ATI RN
Pharmacology and the Nursing Process 10th Edition Test Bank Quizlet Questions
Question 1 of 9
Mr Santos is placed on seizure precaution. Which of the following would be contraindicated?
Correct Answer: A
Rationale: The correct answer is A: Obtain his oral temperature. Seizure precautions typically include avoiding putting objects in the mouth to prevent injury during a seizure. Taking an oral temperature involves placing an object in the mouth, which could pose a risk if a seizure occurs. Choices B, C, and D are not contraindicated as they do not directly involve potential risks during a seizure. Allowing the patient to wear his own clothing, encouraging personal hygiene, and promoting mobility are safe practices that do not increase the risk of harm during a seizure.
Question 2 of 9
A client with serum glucose level of 618mg/dl is admitted to the facility. He’s awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6F (38.1C), heart rate of 116 beats/min, and blood pressure of 108/70mHg. Based on these assessment findings, which nursing diagnosis take highest priority?
Correct Answer: D
Rationale: The correct answer is D, "Ineffective thermoregulation related to dehydration." The client's high serum glucose level of 618mg/dl indicates severe hyperglycemia, leading to dehydration. The client's hot, dry skin and elevated temperature can be signs of dehydration, impacting the body's ability to regulate temperature. Dehydration can also affect other vital signs, contributing to the elevated heart rate and low blood pressure. Addressing ineffective thermoregulation is crucial as it can lead to further complications. Choices A, B, and C are not the highest priority because addressing dehydration and ineffective thermoregulation takes precedence due to the immediate risk of complications such as heatstroke or hypothermia. Deficient volume, decreased cardiac output, and imbalanced nutrition are important but not as urgent in this scenario.
Question 3 of 9
A baby is born temporarily immune to the diseases to which the mother is immune. The nurse understands that this is an example of which of the following types of immunity?
Correct Answer: A
Rationale: The correct answer is A: Naturally acquired passive immunity. This type of immunity occurs when antibodies are passed from mother to baby through the placenta or breast milk, providing temporary protection. The baby does not produce its antibodies, hence it is passive. Choice B, naturally acquired active immunity, involves the body producing its antibodies after exposure to a pathogen. Choice C, artificially acquired passive immunity, involves receiving preformed antibodies from an external source. Choice D, artificially acquired active immunity, involves the body producing antibodies in response to vaccination.
Question 4 of 9
Which of the following would the nurse evaluate as laboratory data that support the occurrence of AIDS?
Correct Answer: D
Rationale: The correct answer is D: 200 CD4+ cells. In AIDS, the immune system is severely compromised, leading to a decrease in CD4+ T cells. A CD4+ count below 200 cells/mm3 is a key indicator of AIDS, as it signifies advanced immunodeficiency. Choices A, B, and C all have CD4+ cell counts above 200, which would not support the occurrence of AIDS. Therefore, the nurse would evaluate a CD4+ count of 200 cells as laboratory data that support the occurrence of AIDS.
Question 5 of 9
The nurse notes that a client’s wound has not improved despite consistent wound care as outlined in the care plan. What should the nurse do next?
Correct Answer: A
Rationale: Step 1: Reassessing the wound and client's condition allows the nurse to identify any factors contributing to the lack of improvement. Step 2: It helps determine if the current care plan needs modifications or if there are underlying issues affecting healing. Step 3: This step ensures a comprehensive evaluation before making any changes to the care plan, promoting evidence-based practice. Step 4: Choosing this option aligns with the nursing process of assessment, which is crucial for making informed decisions in client care. Summary: Option A is correct as it emphasizes the importance of reassessment to gather more information and make informed decisions. Discontinuing the care plan (Option B) without assessment can be harmful. Increasing dressing changes (Option C) may not address the underlying issue. Referring immediately (Option D) may be premature without reassessment.
Question 6 of 9
Which of the following is usually the first symptom of a cataract that the nurse would expect a patient to report during assessment?
Correct Answer: B
Rationale: The correct answer is B: Blurring of vision. This is typically the first symptom of a cataract because the clouding of the lens causes light to scatter, leading to blurred vision. Dry eyes (A) and eye pain (C) are not typically associated with cataracts. Loss of peripheral vision (D) is more commonly seen in conditions like glaucoma. In summary, blurring of vision is the hallmark symptom of cataracts due to lens clouding, distinguishing it from other eye conditions.
Question 7 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 8 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 9 of 9
To treat cervical cancer, a client has had an applicator of radioactive material placed in the vagina. Which observation by the nurse indicates a radiation hazard?
Correct Answer: B
Rationale: The correct answer is B because maintaining the head of the bed at a 30-degree angle can cause the radioactive material to shift within the client's body, increasing the risk of radiation exposure. This position should be avoided to prevent displacement of the applicator. A: Strict bed rest is appropriate to minimize movement and dislodgement of the applicator, ensuring proper treatment delivery. C: Providing a bed bath does not pose a radiation hazard as long as proper precautions are taken. D: Checking the applicator's position every 4 hours is essential for monitoring and ensuring it remains in place to deliver the intended treatment.