ATI RN
Pharmacology and the Nursing Process 10th Edition Test Bank Quizlet Questions
Question 1 of 9
Appropriate nursing interventions for J.E. would be
Correct Answer: A
Rationale: The correct answer is A because it addresses the specific nursing interventions needed for a patient with head injuries like J.E. Skin care and repositioning every 2 hours help prevent pressure ulcers. Maintaining extremity alignment prevents contractures. Respiratory exercises aid in lung expansion and prevent complications. The other choices are incorrect because they either lack essential interventions (B) or include unnecessary or inappropriate interventions (C, D). Teaching the use of an overhead trapeze is not necessary for head injuries, and intermittent positive pressure breathing therapy may not be indicated. Choice A provides a comprehensive and targeted approach to address the specific needs of a patient with head injuries.
Question 2 of 9
A client asks the nurse about the four-point gait when partial weight bearing is permitted. What is the nurse’s BEST response?
Correct Answer: A
Rationale: The correct answer is A because in the four-point gait with partial weight bearing, the client should move the right crutch ahead first to provide support and stability, followed by the left foot. This sequence ensures proper weight distribution and balance. Moving both crutches together (B) may compromise stability. Moving the left crutch and right foot together (C) may cause uneven weight distribution. Moving both crutches and weaker leg together (D) may not provide adequate support for the weaker leg.
Question 3 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.
Question 4 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 5 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 6 of 9
The nurse is aware that in communicating with an elderly client, the nurse will
Correct Answer: B
Rationale: The correct answer is B: Use a low-pitched voice. This is because elderly individuals may have age-related hearing loss, making it difficult for them to hear higher frequencies. Using a low-pitched voice can help ensure that the client can hear and understand the nurse clearly. A: Leaning and shouting at the ear of the client may come across as aggressive and disrespectful. C: Opening the mouth wide while talking is not necessary and may be seen as patronizing. D: Using a medium-pitched voice may still be too difficult for the elderly client to hear clearly due to age-related hearing loss.
Question 7 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 8 of 9
Which of the ff is the effect of a decrease in the number of lymphocytes with age?
Correct Answer: A
Rationale: The correct answer is A: Decreased resistance to infection. Lymphocytes are a crucial part of the immune system, responsible for fighting off infections. A decrease in the number of lymphocytes with age leads to a weakened immune response, making individuals more susceptible to infections. - Choice B: Cognitive problems, is not directly related to lymphocyte levels. - Choice C: Urinary incontinence, is not a typical effect of decreased lymphocytes. - Choice D: Decrease in various blood components, is too broad and not specific to the role of lymphocytes in immunity.
Question 9 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.