ATI RN
Nursing Process Practice Questions Quizlet Questions
Question 1 of 5
A patient is being given penicillin via IV piggyback and develops an anaphylactic reaction. Which of the following should be the nurse’s first action?
Correct Answer: D
Rationale: The correct answer is D: Turn off the antibiotic. This should be the nurse's first action because in an anaphylactic reaction, stopping the administration of the causative agent is crucial to prevent further harm. Continuing the antibiotic (Choice B) can worsen the reaction. Calling the doctor (Choice A) may cause a delay in the immediate intervention needed. Calling for help (Choice C) is important but turning off the antibiotic takes precedence to stop the allergen.
Question 2 of 5
A client with HIV has been prescribed anti viral medications. What instructions related to administration of medications should the nurse give such a client?
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Timing: Antiviral medications should be taken as prescribed to maintain consistent drug levels in the body. 2. Around meals: Taking medications with or without food can affect absorption, so timing around meals helps with consistency. 3. Compliance: Following the timing instructions increases medication effectiveness and reduces the risk of drug resistance. Other Choices: B) Avoiding harsh sunlight: Not directly related to medication administration; may be a precaution for other reasons. C) Having medications with fruit juice: This is not a standard instruction for antiviral medications; may not be suitable for all medications. D) Increasing dose for worsening symptoms: This is dangerous and should only be done under healthcare provider supervision; self-adjusting medication doses can be harmful.
Question 3 of 5
The nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan?
Correct Answer: C
Rationale: Rationale: C: Monitoring body temperature is essential for early detection of infection or fever, which can indicate disease exacerbation in SLE clients. A: Exposure to sunlight can worsen SLE symptoms due to photosensitivity. B: Activity limitations are crucial to prevent flare-ups and reduce disease progression in SLE. D: Corticosteroids should not be stopped abruptly without healthcare provider guidance to prevent symptom recurrence and adrenal insufficiency.
Question 4 of 5
A client is receiving chemotherapy for cancer. The nurse reviews the client’s laboratory report and notes that he has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority?
Correct Answer: D
Rationale: The correct answer is D: Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI. Thrombocytopenia is a low platelet count, which can lead to impaired blood clotting and potential bleeding. Ineffective tissue perfusion is the most critical concern as it can lead to life-threatening complications like hemorrhage. Activity intolerance, impaired tissue integrity, and impaired oral mucous membranes are important but do not pose an immediate threat to the client's life compared to the risk of hemorrhage from thrombocytopenia.
Question 5 of 5
For a client with an exacerbation of rheumatoid arthritis, the physician prescribes the corticosteroid prednisone (Deltasone). When caring for this client, the nurse should monitor for which adverse drug reactions?
Correct Answer: A
Rationale: The correct answer is A. Prednisone is a corticosteroid that can cause adverse reactions such as increased weight due to fluid retention, hypertension due to sodium retention, and insomnia due to its stimulating effects. Vaginal bleeding, jaundice, inflammation, stupor, breast lumps, pain, dyspnea, numbness, and headache are not commonly associated with prednisone use. Monitoring for weight changes, blood pressure, and sleep patterns is essential when administering prednisone to a client with rheumatoid arthritis for early detection and management of adverse reactions.