ATI RN
Test Bank Pharmacology and the Nursing Process Questions
Question 1 of 9
When instructing the client diagnosed with hyperparathyroidism about diet, the nurse should stress the importance of which of the following?
Correct Answer: C
Rationale: The correct answer is C: Restricting sodium. In hyperparathyroidism, there is an excess of parathyroid hormone leading to increased calcium levels. Sodium can worsen calcium excretion, exacerbating the condition. Restricting sodium can help reduce calcium loss. A: Restricting fluids is not necessary unless the client has kidney issues. B: Forcing fluids may not be beneficial and can lead to fluid overload. D: Restricting potassium is not typically necessary unless the client has kidney issues.
Question 2 of 9
Which of the following BP changes alerts the nurse to increasing ICP, and should be reported immediately?
Correct Answer: B
Rationale: The correct answer is B, Widening pulse pressure. This indicates increasing intracranial pressure (ICP) as it signifies a significant difference between systolic and diastolic blood pressure. A widening pulse pressure is a key sign of impending herniation and requires immediate intervention. A: Gradual increase does not provide a clear indication of acute changes in ICP. C: Rapid drop followed by gradual increase may suggest other conditions and is not specific to increasing ICP. D: Rapid fluctuations may occur in various scenarios and do not specifically point to increasing ICP. In summary, a widening pulse pressure is the most critical and specific indicator of increasing ICP among the choices provided.
Question 3 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.
Question 4 of 9
A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data?
Correct Answer: D
Rationale: The correct answer is D because "Unable to palpate femoral pulse in left leg" is an objective finding that can be measured or observed without interpretation or bias. It provides concrete, measurable information about the patient's condition. Choices A, B, and C are subjective data as they rely on the patient's feelings, emotions, and perceptions, which can vary and are open to interpretation. Objective data is crucial in making accurate assessments and decisions in healthcare.
Question 5 of 9
What part of the nursing diagnosis statement suggests the nursing interventions to be included in the plan of care?
Correct Answer: C
Rationale: The correct answer is C: Etiology of the problem. In a nursing diagnosis statement, the etiology describes the underlying cause or contributing factors to the identified problem. This is crucial as it guides the selection of appropriate nursing interventions aimed at addressing the root cause of the issue. By addressing the etiology, nurses can implement interventions that will effectively treat the problem. Choice A (Problem statement) simply identifies the issue without providing insight into its cause. Choice B (Defining characteristics) lists the signs and symptoms of the problem but doesn't directly inform the interventions needed. Choice D (Outcomes criteria) outlines the expected results of the interventions but doesn't directly suggest which interventions to implement. Thus, C is the correct choice as it directly influences the selection of appropriate nursing interventions.
Question 6 of 9
At 1400, the nurse notices that the dressing is saturated and leaking. What is the nurse’s next action?
Correct Answer: B
Rationale: The correct answer is B because a saturated and leaking dressing indicates a potential infection risk and compromised wound healing. The nurse should revise the plan of care and change the dressing immediately to prevent complications. Waiting until 1800 (choice A) could lead to further contamination and delay in treatment. Reassessing in 2 hours (choice C) might worsen the condition. Discontinuing the plan of care (choice D) is not appropriate without addressing the immediate issue.
Question 7 of 9
A nurse is making initial rounds on patients. Which intervention for a patient with poor wound healing should the nurse perform first?
Correct Answer: C
Rationale: The correct answer is C: Observe wound appearance and edges. This is the first intervention the nurse should perform because assessing the wound's appearance and edges provides crucial information about the healing process and any signs of infection. It helps in determining the next steps in the care plan. Reinforcing the dressing (A) and performing dressing changes (B) should come after assessing the wound. Documenting wound characteristics (D) is important but should also follow the initial assessment.
Question 8 of 9
Which of the following are examples of common factors in a client that may influence assessment priorities?
Correct Answer: A
Rationale: The correct answer is A: Diet and exercise program. This is because a client's diet and exercise program directly impact their physical health and well-being, making it an important factor to consider when determining assessment priorities. Understanding their dietary habits and level of physical activity can help identify potential health risks or areas for improvement. Choices B, C, and D are incorrect because they do not directly relate to the client's physical health and well-being, which are crucial factors in determining assessment priorities. Standing in the community (B) may influence social interactions but does not necessarily impact assessment priorities. Ability to pay for services (C) relates to financial considerations rather than health assessment priorities. Developmental stage (D) may be important for understanding the client's cognitive and emotional development, but it is not as directly relevant to assessment priorities as diet and exercise.
Question 9 of 9
To provide safe care for Mrs. Zeno, it is important for the nurse to check the bedside for the presence of:
Correct Answer: C
Rationale: The correct answer is C: An intravenous set-up. Checking for an intravenous set-up is crucial to ensure that Mrs. Zeno is receiving necessary medications or fluids. It allows the nurse to monitor the infusion rate, prevent potential complications like infiltration, and ensure proper medication administration. A tracheostomy set (A) may be important for respiratory support but not essential for immediate safety. A hypothermia blanket (B) is used for temperature management and not directly related to Mrs. Zeno's immediate safety. A syringe and edrophonium HCl (D) are specific to a diagnostic test for myasthenia gravis and not necessary for general bedside safety assessment.