ATI RN
Pharmacology and the Nursing Process 10th Edition Test Bank Quizlet Questions
Question 1 of 5
A client with serum glucose level of 618mg/dl is admitted to the facility. He’s awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6F (38.1C), heart rate of 116 beats/min, and blood pressure of 108/70mHg. Based on these assessment findings, which nursing diagnosis take highest priority?
Correct Answer: D
Rationale: The correct answer is D, "Ineffective thermoregulation related to dehydration." The client's high serum glucose level of 618mg/dl indicates severe hyperglycemia, leading to dehydration. The client's hot, dry skin and elevated temperature can be signs of dehydration, impacting the body's ability to regulate temperature. Dehydration can also affect other vital signs, contributing to the elevated heart rate and low blood pressure. Addressing ineffective thermoregulation is crucial as it can lead to further complications. Choices A, B, and C are not the highest priority because addressing dehydration and ineffective thermoregulation takes precedence due to the immediate risk of complications such as heatstroke or hypothermia. Deficient volume, decreased cardiac output, and imbalanced nutrition are important but not as urgent in this scenario.
Question 2 of 5
A baby is born temporarily immune to the diseases to which the mother is immune. The nurse understands that this is an example of which of the following types of immunity?
Correct Answer: A
Rationale: The correct answer is A: Naturally acquired passive immunity. This type of immunity occurs when antibodies are passed from mother to baby through the placenta or breast milk, providing temporary protection. The baby does not produce its antibodies, hence it is passive. Choice B, naturally acquired active immunity, involves the body producing its antibodies after exposure to a pathogen. Choice C, artificially acquired passive immunity, involves receiving preformed antibodies from an external source. Choice D, artificially acquired active immunity, involves the body producing antibodies in response to vaccination.
Question 3 of 5
The nurse is caring for a client with thrombocytopenia. What is the best way to protect this client?
Correct Answer: C
Rationale: The correct answer is C: Use the smallest needle possible for injections. This is important for a client with thrombocytopenia because they have a low platelet count, leading to an increased risk of bleeding. Using a small needle minimizes the risk of causing bleeding or bruising during injections. Limiting family visits (choice A) is not directly related to protecting the client from bleeding. Encouraging wheelchair use (choice B) is not specifically relevant to protecting the client with thrombocytopenia. Maintaining accurate fluid intake and output records (choice D) is important but not directly related to preventing bleeding in a client with thrombocytopenia.
Question 4 of 5
Which of the ff is an initial sign or symptom of acute bronchitis?
Correct Answer: A
Rationale: Step-by-step rationale: 1. Acute bronchitis is characterized by inflammation of the bronchial tubes. 2. An initial sign of acute bronchitis is a nonproductive cough due to irritation of the bronchial tubes. 3. Anorexia and labored breathing may occur later as the condition progresses. 4. Gastric ulceration is not typically associated with acute bronchitis. Therefore, choice A (Nonproductive cough) is the correct answer as it aligns with the characteristic symptom of acute bronchitis, while the other choices are not typically observed in the initial stages of the condition.
Question 5 of 5
A client has a serum calcium level of 7.2mg/dl. During the physical examination, the nurse expects to assess:
Correct Answer: A
Rationale: The correct answer is A: Trousseau's sign. A serum calcium level of 7.2mg/dl indicates hypocalcemia. Trousseau's sign is a clinical manifestation of hypocalcemia, characterized by carpal spasm induced by inflating a blood pressure cuff above systolic pressure. This occurs due to increased neuromuscular excitability from low calcium levels. Hegar's sign (B) is associated with pregnancy, Homan's sign (C) is a clinical test for deep vein thrombosis, and Goodell's sign (D) is a softening of the cervix during pregnancy. These signs are not relevant to a client with hypocalcemia.
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