ATI RN
Pharmacology and the Nursing Process Test Bank Questions
Question 1 of 5
The nurse notes vigorous bubbling in the water-seal chamber of a chest-drainage system. Which of the following actions should the nurse take to correct the bubbling?
Correct Answer: A
Rationale: The correct answer is A. First, the nurse should assess the chest-drainage system and tubing for any air leaks. Air leaks can cause bubbling in the water-seal chamber, indicating a potential issue with the system's integrity. By examining the entire system, the nurse can identify and correct any leaks to ensure proper functioning of the chest-drainage system. Lowering the level of suction (choice B) may not address the underlying issue of air leaks. Doing nothing (choice C) is not appropriate as vigorous bubbling indicates a problem. Asking the patient to cough forcefully (choice D) is unrelated to addressing bubbling in the water-seal chamber.
Question 2 of 5
The nurse should include in the patient’s teaching plan that if the patient does not take the vitamin B12, which one of the following will develop?
Correct Answer: C
Rationale: The correct answer is C: Pernicious anemia. Vitamin B12 is essential for the production of red blood cells, and its deficiency can lead to pernicious anemia, characterized by decreased red blood cell production. Without adequate vitamin B12, the body cannot properly utilize iron, leading to anemia. Iron deficiency anemia (choice A) is a result of insufficient iron levels, not vitamin B12 deficiency. Sickle cell anemia (choice B) is a genetic disorder affecting hemoglobin, not related to vitamin B12 deficiency. Acquired haemolytic anemia (choice D) is caused by the premature destruction of red blood cells, not by vitamin B12 deficiency.
Question 3 of 5
Which of the ff is the most important factor in the nursing management of a client with CFS?
Correct Answer: D
Rationale: The correct answer is D because educating the client about the disease process and its limitations is crucial in managing Chronic Fatigue Syndrome (CFS). By understanding the disease, the client can make informed decisions regarding their lifestyle, activities, and self-care. This empowers the client to manage symptoms effectively and prevent exacerbations. Choice A is not the most important factor as simply avoiding aggravating the disease does not address the overall management of CFS. Choice B focuses solely on drug therapy, which is only one aspect of the client's management and may not provide significant improvement for all clients with CFS. Choice C, altering diet and environment, can be helpful but may not be the most important factor as understanding the disease process and limitations is essential for long-term management and quality of life.
Question 4 of 5
A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless, temporary change?
Correct Answer: B
Rationale: The correct answer is B: Redness of the upper part of the feet. During lymphangiography, a contrast dye is injected into the lymphatic vessels. This may cause temporary redness in the upper part of the feet due to the dye spreading throughout the lymphatic system. Purplish stools (A), bluish urine (C), and coldness of the soles (D) are not expected side effects of lymphangiography and do not have a direct correlation with the procedure.
Question 5 of 5
When administering a blood transfusion to a client with multiple traumatic injuries, the nurse monitors closely for evidence of a transfusion reaction. Shortly after the transfusion begins, the client complains of chest pain, nausea and itching. When urticarial, tachycardia, and hypotension develop, the nurse stops the transfusion and notifies the physician. The nurse suspects which type of hypersensitivity reaction?
Correct Answer: A
Rationale: The correct answer is A: Type I (immediate, anaphylactic) hypersensitivity reaction. In this scenario, the client experiences symptoms shortly after the transfusion starts, such as chest pain, nausea, itching, urticaria, tachycardia, and hypotension, which are indicative of an immediate hypersensitivity reaction. Type I reactions involve the release of histamine and other inflammatory mediators from mast cells and basophils, leading to the symptoms described. The nurse's prompt action of stopping the transfusion and notifying the physician aligns with managing this type of reaction. Incorrect choices: B: Type II (cytolytic, cytotoxic) hypersensitivity reaction - This type of reaction involves antibodies targeting specific cells, leading to their destruction. The symptoms described in the scenario are not consistent with this type of reaction. C: Type III (immune complex) hypersensitivity reaction - This type of reaction involves the formation of immune complexes that deposit in tissues, causing