ATI RN
Test Bank Pharmacology and the Nursing Process Questions
Question 1 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 2 of 9
A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data?
Correct Answer: D
Rationale: The correct answer is D because "Unable to palpate femoral pulse in left leg" is an objective finding that can be measured or observed without interpretation or bias. It provides concrete, measurable information about the patient's condition. Choices A, B, and C are subjective data as they rely on the patient's feelings, emotions, and perceptions, which can vary and are open to interpretation. Objective data is crucial in making accurate assessments and decisions in healthcare.
Question 3 of 9
Which nursing intervention is appropriate for the nurse to take when setting up supplies for a client who requires a blood transfusion?
Correct Answer: C
Rationale: The correct answer is C because priming the tubing of the blood administration set with 0.9% NS solution ensures that there are no air bubbles in the tubing, preventing air embolism when the blood transfusion starts. This step also ensures that the blood flows smoothly and prevents clotting in the tubing. Choice A is incorrect because adding IV medication in the blood bag can lead to incompatibility issues and should not be done without proper verification and approval. Choice B is incorrect because leaving the blood bag at room temperature for an hour can lead to bacterial growth in the blood, increasing the risk of infection when transfused. Choice D is unrelated to setting up supplies for a blood transfusion and does not address the immediate nursing intervention required in this situation.
Question 4 of 9
The nurse is explaining the action of insulin to a newly diagnosed diabetic client. During the teaching, the nurse reviews the process of insulin secretion in the body. The nurse is correct when stating that insulin is secreted from the:
Correct Answer: C
Rationale: Rationale: 1. Insulin is a hormone produced by beta cells of the pancreas. 2. Beta cells are responsible for monitoring blood glucose levels and secreting insulin in response to high glucose levels. 3. Insulin helps regulate blood glucose by facilitating glucose uptake into cells. 4. Adenohypophysis secretes other hormones, not insulin. 5. Alpha cells of the pancreas secrete glucagon, not insulin. 6. Parafollicular cells of the thyroid secrete calcitonin, not insulin. Summary: Choice C is correct because insulin is indeed secreted from the beta cells of the pancreas. Choices A, B, and D are incorrect as they do not secrete insulin or are related to other hormones.
Question 5 of 9
The nurse is instructing a premenopausal woman about breast self-examination. The nurse should tell the client to do her self-examination:
Correct Answer: C
Rationale: Correct Answer: C - The nurse should tell the client to do her self-examination on the same day each month to establish a routine, making it easier to remember and detect any changes. This consistency helps in early detection of abnormalities. Incorrect Choices: A: Doing it at the end of the menstrual cycle may not be consistent due to varying cycle lengths. B: Doing it on the 1st day of the menstrual cycle may not be practical and could lead to missing potential abnormalities. D: Doing it immediately after her menstrual period may not provide a consistent schedule for self-examination.
Question 6 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 7 of 9
A client with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include:
Correct Answer: B
Rationale: The correct answer is B: Respiratory acidosis. Aspirin can lead to respiratory acidosis due to its effect on the respiratory center in the brainstem. It causes hyperventilation, leading to respiratory alkalosis initially, followed by respiratory acidosis as compensation mechanism fails. Weight gain is not a typical adverse reaction of aspirin. Fine motor tremors are not associated with aspirin therapy. Bilateral hearing loss is a rare but serious side effect of aspirin overdose, not prolonged therapy.
Question 8 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 9 of 9
A patient has a bacterial infection in left lower leg. Which nursing diagnosis will the nurse add to the patient’s care plan?
Correct Answer: C
Rationale: The correct nursing diagnosis is C: Impaired skin integrity. This choice is correct because it directly addresses the bacterial infection in the left lower leg by focusing on the skin's condition. The patient's skin integrity is compromised due to the infection, making this nursing diagnosis appropriate. Choice A (Infection) is too broad and does not specify the impact on the skin. Choice B (Risk for infection) is incorrect because the patient already has a bacterial infection, so the risk has already manifested. Choice D (Staphylococcal leg infection) is too specific and does not address the broader issue of skin integrity. Therefore, the best choice is C as it accurately reflects the patient's current condition and guides appropriate nursing interventions to address the impaired skin integrity caused by the bacterial infection.