ATI RN
Pharmacology and the Nursing Process 10th Edition Test Bank Quizlet Questions
Question 1 of 9
A nurse has developed a plan of care with nursing interventions designed to meet specific client outcomes. The outcomes are not met by the time specified in the plan. What should the nurse do now in terms of evaluation?
Correct Answer: B
Rationale: The correct answer is B: Make recommendations for revising the plan of care. When client outcomes are not met within the specified time frame, the nurse should reassess the plan of care to identify any potential reasons for the lack of progress. By making recommendations for revising the plan of care, the nurse can adjust interventions to better align with the client's needs and facilitate goal achievement. Continuing to follow the written plan of care (choice A) without modification may not address the underlying issues preventing goal attainment. Asking another health care professional to design a plan of care (choice C) may not be necessary if the nurse can assess and revise the current plan. Stating 'goal will be met at a later date' (choice D) does not address the need for immediate action to reassess and modify the plan for better outcomes.
Question 2 of 9
If a client with increased pressure (ICP) demonstrates decorticate posturing, the nurse will observe:
Correct Answer: A
Rationale: The correct answer is A because decorticate posturing is characterized by flexion of both upper and lower extremities. This occurs due to damage to the cerebral hemispheres, resulting in abnormal muscle contractions. Choice B describes decerebrate posturing, which is associated with extension of elbows and knees. Choice C is incorrect as it describes abnormal posturing seen in other conditions. Choice D is also incorrect as it describes a different type of abnormal posturing.
Question 3 of 9
Following the American Cancer Society guidelines, the nurse should recommend that the women:
Correct Answer: B
Rationale: The correct answer is B: Have a mammogram annually. Mammograms are recommended by the American Cancer Society for breast cancer screening in women as they are effective in detecting early signs of breast cancer. Mammograms have been shown to reduce mortality rates from breast cancer. Annual mammograms are crucial for early detection and treatment. A: Performing breast self-examination annually is not recommended as a standalone screening method as it has not been shown to significantly reduce mortality rates. C: Having a normal receptor assay annually is not a standard screening test for breast cancer recommended by the American Cancer Society. D: Having a physician conduct a clinical examination every 2 years is not as effective as annual mammograms for detecting early signs of breast cancer.
Question 4 of 9
For a client diagnosed with idiopathic thrombocytopenic purpura (ITP), which nursing intervention is appropriate?
Correct Answer: B
Rationale: The correct answer is B: Administering platelets, as ordered to maintain an adequate platelet count. In ITP, the client has low platelet count leading to risk of bleeding. Administering platelets helps raise platelet levels and prevent bleeding complications. Teaching coughing and deep-breathing techniques (A) is important for preventing respiratory infections but not directly related to ITP. Giving aspirin (C) is contraindicated as it can further decrease platelet count. Administering stool softeners (D) is important for preventing straining but not specific to managing ITP.
Question 5 of 9
In a client who has human immunodeficiency virus (HIV) infection, CD4+ levels are measured to determine the:
Correct Answer: B
Rationale: Step-by-step rationale: 1. CD4+ cells are a type of white blood cell crucial for immune function. 2. HIV targets and destroys CD4+ cells, leading to immune system damage. 3. Measuring CD4+ levels helps determine the extent of this damage. 4. Therefore, the correct answer is B. Summary: A: Presence of opportunistic infections - CD4+ levels indirectly affect susceptibility, but not measured for this purpose. C: Level of the viral load - Measured separately from CD4+ levels. D: Resistance to antigens - CD4+ levels do not directly indicate resistance.
Question 6 of 9
An adult suffered 2nd and third degree burns over 20% of hid body 2 days ago. What is the best way to assess the client’s fluid balance?
Correct Answer: A
Rationale: The correct answer is A: Maintain strict records of intake and output. This is the best way to assess fluid balance in a burn patient because it provides quantitative data on fluid intake and output, helping to monitor for fluid imbalance. Monitoring skin turgor (B) is unreliable in burn patients due to skin damage. Weighing the client daily (C) may not accurately reflect fluid balance changes. Checking for edema (D) is not specific to assessing fluid balance in burn patients. Maintaining intake and output records allows for precise monitoring and early detection of fluid shifts, making it the most appropriate choice.
Question 7 of 9
Mr. Chua has developed liver cirrhosis. Nurse Bea expects alteration in which laboratory values?
Correct Answer: B
Rationale: The correct answer is B: prothrombin time. In liver cirrhosis, the liver's ability to produce clotting factors is impaired, leading to prolonged prothrombin time. This indicates an increased risk of bleeding. Choice A is incorrect as carbon dioxide levels are not typically affected by liver cirrhosis. Choice C, gastric pH, is unrelated to liver function. Choice D, white blood cell count, is not directly affected by liver cirrhosis. Therefore, the alteration in prothrombin time is the most relevant laboratory value to monitor in this case.
Question 8 of 9
A client has had heavy menstrual bleeding for 6 months. Her gynecologist diagnoses microcytic hypochromic anemia and prescribes ferrous sulfate (Feosol), 300mg PO daily. Before initiating iron therapy, the nurse reviews the client’s medical history. Which condition would contraindicate the use of ferrous sulfate?
Correct Answer: B
Rationale: The correct answer is B: Ulcerative colitis. Iron therapy can exacerbate gastrointestinal issues, including ulcerative colitis due to its potential to cause irritation and inflammation in the digestive tract. This can lead to worsening symptoms and complications for the client. A: Pregnancy is not a contraindication for iron therapy; in fact, it is commonly prescribed during pregnancy to prevent or treat anemia. C: Asthma is not a contraindication for iron therapy as it does not directly interact with asthma or its treatment. D: Severely impaired liver function is not a direct contraindication for iron therapy, although caution may be needed in such cases due to iron metabolism being affected by liver function.
Question 9 of 9
A patient has cloudy penile discharge. For which additional symptoms of urethritis should the nurse assess?
Correct Answer: C
Rationale: The correct answer is C: Painful and frequent urination. Cloudy penile discharge is a common symptom of urethritis, which is inflammation of the urethra. Painful and frequent urination are classic symptoms of urethritis due to irritation and inflammation of the urinary tract. Throat or rectal infection (choice A) are not typically associated with urethritis. Chancres or vesicles on the genitals (choice B) are more indicative of sexually transmitted infections like syphilis or herpes. Oliguria and flank pain (choice D) are more suggestive of kidney or urinary tract issues rather than urethritis.