ATI RN
Pharmacology and the Nursing Process Test Bank Questions
Question 1 of 9
When monitoring for hypernatremia, the nurse should assess the client for:
Correct Answer: C
Rationale: The correct answer is C: Confusion. Hypernatremia is an electrolyte imbalance characterized by high sodium levels in the blood. Confusion is a common symptom as high sodium levels can affect brain function. Dry skin (A) is more indicative of dehydration, tachycardia (B) is a symptom of various conditions, and pale coloring (D) is not specific to hypernatremia. Confusion is a key indicator that the nurse should assess for when monitoring for hypernatremia.
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
Which of the ff. would the nurse explain to the patient is the triad of symptoms associated with Meniere’s disease?
Correct Answer: A
Rationale: The correct answer is A: Hearing loss, vertigo, and tinnitus. Meniere's disease is characterized by a triad of symptoms: recurrent episodes of vertigo, sensorineural hearing loss, and tinnitus. Vertigo is a spinning sensation, hearing loss affects the inner ear, and tinnitus is ringing in the ear. Nausea, vomiting, pain, nystagmus, or headache are not typically part of the classic triad of Meniere's disease symptoms. Therefore, option A is the most appropriate choice based on the specific symptomatology associated with Meniere's disease.
Question 4 of 9
Mrs. Zeno asks the nurse why the disease has occurred. The nurse bases the reply on the knowledge that there is:
Correct Answer: C
Rationale: The correct answer is C: A decreased number of functioning acetyl-choline receptor sites. This is because in diseases like myasthenia gravis, there is an autoimmune attack on acetylcholine receptor sites, leading to decreased functionality. Choice A is incorrect because it refers to a genetic defect in acetylcholine production, which is not typically the cause of myasthenia gravis. Choice B is incorrect as it suggests a reduced amount of acetylcholine, which is not the primary issue in myasthenia gravis. Choice D is incorrect as it mentions inhibition of the enzyme Ache, which is not the main mechanism in this disease.
Question 5 of 9
A client is admitted for postoperative assessment and recovery after surgery for a kidney tumor. The nurse needs to assess for signs of urinary tract infection. Which of the ff measures can be used to help detect UTI?
Correct Answer: B
Rationale: The correct answer is B: Monitor temperature every 4hrs. This is crucial in detecting signs of urinary tract infection as fever is a common symptom. Monitoring temperature regularly allows for early detection and appropriate intervention. A: Encouraging the client to breathe deeply and cough every 2hrs is a measure to prevent respiratory complications postoperatively, not related to UTI detection. C: Splinting the incision when repositioning the client is important for wound care, not for detecting UTI. D: Irrigating tubes as ordered is a specific intervention for tube care, not for monitoring UTI symptoms.
Question 6 of 9
Which of the following groups of terms best describes a nurse-initiated intervention?
Correct Answer: B
Rationale: The correct answer is B because nurse-initiated interventions involve autonomous actions based on clinical judgment to achieve client outcomes. Nurses assess, plan, and implement care independently. Choice A involves physician orders, not nurse-initiated actions. Choice C relates to medical treatment, not nursing interventions. Choice D focuses on collaboration with other providers, not solely nurse-initiated actions. In summary, only choice B aligns with the independent and outcome-focused nature of nurse-initiated interventions.
Question 7 of 9
To reduce symptoms of early morning stiffness in a ptient who has rheumatoid arthritis, the nurse can encourage the patient to:
Correct Answer: A
Rationale: The correct answer is A: take a hot tub bath or shower in the morning. This is effective as the warm water helps to relax muscles and joints, reducing stiffness. It also improves circulation, which can alleviate morning stiffness in patients with rheumatoid arthritis. Incorrect choices: B: Putting joints through passive ROM before active movement may exacerbate stiffness if not done properly. C: Sleeping with a hot pad may provide temporary relief but does not address the root cause of morning stiffness. D: Taking aspirin can help with pain but does not directly address stiffness. Waiting 15 minutes before moving may not be as effective as soaking in warm water.
Question 8 of 9
Which of the following is the most common cause of hyperaldosteronism?
Correct Answer: D
Rationale: The correct answer is D: An adrenal adenoma. Adrenal adenoma is the most common cause of primary hyperaldosteronism, also known as Conn's syndrome. Adrenal adenomas are benign tumors that cause overproduction of aldosterone, leading to increased sodium retention and potassium excretion. This results in hypertension and hypokalemia. Excessive sodium intake (A) and deficient potassium intake (B) are not direct causes of hyperaldosteronism. A pituitary adenoma (C) is associated with other hormone imbalances, such as Cushing's syndrome or acromegaly, but not hyperaldosteronism.
Question 9 of 9
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.