ATI RN
Pharmacology and the Nursing Process 9th Edition Test Bank Questions
Question 1 of 5
The nurse is caring for a client with bronchogenic carcinoma. Which nursing diagnosis takes highest priority?
Correct Answer: B
Rationale: The correct answer is B: Ineffective airway clearance related to obstruction by a tumor or secretions. This is the highest priority because compromised airway clearance can lead to life-threatening complications such as respiratory distress or hypoxia. Ensuring effective airway clearance is crucial in preventing respiratory compromise and maintaining oxygenation. Choices A, C, and D are not the highest priority because they do not directly address the immediate risk to the client's physiological well-being. Treating disturbed body image, anxiety, or imbalanced nutrition are important but can be addressed after ensuring the client's airway is clear and they are able to breathe effectively.
Question 2 of 5
Several days before admission, a client reports finding a small lump in the left breast near the nipple. What should the nurse tell the client to do?
Correct Answer: A
Rationale: The correct answer is A: Inform the physician immediately. This is important because finding a lump in the breast could be a sign of breast cancer, so prompt medical evaluation is crucial. Checking after the next menstrual cycle (B) may delay diagnosis and treatment. Squeezing the nipple (C) can cause harm and is not a reliable method for assessing a lump. Using a heating pad (D) is not recommended as it may mask symptoms and delay proper evaluation. Early detection and intervention are key in improving outcomes for breast cancer.
Question 3 of 5
Miss OB’s malignant tumor in her left breast was discovered to be spreading all over the surrounding and adjacent tissue and not entering the blood stream, it would be:
Correct Answer: A
Rationale: The correct answer is A: Malignant. A malignant tumor spreading to surrounding tissues indicates invasive growth, characteristic of malignancy. It is aggressive and can invade nearby structures. Non-malignant tumors are localized and do not invade surrounding tissues. Benign tumors are non-invasive and do not spread to other parts of the body. Choice D is incorrect because a tumor spreading to surrounding tissues is indicative of malignancy, not benignity.
Question 4 of 5
Which of the following is a discharge criterion from the PACU for a patient following surgery?
Correct Answer: A
Rationale: The correct answer is A: Oxygen saturation above 90%. This is a discharge criterion because adequate oxygen saturation indicates the patient is breathing well and there is no immediate respiratory compromise. Oxygen saturation below 90% (choice C) would indicate hypoxemia and would not be safe for discharge. IV narcotics given less than 15 minutes ago (choice B) can still be in effect and may impair the patient's ability to function post-surgery. IV narcotics given less than 30 minutes ago (choice D) is a longer timeframe but still not ideal for discharge as the effects of the narcotics may not have fully worn off.
Question 5 of 5
Nursing measures in hemodynamic monitoring include assessing for localized ischemia owing to inadequate arterial flow. The nurse should:
Correct Answer: D
Rationale: The correct answer is D because assessing for localized ischemia involves evaluating multiple factors. A: Assessing color and temperature helps determine perfusion. B: Checking capillary refill assesses circulation. C: Evaluating pulse rate indicates cardiac output. Doing all of the above provides a comprehensive assessment of arterial flow and potential ischemia. Other choices are incorrect as they do not cover all aspects necessary for a thorough assessment.