ATI RN
Pharmacology and the Nursing Process 9th Edition Test Bank Questions
Question 1 of 9
For a client with low blood volume, what are the implications of decreasing blood pressure and a rapid heart rate?
Correct Answer: D
Rationale: The correct answer is D: Hypovolemia and shock. Rationale: 1. Low blood volume leads to decreased blood pressure and rapid heart rate as compensatory mechanisms. 2. These signs indicate inadequate perfusion due to reduced blood volume. 3. Hypovolemia can progress to shock if not addressed promptly. Summary: A: Compression of blood vessels is not directly related to low blood volume. B: Increasing circulating blood volume would not occur in a client with low blood volume. C: Inadequate renal perfusion is a consequence of hypovolemia, not an implication of decreasing blood pressure and rapid heart rate.
Question 2 of 9
A client with ascites has a paracentesis, and 1500 ml of fluid is removed. Immediately following the procedure it is most important for the nurse to observe for:
Correct Answer: A
Rationale: The correct answer is A: A rapid, thready pulse. After paracentesis, rapid removal of ascitic fluid can lead to a decrease in intravascular volume, causing hypovolemia and subsequent compensatory mechanisms like tachycardia (rapid pulse). This is a crucial sign that the nurse should monitor for early detection of hypovolemia. B: Decreased peristalsis is not directly related to paracentesis and is not an immediate concern post-procedure. C: Respiratory congestion is not a common complication of paracentesis and is not the most immediate concern. D: An increased temperature is not a typical response to paracentesis and is not a priority observation post-procedure.
Question 3 of 9
Which of the following immunoglobulins is first produced during an acute infection?
Correct Answer: C
Rationale: The correct answer is C: IgM. During an acute infection, the body's initial response is rapid and non-specific, leading to the production of IgM antibodies first. IgM is the first immunoglobulin class produced in response to a new antigen, providing immediate protection. IgG is produced later in the immune response and is responsible for long-term immunity. IgE is involved in allergic reactions and parasitic infections, not typically the first response to infection. IgD is primarily found on the surface of B cells and its function is not well understood in the context of acute infections.
Question 4 of 9
A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient’s daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse?
Correct Answer: B
Rationale: The correct answer is B because the nurse should primarily communicate with the patient, not just the daughter. The nurse should engage the patient in conversation, address them directly, and ensure their needs and concerns are being addressed. Speaking only to the daughter could neglect the patient's autonomy and lead to potential communication barriers. Choices A, C, and D are incorrect as they all involve appropriate communication techniques with the patient, such as making eye contact, leaning forward to show attentiveness, and nodding to indicate understanding. These actions demonstrate good communication skills and rapport-building with the patient, which are important in nursing practice.
Question 5 of 9
A few minutes after beginning a blood transfusion, the nurse notes that the client has chills, dyspnea, and urticaria. The nurse reports this to the physician immediately because the client probably is experiencing which problem?
Correct Answer: A
Rationale: The correct answer is A: A hemolytic reaction to mismatched blood. Chills, dyspnea, and urticaria are indicative of a hemolytic transfusion reaction, which occurs when the recipient's immune system attacks the donor's red blood cells. This can lead to various symptoms, including fever, chills, difficulty breathing, and hives. This type of reaction is most commonly seen with mismatched blood types. Option B (A hemolytic reaction to Rh-incompatible blood) is incorrect because Rh incompatibility typically leads to hemolytic disease of the newborn, not an immediate transfusion reaction. Option C (A hemolytic allergic reaction caused by bacterial contamination of donor blood) is incorrect as bacterial contamination would present with symptoms such as fever and sepsis, not chills, dyspnea, and urticaria. Option D (None of the above) is incorrect as the symptoms presented align with a hemolytic transfusion reaction.
Question 6 of 9
Mang Simon, a hypertensive male client was prescribed with an exercise program. Which intervention would help Mang Simon in maintaining this program?
Correct Answer: D
Rationale: The correct answer is D: Doing it according to his needs and abilities. This option is the most appropriate intervention for Mang Simon to maintain his exercise program. By tailoring the program to his needs and abilities, Mang Simon is more likely to adhere to it and prevent any potential injuries or health risks associated with overexertion. This approach ensures that the exercise routine is realistic and manageable for him, increasing his chances of long-term success. A: Writing down the exercise program may be helpful for organization but does not address the individualization needed for Mang Simon's specific situation. B: Thoroughly explaining the program to his wife, Aling Nena, may provide support but does not directly impact Mang Simon's ability to maintain the program. C: Positive motivation is important, but it alone may not be sufficient to address the practical aspects of adapting the exercise program to Mang Simon's needs and abilities.
Question 7 of 9
For a client with low blood volume, what are the implications of decreasing blood pressure and a rapid heart rate?
Correct Answer: D
Rationale: The correct answer is D: Hypovolemia and shock. Rationale: 1. Low blood volume leads to decreased blood pressure and rapid heart rate as compensatory mechanisms. 2. These signs indicate inadequate perfusion due to reduced blood volume. 3. Hypovolemia can progress to shock if not addressed promptly. Summary: A: Compression of blood vessels is not directly related to low blood volume. B: Increasing circulating blood volume would not occur in a client with low blood volume. C: Inadequate renal perfusion is a consequence of hypovolemia, not an implication of decreasing blood pressure and rapid heart rate.
Question 8 of 9
An adult who has gastroenteritis and is on digitalis ha lab values of: K 3.2 mEq/L, Na 136 mEq/L, Ca 8.8 mg/dl, and Cl 98 mEq/L. the nurse puts which of the following on the client’s plan of care?
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct: 1. The lab value of K at 3.2 mEq/L indicates hypokalemia. 2. Digitalis can worsen hypokalemia and lead to toxicity. 3. Avoiding foods rich in potassium will prevent further lowering of potassium levels. 4. This intervention helps prevent potential digitalis toxicity in the client. Summary of why the other choices are incorrect: A. Stopping digitalis therapy abruptly can lead to rebound effects and worsen the condition. B. Trousseau's and Chvostek's signs are not relevant to the client's current lab values. D. While observing for digitalis toxicity is important, addressing the low potassium level is a more immediate concern in this scenario.
Question 9 of 9
Nurse Dennis provides health promotion to a group of male adults. He is correct when he states that clients with cirrhosis should include which measure to adhere to a home?
Correct Answer: C
Rationale: The correct answer is C: limit daily alcohol intake. This is crucial for clients with cirrhosis as alcohol can exacerbate liver damage. Limiting alcohol intake helps prevent further harm to the liver and promotes overall health. Supplementation with multivitamins (choice A) can be beneficial, but not as essential as avoiding alcohol. Taking sleeping pills (choice B) may worsen liver function and is not recommended. Limiting contact at all times (choice D) is irrelevant to managing cirrhosis.