ATI RN
Pharmacology and the Nursing Process 10th Edition Test Bank Quizlet Questions
Question 1 of 9
The nurse is reviewing information about a client and notes the following documentation: 'Client is confused.' The nurse recognizes this information is an example of what?
Correct Answer: C
Rationale: The correct answer is C: An inference. When the nurse documents that the client is confused, it is an interpretation or conclusion drawn from the observed behavior or symptoms. Inferences are based on subjective and objective data. Subjective data (choice A) is based on what the client states, while a data cue (choice B) is a piece of information that may lead to an inference but is not the actual interpretation. Primary data (choice D) refers to firsthand information obtained directly from the client, which is not the case here. In this scenario, the nurse is making an inference based on the observed confusion, making choice C the correct answer.
Question 2 of 9
An adult suffered 2nd and third degree burns over 20% of hid body 2 days ago. What is the best way to assess the client’s fluid balance?
Correct Answer: A
Rationale: The correct answer is A: Maintain strict records of intake and output. This is the best way to assess fluid balance in a burn patient because it provides quantitative data on fluid intake and output, helping to monitor for fluid imbalance. Monitoring skin turgor (B) is unreliable in burn patients due to skin damage. Weighing the client daily (C) may not accurately reflect fluid balance changes. Checking for edema (D) is not specific to assessing fluid balance in burn patients. Maintaining intake and output records allows for precise monitoring and early detection of fluid shifts, making it the most appropriate choice.
Question 3 of 9
Mr. Chua has developed liver cirrhosis. Nurse Bea expects alteration in which laboratory values?
Correct Answer: B
Rationale: The correct answer is B: prothrombin time. In liver cirrhosis, the liver's ability to produce clotting factors is impaired, leading to prolonged prothrombin time. This indicates an increased risk of bleeding. Choice A is incorrect as carbon dioxide levels are not typically affected by liver cirrhosis. Choice C, gastric pH, is unrelated to liver function. Choice D, white blood cell count, is not directly affected by liver cirrhosis. Therefore, the alteration in prothrombin time is the most relevant laboratory value to monitor in this case.
Question 4 of 9
A nurse is collecting data from a home care client. In addition to information about the client’s health status, what is another observation the nurse should make?
Correct Answer: B
Rationale: The correct answer is B: Safety of the immediate environment. This is crucial for the client's well-being and can impact their health. The nurse should assess for hazards like loose rugs, clutter, or slippery floors. This ensures a safe living environment for the client. The other choices (A, C, D) are not directly related to the client's immediate safety or well-being. The number of rooms in the house (A) is not as important as ensuring the safety of the environment. The frequency of home visits (C) can be planned later based on the initial assessment. The friendliness of the client and family (D) is important for building rapport but does not address the immediate safety concerns of the client.
Question 5 of 9
Nurse Amy teaches a group of nursing students about the factors that cuses biliary cirrhosis. Which factor is associated with the condition?
Correct Answer: C
Rationale: The correct answer is C: chronic biliary inflammation or obstruction. Biliary cirrhosis is a condition characterized by scarring of the liver due to long-term damage to the bile ducts. Chronic biliary inflammation or obstruction can lead to the build-up of bile in the liver, causing damage over time. Acute viral hepatitis (choice A) typically does not directly cause biliary cirrhosis. Alcohol hepatotoxicity (choice B) is more commonly associated with alcoholic liver disease rather than biliary cirrhosis. Hepatic failure with prolonged venous hepatic congestion (choice D) may lead to liver cirrhosis, but it is not specific to biliary cirrhosis.
Question 6 of 9
A client has had heavy menstrual bleeding for 6 months. Her gynecologist diagnoses microcytic hypochromic anemia and prescribes ferrous sulfate (Feosol), 300mg PO daily. Before initiating iron therapy, the nurse reviews the client’s medical history. Which condition would contraindicate the use of ferrous sulfate?
Correct Answer: B
Rationale: The correct answer is B: Ulcerative colitis. Iron therapy can exacerbate gastrointestinal issues, including ulcerative colitis due to its potential to cause irritation and inflammation in the digestive tract. This can lead to worsening symptoms and complications for the client. A: Pregnancy is not a contraindication for iron therapy; in fact, it is commonly prescribed during pregnancy to prevent or treat anemia. C: Asthma is not a contraindication for iron therapy as it does not directly interact with asthma or its treatment. D: Severely impaired liver function is not a direct contraindication for iron therapy, although caution may be needed in such cases due to iron metabolism being affected by liver function.
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 32 y.o. male patient is admitted to a medical unit with a diagnosis of Guillain-Barre Syndrome. His legs are weak, and he is unable to walk without assistance. Which of the ff. is most likely responsible for this syndrome?
Correct Answer: D
Rationale: The correct answer is D: Autoimmune reaction. Guillain-Barre Syndrome is an autoimmune disorder where the immune system mistakenly attacks the peripheral nerves, leading to muscle weakness and paralysis. This is supported by the patient's presentation of weakness in the legs. Bacterial infection (A) can trigger Guillain-Barre Syndrome, but it is not the root cause. High-fat diet (B) and heredity (C) are not associated with the development of this syndrome. In summary, autoimmune reaction is the primary mechanism underlying Guillain-Barre Syndrome, resulting in the patient's muscle weakness and inability to walk.
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.