ATI RN
Test Bank Pharmacology and the Nursing Process Questions
Question 1 of 9
Which of the ff instructions should a nurse give a client with Hodgkin’s disease who is at risk of impaired skin integrity? Choose all that apply
Correct Answer: B
Rationale: Step 1: Keeping the neck in midline helps prevent compression of the lymphatic vessels in the neck, reducing the risk of impaired skin integrity in Hodgkin's disease. Step 2: This position also helps maintain proper blood flow and lymphatic drainage in the neck area. Step 3: Trimming nails short, using mild soap, and supporting bony prominences are not directly related to preventing impaired skin integrity in Hodgkin's disease. Summary: Choice B is correct as it directly addresses the specific risk factor of impaired skin integrity in Hodgkin's disease, while the other choices are not as relevant to this particular concern.
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
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 4 of 9
A client has a routine Papanicolaou (Pap) test during a yearly gynecologic examination. The result reveals a class V finding. What should the nurse tell the client about this finding?
Correct Answer: D
Rationale: The correct answer is D because a class V Pap test finding indicates severe abnormalities, such as high-grade dysplasia or carcinoma in situ. Therefore, the nurse should instruct the client to undergo a biopsy as soon as possible to confirm the diagnosis and initiate appropriate treatment promptly. Choices A, B, and C are incorrect because a class V result is not normal and requires immediate follow-up, rather than waiting or repeating the Pap test at a later time.
Question 5 of 9
The nurse is instructing a premenopausal woman about breast self-examination. The nurse should tell the client to do her self-examination:
Correct Answer: C
Rationale: Correct Answer: C - The nurse should tell the client to do her self-examination on the same day each month to establish a routine, making it easier to remember and detect any changes. This consistency helps in early detection of abnormalities. Incorrect Choices: A: Doing it at the end of the menstrual cycle may not be consistent due to varying cycle lengths. B: Doing it on the 1st day of the menstrual cycle may not be practical and could lead to missing potential abnormalities. D: Doing it immediately after her menstrual period may not provide a consistent schedule for self-examination.
Question 6 of 9
Which nursing intervention is appropriate for the nurse to take when setting up supplies for a client who requires a blood transfusion?
Correct Answer: C
Rationale: The correct answer is C because priming the tubing of the blood administration set with 0.9% NS solution ensures that there are no air bubbles in the tubing, preventing air embolism when the blood transfusion starts. This step also ensures that the blood flows smoothly and prevents clotting in the tubing. Choice A is incorrect because adding IV medication in the blood bag can lead to incompatibility issues and should not be done without proper verification and approval. Choice B is incorrect because leaving the blood bag at room temperature for an hour can lead to bacterial growth in the blood, increasing the risk of infection when transfused. Choice D is unrelated to setting up supplies for a blood transfusion and does not address the immediate nursing intervention required in this situation.
Question 7 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 8 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 9 of 9
The Glasgow coma scale is used to .evaluate the level of consciousness in the neurological and neurological patients. The three assessment factors included in this scale are:
Correct Answer: C
Rationale: The correct answer is C: Eye opening, verbal response, motor response. The Glasgow Coma Scale assesses a patient's level of consciousness using these three factors. Eye opening measures arousal, verbal response assesses communication abilities, and motor response evaluates motor function. In the case of J.E., since he is alert and oriented, his eye opening is intact. His ability to communicate verbally and move his limbs appropriately would be crucial in determining his neurological status. Choices A and B are incorrect as they do not include the necessary assessment factor of eye opening. Choice D is incorrect as it mentions "response to pain" instead of verbal response, which is a key component of the Glasgow Coma Scale.