Practice Test 1 Flashcards
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 FeSo 4 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. FeSO 4 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 ileostomy. 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 pancreatic enzyme 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.
