Pharmacology and the Nursing Process 10th Edition Test Bank

Correct Answer: B

Rationale: The correct answer is B because hyperkalemia presents with symptoms such as muscle weakness, diarrhea, and ECG changes. Muscle weakness is a common sign due to potassium's effect on neuromuscular function. Diarrhea can lead to potassium loss. ECG changes, such as peaked T waves and widened QRS complexes, indicate cardiac involvement. Assessing for these symptoms helps monitor the severity of hyperkalemia and guide treatment. Other choices are incorrect because assessing for fever and chest pain (choice A) are not specific to hyperkalemia. Encouraging fluid restriction (choice C) may not directly address hyperkalemia. Preparing for a cardiac ultrasound (choice D) is not an immediate intervention for hyperkalemia.

Correct Answer: C

Rationale: The correct answer is C: Abdominal girth. Serum albumin helps to increase oncotic pressure in the blood vessels, reducing fluid leakage into the abdomen and decreasing ascites, leading to a decrease in abdominal girth. Option A is incorrect because serum albumin does not directly affect urinary output. Option B is incorrect as serum albumin does not directly impact serum ammonia levels. Option D is incorrect because while serum albumin can help improve liver function, it does not directly treat hepatic encephalopathy.

Correct Answer: C

Rationale: Step-by-step rationale for choice C being correct: 1. Restlessness: Indicates increased work of breathing and hypoxia. 2. Suprasternal retractions: Sign of respiratory distress. 3. paO2 of 62: Indicates severe hypoxemia, common in ARDS. Summary: A: Enlarged heart on x-ray does not directly indicate ARDS. B: Thick green sputum suggests infection, not specific to ARDS. D: Wheezes and slow respirations are not typical of ARDS, and pCO2 is normal in ARDS.

Correct Answer: B

Rationale: The correct answer is B: Ask the patient to describe the type of reaction. This is the first action the nurse should take to assess the severity of the latex allergy and determine appropriate interventions. By gathering more information about the reaction, the nurse can better understand the potential risks and provide safe care. Summary of other choices: A: Immediately placing the patient in isolation is unnecessary and not indicated based solely on the patient's latex allergy. C: Proceeding to the termination phase of the interview is premature without fully assessing the patient's allergy. D: Documenting the allergy is important but should not be the first action without assessing the reaction itself.

Correct Answer: D

Rationale: The correct answer is D: Sitting up leaning slightly forward. This position helps prevent blood from flowing back into the throat, reducing the risk of choking and aspiration. It also allows for better drainage of blood out of the nose. Lying down with feet elevated (choice A) can increase blood flow to the head and worsen the nosebleed. Sitting up with neck extended (choice B) can lead to blood flowing into the throat. Lying down with a small pillow under the head (choice C) may cause blood to flow backward.