Test Bank Pharmacology and the Nursing Process

Correct Answer: C

Rationale: The correct answer is C: Cough. Enalapril is an ACE inhibitor, and a common side effect is a dry, persistent cough due to the accumulation of bradykinin. This is a distinctive side effect of ACE inhibitors and should be reported to the healthcare provider. Acne (A), diarrhea (B), and heartburn (D) are not commonly associated with enalapril use and are less likely side effects.

Correct Answer: B

Rationale: The correct answer is B: Respiratory acidosis. Aspirin can lead to respiratory acidosis due to its effect on the respiratory center in the brainstem. It causes hyperventilation, leading to respiratory alkalosis initially, followed by respiratory acidosis as compensation mechanism fails. Weight gain is not a typical adverse reaction of aspirin. Fine motor tremors are not associated with aspirin therapy. Bilateral hearing loss is a rare but serious side effect of aspirin overdose, not prolonged therapy.

Correct Answer: A

Rationale: The correct answer is A: Provide the patient with a writing board each shift. This intervention addresses the impaired verbal communication by offering an alternative way for the patient to communicate. Writing board enables the patient to express thoughts and feelings, reducing the risk of loneliness. Choice B doesn't directly address the communication issue. Choice C is not relevant to the nursing diagnosis. Choice D, while promoting companionship, doesn't address the specific communication concern stated in the diagnosis.

Correct Answer: D

Rationale: Correct Answer: D. Antagonize the action of K on the heart Rationale: 1. Calcium gluconate stabilizes cardiac cell membranes during hyperkalemia. 2. By antagonizing the effects of potassium on the heart, it helps prevent life-threatening cardiac arrhythmias. 3. It does not lower potassium levels immediately or prevent transient renal failure. 4. Administering calcium gluconate is specific to addressing the cardiac effects of hyperkalemia, not renal or overall potassium reduction.

Correct Answer: D

Rationale: The correct answer is D: Exhale deeply as the nurse re-inflates the cuff. Rationale: 1. When the cuff of the tracheostomy tube is deflated, the client should be instructed to exhale deeply to prevent aspiration of secretions. 2. Exhaling helps to clear the airway by pushing secretions out of the trachea, reducing the risk of aspiration. 3. Inhaling or holding the breath while the cuff is being re-inflated can increase the risk of inhaling secretions. 4. Coughing as the cuff is being deflated (choice A) may not be as effective in clearing secretions as exhaling deeply. 5. Taking a deep breath as the nurse deflates the cuff (choice C) may not be as effective as exhaling deeply in preventing aspiration. In summary, choice D is the correct answer because exhaling deeply helps clear secretions and reduce the risk of aspiration, while the other choices may