Test Bank Pharmacology and the Nursing Process

Correct Answer: A

Rationale: The correct answer is A: Balance. Loss of ability in balance can indicate various health issues like neurological disorders or musculoskeletal problems. The nurse can assess this by observing the patient's gait, balance while standing, and coordination. Speech (B) relates to communication abilities, judgment (C) involves decision-making skills, and endurance (D) is related to stamina and physical capacity, which are not directly linked to loss of ability.

Correct Answer: C

Rationale: The correct answer is C because priming the tubing of the blood administration set with 0.9% NS solution ensures that there are no air bubbles in the tubing, preventing air embolism when the blood transfusion starts. This step also ensures that the blood flows smoothly and prevents clotting in the tubing. Choice A is incorrect because adding IV medication in the blood bag can lead to incompatibility issues and should not be done without proper verification and approval. Choice B is incorrect because leaving the blood bag at room temperature for an hour can lead to bacterial growth in the blood, increasing the risk of infection when transfused. Choice D is unrelated to setting up supplies for a blood transfusion and does not address the immediate nursing intervention required in this situation.

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: B

Rationale: The correct answer is B: Perforation of the colon caused by the liver biopsy. The symptoms of fever, severe abdominal pain, and confusion are indicative of peritonitis, which can result from a bowel perforation during the liver biopsy procedure. Perforation of the colon can lead to leakage of bowel contents into the peritoneal cavity, causing inflammation, infection, and systemic symptoms. This is a serious complication that requires immediate medical attention. Incorrect options: A: Bleeding in the liver caused by the liver biopsy would present with symptoms such as hypotension and signs of internal bleeding, not confusion and severe abdominal pain. C: An allergic reaction to contrast media would typically present with symptoms such as rash, itching, or respiratory distress, not fever, severe abdominal pain, and confusion. D: Normal post procedural pain would not cause confusion and a change in the level of consciousness, which indicates a more serious underlying issue like bowel perforation.

Correct Answer: C

Rationale: The correct answer is C: Implementation. In the nursing process, implementation involves carrying out the care plan, interventions, and education that were determined during the planning phase. Providing education to a client about the importance of adhering to prescribed medications falls under this phase as it involves putting the plan into action to promote positive health outcomes. Assessment (A) involves collecting data about the client's condition, Planning (B) involves developing a care plan based on the assessment findings, and Evaluation (D) involves assessing the effectiveness of the interventions implemented.