Test Bank Pharmacology and the Nursing Process

Correct Answer: B

Rationale: The correct answer is B because in a normal Rinne test, air conduction is heard longer than bone conduction in both ears. This is due to the fact that air conduction involves the transmission of sound waves through the external auditory canal, middle ear, and inner ear, which is more efficient than bone conduction where the sound waves are transmitted directly to the inner ear through the bones of the skull. Therefore, when the tuning fork is placed on the mastoid bone (bone conduction) and then moved next to the ear (air conduction), the sound should be heard longer through air conduction. Choice A is incorrect because normal auditory acuity does not necessarily mean equal perception in both ears. Choice C is incorrect as bone conduction should be heard shorter than air conduction in a normal Rinne test. Choice D is incorrect as the test does not determine which ear perceives sound better, but rather the difference in duration between air and bone conduction.

Correct Answer: A

Rationale: The correct answer is A: An IV line is inserted to provide access to a vein. In shock, adequate intravenous access is crucial to administer fluids and medications rapidly. This helps stabilize the client's condition by restoring blood volume and improving circulation. Choice B is incorrect as immobilization is not a primary intervention for shock in this scenario. Choice C, traction, is not appropriate for managing shock but rather for stabilizing spinal cord injuries. Choice D, using a turning frame, is not relevant to managing shock and does not address the immediate need for fluid resuscitation.

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.

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: A

Rationale: The correct answer is A because it demonstrates data validation in the nursing clinical decision-making process. The nurse assesses the time of the last dressing change and observes old and new drainage, which are relevant data points for wound care. This approach ensures that the decision to remove the dressing is based on accurate and validated information, leading to appropriate patient care. Choice B is incorrect because it relies on subjective information (increased pain and family request) rather than objective data validation. Choice C is incorrect as it involves a direct request for an order without sufficient data validation. Choice D is incorrect because elevating a leg cast based solely on a patient's report of decreased mobility does not involve thorough data validation related to the specific care needed for the patient's condition.