NCSBN 18' Exam 1 Flashcards
- A client with a diagnosis of passive-aggressive personality disorder is seen at the local mental health clinic. A common characteristic of persons with passive-aggressive personality disorder is:
❍ A. Superior intelligence
❍ B. Underlying hostility
❍ C. Dependence on others
❍ D. Ability to share feelings
Answer B is correct.
The client with passive-aggressive personality disorder often has underlying hostility that is exhibited as acting-out behavior. Answers A, C, and D are incorrect. Although these individuals might have a high IQ, it cannot be said that they have superior intelligence. They also do not necessarily have dependence on oth-
ers or an inability to share feelings.
- The client is admitted for evaluation of aggressive behavior and diagnosed with antisocial personality disorder. A key part of the care of such clients is:
❍ A. Setting realistic limits
❍ B. Encouraging the client to express remorse for behavior
❍ C. Minimizing interactions with other clients
❍ D. Encouraging the client to act out feelings of rage
Answer A is correct.
Clients with antisocial personality disorder must have limits set on their behavior because they are artful in manipulating others. Answer B is not correct because they do express feelings and remorse. Answers C and D are incorrect because it is unnecessary to minimize interactions with others or encourage them to
act out rage more than they already do.
- An important intervention in monitoring the dietary compliance of a client with bulimia is:
❍ A. Allowing the client privacy during mealtimes
❍ B. Praising her for eating all her meal
❍ C. Observing her for 1–2 hours after meals
❍ D. Encouraging her to choose foods she likes and to eat in moderation
Answer C is correct.
To prevent the client from inducing vomiting after eating, the client should be observed for 1–2 hours after meals. Allowing privacy as stated in answer A will only give the client time to vomit. Praising the client for eating all of a
meal does not correct the psychological aspects of the disease; thus, answer B is incorrect. Encouraging the client to choose favorite foods might increase stress and
the chance of choosing foods that are low in calories and fats so D is not correct.
- Assuming that all have achieved normal cognitive and emotional development, which of the following children is at greatest risk for accidental poisoning?
❍ A. A 6-month-old
❍ B. A 4-year-old
❍ C. A 12-year-old
❍ D. A 13-year-old
Answer B is correct.
The 4-year-old is more prone to accidental poisoning because children at this age are much more mobile. Answers A, C, and D are incorrect because the 6-month-old is still too small to be extremely mobile, the 12-year-old has begun to understand risk, and the 13-year-old is also aware that injuries can occur and is less
likely to become injured than the 4-year-old.
- Which of the following examples represents parallel play?
❍ A. Jenny and Tommy share their toys.
❍ B. Jimmy plays with his car beside Mary, who is playing withher doll.
❍ C. Kevin plays a game of Scrabble with Kathy and Sue.
❍ D. Mary plays with a handheld game while sitting in her mother’s lap.
Answer B is correct.
Parallel play is play that is demonstrated by two children playing side by side but not together. The play in answers A and C is participative play because the children are playing together. The play in answer D is solitary play because the mother is not playing with Mary.
- The nurse is ready to begin an exam on a 9-month-old infant. The child is sitting in his mother’s lap. Which should the nurse do first?
❍ A. Check the Babinski reflex
❍ B. Listen to the heart and lung sounds
❍ C. Palpate the abdomen
❍ D. Check tympanic membranes
Answer B is correct.
The first action that the nurse should take when beginning to examine the infant is to listen to the heart and lungs. If the nurse elicits the Babinski reflex, palpates the abdomen, or looks in the child’s ear first, the child will begin to cry and it will be difficult to obtain an objective finding while listening to the heart and
lungs. Therefore, answers A, C, and D are incorrect.
- In terms of cognitive development, a 2-year-old would be expected to:
❍ A. Think abstractly
❍ B. Use magical thinking
❍ C. Understand conservation of matter
❍ D. See things from the perspective of others
Answer B is correct.
A 2-year-old is expected only to use magical thinking, such as believing that a toy bear is a real bear. Answers A, C, and D are not expected until the child is much older. Abstract thinking, conservation of matter, and the ability to look at things from the perspective of others are not skills for small children.
- Which of the following best describes the language of a 24-month-old?
❍ A. Doesn’t understand yes and no
❍ B. Understands the meaning of words
❍ C. Able to verbalize needs
❍ D. Asks “why?” to most statements
Answer C is correct.
Children at 24 months can verbalize their needs. Answers A and B are incorrect because children at 24 months understand yes and no, but they do not understand the meaning of all words. Answer D is incorrect; asking “why?” comes
later in development.
- A client who has been receiving urokinase has a large bloody bowel movement. Which action would be best for the nurse to take immediately?
❍ A. Administer vitamin K IM
❍ B. Stop the urokinase
❍ C. Reduce the urokinase and administer heparin
❍ D. Stop the urokinase and call the doctor
Answer D is correct.
Urokinase is a thrombolytic used to destroy a clot following a myocardial infraction. If the client exhibits overt signs of bleeding, the nurse should stop the medication, call the doctor immediately, and prepare the antidote, which is Amicar. Answer B is not correct because simply stopping the urokinase is not enough.
In answer A, vitamin K is not the antidote for urokinase, and reducing the urokinase, as stated in answer B, is not enough.
- The client has a prescription for a calcium carbonate compound to neutralize stomach acid. The nurse should assess the client for:
❍ A. Constipation
❍ B. Hyperphosphatemia
❍ C. Hypomagnesemia
❍ D. Diarrhea
Answer A is correct.
The client taking calcium preparations will frequently develop constipation. Answers B, C, and D do not apply.
- Heparin has been ordered for a client with pulmonary embolis. Which statement, if made by the graduate nurse, indicates a lack of understanding of the medication?
❍ A. “I will administer the medication 1-2 inches away from theumbilicus.”
❍ B. “I will administer the medication in the abdomen.”
❍ C. “I will check the PTT before administering the medication.”
❍ D. “I will need to aspirate when I give Heparin.”
Answer C is correct.
C indicates a lack of understanding of the correct method of administering heparin. A, B, and D indicate understanding and are, therefore, incorrect
answers.
- The nurse is caring for a client with peripheral vascular disease. To correctly assess the oxygen saturation level, the monitor may be placed on the:
❍ A. Hip
❍ B. Ankle
❍ C. Earlobe
❍ D. Chin
Answer C is correct.
If the finger cannot be used, the next best place to apply the oxygen monitor is the earlobe. It can also be placed on the forehead, but the choices in answers A, B, and D will not provide the needed readings.
- While caring for a client with hypertension, the nurse notes the following vital signs: BP of 140/20, pulse 120, respirations 36, temperature 100.8°F. The nurse’s initial action should be to:
❍ A. Call the doctor
❍ B. Recheck the vital signs
❍ C. Obtain arterial blood gases
❍ D. Obtain an ECG
Answer A is correct.
The client is exhibiting a widened pulse pressure, tachycardia, and tachypnea. The next action after obtaining these vital signs is to notify the doctor
for additional orders. Rechecking the vital signs, as in answer B, is wasting time. The doctor may order arterial blood gases and an ECG.
- The nurse is preparing a client with an axillo-popliteal bypass graft for discharge. The client should be taught to avoid:
❍ A. Using a recliner to rest
❍ B. Resting in supine position
❍ C. Sitting in a straight chair
❍ D. Sleeping in right Sim’s position
Answer C is correct.
The client with a femoral popliteal bypass graft should avoid activities that can occlude the femoral artery graft. Sitting in the straight chair and wearing tight clothes are prohibited for this reason. Resting in a supine position, resting in a recliner, or sleeping in right Sim’s are allowed, as stated in answers A, B, and D.
- The doctor has ordered antithrombolic stockings to be applied to the legs of the client with peripheral vascular disease. The nurse knows antithrombolic stockings should be applied:
❍ A. Before rising in the morning
❍ B. With the client in a standing position
❍ C. After bathing and applying powder
❍ D. Before retiring in the evening
Answer A is correct.
The best time to apply antithrombolytic stockings is in themorning before rising. If the doctor orders them later in the day, the client should return to bed, wait 30 minutes, and apply the stockings. Answers B, C, and D are incorrect because there is likely to be more peripheral edema if the client is standing or has just taken a bath; before retiring in the evening is wrong because late in the evening, more peripheral edema will be present.
- The nurse has just received the shift report and is preparing to make rounds. Which client should be seen first?
❍ A. The client with a history of a cerebral aneurysm with an oxygen saturation rate of 99%
❍ B. The client three days post–coronary artery bypass graft with a temperature of 100.2°F
❍ C. The client admitted 1 hour ago with shortness of breath
❍ D. The client being prepared for discharge following a femoral popliteal bypass graft
Answer C is correct.
The client admitted 1 hour ago with shortness of breath should be seen first because this client might require oxygen therapy. The client in answer A with an oxygen saturation of 99% is stable. Answer B is incorrect because this client will have some inflammatory process after surgery, so a temperature of 100.2°F is not unusual. The client in answer D is stable and can be seen later.
- A client with a femoral popliteal bypass graft is assigned to a semiprivate room. The most suitable roommate for this client is the client with:
❍ A. Hypothyroidism
❍ B. Diabetic ulcers
❍ C. Ulcerative colitis
❍ D. Pneumonia
Answer A is correct.
The best roommate for the post-surgical client is the client with hypothyroidism. This client is sleepy and has no infectious process. Answers B, C, and D are incorrect because the client with a diabetic ulcer, ulcerative colitis, or pneumonia can transmit infection to the post-surgical client.
- The nurse is teaching the client regarding use of sodium warfarin. Which statement made by the client would require further teaching?
❍ A. “I will have blood drawn every month.”
❍ B. “I will assess my skin for a rash.”
❍ C. “I take aspirin for a headache.”
❍ D. “I will use an electric razor to shave.”
Answer C is correct.
The client taking an anticoagulant should not take aspirin
because it will further increase bleeding. He should return to have a Protime drawn for bleeding time, report a rash, and use an electric razor. Therefore, answers A, B, and D are incorrect.
- The client returns to the recovery room following repair of an abdominal aneurysm. Which finding would require further investigation?
❍ A. Pedal pulses regular
❍ B. Urinary output 20mL in the past hour
❍ C. Blood pressure 108/50
❍ D. Oxygen saturation 97%
Answer B is correct.
Because the aorta is clamped during surgery, the blood supply to the kidneys is impaired. This can result in renal damage. A urinary output of 20mL is oliguria. In answer A, the pedal pulses that are thready and regular are within normal limits. For answer C, it is desirable for the client’s blood pressure to be slightly low after surgical repair of an aneurysm. The oxygen saturation of 97% in answer D is within normal limits and, therefore, incorrect.
- The nurse is doing bowel and bladder retraining for the client with paraplegia. Which of the following is not a factor for the nurse to consider?
❍ A. Diet pattern
❍ B. Mobility
❍ C. Fluid intake
❍ D. Sexual function
Answer D is correct.
When assisting the client with bowel and bladder training, the least helpful factor is the sexual function. Dietary history, mobility, and fluid intake are important factors; these must be taken into consideration because they relate to constipation, urinary function, and the ability to use the urinal or bedpan. Therefore, answers A, B, and C are incorrect.
- A 20-year-old is admitted to the rehabilitation unit following a motorcycle accident. Which would be the appropriate method for measuring the client for crutches?
❍ A. Measure five finger breadths under the axilla
❍ B. Measure 3 inches under the axilla
❍ C. Measure the client with the elbows flexed 10°
❍ D. Measure the client with the crutches 20 inches from the side of the foot
Answer B is correct.
To correctly measure the client for crutches, the nurse should measure approximately 3 inches under the axilla. Answer A allows for too much distance under the arm. The elbows should be flexed approximately 35°, not 10°, as stated in answer C. The crutches should be approximately 6 inches from the side of the foot, not 20 inches, as stated in answer D.
- The nurse is caring for the client following a cerebral vascular accident. Which portion of the brain is responsible for taste, smell, and hearing?
❍ A. Occipital
❍ B. Frontal
❍ C. Temporal
❍ D. Parietal
Answer C is correct.
The temporal lobe is responsible for taste, smell, and hearing.The occipital lobe is responsible for vision. The frontal lobe is responsible for judgment, foresight, and behavior. The parietal lobe is responsible for ideation, sensory functions, and language. Therefore, answers A, B, and D are incorrect.
- The client is admitted to the unit after a motor vehicle accident with a temperature of 102°F rectally. The most likely explanations for the elevated temperature is that:
❍ A. There was damage to the hypothalamus.
❍ B. He has an infection from the abrasions to the head and face.
❍ C. He will require a cooling blanket to decrease the temperature.
❍ D. There was damage to the frontal lobe of the brain.
Answer A is correct.
Damage to the hypothalamus can result in an elevated temperature because this portion of the brain helps to regulate body temperature. Answers B, C, and D are incorrect because there is no data to support the possibility of an infection, a cooling blanket might not be required, and the frontal lobe is not responsible for regulation of the body temperature.
- The client is admitted to the hospital in chronic renal failure. A diet low in protein is ordered. The rationale for a low-protein diet is:
❍ A. Protein breaks down into blood urea nitrogen and other waste.
❍ B. High protein increases the sodium and potassium levels.
❍ C. A high-protein diet decreases albumin production.
❍ D. A high-protein diet depletes calcium and phosphorous.
Answer A is correct.
A low-protein diet is required because protein breaks down into nitrogenous waste and causes an increased workload on the kidneys. Answers B, C, and D are incorrect.
- The client who is admitted with thrombophlebitis has an order for heparin. The medication should be administered using a/an:
❍ A. Buretrol
❍ B. Infusion controller
❍ C. Intravenous filter
❍ D. Three-way stop-cock
Answer B is correct.
To safely administer heparin, the nurse should obtain an infusion controller. Too rapid infusion of heparin can result in hemorrhage. Answers A, C, and D are incorrect. It is not necessary to have a buretrol, an infusion filter, or a three-way stop-cock.
- The nurse is taking the blood pressure of the obese client. If the blood pressure cuff is too small, the results will be:
❍ A. A false elevation
❍ B. A false low reading
❍ C. A blood pressure reading that is correct
❍ D. A subnormal finding
Answer A is correct.
If the blood pressure cuff is too small, the result will be a blood pressure that is a false elevation. Answers B, C, and D are incorrect. If the blood pressure cuff is too large, a false low will result. Answers C and D have basically the same meaning.
- A 4-year-old male is admitted to the unit with nephotic syndrome. He is extremely edematous. To decrease the discomfort associated with scrotal edema, the nurse should:
❍ A. Apply ice to the scrotum
❍ B. Elevate the scrotum on a small pillow
❍ C. Apply heat to the abdominal area
❍ D. Administer an analgesic
Answer B is correct.
The child with nephotic syndrome will exhibit extreme edema.Elevating the scrotum on a small pillow will help with the edema. Applying ice is contraindicated; heat will increase the edema. Administering a diuretic might be ordered, but it will not directly help the scrotal edema. Therefore, answers A, C, and D are incorrect.
- The client with an abdominal aortic aneurysm is admitted in preparation for surgery. Which of the following should be reported to the doctor?
❍ A. An elevated white blood cell count
❍ B. An abdominal bruit
❍ C. A negative Babinski reflex
❍ D. Pupils that are equal and reactive to light
Answer A is correct.
The elevated white blood cell count should be reported because this indicates infection. A bruit will be heard if the client has an aneurysm, and a negative Babinski is normal in the adult, as are pupils that are equal and reactive to light and accommodation; thus, answers B, C, and D are incorrect.
- If the nurse is unable to elicit the deep tendon reflexes of the patella, the nurse should ask the client to:
❍ A. Pull against the palms
❍ B. Grimace the facial muscles
❍ C. Cross the legs at the ankles
❍ D. Perform Valsalva maneuver
Answer A is correct.
If the nurse cannot elicit the patella reflex (knee jerk), the client should be asked to pull against the palms. This helps the client to relax the legs and makes it easier to get an objective reading. Answers B, C, and D will not help with the test.
- The physician has ordered atropine sulfate 0.4mg IM before surgery. The medication is supplied in 0.8mg per milliliter. The nurse should administer how many milliliters of the medication?
❍ A. 0.25mL
❍ B. 0.5mL
❍ C. 1.0mL
❍ D. 1.25mL
Answer B is correct.
If the doctor orders 0.4mgm IM and the drug is available in 0.8/1mL, the nurse should make the calculation: ?mL = 1mL / 0.8mgm; × .4mg / 1 = 0.5m:. Answers A, C, and D are incorrect.
- The nurse is evaluating the client’s pulmonary artery pressure. The nurse is aware that this test evaluates:
❍ A. Pressure in the left ventricle
❍ B. The systolic, diastolic, and mean pressure of the pulmonary artery
❍ C. The pressure in the pulmonary veins
❍ D. The pressure in the right ventricle
Answer B is correct.
The pulmonary artery pressure will measure the pressure during systole, diastole, and the mean pressure in the pulmonary artery. It will not measure the pressure in the left ventricle, the pressure in the pulmonary veins, or the pressure in the right ventricle. Therefore, answers A, C, and D are incorrect.
- A client is being monitored using a central venous pressure monitor. If the pressure is 2cm of water, the nurse should:
❍ A. Call the doctor immediately
❍ B. Slow the intravenous infusion
❍ C. Listen to the lungs for rales
❍ D. Administer a diuretic
Answer A is correct.
The normal central venous pressure is 5–10cm of water. A reading of 2cm is low and should be reported. Answers B, C, and D indicate that the nurse believes that the reading is too high and is incorrect.
- The nurse identifies ventricular tachycardia on the heart monitor. The nurse should immediately:
❍ A. Administer atropine sulfate
❍ B. Check the potassium level
❍ C. Prepare to administer an antiarrhythmic such as lidocaine
❍ D. Defibrillate at 360 joules
Answer C is correct.
The treatment for ventricular tachycardia is lidocaine. A precordial thump is sometimes successful in slowing the rate, but this should be done only if a defibrillator is available. In answer A, atropine sulfate will speed the rate further; in answer B, checking the potassium is indicated but is not the priority; and in answer D,
defibrillation is used for pulseless ventricular tachycardia or ventricular fibrillation. Also, defibrillation should begin at 200 joules and be increased to 360 joules.
- The doctor is preparing to remove chest tubes from the client’s left chest. In preparation for the removal, the nurse should instruct the client to:
❍ A. Breathe normally
❍ B. Hold his breath and bear down
❍ C. Take a deep breath
❍ D. Sneeze on command
Answer B is correct.
The client should be asked to perform the Valsalva maneuver while the chest tube is being removed. This prevents changes in pressure until an occlusive dressing can be applied. Answers A and C are not recommended, and sneezing is difficult to perform on command.
- The doctor has ordered 80mg of furosemide (Lasix) two times per day. The nurse notes the patient’s potassium level to be 2.5meq/L. The nurse should:
❍ A. Administer the Lasix as ordered
❍ B. Administer half the dose
❍ C. Offer the patient a potassium-rich food
❍ D. Withhold the drug and call the doctor
Answer D is correct.
The potassium level of 2.5meq/L is extremely low. The normal is 3.5–5.5meq/L. Lasix (furosemide) is a nonpotassium sparing diuretic, so answer A is incorrect. The nurse cannot alter the doctor’s order, as stated in answer B, and answer C will not help with this situation.
- Which of the following lab studies should be done periodically if the client is taking warfarin sodium (Coumadin)?
❍ A. Stool specimen for occult blood
❍ B. White blood cell count
❍ C. Blood glucose
❍ D. Erthyrocyte count
Answer A is correct.
An occult blood test should be done periodically to detect any intestinal bleeding on the client with Coumadin therapy. Answers B, C, and D are not
directly related to the question.
- The client has an order for heparin to prevent post-surgical thrombi. Immediately following a heparin injection, the nurse should:
❍ A. Aspirate for blood
❍ B. Check the pulse rate
❍ C. Massage the site
❍ D. Check the site for bleeding
Answer D is correct.
After administering any subcutaneous anticoagulant, the nurse should check the site for bleeding. Answers A and C are incorrect because aspirating and massaging the site are not done. Checking the pulse is not necessary, as in answer B.
- The client with AIDS tells the nurse that he has been using acupuncture to help with his pain. The nurse should question the client regarding this treatment because acupuncture uses:
❍ A. Pressure from the fingers and hands to stimulate the energy points in the body
❍ B. Oils extracted from plants and herbs
❍ C. Needles to stimulate certain points on the body to treat pain
❍ D. Manipulation of the skeletal muscles to relieve stress and pain
Answer C is correct.
Acupuncture uses needles, and because HIV is transmitted by blood and body fluids, the nurse should question this treatment. Answer A describes acupressure, and answers B and D describe massage therapy with the use of oils.
- The nurse is taking the vital signs of the client admitted with cancer of the pancreas. The nurse is aware that the fifth vital sign is:
❍ A. Anorexia
❍ B. Pain
❍ C. Insomnia
❍ D. Fatigue
Answer B is correct.
The fifth vital sign is pain. Nurses should assess and record pain just as they would temperature, respirations, pulse, and blood pressure. Answers A, C, and D are included in the charting but are not considered to be the fifth vital sign and are, therefore, incorrect.
- The 84-year-old male has returned from the recovery room following a total hip repair. He complains of pain and is medicated with morphine sulfate and promethazine. Which medication should be kept available for the client being treated with opoid analgesics?
❍ A. Naloxone (Narcan)
❍ B. Ketorolac (Toradol)
❍ C. Acetylsalicylic acid (aspirin)
❍ D. Atropine sulfate (Atropine)
Answer A is correct.
Narcan is the antidote for the opoid analgesics. Toradol (answer B) is a nonopoid analgesic; aspirin (answer C) is an analgesic, anticoagulant, and antipyretic; and atropine (answer D) is an anticholengergic.
- The doctor has ordered a patient-controlled analgesia (PCA) pump for the client with chronic pain. The client asks the nurse if he can become overdosed with pain medication using this machine. The nurse demonstrates understanding of the PCA if she states:
❍ A. “The machine will administer only the amount that you need to control your pain without any action from you.”
❍ B. “The machine has a locking device that prevents overdosing.”
❍ C. The machine will administer one large dose every 4 hours to relieve your pain.”
❍ D. The machine is set to deliver medication only if you need it.”
Answer B is correct.
The client is concerned about overdosing himself. The machine will deliver a set amount as ordered and allow the client to self-administer a small amount of medication. PCA pumps usually are set to lock out the amount of medication that the client can give himself at 5- to 15-minute intervals. Answer A does not address the client’s concerns, answer C is incorrect, and answer D does not address the client’s concerns.
- The doctor has ordered a Transcutaneous Electrical Nerve Stimulation (TENS) unit for the client with chronic back pain. The nurse teaching the client with a TENS unit should tell the client:
❍ A. “You may be electrocuted if you use water with this unit.”
❍ B. “Please report skin irritation to the doctor.”
❍ C. “The unit may be used anywhere on the body without fear of adverse reactions.”
❍ D. “A cream should be applied to the skin before applying the unit.”
Answer B is correct.
Skin irritation can occur if the TENS unit is used for prolonged periods of time. To prevent skin irritations, the client should change the location of the electrodes often. Electrocution is not a risk because it uses a battery pack; thus, answer A is incorrect. Answer C is incorrect because the unit should not be used on
sensitive areas of the body. Answer D is incorrect because no creams are to be used
with the device.
- The nurse asked the client if he has an advance directive. The reason for asking the client this question is:
❍ A. She is curious about his plans regarding funeral
arrangements.
❍ B. Much confusion can occur with the client’s family if he does not have an advanced directive.
❍ C. An advanced directive allows the medical personnel to make decisions for the client.
❍ D. An advanced directive allows active euthanasia to be carried out if the client is unable to care for himself.
Answer B is correct.
An advanced directive allows the client to make known his wishes regarding care if he becomes unable to act on his own. Much confusion regarding life-saving measures can occur if the client does not have an advanced directive. Answers A, C, and D are incorrect because the nurse doesn’t need to know about
funeral plans and cannot make decisions for the client, and active euthanasia is illegal in most states in the United States.
- A client who has chosen to breastfeed tells the nurse that her nipples became very sore while she was breastfeeding her older child. Which measure will help her to avoid soreness of the nipples?
❍ A. Feeding the baby during the first 48 hours after delivery
❍ B. Breaking suction by placing a finger between the baby’s mouth and the breast when she terminates the feeding
❍ C. Applying hot, moist soaks to the breast several times per day
❍ D. Wearing a support bra
Answer B is correct.
To decrease the potential for soreness of the nipples, the client should be taught to break the suction before removing the baby from the breast. Answer A is incorrect because feeding the baby during the first 48 hours after delivery will provide colostrum but will not help the soreness of the nipples. Answers C and D are incorrect because applying hot, moist soaks several times per day might cause burning of the breast and cause further drying. Wearing a support bra will help with engorgement but will not help the nipples.
- The nurse is performing an assessment of an elderly client with a total hip repair. Based on this assessment, the nurse decides to medicate the client with an analgesic. Which finding most likely prompted the nurse to decide to administer the analgesic?
❍ A. The client’s blood pressure is 130/86.
❍ B. The client is unable to concentrate.
❍ C. The client’s pupils are dilated.
❍ D. The client grimaces during care.
Answer D is correct.
Facial grimace is an indication of pain. The blood pressure in answer A is within normal limits. The client’s inability to concentrate and dilated pupils, as stated in answers B and C, may be related to the anesthesia that he received during surgery.
- An obstetrical client decides to have an epidural anesthetic to relieve pain during labor. Following administration of the anesthesia, the nurse should monitor the client for:
❍ A. Seizures
❍ B. Postural hypertension
❍ C. Respiratory depression
❍ D. Hematuria
Answer C is correct.
Epidural anesthesia involves injecting an anesthetic into the epidural space. If the anesthetic rises above the respiratory center, the client will have impaired breathing; thus, monitoring for respiratory depression is necessary. Answer A, seizure activity, is not likely after an epidural. Answer B, postural hypertension, is
not likely. Answer D, hematuria, is not related to epidural anesthesia.
- The nurse is assessing the client admitted for possible oral cancer. The nurse identifies which of the following to be a late-occurring symptom of oral cancer?
❍ A. Warmth
❍ B. Odor
❍ C. Pain
❍ D. Ulcer with flat edges
Answer C is correct.
Pain is a late sign of oral cancer. Answers A, B, and D are incorrect because a feeling of warmth, odor, and a flat ulcer in the mouth are all early occurrences of oral cancer.
- The nurse understands that the diagnosis of oral cancer is confirmed with:
❍ A. Biopsy
❍ B. Gram Stain
❍ C. Oral culture
❍ D. Oral washings for cytology
Answer A is correct.
The best diagnostic tool for cancer is the biopsy. Other assessment includes checking the lymph nodes. Answers B, C, and D will not confirm a diagnosis of oral cancer.
- The nurse is caring for the patient following removal of a large posterior oral lesion. The priority nursing measure would be to:
❍ A. Maintain a patent airway
❍ B. Perform meticulous oral care every 2 hours
❍ C. Ensure that the incisional area is kept as dry as possible
❍ D. Assess the client frequently for pain
Answer A is correct.
Maintaining a patient’s airway is paramount in the post-operative period. This is the priority of nursing care. Answers B, C, and D are applicable but are not the priority.
- The registered nurse is conducting an in-service for colleagues on the subject of peptic ulcers. The nurse would be correct in identifying which of the following as a causative factor?
❍ A. N. gonorrhea
❍ B. H. influenza
❍ C. H. pylori
❍ D. E. coli
Answer C is correct.
H. pylori bacteria has been linked to peptic ulcers. Answers A, B, and D are not typically cultured within the stomach, duodenum, or esophagus, and are not related to the development of peptic ulcers.
- The patient states, “My stomach hurts about 2 hours after I eat.” Based upon this information, the nurse suspects the patient likely has a:
❍ A. Gastric ulcer
❍ B. Duodenal ulcer
❍ C. Peptic ulcer
❍ D. Curling’s ulcer
Answer B is correct.
Individuals with ulcers within the duodenum typically complain of pain occurring 2–3 hours after a meal, as well as at night. The pain is usually relieved by eating. The pain associated with gastric ulcers, answer A, occurs 30 minutes after eating. Answer C is too vague and does not distinguish the type of ulcer.Answer D is associated with a stress ulcer.
- The nurse is caring for a patient with suspected diverticulitis. The nurse would be most prudent in questioning which of the following diagnostic tests?
❍ A. Abdominal ultrasound
❍ B. Barium enema
❍ C. Complete blood count
❍ D. Computed tomography (CT) scan
Answer B is correct.
A barium enema is contraindicated in the client with diverticulitis because it can cause bowel perforation. Answers A, C, and D are appropriate diagnostic studies for the client with suspected diverticulitis.
- The nurse is planning care for the patient with celiac disease. In teaching about the diet, the nurse should instruct the patient to avoid which of the following for breakfast?
❍ A. Puffed wheat
❍ B. Banana
❍ C. Puffed rice
❍ D. Cornflakes
Answer A is correct.
Clients with celiac disease should refrain from eating foods containing gluten. Foods with gluten include wheat barley, oats, and rye. The other foods are allowed.
- The nurse is teaching about irritable bowel syndrome (IBS). Which of the following would be most important?
❍ A. Reinforcing the need for a balanced diet
❍ B. Encouraging the client to drink 16 ounces of fluid with each meal
❍ C. Telling the client to eat a diet low in fiber
❍ D. Instructing the client to limit his intake of fruits and
vegetables
Answer A is correct.
The nurse should reinforce the need for a diet balanced in all nutrients and fiber. Foods that often cause diarrhea and bloating associated with irritable bowel syndrome include fried foods, caffeinated beverages, alcohol, and spicy foods. Therefore, answers B, C, and D are incorrect.
- In planning care for the patient with ulcerative colitis, the nurse identifies which nursing diagnosis as a priority?
❍ A. Anxiety
❍ B. Impaired skin integrity
❍ C. Fluid volume deficit
❍ D. Nutrition altered, less than body requirements
Answer C is correct.
Fluid volume deficit can lead to metabolic acidosis and electrolyte loss. The other nursing diagnoses in answers A, B, and D might be applicable but are of lesser priority.
- The patient is prescribed metronidazole (Flagyl) for adjunct treatment for a duodenal ulcer. When teaching about this medication, the nurse would include:
❍ A. “This medication should be taken only until you begin to feel better.”
❍ B. “This medication should be taken on an empty stomach to increase absorption.”
❍ C. “While taking this medication, you do not have to be concerned about being in the sun.”
❍ D. “While taking this medication, alcoholic beverages and products containing alcohol should be avoided.”
Answer D is correct.
Alcohol will cause extreme nausea if consumed with Flagyl. Answer A is incorrect because the full course of treatment should be taken. The medication should be taken with a full 8 oz. of water, with meals, and the client should avoid direct sunlight because he will most likely be photosensitive; therefore, answers A, B, and C are incorrect.
- The nurse is preparing to administer a feeding via a nasogastric tube. The nurse would perform which of the following before initiating the feeding?
❍ A. Assess for tube placement by aspirating stomach content
❍ B. Place the patient in a left-lying position
❍ C. Administer feeding with 50% Dextrose
❍ D. Ensure that the feeding solution has been warmed in a microwave for 2 minutes
Answer A is correct.
Before beginning feedings, an x-ray is often obtained to check for placement. Aspirating stomach content and checking the pH for acidity is the best method of checking for placement. Other methods include placing the end in water and checking for bubbling, and injecting air and listening over the epigastric area. Answers B and C are not correct. Answer D is incorrect because warming in the microwave is contraindicated.
- Which is true regarding the administration of antacids?
❍ A. Antacids should be administered without regard to
mealtimes.
❍ B. Antacids should be administered with each meal and snack of the day.
❍ C. Antacids should not be administered with other medications.
❍ D. Antacids should be administered with all other medications, for maximal absorption.
Answer C is correct.
Antacids should be administered with other medications. If antacids are taken with many medications, they render the other medications inactive. All other answers are incorrect.
- The nurse is caring for a patient with a colostomy. The patient asks, “Will I ever be able to swim again?” The nurse’s best response would be:
❍ A. “Yes, you should be able to swim again, even with the colostomy.”
❍ B. “You should avoid immersing the colostomy in water.”
❍ C. “No, you should avoid getting the colostomy wet.”
❍ D. “Don’t worry about that. You will be able to live just like you did before.”
Answer A is correct.
The client with a colostomy can swim and carry on activities as before the colostomy. Answers B and C are incorrect, and answer D shows a lack of empathy.
- The nurse is assisting in the care of a patient who is 2 days post-operative from a hemorroidectomy. The nurse would be correct in instructing the patient to:
❍ A. Avoid a high-fiber diet
❍ B. Continue to use ice packs
❍ C. Take a laxative daily to prevent constipation
❍ D. Use a sitz bath after each bowel movement
Answer D is correct.
The use of a sitz bath will help with the pain and swelling associated with a hemorroidectomy. The client should eat foods high in fiber, so answer A is incorrect. Ice packs, as stated in answer B, are ordered immediately after surgery
only. Answer C is incorrect because taking a laxative daily can result in diarrhea.
- The nurse is assisting in the care of a client with diverticulosis. Which of the following assessment findings must necessitate an immediate report
to the doctor?
❍ A. Bowel sounds are present
❍ B. Intermittent left lower-quadrant pain
❍ C. Constipation alternating with diarrhea
❍ D. Hemoglobin 26% and hematocrit 32
Answer D is correct.
Low hemoglobin and hematocrit might indicate intestinal bleeding. Answers A, B, and C are incorrect, because they do not require immediate action.
- The client is newly diagnosed with juvenile onset diabetes. Which of the following nursing diagnoses is a priority?
❍ A. Anxiety
❍ B. Pain
❍ C. Knowledge deficit
❍ D. Altered thought process
Answer C is correct.
The new diabetic has a knowledge deficit. Answers A, B, and D are not supported within the stem and so are incorrect.
- The nurse is asked by the nurse aide, “Are peptic ulcers really caused by stress?” The nurse would be correct in replying with the following:
❍ A. “Peptic ulcers result from overeating fatty foods.”
❍ B. “Peptic ulcers are always caused from exposure to continual stress.”
❍ C. “Peptic ulcers are like all other ulcers, which all result from stress.”
❍ D. “Peptic ulcers are associated with H. pylori, although there are other ulcers that are associated with stress.”
Answer D is correct.
Peptic ulcers are not always related to stress but are a component of the disease. Answers A and B are incorrect because peptic ulcers are not caused by overeating or continued exposure to stress. Answer C is incorrect because peptic ulcers are related to but not directly caused by stress.
- The nurse is assisting in the assessment of the patient admitted with “extreme abdominal pain.” The nurse asks the client about the medication that he has been taking because:
❍ A. Interactions between medications will cause abdominal pain.
❍ B. Various medications taken by mouth can affect the
alimentary tract.
❍ C. This will provide an opportunity to educate the patient regarding the medications used.
❍ D. The types of medications might be attributable to an abdominal pathology not already identified.
Answer B is correct.
Many medications can irritate the stomach and contribute to abdominal pain. For answer A, not all interactions between medications will cause abdominal pain. Although this might provide an opportunity for teaching, this is not the best time to teach. Therefore, answer C is incorrect. Answer D is incorrect because medication may not be the cause of the pain.
- The nurse is assessing the abdomen. The nurse knows the best sequence to perform the assessment is:
❍ A. Inspection, auscultation, palpation
❍ B. Auscultation, palpation, inspection
❍ C. Palpation, inspection, auscultation
❍ D. Inspection, palpation, auscultation
Answer A is correct.
The nurse should inspect first, then auscultate, and finally palpate. If the nurse palpates first the assessment might be unreliable. Therefore, answers B, C, and D are incorrect.
- The nurse is caring for the client who has been in a coma for 2 months. He has signed a donor card, but the wife is opposed to the idea of organ donation. How should the nurse handle the topic of organ donation with
the wife?
❍ A. Tell the wife that the hospital will honor her wishes regarding organ donation, but contact the organ-retrieval staff
❍ B. Tell her that because her husband signed a donor card, the hospital has the right to take the organs upon the death of her husband
❍ C. Explain that it is necessary for her to donate her husband’s organs because he signed the permit
❍ D. Refrain from talking about the subject until after the death ofher husband
Answer A is correct.
The hospital will certainly honor the wishes of family members even if the patient has signed a donor card. Answer B is incorrect, answer C is not empathetic to the family and is untrue, and answer D is not good nursing etiquette and, therefore, is incorrect.
- The client with cancer refuses to care for herself. Which action by the nurse would be best?
❍ A. Alternate nurses caring for the client so that the staff will not get tired of caring for this client
❍ B. Talk to the client and explain the need for self-care
❍ C. Explore the reason for the lack of motivation seen in the client
❍ D. Talk to the doctor about the client’s lack of motivation
Answer C is correct.
The nurse should explore the cause for the lack of motivation. The client might be anemic and lack energy, or the client might be depressed. Alternating staff, as stated in answer A, will prevent a bond from being formed with the nurse. Answer B is not enough, and answer D is not necessary.
- The charge nurse is making assignments for the day. After accepting the assignment to a client with leukemia, the nurse tells the charge nurse that her child has chickenpox. Which initial action should the charge
nurse take?
❍ A. Change the nurse’s assignment to another client
❍ B. Explain to the nurse that there is no risk to the client
❍ C. Ask the nurse if the chickenpox have scabbed
❍ D. Ask the nurse if she has ever had the chickenpox
Answer D is correct.
The nurse who has had the chickenpox has immunity to the illness and will not transmit chickenpox to the client. Answer A is incorrect because there could be no need to reassign the nurse. Answer B is incorrect because the nurse should be assessed before coming to the conclusion that she cannot spread the infection to the client. Answer C is incorrect because there is still a risk, even though chickenpox has formed scabs.
- The nurse is caring for the client with a mastectomy. Which action would be contraindicated?
❍ A. Taking the blood pressure in the side of the mastectomy
❍ B. Elevating the arm on the side of the mastectomy
❍ C. Positioning the client on the unaffected side
❍ D. Performing a dextrostix on the unaffected side
Answer A is correct.
The nurse should not take the blood pressure on the affected side. Also, venopunctures and IVs should not be used in the affected area. Answers B, C, and D are all indicated for caring for the client. The arm should be elevated to decrease edema. It is best to position the client on the unaffected side and perform a
dextrostix on the unaffected side.
- The client has an order for gentamycin to be administered. Which lab results should be reported to the doctor before beginning the medication?
❍ A. Hematocrit
❍ B. Creatinine
❍ C. White blood cell count
❍ D. Erythrocyte count
Answer B is correct.
Gentamycin is an aminoglycocide. These drugs are toxic to the auditory nerve and the kidneys. The hematocrit is not of significant consideration in this client; therefore, answer A is incorrect. Answer C is incorrect because we would expect the white blood cell count to be elevated in this client because gentamycin is an antibiotic. Answer D is incorrect because the erythrocyte count is also particularly significant to check.
- Which of the following is the best indicator of the diagnosis of HIV?
❍ A. White blood cell count
❍ B. ELISA
❍ C. Western Blot
❍ D. Complete blood count
Answer C is correct.
The most definitive diagnostic tool for HIV is the Western Blot. The white blood cell count, as stated in answer A, is not the best indicator, but a white blood cell count of less than 3,500 requires investigation. The ELISA test, answer B, is a screening exam. Answer D is not specific enough.
- The client presents to the emergency room with a “bull’s eye” rash. Which question would be most appropriate for the nurse to ask the client?
❍ A. “Have you found any ticks on your body?”
❍ B. “Have you had any nausea in the last 24 hours?”
❍ C. “Have you been outside the country in the last 6 months?”
❍ D. “Have you had any fever for the past few days?”
Answer A is correct.
The “bull’s eye” rash is indicative of Lyme’s disease, a disease spread by ticks. The signs and symptoms include elevated temperature, headache,nausea, and the rash. Although answers B and D are important, the question asked which question would be best. Answer C has no significance.
- Which client should be assigned to the nursing assistant?
❍ A. The 18-year-old with a fracture to two cervical vertebrae
❍ B. The infant with meningitis
❍ C. The elderly client with a thyroidectomy 4 days ago
❍ D. The client with a thoracotomy 2 days ago
Answer C is correct.
The client that needs the least-skilled nursing care is the client with the thyroidectomy 4 days ago. Answers A, B, and D are incorrect because the other clients are less stable and require a registered nurse.
- The client presents to the emergency room with a hyphema. Which action by the nurse would be best?
❍ A. Elevate the head of the bed and apply ice to the eye
❍ B. Place the client in a supine position and apply heat to the knee
❍ C. Insert a Foley catheter and measure the intake and output
❍ D. Perform a vaginal exam and check for a discharge
Answer A is correct.
Hyphema is blood in the anterior chamber of the eye and around the eye. The client should have the head of the bed elevated and ice applied. Answers B, C, and D are incorrect and do not treat the problem.
- The client has an order for FeSo4 liquid. Which method of administration would be best?
❍ A. Administer the medication with milk
❍ B. Administer the medication with a meal
❍ C. Administer the medication with orange juice
❍ D. Administer the medication undiluted
Answer C is correct.
FeSO4 or iron should be given with ascorbic acid (vitamin C).This helps with the absorption. It should not be given with meals or milk because this decreases the absorption; thus, answers A and B are incorrect. Giving it undiluted, as stated in answer D, is not good because it tastes bad.
- The client with an ileostomy is being discharged. Which teaching should be included in the plan of care?
❍ A. Using Karaya powder to seal the bag.
❍ B. Irrigating the ileostomy daily.
❍ C. Using stomahesive as the best skin protector.
❍ D. Using Neosporin ointment to protect the skin.
Answer C is correct.
The best protector for the client with an ileostomy to use is stomahesive. Answer A is not correct because the bag will not seal if the client uses Karaya powder. Answer B is incorrect because there is no need to irrigate an ileosto-
my. Neosporin, answer D, is not used to protect the skin because it is an antibiotic.
- Vitamin K is administered to the newborn shortly after birth for which of the following reasons?
❍ A. To stop hemorrhage
❍ B. To treat infection
❍ C. To replace electrolytes
❍ D. To facilitate clotting
Answer D is correct.
Vitamin K is given after delivery because the newborn’s intestinal tract is sterile and lacks vitamin K needed for clotting. Answer A is incorrect because vitamin K is not directly given to stop hemorrhage. Answers B and C are
incorrect because vitamin K does not prevent infection or replace electrolytes.
- Before administering Methyltrexate orally to the client with cancer, the nurse should check the:
❍ A. IV site
❍ B. Electrolytes
❍ C. Blood gases
❍ D. Vital signs
Answer D is correct.
The vital signs should be taken before any chemotherapy agent. If it is an IV infusion of chemotherapy, the nurse should check the IV site as well. Answers B and C are incorrect because it is not necessary to check the electrolytes or blood gasses.
- The nurse is teaching a group of new graduates about the safety needs of the client receiving chemotherapy. Before administering chemotherapy, the nurse should:
❍ A. Administer a bolus of IV fluid
❍ B. Administer pain medication
❍ C. Administer an antiemetic
❍ D. Allow the patient a chance to eat
Answer C is correct.
Before chemotherapy, an antiemetic should be given because most chemotherapy agents cause nausea. It is not necessary to give a bolus of IV fluids, medicate for pain, or allow the client to eat; therefore, answers A, B, and D are incorrect.
- The client is admitted to the postpartum unit with an order to continue the infusion of Pitocin. The nurse is aware that Pitocin is working if the fundus is:
❍ A. Deviated to the left.
❍ B. Firm and in the midline.
❍ C. Boggy.
❍ D. Two finger breadths below the umbilicus.
Answer B is correct.
Pitocin is used to cause the uterus to contract and decrease bleeding. A uterus deviated to the left, as stated in answer A, indicates a full bladder. It is not desirable to have a boggy uterus, making answer C incorrect. This lack of muscle tone will increase bleeding. Answer D is incorrect because Pitocin does not affect the position of the uterus.
- A 5-year-old is a family contact to the client with tuberculosis. Isoniazid(INH) has been prescribed for the
client. The nurse is aware that the length of time that the medication will be taken is:
❍ A. 6 months
❍ B. 3 months
❍ C. 1 year
❍ D. 2 years
Answer A is correct.
Household contacts should take INH approximately 6 months. Answers B, C, and D are incorrect because they indicate either too short or too long of a time to take the medication.
- A 4-year-old with cystic fibrosis has a prescription for Viokase pancreatic enzymes to prevent malabsorption. The correct time to give pancreaticenzyme is:
❍ A. 1 hour before meals
❍ B. 2 hours after meals
❍ C. With each meal and snack
❍ D. On an empty stomach
Answer C is correct.
Viokase is a pancreatic enzyme that is used to facilitate digestion. It should be given with meals and snacks, and it works well in foods such as applesauce. Answers A, B, and D are incorrect.
- A client with osteomylitis has an order for a trough level to be done because he is taking Gentamycin. When should the nurse call the lab to obtain the trough level?
❍ A. Before the first dose
❍ B. 30 minutes before the fourth dose
❍ C. 30 minutes after the first dose
❍ D. 30 minutes before the first dose
Answer B is correct.
Trough levels are the lowest blood levels and should be done 30 minutes before the third IV dose or 30 minutes before the fourth IM dose. Answers A, C, and D are incorrect.
- A new diabetic is learning to administer his insulin. He receives 10U of NPH and 12U of regular insulin each morning. Which of the following statements reflects understanding of the nurse’s teaching?
❍ A. “When drawing up my insulin, I should draw up the regular insulin first.”
❍ B. “When drawing up my insulin, I should draw up the NPH insulin first.”
❍ C. “It doesn’t matter which insulin I draw up first.”
❍ D. “I cannot mix the insulin, so I will need two shots.”
Answer A is correct.
Regular insulin should be drawn up before the NPH. They can be given together, so there is no need for two injections, making answer D incorrect. Answer B is obviously incorrect, and answer C is incorrect because it certainly does matter which is drawn first: Contamination of NPH into regular insulin will result in a hypoglycemic reaction at unexpected times.
- The client is scheduled to have an intravenous cholangiogram. Before the procedure, the nurse should assess the patient for:
❍ A. Shellfish allergies
❍ B. Reactions to blood transfusions
❍ C. Gallbladder disease
❍ D. Egg allergies
Answer A is correct.
Clients having dye procedures should be assessed for allergies to iodine or shellfish. Answers B and D are incorrect because there is no need for the client to be assessed for reactions to blood or eggs. Because an IV cholangiogram is done to detect gallbladder disease, there is no need to ask about answer C.
- Shortly after the client was admitted to the postpartum unit, the nurse notes heavy lochia rubra with large clots. The nurse should anticipate an
order for:
❍ A. Methergine
❍ B. Stadol
❍ C. Magnesium sulfate
❍ D. Phenergan
Answer A is correct.
Methergine is a drug that causes uterine contractions. It is used for postpartal bleeding that is not controlled by Pitocin. Answers B, C, and D are incorrect: Stadol is an analgesic; magnesium sulfate is used for preeclampsia; and phenergan is an antiemetic.
- The client with a recent liver transplant asks the nurse how long he will have to take an immunosuppressant. Which response would be correct?
❍ A. 1 year
❍ B. 5 years
❍ C. 10 years
❍ D. The rest of his life
Answer D is correct.
Cyclosporin is an immunosuppressant, and the client with a liver transplant will be on immunosuppressants for the rest of his life. Answers A, B, and C, then, are incorrect.
- The client is admitted from the emergency room with multiple injuries sustained from an auto accident. His doctor prescribes a histamine blocker. The nurse is aware that the reason for this order is to:
❍ A. Treat general discomfort
❍ B. Correct electrolyte imbalances
❍ C. Prevent stress ulcers
❍ D. Treat nausea
Answer C is correct.
Histamine blockers are frequently ordered for clients who are hospitalized for prolonged periods and who are in a stressful situation. They are not used to treat discomfort, correct electrolytes, or treat nausea; therefore, answers A, B, and D are incorrect.
- The physician prescribes regular insulin, 5 units subcutaneous. Regular insulin begins to exert an effect:
❍ A. In 5–10 minutes
❍ B. In 10–20 minutes
❍ C. In 30–60 minutes
❍ D. In 60–120 minutes
Answer C is correct.
The time of onset for regular insulin is 30–60 minutes. Answers A, B, and D are incorrect because they are not the correct times.
- A 60-year-old diabetic is taking glyburide (Diabeta) 1.25mg daily to treat Type II diabetes mellitus. Which statement indicates the need for further teaching?
❍ A. “I will keep candy with me just in case my blood sugar drops.”
❍ B. “I need to stay out of the sun as much as possible.”
❍ C. “I often skip dinner because I don’t feel hungry.”
❍ D. “I always wear my medical identification.”
Answer C is correct.
The client should be taught to eat his meals even if he is not hungry, to prevent a hypoglycemic reaction. Answers
A, B, and D are incorrect because they indicate knowledge of the nurse’s teaching.
- A 20-year-old female has a prescription for tetracycline. While teaching the client how to take her medicine, the nurse learns that the client is
also taking Ortho-Novum oral contraceptive pills. Which instructions should be included in the teaching plan?
❍ A. The oral contraceptives will decrease the effectiveness of the tetracycline.
❍ B. Nausea often results from taking oral contraceptives and antibiotics.
❍ C. Toxicity can result when taking these two medications together.
❍ D. Antibiotics can decrease the effectiveness of oral contraceptives, so the client should use an alternate method of birth control.
Answer D is correct.
Taking antibiotics and oral contraceptives together decreases the effectiveness of the oral contraceptives. Answers A, B, and C are not necessarily true.
- The client is taking prednisone 7.5mg po each morning to treat his systemic lupus erythematosis. Which statement best explains the reason for taking the prednisone in the morning?
❍ A. There is less chance of forgetting the medication if taken in the morning.
❍ B. There will be less fluid retention if taken in the morning.
❍ C. Prednisone is absorbed best with the breakfast meal.
❍ D. Morning administration mimics the body’s natural secretion of corticosteroid.
Answer D is correct.
Taking corticosteroids in the morning mimics the body’s natural release of cortisol. Answer A is not necessarily true, and answers B and C are not true.
- The client is taking rifampin 600mg po daily to treat his tuberculosis. Which action by the nurse indicates understanding of the medication?
❍ A. Telling the client that the medication will need to be taken with juice
❍ B. Telling the client that the medication will change the color of the urine
❍ C. Telling the client to take the medication before going to bed at night
❍ D. Telling the client to take the medication if the night
sweats occur
Answer B is correct.
Rifampin can change the color of the urine and body fluid. Teaching the client about these changes is best because he might think this is a complication. Answer A is not necessary, answer C is not true, and answer D is not true because this medication should be taken regularly during the course of the treatment.
- The client is diagnosed with multiple myloma. The doctor has ordered cyclophosphamide (Cytoxan). Which instruction should be given to the client?
❍ A. “Walk about a mile a day to prevent calcium loss.”
❍ B. “Increase the fiber in your diet.”
❍ C. “Report nausea to the doctor immediately.”
❍ D. “Drink at least eight large glasses of water a day.”
Answer D is correct.
Cytoxan can cause hemorrhagic cystitis, so the client should drink at least eight glasses of water a day. Answers A and B are not necessary and, so, are incorrect. Nausea often occurs with chemotherapy, so answer C is incorrect.
- An elderly client is diagnosed with ovarian cancer. She has surgery followed by chemotherapy with a fluorouracil (Adrucil) IV. What should the nurse do if she notices crystals in the IV medication?
❍ A. Discard the solution and order a new bag
❍ B. Warm the solution
❍ C. Continue the infusion and document the finding
❍ D. Discontinue the medication
Answer A is correct.
Crystals in the solution are not normal and should not be
administered to the client. Discard the bad solution immediately. Answer B is incorrect because warming the solution will not help. Answer C is incorrect, and answer D requires a doctor’s order.
- The 10-year-old is being treated for asthma. Before administering Theodur, the nurse should check the:
❍ A. Urinary output
❍ B. Blood pressure
❍ C. Pulse
❍ D. Temperature
Answer C is correct.
Theodur is a bronchodilator, and a side effect of bronchodilators is tachycardia, so checking the pulse is important. Extreme tachycardia should be reported to the doctor. Answers A, B, and D are not necessary.
- Which information obtained from the mother of a child with cerebral palsy correlates to the diagnosis?
❍ A. She was born at 40 weeks gestation.
❍ B. She had meningitis when she was 6 months old.
❍ C. She had physiologic jaundice after delivery.
❍ D. She has frequent sore throats.
Answer B is correct.
The diagnosis of meningitis at age 6 months correlates to a diagnosis of cerebral palsy. Cerebral palsy, a neurological disorder, is often associated with birth trauma or infections of the brain or spinal column. Answers A, C and D are not related to the question.
- A 6-year-old with cerebral palsy functions at the level of an 18-month-old. Which finding would support that assessment?
❍ A. She dresses herself.
❍ B. She pulls a toy behind her.
❍ C. She can build a tower of eight blocks.
❍ D. She can copy a horizontal or vertical line.
Answer B is correct.
Children at 18 months of age like push-pull toys. Children at approximately 3 years of age begin to dress themselves and build a tower of eight blocks. At age four, children can copy a horizontal or vertical line. Therefore, answers A, C, and D are incorrect.
- A 5-year-old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery?
❍ A. Decreased appetite
❍ B. A low-grade fever
❍ C. Chest congestion
❍ D. Constant swallowing
Answer D is correct.
A complication of a tonsillectomy is bleeding, and constant swallowing may indicate bleeding. Decreased appetite is expected after a tonsillectomy, as is a low-grade temperature; thus, answers A and B are incorrect. In answer C, chest congestion is not normal but is not associated with the tonsillectomy.
- The child with seizure disorder is being treated with phenytoin (Dilantin).Which of the following statements by the patient’s mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy?
❍ A. “She is very irritable lately.”
❍ B. “She sleeps quite a bit of the time.”
❍ C. “Her gums look too big for her teeth.”
❍ D. “She has gained about 10 pounds in the last six months.”
Answer C is correct.
Hyperplasia of the gums is associated with Dilantin therapy.Answer A is not related to the therapy; answer B is a side effect; and answer D is not related to the question.
