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:

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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 question would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea?

Correct Answer: B

Rationale: The correct answer is B because asking about the frequency of bowel movements is crucial in assessing diarrhea, a common symptom. This information helps determine the severity and duration of the condition, guiding the nurse in identifying potential causes and appropriate interventions. Choice A focuses on the cause of upset stomach, not specifically diarrhea. Choice C is more related to incontinence rather than diarrhea. Choice D is important but not directly related to establishing a nursing diagnosis for diarrhea. Therefore, Choice B is the most appropriate question to assist in accurately assessing and diagnosing diarrhea.

Question 3 of 9

The physician orders furosemide (Lasix) 40 mg IV STAT for an acutely fluid-overloaded patient. Why was the IV route likely chosen?

Correct Answer: B

Rationale: The correct answer is B: IV is the route of choice for rapid administration. IV route allows for quick onset of action, crucial in acutely fluid-overloaded patients needing immediate diuresis. Option A is incorrect as furosemide can be given orally too. Option C is less relevant in this urgent situation where speed is key. Option D is also incorrect as the side effects are not determined by route of administration.

Question 4 of 9

The nurse is intervening for a family member with role strain. Which direct care nursing intervention is most appropriate?

Correct Answer: B

Rationale: The correct answer is B: Counseling about respite care options. This intervention is most appropriate as it addresses the issue of role strain by providing the family member with support and options for temporary relief from caregiving responsibilities. Respite care allows the family member to take a break and recharge, reducing stress and preventing burnout. A: Assisting with activities of daily living is important but may not directly address the underlying issue of role strain. C: Teaching range-of-motion exercises is beneficial for physical well-being but does not directly address the emotional and psychological impact of role strain. D: Consulting with a social worker may be helpful for additional support but may not provide immediate relief or practical solutions for the family member's role strain.

Question 5 of 9

A client with end-stage acquired immunodeficiency syndrome (AIDS) has profound manifestations of Cryptosporidium infection caused by the protozoa. In planning the client’s care, the nurse should focus on his need for:

Correct Answer: C

Rationale: The correct answer is C: Fluid replacement. In end-stage AIDS with Cryptosporidium infection, the client experiences severe diarrhea leading to dehydration and electrolyte imbalances. Fluid replacement is crucial to prevent hypovolemia and maintain electrolyte balance. Adequate hydration supports renal function, prevents further complications, and aids in the elimination of the infectious agent. Pain management (A) may be needed for discomfort but is not the priority. Antiretroviral therapy (B) is essential for managing HIV but does not directly address the immediate issue of dehydration. High-calorie intake (D) is important for overall nutrition but does not address the urgent need for fluid replacement in this situation.

Question 6 of 9

The cause of death of most AIDS patients who develop multiple opportunistic infections is/are the following: a.Weakened immune system impairs response to therapy

Correct Answer: A

Rationale: Rationale for Correct Answer (A): Most AIDS patients with multiple opportunistic infections die due to a weakened immune system impairing response to therapy. When the immune system is compromised, the body struggles to fight off infections effectively, even with treatment. This results in the infections becoming more severe and ultimately leading to death. Summary of Other Choices: B: Weakened immune system impairs resistance to infection - While this is true, it doesn’t directly address the cause of death in AIDS patients with multiple infections. C: Infection cannot be treated effectively - This is not entirely accurate as infections can be treated, but the weakened immune system hinders the response to treatment. Overall, Choice A is the most accurate as it directly links the weakened immune system to the inability to respond effectively to therapy, leading to fatal outcomes.

Question 7 of 9

When assessing a client with a disorder of the hematopoietic or the lymphatic, why is it important for the nurse to obtain a dietary history?

Correct Answer: A

Rationale: The correct answer is A because compromised nutrition can lead to deficiencies in essential nutrients required for the production of blood cells and hemoglobin. Iron, vitamins, and minerals obtained from food are crucial for erythropoiesis and maintaining a healthy immune system. Without these nutrients, the body may struggle to produce an adequate amount of healthy red blood cells, leading to anemia and compromised immune function. Choice B is incorrect because excessive fat in the diet is not directly linked to interfering with the production of blood cells and hemoglobin. Choice C is incorrect as inconsistent dieting may affect overall health but is not specifically related to hematopoiesis. Choice D is incorrect because while iron and protein are important for blood cell production, excessive amounts of these elements are unlikely to interfere with the production of blood cells and hemoglobin.

Question 8 of 9

Antimetabolites are a diverse group of antineoplastic agents that interfere with various metabolic actions of the cell. The mechanism of action of antimetabolites interferes with:

Correct Answer: D

Rationale: The correct answer is D because antimetabolites interfere with the synthesis of nucleic acids (RNA and/or DNA), affecting multiple stages of RNA and DNA synthesis. This disruption hinders cell division and leads to cell death. Choices A and B are incorrect because antimetabolites do not specifically target cell division during the M phase or normal cellular processes during the S phase. Choice C is also incorrect because antimetabolites primarily target nucleic acid synthesis rather than altering the chemical structure of DNA or the binding between DNA molecules.

Question 9 of 9

Before, during and after seizure. The nurse knows that the patient is ALWAYS placed in what position?

Correct Answer: C

Rationale: The correct answer is C: Side lying position. This position helps prevent aspiration of secretions and promotes drainage from the mouth during and after a seizure. Placing the patient in a side lying position also helps prevent injury from falling and facilitates monitoring of the patient's airway. Incorrect choices: A: Low fowler's - This position does not provide optimal airway protection and may increase the risk of aspiration during a seizure. B: Modified trendelenburg - This position may worsen the patient's airway patency and does not facilitate drainage of secretions. D: Supine - Placing the patient in a supine position can lead to aspiration and compromise the airway, especially during a seizure. Summary: The side lying position is the most appropriate choice as it ensures airway protection, facilitates drainage, and reduces the risk of aspiration during and after a seizure.

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