Pharmacology and the Nursing Process Test Bank

Correct Answer: A

Rationale: The correct answer is A. First, the nurse should assess the chest-drainage system and tubing for any air leaks. Air leaks can cause bubbling in the water-seal chamber, indicating a potential issue with the system's integrity. By examining the entire system, the nurse can identify and correct any leaks to ensure proper functioning of the chest-drainage system. Lowering the level of suction (choice B) may not address the underlying issue of air leaks. Doing nothing (choice C) is not appropriate as vigorous bubbling indicates a problem. Asking the patient to cough forcefully (choice D) is unrelated to addressing bubbling in the water-seal chamber.

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: A

Rationale: The correct answer is A: Is written as a two-part statement. This is because a nursing diagnosis typically consists of two parts: the problem (risk for aspiration) and the related factor (reduced level of consciousness). By using a two-part statement, the nurse clearly identifies the client's current health problem and the underlying reason for it. This format helps in developing appropriate nursing interventions to address the issue. Choice B is incorrect because the nursing diagnosis does not describe the client's response to a health problem; it identifies the potential risk for aspiration. Choice C is incorrect as the diagnosis does not focus on enhancement but rather on potential harm. Choice D is incorrect because the nursing diagnosis is based on the available evidence of the client's reduced level of consciousness, which poses a risk for aspiration.

Correct Answer: A

Rationale: The correct answer is A: Hyperkalemia. In acute Addisonian crisis, the adrenal glands do not produce enough cortisol and aldosterone, leading to electrolyte imbalances. This results in increased potassium levels (hyperkalemia) due to lack of aldosterone to promote potassium excretion. Hypernatremia (choice B) is less likely as aldosterone deficiency leads to sodium loss. Reduced BUN (choice C) is unlikely as Addison's crisis does not directly affect urea levels. Hyperglycemia (choice D) is not typically seen in Addisonian crisis as cortisol deficiency usually results in hypoglycemia.

Correct Answer: A

Rationale: The correct answer is A because it demonstrates an understanding of the key factors in managing hyperosmolar hyperglycemic nonketotic syndrome (HHNS), which include avoiding dehydration and being aware of changes in urination, thirst, and hunger. This statement shows awareness of the importance of maintaining hydration and recognizing early signs of worsening symptoms. Choice B is incorrect as consuming sugary soda can exacerbate the condition by further increasing blood sugar levels. Choice C is incorrect because while monitoring blood glucose levels is important, it is not the primary method of preventing HHNS. Choice D is incorrect because consuming high-carbohydrate snacks can contribute to elevated blood glucose levels, which is counterproductive in managing HHNS.