Questions 9

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Pharmacology and the Nursing Process Test Bank Questions

Question 1 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

Question 2 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

Question 3 of 5

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 4 of 5

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 5 of 5

A client undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: TIS, NO, MO. What does this classification mean?

Correct Answer: B

Rationale: Step 1: TIS stands for carcinoma in situ, which means cancer cells are present only in the layer of cells where they first developed. Step 2: N0 indicates no abnormal regional lymph nodes are involved. Step 3: M0 signifies no evidence of distant metastasis. Therefore, the correct answer is B because it accurately interprets the TNM staging system for the biopsy report. Summary: A: Incorrect - TIS indicates carcinoma in situ, not no evidence of primary tumor. C: Incorrect - TIS already assesses tumor presence, ruling out this option. D: Incorrect - TIS is not about ascending degrees of distant metastasis.

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