Test Bank Pharmacology and the Nursing Process

Correct Answer: A

Rationale: The correct answer is A because it demonstrates data validation in making a nursing clinical decision. The nurse assesses the time of the last dressing change and compares it with the appearance of old and new drainage. This process ensures that the decision to remove the wound dressing is based on accurate and validated data, leading to appropriate patient care. Choice B is incorrect because it does not involve data validation. The decision is driven by increased pain and family requests, without verifying the underlying cause. Choice C is incorrect as it involves responding to a patient's reported symptom (leg cramps), but it does not involve data validation in making the clinical decision. Choice D is incorrect as it relies solely on the patient's report of decreased mobility without further data validation.

Correct Answer: D

Rationale: The correct answer is D. Taking piroxicam with food or an oral antacid can help reduce GI irritation as it can protect the stomach lining. Piroxicam is known to cause GI upset due to its effects on prostaglandin synthesis. Spacing the administration every 4 hours (choice A) may not necessarily prevent GI upset. Using the drug for a short time only (choice B) may not address the immediate concern of GI irritation. Decreasing the piroxicam dosage (choice C) may not be necessary if taking it with food or an antacid can effectively alleviate the GI upset.

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.

Correct Answer: A

Rationale: The correct answer is A: after the surgery, bleeding is normal. This is because after a TURP procedure, it is common for some bleeding to occur, leading to blood clots in the urine bag. The surgical site undergoes trauma, causing bleeding as a part of the healing process. Choice B is incorrect because while irrigation may be done post-surgery, blood clots in the urine bag are expected due to the surgery itself, not just irrigation. Choice C is incorrect as it is normal for some bleeding to occur after TURP, and immediate physician intervention is not necessary unless excessive bleeding is observed. Choice D is incorrect as tugging on the catheter may cause bleeding, but in this case, the presence of blood clots is likely due to the surgery itself, not catheter irritation.

Correct Answer: C

Rationale: The correct answer is C: Eye opening, verbal response, motor response. The Glasgow Coma Scale assesses a patient's level of consciousness using these three factors. Eye opening measures arousal, verbal response assesses communication abilities, and motor response evaluates motor function. In the case of J.E., since he is alert and oriented, his eye opening is intact. His ability to communicate verbally and move his limbs appropriately would be crucial in determining his neurological status. Choices A and B are incorrect as they do not include the necessary assessment factor of eye opening. Choice D is incorrect as it mentions "response to pain" instead of verbal response, which is a key component of the Glasgow Coma Scale.