ATI RN
Pharmacology and the Nursing Process Test Bank Questions
Question 1 of 9
The nurse is caring for a patient who has an open wound and is evaluating the progress of wound healing. Which priority action will the nurse take?
Correct Answer: C
Rationale: The correct answer is C because measuring the wound and observing for redness, swelling, or drainage are essential steps in evaluating wound healing progress. Measuring the wound provides objective data on its size changes, while observing for signs of infection like redness, swelling, or drainage helps identify complications. - Choice A is incorrect because the nursing assistive personnel may not have the necessary knowledge to assess wound healing accurately. - Choice B is incorrect because documenting progress as "better" without objective data is subjective and does not provide a clear picture of the wound status. - Choice D is incorrect because leaving the dressing off can expose the wound to contaminants and compromise healing, making it a potentially harmful action.
Question 2 of 9
A new nurse writes the following nursing diagnoses on a patient’s care plan. Which nursing diagnosis will cause the nurse manager to intervene?
Correct Answer: B
Rationale: The correct answer is B: Hemorrhage. The nurse manager would intervene because hemorrhage is a life-threatening condition requiring immediate attention. Wandering (A), urinary retention (C), and impaired swallowing (D) are important assessments but do not pose the same level of immediate risk as hemorrhage. The nurse manager would prioritize addressing the hemorrhage to ensure the patient's safety and well-being.
Question 3 of 9
A client with spinal cord injury at the level of T3 complains of a sudden severe headache and nasal congestion. The nurse observes that the client has a flushed skin with goose bumps. Which of the ff actions should the nurse first take?
Correct Answer: C
Rationale: The correct answer is C: Call the physician. In this scenario, the sudden severe headache and nasal congestion along with flushed skin and goosebumps suggest autonomic dysreflexia, a medical emergency in spinal cord injury at or above T6. The nurse should immediately call the physician to address this potentially life-threatening situation. Raising the client's head (A) may worsen the condition, placing the client on a firm mattress (B) is not a priority, and administering an analgesic (D) without addressing the underlying cause could lead to further complications. The priority is to identify and address the cause of autonomic dysreflexia promptly.
Question 4 of 9
A female client with human immunodeficiency virus (HIV) receives family-planning counseling. Which statement about safer sex practices for persons with HIV is accurate?
Correct Answer: B
Rationale: The correct answer is B: A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse. Rationale: 1. Latex condoms create a physical barrier that helps prevent the exchange of bodily fluids containing HIV. 2. Spermicide can further reduce the risk of HIV transmission by killing some viruses and bacteria. 3. Research shows that consistent and correct use of condoms is highly effective in reducing the risk of HIV transmission. 4. Other choices are incorrect: - A: Unprotected sex between HIV-positive individuals can lead to the transmission of drug-resistant strains or different strains of HIV. - C: Contraceptive methods like birth control pills do not protect against HIV transmission. - D: The intrauterine device is not specifically recommended for clients with HIV due to potential risks of infection.
Question 5 of 9
At health fair, an oncology nurse answers questions about risk factors for various types of cancer. One person with a family history of colon cancer asks the nurse to identify risk factors for this type of cancer. The nurse should identify:
Correct Answer: C
Rationale: The correct answer is C: Obesity. Obesity is a known risk factor for colon cancer as it can lead to chronic inflammation and changes in hormone levels, increasing the risk of developing cancerous cells in the colon. Smoking (choice A) is more strongly associated with lung cancer. Heavy alcohol consumption (choice B) is linked to increased risk of liver and esophageal cancer, not colon cancer. Saccharin consumption (choice D) has not been definitively linked to colon cancer. In summary, obesity is the most relevant risk factor for colon cancer among the choices provided.
Question 6 of 9
Which of the following groups of terms best describes a nurse-initiated intervention?
Correct Answer: B
Rationale: The correct answer is B because nurse-initiated interventions involve autonomous actions based on clinical judgment to achieve client outcomes. Nurses assess, plan, and implement care independently. Choice A involves physician orders, not nurse-initiated actions. Choice C relates to medical treatment, not nursing interventions. Choice D focuses on collaboration with other providers, not solely nurse-initiated actions. In summary, only choice B aligns with the independent and outcome-focused nature of nurse-initiated interventions.
Question 7 of 9
Which initial intervention is most appropriate for a patient who has a new onset of chest pain?
Correct Answer: B
Rationale: The correct answer is B, notifying the health care provider. This is the most appropriate initial intervention because chest pain can be a symptom of a serious medical condition like a heart attack. The health care provider needs to be informed immediately to assess the situation and provide appropriate treatment. Reassessing the patient (A) may delay crucial medical intervention. Administering pain medication (C) without knowing the cause of chest pain can be dangerous. Calling radiology for a chest x-ray (D) is not the initial step in managing new onset chest pain.
Question 8 of 9
A nurse has been examining the vital signs of the client for the past 2 days. On a particular day, she observe a sudden change in the vital signs of the client. Which of the ff steps should the nurse take immediately?
Correct Answer: A
Rationale: The correct answer is A: Inform the physician. This is essential because a sudden change in vital signs may indicate a critical condition that requires immediate medical attention. The physician needs to be informed promptly to assess the situation and provide appropriate interventions. Summary: - B: Changing environmental settings is not a priority when dealing with sudden changes in vital signs. - C: Altering diet intake is not an immediate response to sudden changes in vital signs. - D: Decreasing physical activity may not address the underlying cause of the sudden change in vital signs.
Question 9 of 9
While bathing an 82 y.o. man hospitalized with pneumonia, a nurse notes an ulcerated area on his penis. What action should the nurse take first?
Correct Answer: A
Rationale: The correct action is to report the ulcer to the admitting care provider first. This is essential because the ulcer could be a sign of an underlying infection or condition that needs immediate attention, especially in a hospitalized patient with pneumonia. Reporting the ulcer ensures prompt evaluation and appropriate treatment. The other options are incorrect because teaching about STD prevention and asking about syphilis assume the cause of the ulcer is related to a sexually transmitted infection, which may not be the case in this scenario. Additionally, cleaning the ulcer without proper assessment and diagnosis by a healthcare provider can lead to complications or delay in appropriate treatment.