ATI RN
Test Bank Pharmacology and the Nursing Process Questions
Question 1 of 9
On the third day after a partial thyroidectomy, a client exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life- threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?
Correct Answer: A
Rationale: Rationale: 1. Following thyroid surgery, there is a risk of damaging the parathyroid glands, leading to hypocalcemia. 2. Symptoms of hypocalcemia include muscle twitching, hyperirritability, numbness, and tingling. 3. These symptoms align with the client's presentation, indicating a probable electrolyte imbalance. 4. Hypocalcemia is a common complication post-thyroidectomy due to parathyroid gland damage. 5. Prompt recognition and treatment of hypocalcemia are essential to prevent severe complications. Summary: B: Hyperkalemia - Not typically associated with thyroid surgery, symptoms differ. C: Hyponatremia - Unlikely post-thyroidectomy, symptoms don't match presentation. D: Hypermagnesemia - Rare post-thyroidectomy, symptoms and electrolyte disturbance don't align.
Question 2 of 9
The Glasgow coma scale is used to .evaluate the level of consciousness in the neurological and neurological patients. The three assessment factors included in this scale are:
Correct Answer: C
Rationale: The correct answer is C: Eye opening, verbal response, motor response. The Glasgow Coma Scale assesses a patient's level of consciousness using these three factors. Eye opening measures arousal, verbal response assesses communication abilities, and motor response evaluates motor function. In the case of J.E., since he is alert and oriented, his eye opening is intact. His ability to communicate verbally and move his limbs appropriately would be crucial in determining his neurological status. Choices A and B are incorrect as they do not include the necessary assessment factor of eye opening. Choice D is incorrect as it mentions "response to pain" instead of verbal response, which is a key component of the Glasgow Coma Scale.
Question 3 of 9
Which of the following guidekines does not observe surgical asepisi in the operating room?
Correct Answer: A
Rationale: The correct answer is A because in surgical asepsis, sterile articles should not touch other sterile articles or surfaces to maintain sterility. Choice B is correct as surgical team gowns are sterile in front. Choice C is correct as any breach makes the area contaminated. Choice D is correct as sterile drapes create a sterile field.
Question 4 of 9
The nurse will assess a loss of ability in which of the following areas?
Correct Answer: A
Rationale: The correct answer is A: Balance. Loss of ability in balance can indicate various health issues like neurological disorders or musculoskeletal problems. The nurse can assess this by observing the patient's gait, balance while standing, and coordination. Speech (B) relates to communication abilities, judgment (C) involves decision-making skills, and endurance (D) is related to stamina and physical capacity, which are not directly linked to loss of ability.
Question 5 of 9
Pulmonary edema is characterized by:
Correct Answer: C
Rationale: Rationale: 1. Pulmonary edema is caused by increased hydrostatic pressure in the pulmonary circulation. 2. Elevated left ventricular end-diastolic pressure signifies heart failure, a common cause of pulmonary edema. 3. A rise in pulmonary venous pressure is a consequence of increased hydrostatic pressure. Therefore, all three alterations (A, B, D) are characteristic of pulmonary edema. Option C is correct. Choices A, B, and D are incorrect because they are all individually associated with pulmonary edema and collectively represent the condition.
Question 6 of 9
A nurse is developing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Risk for loneliness related to impaired verbal communication?
Correct Answer: A
Rationale: The correct answer is A: Provide the patient with a writing board each shift. This intervention addresses the impaired verbal communication by offering an alternative way for the patient to communicate. Writing board enables the patient to express thoughts and feelings, reducing the risk of loneliness. Choice B doesn't directly address the communication issue. Choice C is not relevant to the nursing diagnosis. Choice D, while promoting companionship, doesn't address the specific communication concern stated in the diagnosis.
Question 7 of 9
At 1400, the nurse notices that the dressing is saturated and leaking. What is the nurse’s next action?
Correct Answer: B
Rationale: The correct answer is B because a saturated and leaking dressing indicates a potential infection risk and compromised wound healing. The nurse should revise the plan of care and change the dressing immediately to prevent complications. Waiting until 1800 (choice A) could lead to further contamination and delay in treatment. Reassessing in 2 hours (choice C) might worsen the condition. Discontinuing the plan of care (choice D) is not appropriate without addressing the immediate issue.
Question 8 of 9
After being in remission from Hodgkin’s disease for 18 months, a client develops a fever of unknown origin. The physician orders a blind liver biopsy to rule out advancing Hodgkin’sdisease and infection. Twenty-four hours after the biopsy, the client has a fever, complains of severe abdominal pain, and seems increasingly confused. The nurse suspects that these finding result from:
Correct Answer: B
Rationale: The correct answer is B: Perforation of the colon caused by the liver biopsy. The symptoms of fever, severe abdominal pain, and confusion are indicative of peritonitis, which can result from a bowel perforation during the liver biopsy procedure. Perforation of the colon can lead to leakage of bowel contents into the peritoneal cavity, causing inflammation, infection, and systemic symptoms. This is a serious complication that requires immediate medical attention. Incorrect options: A: Bleeding in the liver caused by the liver biopsy would present with symptoms such as hypotension and signs of internal bleeding, not confusion and severe abdominal pain. C: An allergic reaction to contrast media would typically present with symptoms such as rash, itching, or respiratory distress, not fever, severe abdominal pain, and confusion. D: Normal post procedural pain would not cause confusion and a change in the level of consciousness, which indicates a more serious underlying issue like bowel perforation.
Question 9 of 9
Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient? The nurse determines to remove a wound dressing when the patient reveals the time
Correct Answer: A
Rationale: The correct answer is A because it demonstrates data validation in making a nursing clinical decision. The nurse assesses the time of the last dressing change and compares it with the appearance of old and new drainage. This process ensures that the decision to remove the wound dressing is based on accurate and validated data, leading to appropriate patient care. Choice B is incorrect because it does not involve data validation. The decision is driven by increased pain and family requests, without verifying the underlying cause. Choice C is incorrect as it involves responding to a patient's reported symptom (leg cramps), but it does not involve data validation in making the clinical decision. Choice D is incorrect as it relies solely on the patient's report of decreased mobility without further data validation.