Test Bank Pharmacology and the Nursing Process

Questions 67

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Test Bank Pharmacology and the Nursing Process Questions

Question 1 of 5

Which of the ff instructions should a nurse give a client with Hodgkin�s disease who is at risk of impaired skin integrity? Choose all that apply

Correct Answer: B

Rationale: Step 1: Keeping the neck in midline helps prevent compression of the lymphatic vessels in the neck, reducing the risk of impaired skin integrity in Hodgkin's disease. Step 2: This position also helps maintain proper blood flow and lymphatic drainage in the neck area. Step 3: Trimming nails short, using mild soap, and supporting bony prominences are not directly related to preventing impaired skin integrity in Hodgkin's disease. Summary: Choice B is correct as it directly addresses the specific risk factor of impaired skin integrity in Hodgkin's disease, while the other choices are not as relevant to this particular concern.

Question 2 of 5

The nurse understands that which of the ff. is a side effect most likely to be reported by patients receiving enalapril maleate (Vasotec)?

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.

Question 3 of 5

Why should the nurse closely monitor a client to ensure that the venous access device remains in the vein during a transfusion?

Correct Answer: B

Rationale: The correct answer is B: It minimizes the risk of circulatory overload. When a venous access device dislodges during a transfusion, there is a risk of the infusion going into the surrounding tissues instead of the vein, leading to circulatory overload. This can result in fluid overload and potentially lead to serious complications such as heart failure. Monitoring the device ensures that the medication is delivered safely and effectively into the bloodstream. Choices A, C, and D are incorrect: A: Monitoring the device does not directly minimize the risk of phlebitis, which is inflammation of the vein. C: Monitoring the device does not directly minimize the risk of pulmonary complications, which are not typically associated with a dislodged venous access device. D: Monitoring the device does not directly minimize the risk of localized edema embolism, which is a blockage caused by a blood clot, air bubble, or other material in a blood vessel.

Question 4 of 5

A patient has a bacterial infection in left lower leg. Which nursing diagnosis will the nurse add to the patient�s care plan?

Correct Answer: C

Rationale: The correct nursing diagnosis is C: Impaired skin integrity. This choice is correct because it directly addresses the bacterial infection in the left lower leg by focusing on the skin's condition. The patient's skin integrity is compromised due to the infection, making this nursing diagnosis appropriate. Choice A (Infection) is too broad and does not specify the impact on the skin. Choice B (Risk for infection) is incorrect because the patient already has a bacterial infection, so the risk has already manifested. Choice D (Staphylococcal leg infection) is too specific and does not address the broader issue of skin integrity. Therefore, the best choice is C as it accurately reflects the patient's current condition and guides appropriate nursing interventions to address the impaired skin integrity caused by the bacterial infection.

Question 5 of 5

The nurse assesses the motor functions during a neurologic examination of a client. Which of the ff steps will help the nurse perform the examination effectively? Choose all that apply

Correct Answer: A

Rationale: Step-by-step rationale: 1. Allowing the client to grasp the nurse's hand firmly assesses grip strength and motor coordination. 2. This step helps evaluate the client's ability to follow instructions and perform a coordinated motor task accurately. 3. Assessing grip strength is essential in determining any muscle weakness or neurological deficits. 4. It also provides insight into the client's motor function and coordination abilities. Summary: - Choice B is incorrect because it focuses on sensory functions rather than motor functions. - Choice C assesses fine motor skills, not grip strength and coordination. - Choice D evaluates cognition and logic, which are not directly related to motor function assessment.

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