Pharmacology and the Nursing Process Test Bank

Correct Answer: B

Rationale: Step 1: TIS stands for carcinoma in situ, which means cancer cells are present only in the layer of cells where they first developed. Step 2: N0 indicates no abnormal regional lymph nodes are involved. Step 3: M0 signifies no evidence of distant metastasis. Therefore, the correct answer is B because it accurately interprets the TNM staging system for the biopsy report. Summary: A: Incorrect - TIS indicates carcinoma in situ, not no evidence of primary tumor. C: Incorrect - TIS already assesses tumor presence, ruling out this option. D: Incorrect - TIS is not about ascending degrees of distant metastasis.

Correct Answer: A

Rationale: The correct answer is A because monitoring the client's temperature before, during, and after the transfusion allows the nurse to identify any changes or trends that may indicate a complication related to the blood transfusion. This comprehensive monitoring helps differentiate between a normal body response to cold blood infusion and a potential adverse reaction. Choice B is incorrect because documenting the client's temperature only after the transfusion may miss important changes during the process. Choice C is incorrect as the temperature of the blood before transfusion does not directly indicate the client's response to the chilled blood. Choice D is incorrect as comparing the client's temperature with the temperature of the blood alone does not provide a complete picture of the client's condition throughout the transfusion process.

Correct Answer: D

Rationale: The correct answer is D because Buck's extension traction is not used definitively to treat fractures in children due to their growing bones. Instead, it is used temporarily in adults to control muscle spasm and pain. - A: Correct - Buck's extension traction is indeed used temporarily in adults to control muscle spasm and pain. - B: Correct - Buck's extension traction is applied by an orthopedic surgeon under aseptic conditions using wires and pins. - C: Correct - The pulling force in Buck's extension traction is indeed transmitted to the musculoskeletal structures. Therefore, the incorrect option is D as Buck's extension traction is not used definitively to treat fractures in children.

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.

Correct Answer: A

Rationale: The correct action is to report the ulcer to the admitting care provider first. This is essential because the ulcer could be a sign of an underlying infection or condition that needs immediate attention, especially in a hospitalized patient with pneumonia. Reporting the ulcer ensures prompt evaluation and appropriate treatment. The other options are incorrect because teaching about STD prevention and asking about syphilis assume the cause of the ulcer is related to a sexually transmitted infection, which may not be the case in this scenario. Additionally, cleaning the ulcer without proper assessment and diagnosis by a healthcare provider can lead to complications or delay in appropriate treatment.