ATI RN
Test Bank Pharmacology and the Nursing Process Questions
Question 1 of 9
The nurse understands that which of the ff. is a side effect most likely to be reported by patients receiving enalapril maleate (Vasotec)?
Correct Answer: C
Rationale: The correct answer is C: Cough. Enalapril is an ACE inhibitor, and a common side effect is a dry, persistent cough due to the accumulation of bradykinin. This is a distinctive side effect of ACE inhibitors and should be reported to the healthcare provider. Acne (A), diarrhea (B), and heartburn (D) are not commonly associated with enalapril use and are less likely side effects.
Question 2 of 9
The nurse teaches a patient how to live with a new tracheostomy. Which of the ff. instructions is appropriate?
Correct Answer: C
Rationale: The correct answer is C: “Be sure to protect your tracheostomy from pollutants such as powders, hair, and chemicals.” This instruction is appropriate because keeping the tracheostomy site clean and free from pollutants is crucial in preventing infections and complications. Powders, hair, and chemicals can lead to irritation and blockages, increasing the risk of infection. Explanation of why other choices are incorrect: A: “Never suction your tracheostomy; you might damage your trachea.” - This is incorrect because suctioning is a necessary part of tracheostomy care to clear secretions and ensure proper breathing. B: “You should not feel bad about the tracheostomy – you should feel lucky to be alive.” - This is incorrect as it does not provide practical instructions for tracheostomy care and may not address the patient's emotional concerns adequately. D: “Your tracheostomy will be cleaned each time you visit your doctor.” - This is
Question 3 of 9
The nurse assesses the motor functions during a neurologic examination of a client. Which of the ff steps will help the nurse perform the examination effectively? Choose all that apply
Correct Answer: A
Rationale: Step-by-step rationale: 1. Allowing the client to grasp the nurse's hand firmly assesses grip strength and motor coordination. 2. This step helps evaluate the client's ability to follow instructions and perform a coordinated motor task accurately. 3. Assessing grip strength is essential in determining any muscle weakness or neurological deficits. 4. It also provides insight into the client's motor function and coordination abilities. Summary: - Choice B is incorrect because it focuses on sensory functions rather than motor functions. - Choice C assesses fine motor skills, not grip strength and coordination. - Choice D evaluates cognition and logic, which are not directly related to motor function assessment.
Question 4 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 5 of 9
Which of the ff. actions would the nurse include in the plan of care to reduce the symptoms of the patient who has vertigo?
Correct Answer: C
Rationale: The correct answer is C: Avoid sudden movements. Vertigo is a type of dizziness where a person feels like they're spinning or the world around them is spinning. Sudden movements can worsen vertigo symptoms. By avoiding sudden movements, the nurse can help reduce the patient's vertigo symptoms. Avoiding noises (A) may help with other conditions like migraines, but it is not specifically helpful for vertigo. Encouraging fluid intake (B) is important for overall health but does not directly address vertigo symptoms. Administering analgesics (D) may help with pain but will not address the underlying cause of vertigo. Therefore, choosing option C is the most appropriate action to include in the plan of care for reducing vertigo symptoms.
Question 6 of 9
Which of the ff nursing interventions is taken as a precautionary measure if shock develops when a client with a spinal cord injury is hospitalized?
Correct Answer: A
Rationale: The correct answer is A: An IV line is inserted to provide access to a vein. In shock, adequate intravenous access is crucial to administer fluids and medications rapidly. This helps stabilize the client's condition by restoring blood volume and improving circulation. Choice B is incorrect as immobilization is not a primary intervention for shock in this scenario. Choice C, traction, is not appropriate for managing shock but rather for stabilizing spinal cord injuries. Choice D, using a turning frame, is not relevant to managing shock and does not address the immediate need for fluid resuscitation.
Question 7 of 9
Just as the nurse was entering the room, the patient who was sitting on his chair begins to have a seizure. Which of the following must the nurse do first?
Correct Answer: A
Rationale: The correct answer is A: Ease the patient to the floor. This is the first step because it helps prevent injury during a seizure. Lowering the patient to the floor prevents falls and protects the patient's head. Choices B, C, and D are incorrect. Choice B can cause injury or obstruct the airway, choice C involves unnecessary movement, and choice D can lead to further harm or injury. It is crucial to prioritize safety and prevent harm during a seizure episode.
Question 8 of 9
After being in remission from Hodgkin’s disease for 18 months, a client develops a fever of unknown origin. The physician orders a blind liver biopsy to rule out advancing Hodgkin’sdisease and infection. Twenty-four hours after the biopsy, the client has a fever, complains of severe abdominal pain, and seems increasingly confused. The nurse suspects that these finding result from:
Correct Answer: B
Rationale: The correct answer is B: Perforation of the colon caused by the liver biopsy. The symptoms of fever, severe abdominal pain, and confusion are indicative of peritonitis, which can result from a bowel perforation during the liver biopsy procedure. Perforation of the colon can lead to leakage of bowel contents into the peritoneal cavity, causing inflammation, infection, and systemic symptoms. This is a serious complication that requires immediate medical attention. Incorrect options: A: Bleeding in the liver caused by the liver biopsy would present with symptoms such as hypotension and signs of internal bleeding, not confusion and severe abdominal pain. C: An allergic reaction to contrast media would typically present with symptoms such as rash, itching, or respiratory distress, not fever, severe abdominal pain, and confusion. D: Normal post procedural pain would not cause confusion and a change in the level of consciousness, which indicates a more serious underlying issue like bowel perforation.
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.