Test Bank Pharmacology and the Nursing Process

Test Bank Pharmacology and the Nursing Process Related

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A client with supraglottic cancer undergoes a partial laryngectomy. Postoperatively, a cuffed tracheostomy tube is in place. When removing secretions that pool above the cuff, the nurse should instruct the client to:

  • A. Cough as the cuff is being deflated
  • B. Hold the breath as the cuff is being re-inflated
  • C. Take a deep breath as the nurse deflates the
  • D. Exhale deeply as the nurse re-inflates the cuff cuff
Correct Answer: D

Rationale: The correct answer is D: Exhale deeply as the nurse re-inflates the cuff.
Rationale:
1. When the cuff of the tracheostomy tube is deflated, the client should be instructed to exhale deeply to prevent aspiration of secretions.
2. Exhaling helps to clear the airway by pushing secretions out of the trachea, reducing the risk of aspiration.
3. Inhaling or holding the breath while the cuff is being re-inflated can increase the risk of inhaling secretions.
4. Coughing as the cuff is being deflated (choice A) may not be as effective in clearing secretions as exhaling deeply.
5. Taking a deep breath as the nurse deflates the cuff (choice C) may not be as effective as exhaling deeply in preventing aspiration.
In summary, choice D is the correct answer because exhaling deeply helps clear secretions and reduce the risk of aspiration, while the other choices may

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The nurse is explaining the action of insulin to a newly diagnosed diabetic client. During the teaching, the nurse reviews the process of insulin secretion in the body. The nurse is correct when stating that insulin is secreted from the:

  • A. adenohypohysis.
  • B. alpha cells of the pancreas.
  • C. beta cells of the pancreas.
  • D. parafollicular cells of the thyroid.
Correct Answer: C

Rationale: Rationale:
1. Insulin is a hormone produced by beta cells of the pancreas.
2. Beta cells are responsible for monitoring blood glucose levels and secreting insulin in response to high glucose levels.
3. Insulin helps regulate blood glucose by facilitating glucose uptake into cells.
4. Adenohypophysis secretes other hormones, not insulin.
5. Alpha cells of the pancreas secrete glucagon, not insulin.
6. Parafollicular cells of the thyroid secrete calcitonin, not insulin.

Summary:
Choice C is correct because insulin is indeed secreted from the beta cells of the pancreas. Choices A, B, and D are incorrect as they do not secrete insulin or are related to other hormones.

The nurse assesses the motor functions during a neurologic examination of a client. Which of the ff steps will help the nurse perform the examination effectively? Choose all that apply

  • A. Allow the client to grasp the nurses hand firmly
  • B. Check the patient’s sensitivity to heat, cold, touch, and pain.
  • C. Ask the client to pick up small and large objects between the thumb and forefinger
  • D. Ask questions that require cognition and logic
Correct Answer: A

Rationale: Step-by-step rationale:
1. Allowing the client to grasp the nurse's hand firmly assesses grip strength and motor coordination.
2. This step helps evaluate the client's ability to follow instructions and perform a coordinated motor task accurately.
3. Assessing grip strength is essential in determining any muscle weakness or neurological deficits.
4. It also provides insight into the client's motor function and coordination abilities.

Summary:
- Choice B is incorrect because it focuses on sensory functions rather than motor functions.
- Choice C assesses fine motor skills, not grip strength and coordination.
- Choice D evaluates cognition and logic, which are not directly related to motor function assessment.

Which of the following guidekines does not observe surgical asepisi in the operating room?

  • A. sterile articles may touch other sterile articles or surface and remain sterile
  • B. gowns of surgical team are considered sterile in front from the chest down to the bottom of the gown
  • C. whenever a sterile barrier is breached, the area must be considered contaminated
  • D. sterile drapes are used to create a sterile field
Correct Answer: A

Rationale: The correct answer is A because in surgical asepsis, sterile articles should not touch other sterile articles or surfaces to maintain sterility. Choice B is correct as surgical team gowns are sterile in front. Choice C is correct as any breach makes the area contaminated. Choice D is correct as sterile drapes create a sterile field.

The nurse will assess a loss of ability in which of the following areas?

  • A. Balance
  • B. Speech
  • C. Judgment
  • D. Endurance
Correct Answer: A

Rationale: The correct answer is A: Balance. Loss of ability in balance can indicate various health issues like neurological disorders or musculoskeletal problems. The nurse can assess this by observing the patient's gait, balance while standing, and coordination. Speech (B) relates to communication abilities, judgment (C) involves decision-making skills, and endurance (D) is related to stamina and physical capacity, which are not directly linked to loss of ability.

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?

  • A. Ease the patient to the floor
  • B. Insert a padded tongue depressor between his jaws
  • C. Lift the patient and put him on the bed
  • D. Restraint patient’s body movement
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.

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