Pharmacology and the Nursing Process Test Bank

Correct Answer: C

Rationale: The correct answer is C: Call the physician. In this scenario, the sudden severe headache and nasal congestion along with flushed skin and goosebumps suggest autonomic dysreflexia, a medical emergency in spinal cord injury at or above T6. The nurse should immediately call the physician to address this potentially life-threatening situation. Raising the client's head (A) may worsen the condition, placing the client on a firm mattress (B) is not a priority, and administering an analgesic (D) without addressing the underlying cause could lead to further complications. The priority is to identify and address the cause of autonomic dysreflexia promptly.

Correct Answer: B

Rationale: The correct answer is B because during the evaluation phase of nursing care for a client with COPD, the nurse should review the client's progress toward meeting the goals set during the planning phase. This involves assessing whether the interventions implemented are effective in improving the client's condition and if the goals are being achieved. This step is crucial in determining the overall effectiveness of the care provided and making any necessary adjustments to the plan. A: Documenting interventions is important but not the primary focus during the evaluation phase. C: Delegating further care is not typically done during the evaluation phase as it is more about assessing the current care plan. D: Ensuring compliance with physician orders is important but does not encompass the holistic evaluation of the client's progress towards goals.

Correct Answer: C

Rationale: The correct answer is C because performing chest physiotherapy (CPT) at least two hours after meals helps prevent aspiration during the procedure. This timing reduces the risk of vomiting or regurgitation of food during CPT, which could lead to aspiration pneumonia. Slapping the chest wall gently (A) may not effectively clear secretions. Using vibration techniques (B) is not typically recommended for routine CPT. Planning apical drainage at the beginning of the session (D) is not necessary as it is not a standard practice for CPT.

Correct Answer: A

Rationale: Step-by-step rationale for why choice A is correct: 1. Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor. 2. ACE inhibitors like enalapril maleate block the conversion of angiotensin I to angiotensin II. 3. By inhibiting the formation of angiotensin II, enalapril maleate decreases the levels of angiotensin II. 4. Angiotensin II is a potent vasoconstrictor, so decreasing its levels leads to vasodilation and decreased blood pressure. Summary of why other choices are incorrect: - Choice B: Enalapril maleate primarily dilates arterioles by decreasing angiotensin II levels, not veins. - Choice C: Enalapril maleate does not directly adjust extracellular volume; it primarily affects the renin-angiotensin-aldosterone system. - Choice D: Enalapril maleate

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.