Test Bank Pharmacology and the Nursing Process

Correct Answer: C

Rationale: The correct answer is C: Auscultate lung sounds. By auscultating lung sounds, the nurse can assess for changes in breath sounds which can indicate improvement or deterioration in the patient's condition. This helps monitor the effectiveness of therapy for a pneumothorax and chest-drainage system. Palpating for crepitus (A) is not directly related to monitoring therapy effectiveness. Documenting sputum color and amount (B) is important but does not specifically monitor therapy effectiveness. Monitoring suction level (D) is crucial but does not directly assess the patient's response to therapy.

Correct Answer: B

Rationale: The correct answer is B because in a normal Rinne test, air conduction is heard longer than bone conduction in both ears. This is due to the fact that air conduction involves the transmission of sound waves through the external auditory canal, middle ear, and inner ear, which is more efficient than bone conduction where the sound waves are transmitted directly to the inner ear through the bones of the skull. Therefore, when the tuning fork is placed on the mastoid bone (bone conduction) and then moved next to the ear (air conduction), the sound should be heard longer through air conduction. Choice A is incorrect because normal auditory acuity does not necessarily mean equal perception in both ears. Choice C is incorrect as bone conduction should be heard shorter than air conduction in a normal Rinne test. Choice D is incorrect as the test does not determine which ear perceives sound better, but rather the difference in duration between air and bone conduction.

Correct Answer: C

Rationale: The correct answer is C: Menstrual irregularities. After a unilateral adrenalectomy, the remaining adrenal gland may be affected by spironolactone, leading to hormonal imbalances and menstrual irregularities. This drug is a potassium-sparing diuretic that can interfere with the production of aldosterone, affecting hormonal regulation. Breast tenderness (A) is not a common side effect of spironolactone. Increased facial hair (B) is associated with hirsutism, not typically seen with spironolactone. Hair loss (D) is more commonly associated with other medications like chemotherapy, not spironolactone.

Correct Answer: A

Rationale: The correct answer is A because bodily fluids and excretions (urine, feces, vomitus) can become contaminated with radiation from the implant. Therefore, they should be considered highly radioactive and handled appropriately. Choice B is incorrect because the client may remain radioactive for a longer period than 10 days post-implant removal. Choice C is incorrect because soiled linens should be handled according to radiation safety protocols and removed promptly. Choice D is incorrect because bed rest is not necessary unless specifically indicated by the healthcare provider; the client should be encouraged to move around as tolerated to prevent complications.

Correct Answer: A

Rationale: The correct answer is A because it demonstrates data validation in nursing clinical decision-making. In this scenario, the nurse considers the patient's self-reported information (time of last dressing change and observation of old and new drainage) as key data points to validate the need for changing the wound dressing. This aligns with the principles of evidence-based practice and ensures that the decision is based on accurate and relevant information. Choices B, C, and D are incorrect because they do not involve the systematic validation of data to inform the nursing decision-making process. Choice B relies on family input rather than objective data, Choice C jumps to a treatment decision without confirming the underlying cause, and Choice D does not involve validating the patient's reported symptom before taking action.