ATI RN
Pharmacology and the Nursing Process Test Bank Questions
Question 1 of 9
The primary underlying disorder of pulmonary edema is:
Correct Answer: A
Rationale: Step 1: Pulmonary edema is caused by fluid accumulation in the lungs due to increased pressure in the pulmonary vasculature. Step 2: Decreased left ventricular pumping leads to congestive heart failure, causing increased pressure in pulmonary circulation. Step 3: This increased pressure forces fluid from the capillaries into the alveoli, causing pulmonary edema. Step 4: Increased left atrial contractility (B) would not directly lead to pulmonary edema. Step 5: Decreased right ventricular elasticity (C) and increased right atrial pressure (D) are not directly related to the pathophysiology of pulmonary edema. Summary: The correct answer is A because decreased left ventricular pumping directly contributes to the increased pressure in the pulmonary circulation that leads to pulmonary edema. Choices B, C, and D do not align with the primary underlying disorder of pulmonary edema.
Question 2 of 9
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
Question 3 of 9
A community nurse will perform chest physiotherapy for Mrs. Dy every 3 hours. It is important for the nurse to:
Correct Answer: C
Rationale: The correct answer is C because performing chest physiotherapy (CPT) at least two hours after meals helps prevent aspiration during the procedure. This timing reduces the risk of vomiting or regurgitation of food during CPT, which could lead to aspiration pneumonia. Slapping the chest wall gently (A) may not effectively clear secretions. Using vibration techniques (B) is not typically recommended for routine CPT. Planning apical drainage at the beginning of the session (D) is not necessary as it is not a standard practice for CPT.
Question 4 of 9
A nurse has been caring for a client with chronic obstructive pulmonary disease (COPD). What should the nurse focus on during the evaluation phase?
Correct Answer: B
Rationale: The correct answer is B because during the evaluation phase of nursing care for a client with COPD, the nurse should review the client's progress toward meeting the goals set during the planning phase. This involves assessing whether the interventions implemented are effective in improving the client's condition and if the goals are being achieved. This step is crucial in determining the overall effectiveness of the care provided and making any necessary adjustments to the plan. A: Documenting interventions is important but not the primary focus during the evaluation phase. C: Delegating further care is not typically done during the evaluation phase as it is more about assessing the current care plan. D: Ensuring compliance with physician orders is important but does not encompass the holistic evaluation of the client's progress towards goals.
Question 5 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 6 of 9
The patient is having difficulty coping with her new diagnosis of lymphoma. Which response by the nurse is most helpful?
Correct Answer: C
Rationale: The correct answer is C because it helps the patient explore her support system. By asking who she usually goes to when facing problems, the nurse encourages the patient to identify her sources of emotional support, which can help her cope with the new diagnosis. This response acknowledges the patient's need for support and fosters a therapeutic relationship. Explanation for incorrect choices: A: "Don't worry. You'll be okay." - This response dismisses the patient's feelings and offers false reassurance, which may not address her emotional needs. B: "The treatments you are receiving will make you feel better very soon." - While this statement provides information about treatment, it does not directly address the patient's difficulty in coping with the diagnosis. D: "Have you made end-of-life decisions?" - This response may be premature and could unnecessarily increase the patient's anxiety about her prognosis.
Question 7 of 9
A narcotic analgesic is ordered for postoperative pain. Why are narcotics given in low doses to the laryngectomy patient?
Correct Answer: A
Rationale: The correct answer is A because narcotics in high doses can depress the respiratory rate and cough reflex, which can be especially dangerous for a laryngectomy patient due to the risk of airway compromise. Low doses can provide pain relief without significant respiratory depression. Choices B and C are incorrect because narcotics typically do not increase respiratory tract secretions or cause stomal edema. Choice D is incorrect because while narcotics can potentially cause addiction, this is not the primary reason for giving low doses to laryngectomy patients.
Question 8 of 9
An adult is receiving NSAID. Which of the following would the nurse include in the teaching about this medication?
Correct Answer: B
Rationale: The correct answer is B: Take the NSAID with meals. Taking NSAIDs with meals helps reduce stomach irritation and risk of developing ulcers. Food acts as a protective barrier and helps in the absorption of the medication. Incorrect Choices: A: Taking NSAID with aspirin can increase the risk of stomach irritation and bleeding due to combined antiplatelet effects. C: Orange juice does not potentiate the effect of NSAIDs and may even worsen stomach irritation due to its acidity. D: NSAIDs do not coat the stomach lining; in fact, they can irritate the stomach lining and increase the risk of ulcers.
Question 9 of 9
During a routine checkup, the nurse assesses a client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the common AIDS-related cancer?
Correct Answer: D
Rationale: The correct answer is D: Kaposi’s sarcoma. This is a common AIDS-related cancer caused by Human Herpesvirus 8 (HHV-8) in immunosuppressed individuals. It presents as purplish lesions on the skin and mucous membranes. Squamous cell carcinoma (A) is not specific to AIDS. Leukemia (B) and Multiple myeloma (C) are not commonly associated with AIDS. Kaposi’s sarcoma is the hallmark cancer seen in AIDS patients due to their weakened immune system.