor spreading to surrounding tissues indicates invasive growth, characteristic of malignancy. It is aggressive and can invade nearby structures. Non-malignant tumors are localized and do not invade surrounding tissues. Benign tumors are non-invasive and do not spread to other parts of the body. Choice D is incorrect because a tumor spreading to surrounding tissues is indicative of malignancy, not benignity.
Question 4 of 9
Several days before admission, a client reports finding a small lump in the left breast near the nipple. What should the nurse tell the client to do?
Correct Answer: A
Rationale: The correct answer is A: Inform the physician immediately. This is important because finding a lump in the breast could be a sign of breast cancer, so prompt medical evaluation is crucial. Checking after the next menstrual cycle (B) may delay diagnosis and treatment. Squeezing the nipple (C) can cause harm and is not a reliable method for assessing a lump. Using a heating pad (D) is not recommended as it may mask symptoms and delay proper evaluation. Early detection and intervention are key in improving outcomes for breast cancer.
Question 5 of 9
In an individual with Sjogren’s syndrome, nursing care should focus on:
Correct Answer: A
Rationale: The correct answer is A: Moisture replacement. Sjogren's syndrome is an autoimmune disorder that primarily affects the moisture-producing glands, leading to dryness in the eyes, mouth, and other mucous membranes. Nursing care should focus on managing these symptoms by providing moisture replacement through artificial tears, lubricating eye drops, and hydrating mouthwashes. This helps prevent complications such as corneal damage and dental issues. Nutritional supplementation (B) may be needed if there are difficulties in eating due to dry mouth, but it is not the primary focus. Electrolyte balance (C) and arrhythmia management (D) are not directly related to the symptoms of Sjogren's syndrome and are therefore not the main priorities in nursing care for this condition.
Question 6 of 9
Which of the ff. nursing interventions would have the highest priority in the plan of care for the postoperative eye patient?
Correct Answer: C
Rationale: The correct answer is C: Report sudden onset of acute pain. This is the highest priority because sudden onset of acute pain postoperatively can indicate a serious complication such as hemorrhage or infection. Prompt reporting allows for timely intervention to prevent further complications. A: Do not leave the patient unattended at any time - While important for safety, it is not the highest priority compared to addressing sudden onset of acute pain. B: Teach the patient not to bend over - Important for preventing complications postoperatively, but not as urgent as addressing sudden onset of acute pain. D: Apply sandbags to either side of the head - This intervention is not typically indicated for postoperative eye patients and would not address the potential serious complication of sudden onset of acute pain.
Question 7 of 9
Nursing measures in hemodynamic monitoring include assessing for localized ischemia owing to inadequate arterial flow. The nurse should:
Correct Answer: D
Rationale: The correct answer is D because assessing for localized ischemia involves evaluating multiple factors. A: Assessing color and temperature helps determine perfusion. B: Checking capillary refill assesses circulation. C: Evaluating pulse rate indicates cardiac output. Doing all of the above provides a comprehensive assessment of arterial flow and potential ischemia. Other choices are incorrect as they do not cover all aspects necessary for a thorough assessment.
Question 8 of 9
Mang Simon, a hypertensive male client was prescribed with an exercise program. Which intervention would help Mang Simon in maintaining this program?
Correct Answer: D
Rationale: The correct answer is D: Doing it according to his needs and abilities. This option is the most appropriate intervention for Mang Simon to maintain his exercise program. By tailoring the program to his needs and abilities, Mang Simon is more likely to adhere to it and prevent any potential injuries or health risks associated with overexertion. This approach ensures that the exercise routine is realistic and manageable for him, increasing his chances of long-term success. A: Writing down the exercise program may be helpful for organization but does not address the individualization needed for Mang Simon's specific situation. B: Thoroughly explaining the program to his wife, Aling Nena, may provide support but does not directly impact Mang Simon's ability to maintain the program. C: Positive motivation is important, but it alone may not be sufficient to address the practical aspects of adapting the exercise program to Mang Simon's needs and abilities.
Question 9 of 9
Mr. Garcia, a 41-year old chronic alcohol drinker is admitted to the hospital after vomiting bright red blood. He was diagnosed to have a bleeding gastric ulcer and suddenly develops sudden sharp pain in the midepigastric region with a rigid boardlike abdomen. This likely indicates:
Correct Answer: C
Rationale: The sudden sharp pain in the midepigastric region with a rigid boardlike abdomen in a patient with a bleeding gastric ulcer indicates a perforation of the ulcer. Perforation leads to leakage of gastric contents into the peritoneal cavity, causing peritonitis. This presentation requires immediate surgical intervention. Option A is incorrect as intestinal development does not correlate with the symptoms described. Option B is incorrect because inflammation of the esophagus would not lead to a rigid boardlike abdomen. Option D is incorrect as the sudden onset of symptoms is more indicative of a complication like perforation rather than the development of additional ulcers.