ATI RN
Pharmacology and the Nursing Process 10th Edition Test Bank Quizlet Questions
Question 1 of 9
A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention is most appropriate for the nursing diagnostic statement Risk for falls?
Correct Answer: D
Rationale: The correct answer is D. This intervention is appropriate because it addresses the patient's reduced muscle strength following a left-sided stroke and the risk for falling. Assisting the patient into and out of bed regularly helps prevent falls by ensuring safe mobility and reducing the likelihood of accidents. It promotes independence while also providing necessary support. A: Keeping all side rails down at all times may increase the risk of falls as it removes a safety measure that can help prevent falls. B: Encouraging the patient to remain in bed most of the shift can lead to deconditioning and muscle weakness, increasing the risk of falls. C: Placing the patient in a room away from the nurses' station does not directly address the risk for falls and may hinder timely assistance in case of emergencies. In summary, option D is the most appropriate intervention as it addresses the patient's needs, promotes safety, and supports mobility to prevent falls effectively.
Question 2 of 9
A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse’s initial action in response to these observations?
Correct Answer: C
Rationale: The correct initial action for the nurse is to ask the patient about the facial grimacing with movement (Choice C). This is because the patient's non-verbal cues (facial grimacing) are contradicting their verbal report of low pain level. By asking the patient directly, the nurse can clarify the discrepancy and gain a better understanding of the patient's actual pain level and needs. Choice A is incorrect as it disregards the patient's observed discomfort. Choice B assumes the patient does not want pain medicine without clarifying the situation first. Choice D is premature as administering pain medication without further assessment may not be appropriate or safe. In summary, asking the patient about the facial grimacing is essential to ensure accurate pain assessment and appropriate intervention.
Question 3 of 9
A nurse finds Mr. Gabatan under the wreckage of the car. He is conscious, breathing satisfactorily, and lying on the back complaining of pain in the back and an inability to move his legs. The nurse should first:
Correct Answer: C
Rationale: The correct answer is C because in cases of suspected spinal injury, it is crucial to keep the spine immobilized to prevent further damage. Rolling Mr. Gabatan onto his abdomen helps protect his spine by maintaining alignment. Placing a pad under his head provides support and covering him with any material available helps maintain his body temperature. Moving him without proper spinal precautions (options A, B, D) could worsen his condition. Seeking additional help is important, but ensuring spinal immobilization comes first. Sitting him up or moving him onto a flat piece of lumber can exacerbate spinal injuries. Therefore, option C is the most appropriate initial action.
Question 4 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.
Question 5 of 9
The multilumen pulmonary artery catheter allows the nurse to measure hemodynamic pressures at different points in the heart. When the tip enters the small branches of the pulmonary artery, the nurse can assess all of the following except:
Correct Answer: C
Rationale: The correct answer is C: Pulmonary artery obstructive pressure (PACP). The multilumen pulmonary artery catheter measures hemodynamic pressures in the heart. When the catheter tip enters small branches of the pulmonary artery, it can assess Central Venous Pressure (A), Pulmonary Artery Capillary Pressure (B), and Pulmonary Artery Wedge Pressure (D). Pulmonary artery obstructive pressure is not a standard hemodynamic measurement and is not assessed using this catheter. It is crucial to differentiate between the various pressures measured to accurately assess the patient's cardiac status.
Question 6 of 9
Which of the ff dietary recommendations should a nurse give to a client taking diuretics?
Correct Answer: A
Rationale: The correct answer is A: Include potassium-rich foods. Diuretics can cause potassium loss, leading to hypokalemia. Including potassium-rich foods helps prevent this deficiency. Choice B is incorrect because fruits and fruit juices are often good sources of potassium. Choice C is incorrect as protein-rich foods do not specifically address potassium needs. Choice D is incorrect as dairy products are also good sources of potassium. Therefore, recommending potassium-rich foods is essential to prevent hypokalemia in clients taking diuretics.
Question 7 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 8 of 9
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.
Question 9 of 9
The nurse has been teaching an adult who has iron deficiency anemia about those foods that she needs to include in her meal plans. Which of the following, if selected, would indicate to the nurse that the client understands the dietary instructions?
Correct Answer: A
Rationale: The correct answer is A: Citrus fruits and green leafy vegetables. Citrus fruits and green leafy vegetables are good sources of Vitamin C and iron, which are essential for individuals with iron deficiency anemia. Vitamin C enhances the absorption of iron from plant-based sources, while green leafy vegetables provide iron. Bananas and nuts (choice B) are not significant sources of iron. Coffee and tea (choice C) can inhibit iron absorption. Dairy products (choice D) are not high in iron and can also inhibit iron absorption. Therefore, choosing citrus fruits and green leafy vegetables indicates understanding of the dietary instructions for managing iron deficiency anemia.