a nurse is caring for a client who has streptococcal pneumonia and a prescription for penicillin g by intermittent iv bolus 10 minutes into the infusi a nurse is caring for a client who has streptococcal pneumonia and a prescription for penicillin g by intermittent iv bolus 10 minutes into the infusi
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Nursing Elites

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ATI Pharmacology Test Bank

1. A client with streptococcal pneumonia is receiving penicillin G by intermittent IV bolus. 10 minutes into the infusion of the third dose, the client reports itching at the IV site, dizziness, and shortness of breath. What should the nurse do first?

Correct answer: A

Rationale: In this scenario, the client is exhibiting signs of anaphylaxis, a severe allergic reaction. The priority action for the nurse is to stop the infusion immediately to prevent further administration of the allergen and worsening symptoms. Once the infusion is stopped, the nurse can then proceed with additional interventions, such as calling the provider, assessing the client's respiratory status, and providing appropriate care as needed.

2. A healthcare professional is preparing to transfer a client from a chair to the bed. The client can bear partial weight and has upper body strength. Which device should the professional use?

Correct answer: C

Rationale: A stand-assist lift is the most suitable device for transferring a client who can bear partial weight and has upper body strength. This lift provides support and assistance for clients to stand up and be safely transferred. A gait belt is used for providing support during walking or transferring short distances for clients who need minimal assistance with balance and strength. A mechanical lift is typically used for clients who are non-weight bearing or have limited weight-bearing capacity. A slide board is utilized for transferring clients who are unable to bear weight on their legs and need assistance in sliding from one surface to another.

3. A patient with diabetes is admitted with high blood sugar levels. What is the nurse's priority intervention?

Correct answer: A

Rationale: Administering insulin is the priority intervention for a patient admitted with high blood sugar levels because it helps lower the blood sugar levels effectively and rapidly. Insulin is a crucial medication for managing hyperglycemia in diabetes. Encouraging exercise (choice B) can be beneficial in the long term for managing blood sugar levels but is not the most immediate priority. While staying hydrated (choice C) is important, it is not the priority intervention when dealing with high blood sugar levels. Providing a low-sugar diet (choice D) is essential for long-term diabetes management but is not the immediate action needed to address high blood sugar levels in an admitted patient.

4. A nurse in a prenatal clinic is educating a client about expected changes during pregnancy. The nurse should instruct the client about which change during pregnancy is related to the slowing of the gastrointestinal tract?

Correct answer: B

Rationale: During pregnancy, the hormonal changes can lead to the slowing down of the gastrointestinal tract, causing constipation. This occurs due to increased progesterone levels, which relax smooth muscles, including those in the intestines, leading to slower bowel movements. Diarrhea is not typically associated with the slowing of the gastrointestinal tract during pregnancy. While there may be changes in the absorption of nutrients like iron and calcium, they are not directly related to the slowing of the gastrointestinal tract.

5. The nurse is caring for a postthyroidectomy patient at risk for hypocalcemia. What action should the nurse take when assessing for hypocalcemia?

Correct answer: D

Rationale: Muscle twitching and numbness or tingling of the lips, fingers, and toes are signs of hyperirritability of the nervous system due to hypocalcemia. The other options describe complications the nurse should also be observing for; however, tetany and neurologic alterations are primary indications of hypocalcemia. Monitoring for an elevated thyroid-stimulating hormone (choice A) is not relevant in assessing for hypocalcemia. Observing for swelling of the neck, tracheal deviation, and severe pain (choice B) are more related to airway compromise. Evaluating the quality of the patient's voice postoperatively (choice C) is important but not a primary sign of hypocalcemia.

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