ATI RN
Pharmacology and the Nursing Process 9th Edition Test Bank Questions
Question 1 of 9
In an individual with Sjogren’s syndrome, nursing care should focus on:
Correct Answer: A
Rationale: The correct answer is A: Moisture replacement. Sjogren's syndrome is an autoimmune disorder that primarily affects the moisture-producing glands, leading to dryness in the eyes, mouth, and other mucous membranes. Nursing care should focus on managing these symptoms by providing moisture replacement through artificial tears, lubricating eye drops, and hydrating mouthwashes. This helps prevent complications such as corneal damage and dental issues. Nutritional supplementation (B) may be needed if there are difficulties in eating due to dry mouth, but it is not the primary focus. Electrolyte balance (C) and arrhythmia management (D) are not directly related to the symptoms of Sjogren's syndrome and are therefore not the main priorities in nursing care for this condition.
Question 2 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 3 of 9
The nurse has entered a client’s room to find the client diaphoretic (sweat-covered) and shivering, inferring that the client has a fever. How should the nurse best follow up this cue and inference?
Correct Answer: A
Rationale: Step 1: Assess the client's vital signs to confirm presence of fever. Step 2: Measure client's oral temperature to obtain accurate reading. Step 3: Document temperature and report findings to healthcare provider. Step 4: Initiate appropriate interventions based on temperature reading. Step 5: Reassess client's condition to evaluate effectiveness of interventions. Summary: Option A is correct as it directly addresses the cue of fever by confirming the temperature. Options B, C, and D are incorrect as they do not directly address the need to assess the client's temperature for accurate evaluation and intervention.
Question 4 of 9
A client with end-stage acquired immunodeficiency syndrome (AIDS) has profound manifestations of Cryptosporidium infection caused by the protozoa. In planning the client’s care, the nurse should focus on his need for:
Correct Answer: C
Rationale: The correct answer is C: Fluid replacement. In end-stage AIDS with Cryptosporidium infection, the client experiences severe diarrhea leading to dehydration and electrolyte imbalances. Fluid replacement is crucial to prevent hypovolemia and maintain electrolyte balance. Adequate hydration supports renal function, prevents further complications, and aids in the elimination of the infectious agent. Pain management (A) may be needed for discomfort but is not the priority. Antiretroviral therapy (B) is essential for managing HIV but does not directly address the immediate issue of dehydration. High-calorie intake (D) is important for overall nutrition but does not address the urgent need for fluid replacement in this situation.
Question 5 of 9
Which of the ff. nursing interventions would have the highest priority in the plan of care for the postoperative eye patient?
Correct Answer: C
Rationale: The correct answer is C: Report sudden onset of acute pain. This is the highest priority because sudden onset of acute pain postoperatively can indicate a serious complication such as hemorrhage or infection. Prompt reporting allows for timely intervention to prevent further complications. A: Do not leave the patient unattended at any time - While important for safety, it is not the highest priority compared to addressing sudden onset of acute pain. B: Teach the patient not to bend over - Important for preventing complications postoperatively, but not as urgent as addressing sudden onset of acute pain. D: Apply sandbags to either side of the head - This intervention is not typically indicated for postoperative eye patients and would not address the potential serious complication of sudden onset of acute pain.
Question 6 of 9
A client with uterine cancer asks the nurse, “Which is the most common type of cancer in women?” The nurse replies that it’s breast cancer. Which type of cancer causes the most deaths in women?
Correct Answer: B
Rationale: The correct answer is B: Lung cancer. It causes the most deaths in women because it is often diagnosed at advanced stages when treatment options are limited. Breast cancer, although common, has a higher survival rate. Brain cancer is relatively rare compared to lung cancer. Colon and rectal cancer, while prevalent, do not surpass lung cancer in terms of mortality rates in women.
Question 7 of 9
A patient who is recovering from a stroke becomes easily frustrated when unable to complete a task. Which of the ff. responses by the nurse will best help the patient get the task done?
Correct Answer: C
Rationale: The correct answer is C: Break the task down into simple steps. This response is the best because it helps the patient by breaking down the task into manageable parts, making it less overwhelming and more achievable. By providing clear and simple steps, the patient can focus on one aspect at a time, reducing frustration and increasing the likelihood of successful completion. Choice A is incorrect because performing the task for the patient does not promote independence or skill development. Choice B is incorrect as it dismisses the patient's feelings of frustration without offering a solution. Choice D is incorrect because having another patient demonstrate may not address the specific needs and abilities of the recovering stroke patient.
Question 8 of 9
Which laboratory test value is elevated in clients who smoke and can’t be used as a general indicator of cancer?
Correct Answer: C
Rationale: The correct answer is C: Serum calcitonin level. Smoking can elevate serum calcitonin levels due to the effect of nicotine. However, an elevated serum calcitonin level is not a general indicator of cancer. Step 1: Understand that smoking can increase serum calcitonin levels. Step 2: Recognize that elevated serum calcitonin levels are not specific to cancer and can be influenced by other factors. Step 3: Differentiate between a marker that is specific to cancer (such as carcinoembryonic antigen) and one that can be affected by smoking but not necessarily indicative of cancer (serum calcitonin). Thus, while smoking can elevate serum calcitonin levels, it is not a reliable indicator of cancer.
Question 9 of 9
A hospital’s wound nurse consultant made a recommendation for nurses on the unit about how to care for the patient’s dressing changes. Which action should the nurses take next?
Correct Answer: A
Rationale: The correct answer is A: Include dressing change instructions and frequency in the care plan. This is the correct action because it ensures consistency in care and communication among the nursing team. By documenting the dressing change instructions and frequency in the care plan, all nurses will have clear guidance on how to perform the dressing changes correctly and at the appropriate intervals. This promotes continuity of care and helps prevent errors or omissions in the dressing change process. Option B is incorrect as it is not realistic to expect the wound nurse to perform all dressing changes. Option C is unnecessary unless there are specific concerns requiring the health care provider's attention. Option D is not appropriate as encouraging the patient to perform dressing changes may not be safe or feasible depending on the patient's condition.