Test Bank Pharmacology and the Nursing Process

Test Bank Pharmacology and the Nursing Process Related

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Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient? The nurse determines to remove a wound dressing when the patient reveals the time

  • A. of the last dressing change and notices old and new drainage. The nurse administers pain medicine due at 1700 at 1600 because the patient reports
  • B. increased pain and the family wants something done. The nurse immediately asks the health care provider for an order of potassium when a
  • C. patient reports leg cramps.
  • D. The nurse elevates a leg cast when the patient reports decreased mobility.
Correct Answer: A

Rationale: The correct answer is A because the nurse is using data validation by comparing the time of the last dressing change with the appearance of old and new drainage. This process ensures that the decision to remove the wound dressing is based on accurate and relevant information. By assessing both the time of the last dressing change and the characteristics of the drainage, the nurse is validating the need for the intervention.

Option B is incorrect because administering pain medicine based solely on a patient's report of increased pain without further validation does not demonstrate data validation. Option C is incorrect as the nurse immediately requesting an order of potassium without further assessment of the patient's condition is not an example of data validation. Option D is incorrect as elevating a leg cast based solely on a patient's report of decreased mobility without further assessment does not involve data validation.

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A client with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include:

  • A. Weight gain
  • B. Respiratory acidosis
  • C. Fine motor tremors
  • D. Bilateral hearing loss
Correct Answer: B

Rationale: The correct answer is B: Respiratory acidosis. Aspirin can lead to respiratory acidosis due to its effect on the respiratory center in the brainstem. It causes hyperventilation, leading to respiratory alkalosis initially, followed by respiratory acidosis as compensation mechanism fails. Weight gain is not a typical adverse reaction of aspirin. Fine motor tremors are not associated with aspirin therapy. Bilateral hearing loss is a rare but serious side effect of aspirin overdose, not prolonged therapy.

What part of the nursing diagnosis statement suggests the nursing interventions to be included in the plan of care?

  • A. Problem statement
  • B. Defining characteristics
  • C. Etiology of the problem
  • D. Outcomes criteria
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.

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 is reviewing the medication history of a new preoperative patient who is nil by mouth (NPO). The nurse notes that the patient has been on long-term oral steroid therapy. The nurse understands that which of the following is the reason that steroids cannot be abruptly stopped?

  • A. Higher steroid levels are needed during
  • B. Malignant hypertension will occur.
  • C. Respiratory failure will result.
  • D. Malignant hyperthermia will result.
Correct Answer: A

Rationale: The correct answer is A because abruptly stopping steroids can lead to adrenal insufficiency due to suppression of the adrenal glands. This can result in a sudden drop in cortisol levels, which are essential for various physiological functions. Patients on long-term steroid therapy need a gradual taper to allow the adrenal glands to resume cortisol production. Choices B, C, and D are incorrect as they do not directly relate to the physiological effects of stopping steroids abruptly.

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?

  • A. It’s normal and requires no action
  • B. It calls for a repeat Pap test in 6 weeks
  • C. It calls for a repeat Pap test in 3 months
  • D. It calls for a biopsy as soon as possible
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.

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