While completing an admission database, the nurse is interviewing a patient who states “I am allergic to latex.” Which action will the nurse take first?

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Pharmacology and the Nursing Process 10th Edition Test Bank Questions

Question 1 of 5

While completing an admission database, the nurse is interviewing a patient who states “I am allergic to latex.” Which action will the nurse take first?

Correct Answer: B

Rationale: The correct answer is B: Ask the patient to describe the type of reaction. This is the first action the nurse should take because it is essential to assess the severity of the latex allergy to determine the appropriate precautions and interventions. By asking the patient to describe the type of reaction, the nurse can gather crucial information to ensure patient safety. Choice A is incorrect because placing the patient in isolation is not necessary for a latex allergy. Choice C is incorrect as terminating the interview prematurely is not appropriate without gathering important information about the allergy. Choice D is incorrect because documenting the allergy is important, but assessing the type of reaction should be the initial priority.

Question 2 of 5

While completing an admission database, the nurse is interviewing a patient who states “I am allergic to latex.” Which action will the nurse take first?

Correct Answer: B

Rationale: The correct answer is B: Ask the patient to describe the type of reaction. First, the nurse needs to assess the severity of the latex allergy to determine the appropriate interventions. Understanding the type of reaction can help guide treatment and prevent future exposure. Isolating the patient (choice A) is not necessary unless there is a severe reaction. Terminating the interview (choice C) prematurely is not appropriate as crucial information may be missed. Documenting the allergy (choice D) is important but not as urgent as assessing the reaction type.

Question 3 of 5

A nurse adds a nursing diagnosis to a patient’s care plan. Which information did the nurse document?

Correct Answer: A

Rationale: The correct answer is A because it follows the correct format of a nursing diagnosis: "Problem related to Etiology." In this case, "Decreased cardiac output" is the problem, and "altered myocardial contractility" is the cause. This format helps identify the specific issue and its underlying cause, allowing for targeted interventions. Choice B is incorrect as it doesn't follow the problem-etiology format and lacks specificity. Choice C is also incorrect as it lacks a clear nursing diagnosis and specific etiology. Choice D is incorrect as it presents a symptom rather than a nursing diagnosis with an associated cause. Overall, choice A is the best option as it provides a clear, specific nursing diagnosis that guides appropriate nursing interventions.

Question 4 of 5

A nurse is completing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Impaired skin integrity related to shearing forces?

Correct Answer: B

Rationale: The correct answer is B because turning the patient every 2 hours helps prevent pressure ulcers caused by shearing forces. This intervention redistributes pressure, improving blood flow to the skin, thus reducing the risk of skin breakdown. Administering pain medication (A) does not directly address the skin integrity issue. Monitoring vital signs (C) is important but does not address skin integrity. Keeping bed rails up (D) may actually increase the risk of shearing forces.

Question 5 of 5

The nurse establishes trust and talks with a school-aged patient before administering an injection. Which type of implementation skill is the nurse using?

Correct Answer: B

Rationale: The correct answer is B: Interpersonal. The nurse is using interpersonal skills by establishing trust and communicating with the patient before administering the injection. This helps build rapport and alleviate anxiety. Cognitive skills involve problem-solving and critical thinking, not direct patient interaction. Psychomotor skills relate to physical tasks like giving injections. Judgmental skills involve making decisions based on critical thinking, not directly related to patient communication.

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