Silvestri1801-1900
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Comprehensive Review CD Questions 1801-1900 {COMP: No Equations/Formulas; No questions} 1801. When performing an assessment of a client’s skin, the nurse notes the presence of multiple straight and wavy threadlike lines beneath the skin and suspects the presence of scabies. Which of the following precautions will the nurse institute before completing the assessment of the client? 1. Don a mask and gloves 2. Put on a pair of gloves 3. Put on a gown and gloves 4. Don a mask and a gown Answer: 3 Rationale: The Centers for Disease Control and Prevention recommend the wearing of gowns and gloves for close contact with a person infested with scabies. Masks are not necessary. Transmission via clothing and other inanimate objects is uncommon. Scabies is usually transmitted from person to person by direct skin contact. All contacts that the client has had should be treated at the same time. Test-Taking Strategy: Consider the mode of transmission of scabies and use the process of elimination. Since scabies is transmitted by direct skin contact, eliminate options 1, 2, and 4. If you had difficulty with this question, review standard precautions and the transmission mode of scabies. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, pp. 83-84. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 1031. 1802. A nurse has just been told by the physician that an order has been written to administer an iron injection to a client. The nurse anticipates giving the medication by which method? 1. Z-track 2. Subcutaneous using a ⅝-inch needle 3. Intramuscular using a 1-inch needle 4. Direct intravenous push after dilution Answer: 1 Rationale: The correct technique for administering parenteral iron is deep in the gluteal muscle using the Z-track technique, and usually a 1½-inch needle is used to administer the injection, depending on the size of the client. This method minimizes the possibility that the injection will stain the skin a dark color. The medication is not given by the subcutaneous route or by direct intravenous push. Test-Taking Strategy: Use principles of medication administration by the parenteral route
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and the process of elimination to answer the question. Eliminate option 4 because of the word “injection” in the question. From the remaining options, recalling that the issue with this medication is to avoid staining the skin will direct you to option 1. Review the procedure for the administration of an iron injection if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Perry, A., & Potter, P. (2004). Clinical nursing skills & techniques (5th ed.). St. Louis: Mosby, p. 528. 1803. A nurse is assisting in developing a plan of care for the client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. Which nursing intervention would the nurse suggest including in the plan of care to manage this symptom? 1. Keep the call bell within reach for the client 2. Administer a sedative at bedtime 3. Administer an antipyretic at bedtime 4. Provide a back rub and comfort measures before bedtime Answer: 3 Rationale: For clients with AIDS who experience night fever and night sweats, it is useful to offer the client an antipyretic prior to bedtime. It is also helpful to keep a change of bed linens and nightclothes nearby for use. The pillow should have a plastic cover, and a towel may be placed over the pillowcase if there is profuse diaphoresis. The client should have liquids at the bedside to drink. Options 1, 2, and 4 are important interventions but they are unrelated to the issue of fever and night sweats. Test-Taking Strategy: Focus on the issue of the question—night fever and night sweats. Options 1, 2, and 4 are helpful and important interventions but do not address the issue of the question. Since night fever and sweats occur serially, it is most helpful to give the antipyretic before sleep as a prophylactic measure. Review nursing measures for the client with AIDS if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Immune Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 2395. 1804. A nurse is assisting in preparing a plan of care for the client with acquired immunodeficiency syndrome (AIDS) who has nausea. Which dietary measure would the nurse include in the plan? 1. Dairy products with each snack and meal 2. Red meat daily 3. Addition of spices to food to make the taste more palatable 4. Foods that are at a cool temperature
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Answer: 4 Rationale: The AIDS client experiencing nausea should avoid fatty products, such as diary products and red meat. Meals should be small and frequent to lessen the chance of vomiting. Spices and odorous foods should be avoided, since they aggravate nausea. Foods are best tolerated either cool or at room temperature. Test-Taking Strategy: Use knowledge related to the effects of AIDS on the gastrointestinal system to assist in answering the question. Additionally, general principles related to nutrition in a client with an immunosuppressive disorder will assist in directing you to option 4. Review these measures if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Immune Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 551. 1805. A perinatal client with a history of heart disease has been instructed on care at home. Which statement by the client would indicate that the client understands her needs? 1. “There is no restriction on people who visit me.” 2. “I should avoid stressful situations.” 3. “My weight gain is not important.” 4. “I should rest on my right side.” Answer: 2 Rationale: To avoid contracting infections, persons with active infections should not be allowed to visit the client. Stress causes increased heart workload. Too much weight gain causes an increase in body requirements and stress on the heart. Resting should be on the left side to promote blood return. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 3 because of the absolute words “no” and “not” used in these options, respectively. Recalling the concepts related to blood return during pregnancy will assist in eliminating option 4. If you had difficulty with this question, review care to the perinatal client with heart disease. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Antepartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 913. 1806. A hospital employee is removing trash from a nursing unit and accidentally pricks a finger with the needle that was discarded in the trash. The employee never received the hepatitis B vaccine and asks the nurse what can be given to him for protection. The nurse tells the hospital employee that which of the following will be administered? 1. Hepatitis B immune globulin and hepatitis B vaccine
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2. Hepatitis B immune globulin 3. Immune globulin 4. Hepatitis B vaccine Answer: 1 Rationale: Immune globulin is given prophylactically for hepatitis A. Hepatitis B immune globulin is indicated for persons exposed to the hepatitis B virus. Vaccination is effective for long-term prevention of hepatitis B in health care workers. Both the vaccine and the hepatitis B immune globulin may be given at the same time. Since the hospital employee was pricked by a needle from an unknown source, both vaccine and hepatitis B immune globulin will be administered. Test-Taking Strategy: Use the process of elimination. Noting that the question states that the client never received the hepatitis B vaccine will assist in eliminating options 2 and 3. From the remaining options, focus on the data in the question. Since the hospital employee was pricked by a needle from an unknown source, both hepatitis B immune globulin and hepatitis B vaccine need to be administered. Review hepatitis B immune globulin and hepatitis B vaccine if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 427, 13261327. 1807. A nurse is providing dietary instructions to a client with tuberculosis (TB). The nurse would specifically instruct the client to increase intake of which of the following food items in the daily diet? 1. Meats and citrus fruits 2. Cereals and broccoli 3. Eggs and bacon 4. Rice and fish Answer: 1 Rationale: The nurse teaches the client with TB to increase intake of protein, iron, and vitamin C. Foods rich in vitamin C include citrus fruits, berries, melons, pineapple, broccoli, cabbage, green peppers, tomatoes, potatoes, chard, kale, asparagus, and turnip greens. Food sources that are rich in iron include liver and other meats, from which 10% to 30% of available iron is absorbed. Less than 10% of iron is absorbed from eggs, and less than 5% is absorbed from grains and vegetables. Test-Taking Strategy: Recalling that the diet for the client with TB should be high in protein, vitamin C, and calories will assist in answering this question. It is also necessary to know which types of foods contain these various nutrients. If you had difficulty with this question, review these nutritional concepts for the client with TB. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Fundamental Skills
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Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 537. 1808. A nurse is providing dietary instructions to a client with renal calculi, and the laboratory analysis has revealed that the calculi are composed of uric acid. The nurse tells the client that it would be helpful to: 1. Include organ meat type foods in the diet 2. Increase intake of seafood in the diet 3. Increase intake of legumes in the diet 4. Increase intake of cranberries and citrus fruits Answer: 3 Rationale: Dietary instructions to the client with uric acid type stones include increasing legumes, green vegetables, and fruits (except prunes, grapes, cranberries, and citrus fruits) to increase the alkalinity of the urine. The client should also be instructed to decrease purine sources such as organ meats, gravies, red wines, goose, venison, and seafood. Test-Taking Strategy: Use the process of elimination and focus on the issue—a client with uric acid calculi. Recalling that the goal is to increase the alkalinity of the urine will assist in directing you to option 3. If you had difficulty with this question, review the dietary instructions associated with this type of renal calculi. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Peckenpaugh, N. (2003). Nutrition essentials and diet therapy (9th ed.). Philadelphia: W.B. Saunders, p. 301. 1809. A nurse is caring for a client with a nasogastric tube. Which observation is most reliable in determining that the tube is correctly placed? 1. The aspirate is dark green in color 2. The aspirate is negative for guaiac 3. The tube is inserted the length measured from the client’s ear to nose and from the nose to xiphoid process 4. The pH of the aspirate is 5 Answer: 4 Rationale: After a nurse inserts a nasogastric tube into a client, the correct location of the tube must be verified. The presence of blood (option 2) is unrelated to the location of the tube. Aspirate is dark green in color, and the tube is inserted the length measured from the client’s ear to nose and from the nose to the xiphoid process. However, testing the pH of the gastric fluid and determining its acidity most reliability verifies that the tube is correctly placed. Test-Taking Strategy: Use the process of elimination noting the key words most reliable. Eliminate option 2 because it is unrelated to the question. Although options 1 and 3 are accurate, testing the pH of the aspirate is most reliable in determining correct placement of the tube. If you had difficulty with this question, review nasogastric insertion and
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placement techniques. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills Reference: Christensen, B., & Kockrow, E. (2003). Foundations of nursing (4th ed.). St. Louis: Mosby, p. 479. 1810. A nurse is preparing to perform chest physiotherapy (CPT) on a client. Before determining the correct position to place the client, the nurse must ascertain: 1. The client’s capability for lung expansion 2. The lung areas involved 3. The client’s procedure for performing deep breathing techniques 4. The close proximity of the oxygen tank Answer: 2 Rationale: The goal of CPT is to mobilize secretions for improved respiratory function. The nurse must determine which areas of the lungs should be targeted for this technique. The client’s capability for lung expansion is secondary to the lung assessment. Deep breathing routines and oxygen use do not specifically relate to client positioning. Test-Taking Strategy: Use the process of elimination and focus on the issue—client positioning. Deep breathing routines and the close proximity of oxygen are unrelated to positioning the client; therefore eliminate options 3 and 4. Eliminate option 1 because lung expansion is secondary to the primary purpose (mobilization of secretions) of CPT. Review the procedure for performing CPT if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills References: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, pp. 672673. Potter, P., & Perry, A. (2003). Essentials for practice (5th ed.). St. Louis: Mosby, pp. 671, 833. 1811. A client is admitted to the hospital with a bowel obstruction secondary to a recurrent malignancy, and the physician plans to insert a Miller-Abbott tube. When the nurse tries to explain the procedure, the client interrupts the nurse and states, “I don’t want to hear about that. Just let the doctor do it.” Based on the client’s statement, the nurse determines that the best action is to: 1. Leave the room 2. Ask the client if he would like another nurse to care for him 3. Explain to the client that all clients have the right to know about medical procedures 4. Remain with the client and be silent Answer: 4 Rationale: The nurse needs to recognize that the client has a greater need for security and acceptance than education. In option 4, the nurse conveys acceptance of the client and
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uses the therapeutic tool of silence. Options 1, 2, and 3 block communication and do not address the client’s need. Test-Taking Strategy: Use the process of elimination and therapeutic communication techniques. The nursing actions in options 1, 2, and 3 will block communication. Remaining with the client (option 4) demonstrates acceptance. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 661. 1812. A nurse is evaluating the effectiveness of meperidine hydrochloride (Demerol) for pain management for a client in labor. The nurse determines that the medication is effective if the client exhibits: 1. Complete pain relief and a period of rest from labor contractions 2. Moderate pain relief while a progressive labor pattern continues 3. Moderate pain relief with increased amounts of bloody show 4. Contractions that are longer, stronger, and closer together Answer: 2 Rationale: Effective pain management during labor does not interrupt the labor process but does provide relaxation and moderate pain relief to the mother. Increased bloody show and increased intensity of the contractions are not indications of effective pain management. Test-Taking Strategy: Use the process of elimination to answer the question. Eliminate options 3 and 4 first because increased bloody show and increased intensity of the contractions are not indications of effective pain management. From the remaining options, the key words are progressive labor pattern continues. This should direct you to option 2. Review the effects of meperidine hydrochloride on the client in labor if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Intrapartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 500. 1813. A nurse is reading a client’s urinalysis report. The nurse interprets that which of the following items found on the report is considered abnormal? 1. Negative glucose 2. Positive protein 3. pH 6.0 4. Specific gravity 1.018 Answer: 2 Rationale: Urine has a pH range of 4.5 to 8 and a specific gravity ranging from 1.010 to
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1.025. Urine is typically screened for protein, glucose, ketones, bilirubin, casts, crystals, red blood cells, and white blood cells, all of which should be negative. Test-Taking Strategy: Focus on the issue—an abnormal report. Noting the word “positive” in option 2 will direct you to this option. If you had difficulty with this question, review normal urinalysis results. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 1117. 1814. A client with an endotracheal tube gets easily frustrated when trying to communicate personal needs to the nurse. The nurse determines that which of the following methods for communication may be the easiest for the client? 1. Have the family interpret needs 2. Use a picture or word board 3. Use a pad and paper 4. Devise a system of hand signals Answer: 2 Rationale: The client with an endotracheal tube in place cannot speak. The nurse devises an alternative communication system with the client. Use of a picture or word board is the simplest method of communication, because it requires only pointing at the word or object. A pad and pencil is an acceptable alternative, but it requires more client effort and more time. The use of hand signals may not be a reliable method, because it may not meet all needs, and is subject to misinterpretation. The family does not need to bear the burden of communicating the client’s needs, and they may not understand them either. Test-Taking Strategy: Use the process of elimination. Note the key words easily frustrated in the question and easiest in the stem of the question. Options 3 and 4 are obviously not the “easiest” and are therefore eliminated first. Since the family may not necessarily know what the client is trying to communicate, this option (option 1) could cause added frustration for the client. Review communication methods for the client with an endotracheal tube if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Fundamental Skills Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1893. 1815. A nurse is collecting data from a client seen in the health care clinic for the first time. When the nurse asks the client about current prescribed medications, the client tells the nurse that rosiglitazone maleate (Avandia) is taken daily. Based on this finding, the nurse elicits data from the client regarding the presence of which condition? 1. Asthma 2. Diabetes mellitus
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3. Emphysema 4. Chronic bronchitis Answer: 2 Rationale: Rosiglitazone maleate is an antidiabetic medication used for clients with type 2 diabetes mellitus, and the medication reduces the plasma glucose level. It is used as monotherapy or in combination with metformin (Glucophage) as an adjunct to diet and exercise. It is not used to treat respiratory conditions. Test-Taking Strategy: Use the process of elimination. Note the similarity between options 1, 3, and 4 in that they all identify a respiratory-related disorder. Review the action and use of this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 952. 1816. A nurse is assisting in preparing a teaching plan for a client who has just been given a prescription for pioglitazone (Actos). The nurse plans to provide instructions to the client about which of the following related to this medication? 1. Signs of hypoglycemia 2. The need to increase the daily intake of calories by 750 3. The need to take the medication 1 hour following a meal 4. Signs of anemia Answer: 1 Rationale: Pioglitazone is an antidiabetic medication used for clients with type 2 diabetes mellitus, and the medication reduces the plasma glucose level. It is used as monotherapy or in combination with a sulfonylurea, metformin (Glucophage), or insulin as an adjunct to diet and exercise. It should be taken 15 to 30 minutes before a meal. A prescribed diet is an essential component of treatment in a diabetic client, but the client is not told to increase calorie intake unless specifically prescribed by the physician. The client is instructed in the signs of hypoglycemia because this effect can occur with the use of antidiabetic medications. The client is also instructed regarding the intervention necessary if hypoglycemia occurs. Anemia is not associated with the use of this medication. Test-Taking Strategy: Use the process of elimination. Recalling that the medication is an antidiabetic will direct you to option 1. Review this medication and the associated client teaching points if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 864. 1817. A nurse is collecting data from a client who is taking pantoprazole (Protonix). The nurse determines that the medication is effective if the client states relief of:
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1. A nighttime cough 2. Heartburn 3. Constipation 4. Migraine headaches Answer: 2 Rationale: Pantoprazole is a gastric acid pump inhibitor that increases the gastric pH and reduces gastric acid production. It is used to treat gastric and duodenal ulcers and gastroesophageal reflux disease. It is not used to treat cough, constipation, or migraine headaches. Test-Taking Strategy: Note the name of the medication—pantoprazole. Remembering that medication names for acid pump inhibitors end with the suffix zole will direct you to option 2. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 825. 1818. Entacapone (Comtan) is prescribed for a client with a diagnosis of Parkinson’s disease. The nurse reinforces medication instructions to the client and tells the client that a frequent side effect is: 1. An elevation in blood pressure 2. Joint pain 3. Urine discoloration to dark yellow or orange 4. Pruritus Answer: 3 Rationale: Entacapone is an antiparkinsonian agent that is used in conjunction with levodopa to improve the quality of life in clients with Parkinson’s disease. A frequent side effect is urine discoloration to dark yellow or orange. Orthostatic hypotension is also a frequent side effect. Joint pains and pruritus are not associated with the use of this medication. Test-Taking Strategy: Specific knowledge regarding this medication is required to answer this question. Remember, a frequent side effect of entacapone is urine discoloration to dark yellow or orange. If you are unfamiliar with the side effects of this medication, review this content. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 378. 1819. A nurse employed in a neighborhood health care clinic notes that the physician has prescribed oseltamivir (Tamiflu). The nurse teaches the client specific home care measures knowing that this medication was prescribed to treat:
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1. A cold sore 2. Influenza virus 3. Herpes zoster 4. Varicella zoster Answer: 2 Rationale: Oseltamivir is an oral antiviral medication used to treat influenza A and B virus. It is not used to treat a cold sore, herpes zoster, or varicella zoster. Test-Taking Strategy: Use the process of elimination and knowledge regarding the action and use of this medication. Noting the name of the medication—Tamiflu—will assist in directing you to option 2. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 806. 1820. A priority for a client diagnosed with placental abruption is to minimize alterations in fetal tissue perfusion. The nurse determines that fetal tissue perfusion is adequate if which of the following is noted? 1. Decreased fetal heart rate variability 2. Presence of late decelerations 3. Presence of accelerations 4. Evidence of fetal bradycardia Answer: 3 Rationale: Accelerations are an indication of fetal well-being and an oxygenated fetal central nervous system. Bradycardia, late decelerations, and decreased variability are representative of decreased oxygenation of the fetus. Test-Taking Strategy: Use the process of elimination and knowledge regarding the indications of fetal well-being. Eliminate options 1, 2, and 4 knowing that accelerations are an indication of fetal well-being. If you had difficulty with this question, review the significance of bradycardia, late decelerations, and decreased variability in the fetus. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum References: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 876-877. Matteson, P. (2001). Women’s health during the childbearing years: A community-based approach. St. Louis: Mosby, p. 346. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 346. 1821. A cooperative, compliant adult client taking 600 mg of carbamazepine (Tegretol) twice daily experienced two seizures at home during the past 2 weeks. The nurse interprets this information as:
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1. A need to increase the dose of the medication 2. A possible hysterical response 3. Not unusual 4. A need for a second anticonvulsant medication to be added to the treatment plan Answer: 4 Rationale: Carbamazepine (Tegretol) is an anticonvulsant used to treat seizures. The maintenance daily dose is between 800 and 1200 mg. The goal of all therapy for clients with seizures is no seizure activity. Because this high dose of carbamazepine (Tegretol) is not controlling the seizures, the use of an additional anticonvulsant is warranted. Options 1, 2, and 3 are incorrect interpretations. Test-Taking Strategy: Use the process of elimination focusing on the issue—the need to control the seizures. This issue and noting the medication dose identified in the question will direct you to option 4. Review content regarding carbamazepine if you are unfamiliar with this medication. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 165. Kee, J., & Hayes, E. (2003). Pharmacology: A nursing process approach (4th ed.). Philadelphia: W.B. Saunders, p. 281. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 368. 1822. A client being discharged from the hospital with a diagnosis of gastric ulcer has an order for sucralfate (Carafate) 1 gram by mouth four times daily. The nurse interprets that the client understands proper use of the medication if the client states to take it: 1. Every 6 hours around the clock 2. One hour after meals and at bedtime 3. With meals and at bedtime 4. One hour before meals and at bedtime Answer: 4 Rationale: The medication should be scheduled for administration 1 hour before meals and at bedtime. This timing will allow the medication to form a protective coating over the ulcer before it becomes irritated by food intake, gastric acid production, and mechanical movement. The other options are incorrect. Test-Taking Strategy: Use the process of elimination. Recalling the action of this medication—to form a protective coating—will assist in directing you to the correct option. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2004). Saunders nursing drug handbook 2004. Philadelphia: W.B. Saunders, p. 940.
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1823. A client is to receive medication via patient-controlled analgesia (PCA), and the nursing instructor asks the nursing student caring for the client to describe the use of the PCA. The instructor determines that the student needs instructions about the PCA if the student stated that: 1. PCA enables the client to titrate analgesics 2. PCA delivers predetermined amounts of analgesia at present intervals 3. Clients using PCA initiate the infusion by programming a pump 4. A continuous intravenous (IV) solution is needed to keep the vein open between analgesia infusions Answer: 3 Rationale: Patient-controlled analgesia (PCA) involves the use of a programmed syringe pump that delivers predetermined amounts of analgesia at preset intervals. PCA enables the client to titrate analgesics to maintain a consistent serum level of the narcotic rather than experience the peaks and troughs that occur with PRN injections. The pump is programmed by nursing staff as prescribed by the physician. The client will have IV fluids infusing to keep the vein open between analgesia infusions. Test-Taking Strategy: Note the key words needs instructions. These words indicate a false response question and that you need to select the incorrect student statement. Try to visualize the PCA and its use by the client. Remembering that a client would not program the pump should direct you to the correct option for this question as stated. If you had difficulty answering this question, review the principles related to the PCA pump. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Leadership/Management References: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 595-597. Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 245. 1824. A nurse is employed in a newborn nursery. The nurse is aware that medication toxicity is more likely to occur in the neonate than in an adult because: 1. The lungs are not developed 2. The kidneys are smaller than adults 3. Cerebral function is not fully developed 4. The liver is immature Answer: 4 Rationale: The increased medication sensitivity of neonates and infants is due largely to the immature state of five pharmacokinetic processes. These include medication absorption, renal medication excretion, hepatic medication metabolism, protein binding of medication, and exclusion of medication from the central nervous system by the bloodbrain barrier. Test-Taking Strategy: Use the process of elimination focusing on the issue—medication toxicity in the neonate. Recalling the characteristics of a newborn or neonate will assist
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in answering the question. Also, note that the key word in the correct option is immature. If you had difficulty with this question, review the characteristics of a neonate. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology References: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 86. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 134. 1825. A nurse is reinforcing instructions to the spouse of a client who is taking tacrine (Cognex) for the management of moderate dementia associated with Alzheimer’s disease. The nurse tells the spouse which of the following? 1. If flu-like symptoms occur, it is necessary to notify the physician immediately 2. If a dose is missed, double up on the next dose 3. If a change in the color of the stools occurs, notify the physician 4. Do not administer food with the medication Answer: 3 Rationale: Tacrine (Cognex) may be administered between meals on an empty stomach, and if gastrointestinal upset occurs, it may be administered with meals. Flu-like symptoms without fever and gastrointestinal symptoms are frequent side effects that may occur with the use of the medication. The client or spouse should never be instructed to double the dose of any medication if it was missed, and the client and caregiver are instructed to notify the physician if nausea, vomiting, diarrhea, rash, jaundice, or changes in the color of the stool occur. This may be indicative of the potential occurrence of hepatitis. Test-Taking Strategy: Use the process of elimination. Eliminate option 2 first using general principles related to medication administration. From the remaining options, if you can recall that an adverse reaction associated with the use of the medication is hepatitis you will easily be directed to option 3. If you are unfamiliar with the use of this medication and its potential adverse reactions, review this content. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2004). Saunders nursing drug handbook 2004. Philadelphia: W.B. Saunders, p. 948. 1826. A client is admitted to the labor and delivery suite with an intrauterine fetal demise. A nurse determines that the discussion with the parents was most effective in preparing them for the delivery when the parents: 1. State they have no questions 2. Request to hold the infant following delivery 3. Are surprised by the appearance of the infant following delivery 4. Refuse a footprint and picture of the infant to take home
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Answer: 2 Rationale: The nurse should explain to the parents the expected events following delivery of the fetus and should tell the parents that they can hold their infant following delivery. Viewing and holding the dead infant can alleviate any negative images the mother or her partner may have. Providing a picture or other mementos will help preserve the memory of the infant. If the parents refuse a picture, most hospitals will keep a picture and copy of the footprints on file for parents to access later. Parents should be encouraged to verbalize their feelings, ask questions about the process, and make their own decisions about care as much as possible. Test-Taking Strategy: Use the process of elimination noting the key words most effective. Seek the option that identifies preparedness of the parents for delivery. Option 2 is the option that most clearly identifies this preparedness. Review care to the parents experiencing intrauterine fetal demise if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Caring Content Area: Maternity/Postpartum References: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 1165. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 648. 1827. In reviewing the admission assessment data and physician’s orders for a client with peptic ulcer disease, the nurse notes that the client has a history of renal disease. Based on these data, the nurse determines that the most likely antacid to be prescribed for this client is: 1. Aluminum hydroxide (Amphojel) 2. Magnesium oxide (Mag-Ox 400) 3. Aluminum and magnesium combination (Maalox) 4. Aluminum and calcium (Camalox) Answer: 1 Rationale: Aluminum hydroxide lowers serum phosphate levels by binding with dietary phosphorus to form insoluble aluminum phosphate. The phosphate is then excreted in the feces. Aluminum hydroxide will not affect the renal system as much as other antacids. The medications identified in options 2, 3, and 4 are partially excreted by the kidneys; therefore they may cause a problem in clients with renal disease. Test-Taking Strategy: Note that the client has a history of renal disease. Also note that options 2, 3, and 4 are similar and contain magnesium. Therefore eliminate these options. If you had difficulty with this question, review these medications. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 41. Kee, J., & Hayes, E. (2003). Pharmacology: A nursing process approach (4th ed.).
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Philadelphia: W.B. Saunders, p. 670. 1828. Dantrolene (Dantrium) is prescribed for a client with a spinal cord injury for discomfort due to spasticity. The nurse determines that toxicity is present when which of the following laboratory values is altered? 1. Sedimentation rate 2. White blood cell count 3. Liver function studies 4. Creatinine level Answer: 3 Rationale: The risk of hepatotoxicity can occur with dantrolene, and liver function studies need to be monitored while the client is taking this medication. The sedimentation rate measures the presence of inflammation and infection. The white blood cell count measures the body’s immune defense system. The creatinine level measures renal function. Test-Taking Strategy: Knowledge regarding the toxic effects of dantrolene is required to answer the question. Correlate this medication with the potential for hepatotoxicity to answer questions similar to this one. If you had difficulty with this question, review the toxic effects of dantrolene. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 286. 1829. A newborn infant receives naloxone (Narcan) to reverse opiate-induced respiratory depression that occurred following labor and delivery. The nurse continues to monitor the respiratory status of a newborn infant following the administration of this medication because: 1. The newborn infant may demonstrate a gradual reappearance of respiratory depression as the antagonist’s short-lived effects diminish 2. The newborn infant may have an underlying respiratory disorder 3. The effects of naloxone are long lasting 4. The use of naloxone in newborn infants is toxic Answer: 1 Rationale: Naloxone is a short-term opiate antagonist. It reverses the respiratory depression that can be exhibited in newborn infants whose mothers have been treated with opiates for the pain of labor and delivery. Because it is short acting, and the newborn’s liver is immature, respiratory depression may reoccur after the duration of effects of naloxone. Test-Taking Strategy: Knowledge regarding the effects of naloxone is required to answer the question. Remember, it is specifically used to reverse respiratory depression. Also note the relation of the words “respiratory depression” in the question and in the correct option. If you had difficulty with this question, review this medication. Level of Cognitive Ability: Analysis
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Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, pp. 748-750. 1830. A client is being treated with atenolol (Tenormin) for hypertension. The client tells the nurse, “I am very tired since I began taking the medication.” Based on the client’s statement, the nurse determines that which nursing diagnosis written in the client’s plan of care is appropriate? 1. Ineffective Airway Clearance 2. Decreased Cardiac Output 3. Ineffective Health Maintenance 4. Self Care Deficit Answer: 2 Rationale: Atenolol is a beta-blocker, causing a decrease in heart rate and blood pressure and a decrease in cardiac output. Fatigue is the most common side effect. If this interferes with client’s activity level, dosage can be adjusted to eliminate this side effect. The defining characteristics of decreased cardiac output include complaints of fatigue or weakness. There are no data in the question that relate to the nursing diagnoses Ineffective Airway Clearance, Ineffective Health Maintenance, or Self Care Deficit. Test-Taking Strategy: When the question asks for selection of an appropriate nursing diagnosis, focus on the data presented in the question and use these data to select the correct option. Focusing on the client’s statement and considering the action of this medication will direct you to option 2. Review the defining characteristics of Decreased Cardiac Output if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 317. Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 91. 1831. A nurse is caring for a client with Paget’s disease. The nurse understands that the client is receiving calcitonin (Calcimar) to: 1. Regulates serum calcium concentrations 2. Promote the excretion of calcium in the urine 3. Decrease gastrointestinal absorption of calcium 4. Increase bone metabolism Answer: 1 Rationale: Calcitonin works in conjunction with parathyroid hormone (PTH) to regulate calcium levels by decreasing the rate of bone reabsorption and regulating bone metabolism. Options 2, 3, and 4 are not the purposes for administering this medication to this client.
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Test-Taking Strategy: Knowledge related to the purpose and action of the medications used to treat Paget’s disease is required to answer this question. If you had difficulty with this question, review the action and purpose of calcitonin and the treatment for Paget’s disease. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 153. Kee, J., & Hayes, E. (2003). Pharmacology: A nursing process approach. (4th ed.). Philadelphia: W.B. Saunders, pp. 724, 726. 1832. A client receiving therapy with carbidopa/levodopa (Sinemet) is upset and tells the nurse that his urine has turned a darker color since beginning to take this medication. The client wants to discontinue its use. In formulating a response to the client’s concerns, the nurse interprets that this change is: 1. Indicative of developing toxicity 2. A sign of interaction with another medication 3. A harmless side effect of the medication 4. A result of taking the medication with milk Answer: 3 Rationale: With carbidopa/levodopa therapy, a darkening of the urine or sweat may occur. The client should be reassured that this is a harmless side effect of the medication, and its use should be continued. Options 1, 2, and 4 are incorrect. Test-Taking Strategy: Knowledge of the side effects of this medication is needed to answer this question. Remember, a darkening of the urine or sweat is a harmless side effect of the medication. If you had difficulty with this question, review the side effects of this medication. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 167. 1833. A client with a history of simple partial seizures is taking clorazepate (Tranxene). The client asks the nurse if there is a risk of addiction. The nurse’s response is based on the understanding that clorazepate: 1. Is not habit-forming either physically or psychologically 2. Leads to physical and psychological dependence with prolonged high-dose therapy 3. Leads to physical tolerance, but only after 10 or more years of therapy 4. Can result in psychological dependence only, due to the nature of the medication Answer: 2 Rationale: Clorazepate is classified as an anticonvulsant, antianxiety agent, and sedative/hypnotic (benzodiazepine). The medication can lead to physical or
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psychological dependence when there is prolonged therapy at high doses. For this reason, the amount of medication that is readily available to the client at any one time is restricted. Options 1, 3, and 4 are incorrect. Test-Taking Strategy: Focus on the name of the medication. Recalling that the medication is a benzodiazepine leads you to conclude that this medication can lead to physical as well as psychological dependence. If you had difficulty with this question, review this medication. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 248. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 338. 1834. A client who takes chlorothiazide (Diuril) every evening expresses frustration with the medication and wants to stop therapy. When the nurse explores the reasoning, the client says, “It keeps me up all night. I feel as though I should bring my pillow into the bathroom!” The nurse interprets that the client can best be assisted to successfully adapt to this therapy by: 1. Switching to a morning administration of the medication 2. Taking a sleep aid with the medication 3. Limiting oral fluids before bedtime 4. Asking the physician for a new brand of medication Answer: 1 Rationale: Diuretic therapy should be administered in the morning to cause the least disruption as possible in the client’s sleep cycle. Options 2, 3, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination. Look at the name of the medication and determine that it is a diuretic. Recalling that diuretics need to taken in the morning will direct you to option 1. Review the client teaching points related to this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Teaching/Learning Content Area: Pharmacology References: Kee, J., & Hayes, E. (2003). Pharmacology: A nursing process approach (4th ed.). Philadelphia: W.B. Saunders, p. 590. Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, pp. 405, 408. 1835. A nurse is scheduled to administer a dose of digoxin (Lanoxin) to a client with atrial fibrillation. The client has a potassium level of 4.6 mEq/L. The nurse interprets that the: 1. Dose should be omitted for that day 2. Client needs a dose of potassium before receiving the digoxin
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3. Dose should be withheld and the physician notified 4. Dose should be administered as prescribed Answer: 4 Rationale: Hypokalemia can make the client more susceptible to digoxin toxicity. The nurse monitors the results of potassium levels drawn on the client. The normal reference range of potassium for an adult is 3.5 to 5.1 mEq/L. If the potassium level is low, the dose is withheld and the physician is notified. In this situation, the dose should be administered as prescribed because the potassium level is within the normal range. Test-Taking Strategy: To answer this question correctly, you must know that hypokalemia potentiates digoxin toxicity, and normal potassium levels. Noting that the client’s potassium level is within normal limits will direct you to option 4. Review the normal potassium level and the nursing considerations related to the administration of digoxin if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 326. Kee, J., & Hayes, E. (2003). Pharmacology: A nursing process approach (4th ed.). Philadelphia: W.B. Saunders, p. 569. 1836. A client who was started on anticonvulsant therapy with clonazepam (Klonopin) tells the nurse of increasing clumsiness and unsteadiness since starting the medication. The client is visibly upset by these manifestations and asks the nurse what to do. The nurse’s response is based on the understanding that these symptoms: 1. Indicate that the client is experiencing a severe untoward reaction to the medication 2. Are most severe during initial therapy and decrease or disappear with long-term use 3. Are probably the result of an interaction with another medication 4. Usually occur when the client takes the medication with food Answer: 2 Rationale: Drowsiness, unsteadiness, and clumsiness are expected effects of the medication during early therapy. They are dose-related, and usually diminish or disappear altogether with continued use of the medication. It does not indicate that a severe untoward reaction is occurring. It is also unrelated to interaction with another medication. The client is encouraged to take this medication with food to minimize gastrointestinal upset. Test-Taking Strategy: Specific knowledge regarding this medication is needed to answer this question. Recalling that the effects described in the question occur early in the course of therapy and decrease or disappear with long-term use will direct you to option 2. If you had difficulty with this question, review this medication. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005.
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Philadelphia: W.B. Saunders, p. 245. 1837. A client has been prescribed cyclobenzaprine (Flexeril) in the treatment of painful muscle spasms accompanying a herniated intervertebral disk. The nurse would withhold the medication and question the order if the client had concurrent orders to take: 1. Furosemide (Lasix) 2. Valproic acid (Depakene) 3. Ibuprofen (Motrin) 4. Tranylcypromine (Parnate) Answer: 4 Rationale: The client should not receive cyclobenzaprine if the client has taken a monoamine oxidase (MAO) inhibitor such as tranylcypromine or phenelzine (Nardil) within the last 14 days. Otherwise, the client could experience hypertensive crisis, convulsions, or death. Options 1, 2, and 3 are not contraindicated with the use of this medication. Test-Taking Strategy: Knowledge regarding cyclobenzaprine and the contraindications in its use is required to answer the question. Remember that cyclobenzaprine is not taken with MAO inhibitors. If you had difficulty with this question, review this medication and the contraindications associated with its use. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 269. 1838. An infant is suspected to be human immunodeficiency virus (HIV) positive, and the nurse provides information to the parents about the care of their infant. Which of the following indicates to the nurse that the parents need further information about the care of their HIV positive infant? 1. The parents state they will not allow anyone with a cold to hold and kiss the baby 2. The parents are able to verbalize signs and symptoms of the infant’s failure to thrive 3. The parents ask for a prescription for an antiretroviral medication 4. The parents plan to use rice cereal to help with watery stools when they occur Answer: 4 Rationale: If an infant is having diarrhea, the parents need to seek medical attention because this could be the beginning of an opportunistic infection. Self-treatment is not encouraged. Asking for antiretroviral therapy, understanding signs and symptoms of failure to thrive, and being protective of an immunocompromised infant are evidence of understanding the needs of the infant. Test-Taking Strategy: Use the process of elimination noting the key words need further information. These words indicate a false response question and that you need to select the incorrect client statement. Recalling the signs of an opportunistic infection will direct you to option 4. If you had difficulty with this question, review parent education points for the newborn infant suspected to be HIV positive. Level of Cognitive Ability: Analysis
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Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Child Health References: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 689, 1066-1067. Matteson, P. (2001). Women’s health during the childbearing years: A community-based approach. St. Louis: Mosby, p. 692. 1839. A pregnant woman has tested positive for human immunodeficiency virus (HIV). The nurse reinforces information to the client about HIV and determines that additional information is necessary when the client states: 1. “Breast-feeding after delivery is best for my baby.” 2. “I can continue to hug and hold my other children.” 3. “It may be two years before I know if my baby has HIV.” 4. “My husband and I can still sleep together in the same bed.” Answer: 1 Rationale: Breast-feeding is contraindicated if the mother is positive for human immunodeficiency virus (HIV) because the virus may be spread to the infant in the breast milk. HIV is not spread through casual contact, so holding, hugging, and sleeping with other family members is not prohibited. A newborn may test positive for HIV for up to 2 years after birth because of placental transfer of maternal antibodies. It is vital that the nurse ascertains that the client has correct knowledge regarding the transmission of the disease and precautions necessary to prevent the spread of HIV. Test-Taking Strategy: Use the process of elimination noting the key words additional information is necessary. Recalling that HIV is spread by direct contact with infected body fluids will direct you to option 1. If you had difficulty with this question, review the methods of transmission of the HIV virus. Level of Cognitive Ability: Analysis Client Needs: Safe, Effective Care Environment Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum References: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 422. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 728. 1840. A client with congestive heart failure is being discharged home and will be taking furosemide (Lasix). The nurse determines that teaching has been effective if the client states which of the following? 1. “I will check my ankles every day for swelling.” 2. “I will take my pulse every day.” 3. “I will measure my urine output.” 4. “I will weigh myself every day.” Answer: 4 Rationale: A client taking furosemide (Lasix) must be able to monitor fluid status throughout therapy. Monitoring daily weight is the easiest and most accurate way to
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accomplish this. Options 1 and 3 are incorrect because of the difficulty of assessing fluid status accurately in this way. Additionally, in order for option 3 to be correct, fluid intake would need to be measured. Option 2 is incorrect and unrelated to the administration of furosemide. Test-Taking Strategy: Use the process of elimination. In client teaching questions, try to select the option that would be the easiest and most effective for a nurse to teach and for the client to understand. Remember, if you teach a client to do something that is too complicated, there will be no compliance. Option 4 provides the easiest and most accurate way to measure fluid status. If you had difficulty with this question, review the measures that will effectively determine a therapeutic response to furosemide. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 480. 1841. A client is being treated for heart failure and is receiving digoxin (Lanoxin). The client’s vital signs are blood pressure 85/50 mm Hg, pulse rate 96 beats per minute, respirations 26 breaths per minute. To evaluate the therapeutic effectiveness of this medication, the nurse would expect which of the following changes in the client’s vital signs? 1. Blood pressure 85/50 mm Hg, pulse rate 60 beats per minute, respirations 26 breaths per minute 2. Blood pressure 98/60 mm Hg, pulse rate 80 beats per minute, respirations 24 breaths per minute 3. Blood pressure 130/70 mm Hg, pulse rate 104 beats per minute, respirations 20 breaths per minute 4. Blood pressure 110/40 mm Hg, pulse rate 110 beats per minute, respirations 20 breaths per minute Answer: 2 Rationale: The main function of digoxin is inotropic. The increased myocardial contractility is associated with increased cardiac output, causing an increase in the blood pressure in a client with heart failure. Digoxin has a negative chronotropic effect (decreases heart rate) and will therefore cause a slowing of the heart rate. As cardiac output improves, there should be an improvement in respirations as well. Test-Taking Strategy: This question requires knowledge of the action of digoxin. Knowing that digoxin slows the heart rate will assist in eliminating options 3 and 4. Knowing that digoxin improves cardiac output will assist in eliminating option 1. This leaves option 2 as the correct option. If you had difficulty with this question, review the therapeutic effects of digoxin. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005.
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Philadelphia: W.B. Saunders, p. 326. Kee, J., & Hayes, E. (2003). Pharmacology: A nursing process approach (4th ed.). Philadelphia: W.B. Saunders, p. 569. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, pp. 540, 542. 1842. A client with a partial right adrenalectomy is placed on corticosteroid replacement therapy. Which of the following would indicate that the client is experiencing an adverse effect related to the pharmacological treatment? 1. Hypoglycemia 2. Hypotension 3. Dry mouth 4. Tarry stools Answer: 4 Rationale: Glucocorticoids increase gastric secretion, and this can result in peptic ulcers and gastrointestinal bleeding. Corticosteroids increase blood glucose levels. Hypotension and dry mouth are not side effects of corticosteroid therapy. Test-Taking Strategy: Knowledge regarding the adverse effects associated with corticosteroid therapy is required to answer this question. Remember, glucocorticoids can cause gastrointestinal bleeding. Review the adverse effects associated with corticosteroids if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology Reference: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 767. 1843. A client is being discharged following treatment for left ventricular heart failure. The nurse is teaching the client the purpose, actions, adverse effects, and use of digoxin (Lanoxin) 0.25 mg daily and hydrochlorothiazide (HydroDIURIL) 50 mg prescribed for daily use. Which statement by the client indicates that further discharge teaching is needed? 1. “I should decrease my intake of foods high in potassium, such as bananas.” 2. “I should take my radial pulse before taking these medications.” 3. “These medications will cause an increase in urine output.” 4. “These medications should be taken in the morning rather than in the evening.” Answer: 1 Rationale: Digoxin is a cardiac glycoside and hydrochlorothiazide is a diuretic. Clients on digoxin have an increased risk of digoxin toxicity from the potassium-depleting effect of hydrochlorothiazide. Therefore the diet should be high in potassium. The client should take their pulse before taking cardiac glycosides. A combined therapeutic effect of these medications is to increase urine output. The increased blood flow to the kidneys as a result of enhanced cardiac contractility from the digoxin will promote urinary output. Hydrochlorothiazide increases urine excretion of sodium and water by inhibiting sodium reabsorption in the nephron. For best therapeutic effects, these medications should be
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taken at the same time in the morning to avoid sleep disturbances from the need to urinate. Test-Taking Strategy: Note the key words further discharge teaching is needed. These words indicate a false response question and that you need to select the incorrect client statement. Recalling that potassium depletion can occur with the use of these medications will direct you to option 1. If you had difficulty with this question, review these medications. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Pharmacology References: Kee, J., & Hayes, E. (2003). Pharmacology: A nursing process approach (4th ed.). Philadelphia: W.B. Saunders, p. 570. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 541. 1844. A nurse is assisting in developing a plan of care for a pregnant client with acquired immunodeficiency syndrome (AIDS). The nurse determines that which of the following is the priority nursing diagnosis for this client? 1. Ineffective Health Maintenance 2. Risk for Infection 3. Disturbed Sensory Perception 4. Deficient Fluid Volume Answer: 2 Rationale: Acquired immunodeficiency syndrome decreases the body’s immune response, making the infected person susceptible to infections. AIDS affects helper T lymphocytes, which are vital to the body’s defense system. Opportunistic infections are a primary cause of death in persons infected with AIDS. Therefore preventing infection is a priority of nursing care. Although the nursing diagnoses in options 1, 3, and 4 may be a concern at some point in the care of the client, these are not the priority. Test-Taking Strategy: Note the key word priority. Use Maslow’s Hierarchy of Needs theory to eliminate options 1 and 3. From the remaining options, recalling that AIDS affects the body’s immune system will direct you to option 2. If you had difficulty with this question, review the priority concerns related to the client with AIDS. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing References: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 203. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 727. 1845. A nurse in the preoperative holding unit administers a dose of scopolamine to a client. The nurse monitors the client for which common side effect of the medication? 1. Dry mouth
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2. Pupillary constriction 3. Excessive urination 4. Diaphoresis Answer: 1 Rationale: Scopolamine is an anticholinergic medication that causes the frequent side effects of dry mouth, urinary retention, decreased sweating, and dilation of the pupils. Each of the incorrect options is the opposite of a side effect of this medication. Test-Taking Strategy: Use the process of elimination. Recalling that this medication is an anticholinergic will direct you to option 1. If the medication is unfamiliar to you, review its action and side effects. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2004). Saunders nursing drug handbook 2004. Philadelphia: W.B. Saunders, p. 908. 1846. A client is being discharged home following recovery from an anterior myocardial infarction with recurrent angina. The client will be taking diltiazem (Cardizem SR) two times daily, isosorbide dinitrate (Isordil) four times daily, and nitroglycerin (Nitrostat) sublingually as needed, and the nurse reinforces information to the client about the medications. Which statement by the client indicates that further teaching is needed about the medications? 1. “All three of these medications will help to decrease the intensity of my chest pain.” 2. “All three of these medications will increase blood flow to my heart.” 3. “I should notify my doctor immediately if I experience headaches with any of these medications.” 4. “I will store these medications in a cool place, away from light.” Answer: 3 Rationale: Because of the vasodilating effects of nitrates, headache is a common side effect. Medical attention is not needed unless the headaches increase in severity or frequency. All three medications are nitrates, which improve myocardial circulation by dilating coronary arteries and collateral vessels, thus increasing blood flow to the heart. These medications are used to help prevent the frequency, intensity, and duration of anginal attacks. Nitrates should be stored in a cool place and in a dark container. Heat and light cause these medications to break down and lose their potency. Test-Taking Strategy: Note the key words further teaching is needed. These words indicate a false response question and that you need to select the incorrect client statement. Recalling that these medications have a vasodilating effect and that headache is a common side effect will direct you to option 3. If you had difficulty with this question, review these medications. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005.
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Philadelphia: W.B. Saunders, p. 108. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 608. 1847. A nurse has reinforced instructions to a client with Parkinson’s disease who is taking carbidopa/levodopa (Sinemet). Which statement by the client indicates the need for further instruction? 1. “I will take the medication just before meals to avoid nausea.” 2. “I will eat lots of foods high in vitamin B6.” 3. “I will get up slowly to prevent dizziness.” 4. “I may need to take this medication for the rest of my life.” Answer: 2 Rationale: Foods high in vitamin B6 can counteract the effects of carbidopa/levodopa, and their intake should be limited. Options 1, 3, and 4 are accurate statements regarding this medication. Test-Taking Strategy: Note the key words need for further instruction. These words indicate a false response question and that you need to select the incorrect client statement. Remember, foods high in vitamin B6 can counteract the effects of this medication. If you had difficulty with this question, review this medication. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2004). Saunders nursing drug handbook 2004. Philadelphia: W.B. Saunders, p. 168. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 497. 1848. A client being seen in the clinic is taking phenytoin (Dilantin), and the client’s phenytoin blood level is within therapeutic range and the client’s seizures are controlled. Which of the following if observed by the nurse on data collection would require physician notification and possible discontinuation of the medication? 1. Diplopia 2. Bleeding gums 3. Mental impairment 4. Diffuse body rash Answer: 4 Rational e: Stevens-Johnson syndrome is a rash indicating an allergy, and if this occurs the physician needs to be notified for consideration of medication discontinuation. Options 1, 2, and 3 are also side effects of the medication, but may be reversed with medication dose alteration rather than medication discontinuation. Test-Taking Strategy: Note the key words possible discontinuation of the medication. Options 1, 2, and 3 require attention, but a rash indicates an allergic response and an allergy can be life-threatening. If you are unfamiliar with this medication, review this content.
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Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 856. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 361. 1849. A young pregnant woman with diabetes mellitus has lost 10 pounds during the first 15 weeks’ gestation. The client tells the nurse that, “I do not eat regular meals.” Based on the client’s statement, the nurse determines that the best response would be which of the following? 1. “If you do not eat regular meals you will hurt your baby.” 2. “Can you tell me more about what you are eating?” 3. “I’ll have the doctor review your diet history.” 4. “It does not matter anymore how much weight you gain.” Answer: 2 Rationale: It is important for the nurse to obtain additional information from the client. In option 2, the nurse is using the therapeutic communication tool of validation and clarification in order to obtain more information. The other options will block communication. Option 1 devalues the client and shows disapproval. Option 3 is avoiding the issue, and option 4 provides false reassurance. Test-Taking Strategy: Use therapeutic communication techniques. Note that option 2 is open-ended and will encourage communication. Additionally, option 2 identifies the process of gathering data, the first step in the nursing process. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Analysis Client’s Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Maternity/Antepartum References: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 889-890. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 707. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 437. 1850. A client with a thoracic spinal cord injury is receiving dantrolene sodium (Dantrium). Which statement by the client indicates to the nurse that the client is having an undesired medication effect? 1. “I’m feeling drowsy.” 2. “My legs are very relaxed.” 3. “I can’t seem to get enough to eat.” 4. “My urine has a bluish color.” Answer: 1
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Rationale: Drowsiness, diarrhea, and hepatotoxicity are the major adverse effects of this muscle relaxant, which is used to treat the chronic spasticity seen in spinal cord injury. The drowsiness may interfere with the client’s rehabilitation. Some clients have anorexia and hematuria. Test-Taking Strategy: Use the process of elimination focusing on the issue—an undesired medication effect. Option 2 is a desired effect, so eliminate this option. Options 3 and 4 are unrelated to this medication. Also remember that many medications cause nausea or gastric irritation, so option 3 could be eliminated, and very few medications cause blue urine, making option 4 incorrect. If you had difficulty with this question, review the undesired effects of this medication. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 285. 1851. A nurse is assisting in monitoring a client who received hydralazine hydrochloride (Apresoline) to treat autonomic dysreflexia. Which finding most accurately indicates that the medication is effective? 1. Muscle spasms subside 2. Blood pressure declines 3. Intensity of seizure activity declines 4. Client states that they feel better Answer: 2 Rationale: Hydralazine hydrochloride is a potent ganglionic blocking agent that will decrease the blood pressure by vasodilation. It may be given by slow intravenous push during an episode of extreme hypertension. Options 1, 3, and 4 are not intended effects of the medication. Test-Taking Strategy: Recalling that hydralazine hydrochloride is an antihypertensive agent will direct you to option 2. If you are unfamiliar with this medication, note the relation between the name of the medication and the action; in this case, Apresoline and pressure. If you had difficulty with this question, review the action of this medication. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 527. 1852. A client with acquired immunodeficiency syndrome (AIDS) has an opportunistic respiratory fungal infection and is receiving intravenous amphotericin B (Fungizone). The nurse assisting in caring for the client monitors for which sign that indicates an adverse effect of the medication? 1. Decreased urine output 2. Orange colored urine
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3. Pale colored stools 4. Jaundice Answer: 1 Rationale: Clients receiving amphotericin B may develop nephrotoxicity. Clients should be monitored for oliguria, hematuria, cloudy urine, decreased urine output, and elevated renal function laboratory values. Amphotericin B does not cause the urine to turn orange in color. Pale colored stools indicate hepatotoxicity as does jaundice; hepatotoxicity is not an adverse effect. Test-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 first because they both relate to hepatotoxicity. From the remaining options recalling that amphotericin B is nephrotoxic will direct you to the correct option. Review the adverse effects of this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 65. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 1015. 1853. A 38-week gestational pregnant woman arrives at the emergency department. She reports the presence of bright red vaginal bleeding and denies the presence of any pain. Based on this information, the nurse determines that the client may be experiencing: 1. The passage of the mucous plug 2. Abruptio placentae 3. Rupture of the amniotic sac 4. Placenta previa Answer: 4 Rationale: The primary symptom in placenta previa is painless vaginal bleeding in the second or third trimester of pregnancy. Passage of the mucous plug appears as pink or blood-tinged mucus. A ruptured amniotic sac would include findings such as watery vaginal drainage. Findings of abruptio placentae include dark red vaginal bleeding and abdominal pain. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 3 because these conditions would not produce bloody discharge. From the remaining options, it is necessary to recall the signs and symptoms of both placenta previa and abruptio placentae. Recalling that painless vaginal bleeding occurs in placenta previa will direct you to the correct option. If you had difficulty with this question, review the signs associated with both disorders. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum References: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 872.
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Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 672. 1854. A client informs the nurse that she has been taking acarbose (Precose) as prescribed. The nurse determines that a therapeutic effect of the medication has occurred if which of the following is noted? 1. A serum lipase level of 100 units/L 2. A 2-hour postprandial serum glucose level of 120 mg/dl 3. A sodium level of 140 mEq/L 4. A blood urea nitrogen (BUN) level of 15 mg/dl Answer: 2 Rationale: Acarbose is an oral antidiabetic medication used as an adjunct to diet to lower blood glucose levels in clients with non–insulin-dependent diabetes mellitus whose hyperglycemia cannot be managed by diet alone. All of the laboratory values presented in the options are within a normal value. Lipase level monitors pancreatic activity. Sodium is an electrolyte. The BUN measures renal function. A 2-hour postprandial serum glucose reading of 120 mg/dl would identify a therapeutic effect of the medication. Test-Taking Strategy: Focus on the name of the medication. If you are unfamiliar with this medication, note its name—Precose. This can provide you with a clue that the medication is administered prior to something. Knowing that antidiabetics are administered prior to the meal may assist in directing you to the correct option. Review the purpose of this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 4. Kee, J., & Hayes, E. (2003). Pharmacology: A nursing process approach (4th ed.). Philadelphia: W.B. Saunders, p. 746. 1855. A nurse employed in the emergency department receives a telephone call from the emergency alert system informing the department that a child who ingested a bottle of acetaminophen (Tylenol) is on route to the emergency department. The nurse prepares the room for the arrival of the child and checks the medication supply to determine if which medication that is the antidote is available? 1. Phytonadione (Vitamin K) 2. Protamine sulfate 3. Acetylcysteine (Mucomyst) 4. Pancreatin Answer: 3 Rationale: Acetylcysteine is the antidote for acetaminophen. Protamine sulfate is the antidote for heparin. Phytonadione is the antidote for warfarin sodium (Coumadin). Pancreatin is a pancreatic enzyme replacement or supplement. Test-Taking Strategy: Knowledge regarding the appropriate antidote for acetaminophen is required to answer the question. Remember, acetylcysteine is the antidote for
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acetaminophen. Review the various medication antidotes if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 9. 1856. A nurse is caring for a client who has been taking acetazolamide (Diamox) for glaucoma. The nurse reviews the assessment data documented in the client’s medical record and determines that a potential adverse effect of the medication may be occurring if which of the following is noted? 1. No change in the level of peripheral vision 2. Jaundice 3. Pupillary constriction in response to light 4. Tinnitus Answer: 2 Rationale: Acetazolamide is a carbonic anhydrase inhibitor used in the treatment of open-angle, secondary, or angle-closure glaucoma to reduce the rate of aqueous humor formation and to lower intraocular pressure. Adverse effects relate to nephrotoxicity, hepatotoxicity, and bone marrow depression. Jaundice is a sign of hepatotoxicity. A decrease in the level of peripheral vision would indicate a complication of glaucoma. Pupillary constriction in response to light is a normal response. Tinnitus is unrelated to this medication. Test-Taking Strategy: Focus on the issue—an adverse effect of the medication. Eliminate option 3 because this is a normal response. From the remaining options, remembering that nephrotoxicity, hepatotoxicity, and bone marrow depression indicate adverse effects will direct you to the correct option. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 10. Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 1103. 1857. A client reports to the clinic for follow-up after a 1-month treatment with acebutolol (Sectral). The nurse determines that a therapeutic effect of the medication has occurred if which of the following is noted? 1. A blood pressure of 130/84 mm Hg 2. An apical pulse rate of 88 beats per minute 3. Palpable peripheral pulses 4. Maintenance of desired weight
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Answer: 1 Rationale: Acebutolol is a beta-adrenergic blocker used primarily to manage mild to moderate hypertension or cardiac dysrhythmias. The expected therapeutic response is a controlled blood pressure within normal limits. Although a pulse rate of 88 beats per minute is also normal, no reference is made regarding the quality or regularity of the pulse. Options 3 and 4 are unrelated to the action of the medication. Test-Taking Strategy: Remember that medication names that end in the letters “lol” are beta blockers and that beta blockers lower blood pressure. This should assist in directing you to the correct option. Review this medication if you had difficulty with the question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 6. 1858. A nurse is caring for a client experiencing a partial placental abruption. The client is uncooperative and is refusing any interventions until her husband arrives at the hospital. The nurse analyzes the client’s behavior as most likely the result of: 1. Emotional immaturity 2. An undiagnosed psychiatric disorder 3. Acute anxiety and the need for support 4. A stubborn personality Answer: 3 Rationale: Any of the situations identified in the options may contribute to the reason for the client’s behavior, but the most likely reason is anxiety. Option 3 is the only option that supports the information identified in the question. The client may be anxious about the unknown effects of complications, and the presence of a support person while dealing with a crisis is crucial. There are no data in the question to support options 1, 2, and 4. Test-Taking Strategy: Use the process of elimination focusing on the data in the question. Noting the key words refusing any interventions until her husband arrives will direct you to option 3. Additionally, there are no data in the question to support options 1, 2, and 4. Review the psychosocial aspects of care for a client with a partial placental abruption if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum References: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 874-876. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 674. 1859. A nurse reinforces instructions to a client with myxedema about the dosage, method of administration, and side effects of levothyroxine sodium (Synthroid). Which statement by the client would indicate an understanding of the nurse’s instructions?
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1. “I can expect to have diarrhea, insomnia, and excessive sweating.” 2. “If I feel nervous or have tremors I should only take half the dose.” 3. “I should apply the topical patch to a nonhairy area.” 4. “I will report any episodes of palpitations, chest pain, or dyspnea.” Answer: 4 Rationale: A major concern when initiating thyroid hormone replacement therapy is that the dose may be too high, which can lead to cardiovascular problems. As a result, clients need to be aware of the early signs and symptoms of toxicity and that they must report these immediately to their physician. Diarrhea, insomnia, and excessive sweating are signs and symptoms of hyperthyroidism, and while they can occur with thyroid replacement therapy, they are not expected and should be reported. Tremors and nervousness are also signs of toxicity, which need to be reported. Clients should never take it upon themselves to adjust hormone dosage. Levothyroxine sodium is not administered topically. Test-Taking Strategy: Focus on the issue—an understanding of the nurse’s instructions. General principles related to medication therapy will assist in eliminating option 2. From the remaining options, focus on the name of the medication and recall the effects of thyroid replacement therapy. This will direct you to option 4. If you had difficulty with this question, review this medication. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 633. 1860. A client has a prescription for niacin (Nicobid, Niacor). The nurse determines that the client understands the importance of this therapy if the client verbalized the importance of periodic monitoring of: 1. Renal function studies 2. The serum cholesterol level 3. The blood urea nitrogen level 4. The creatinine level Answer: 2 Rationale: Niacin is used as adjunctive therapy in the management of hyperlipidemia. This is used in conjunction with a low-fat and low-cholesterol diet, exercise, and smoking cessation. Serum cholesterol and triglyceride levels are monitored periodically to assess the effectiveness of therapy. The laboratory studies in options 1, 3, and 4 assess renal function. Test-Taking Strategy: Use the process of elimination. Eliminate options 1, 3, and 4 because they are similar and assess renal function. Remember, niacin is used as adjunctive therapy in the management of hyperlipidemia. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation
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Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 766. 1861. A client with aldosteronism has been instructed on spironolactone (Aldactone) treatment. Which client statement indicates that the client needs further teaching about the medication? 1. “This medication will make me void frequently.” 2. “This medication will decrease my blood glucose.” 3. “My blood pressure should get back to normal.” 4. “My potassium level may increase.” Answer: 2 Rationale: Spironolactone is a potassium-sparing diuretic. It does not lower blood glucose level. Spironolactone counteracts the effect of aldosterone; it promotes sodium and water excretion, decreases circulating volume, and therefore decreases blood pressure and inhibits the excretion of potassium. Test-Taking Strategy: Note the key words needs further teaching. These words indicate a false response question and that you need to select the incorrect client statement. Recalling that this medication is a potassium-sparing diuretic and is prescribed for blood pressure control will direct you to option 2. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 985. 1862. A client with chronic atrial fibrillation is being started on quinidine sulfate (Quinidex Extentabs) as maintenance therapy for dysrhythmia suppression. The nurse determines that the client needs instruction about this medication if the client stated to: 1. Take the dose at the same time each day 2. Avoid chewing the sustained release tablets 3. Take the medication with food if gastrointestinal (GI) upset occurs 4. Stop taking the prescribed digoxin (Lanoxin) after starting this new medication Answer: 4 Rationale: Medication-specific teaching points for quinidine sulfate include the following: take the medication exactly as prescribed; do not chew the sustained release tablets; take the medication with food if GI upset occurs; wear a Medic-Alert bracelet or tag; and get periodic checks of heart rhythm and blood counts. This medication is initiated for atrial flutter or fibrillation only after being digitalized. Test-Taking Strategy: Note the key words needs instruction. These words indicate a false response question and that you need to select the incorrect client statement. Options 1 and 2 are general instructions for medication use and are therefore eliminated first. From the remaining options, remember that it is not usual practice to “stop taking” a “prescribed” medication. This will direct you to option 4. If you had difficulty with this
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question, review this medication. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, pp. 326, 918. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 553. 1863. Which statement indicates that a client with Addison’s disease knows how to safely manage a medication regimen that consists of daily doses of glucocorticoids? 1. “I will need to call my doctor for an increase in medication dose when I’m experiencing a lot of stress.” 2. “I should stop my medication if I begin to experience any unpleasant side effects.” 3. “The medication I am taking is very safe and does not cause side effects.” 4. “If I’m nauseated and can’t take my medicine for a few days, I can do without them.” Answer: 1 Rationale: The client with Addison’s disease will require lifelong replacement of adrenal hormones. The medications must be taken daily, and an alternate route of administration must be used if the client cannot take oral medications for any reason, such as nausea and vomiting. Additional doses of glucocorticoids will be needed during times of acute stress. The nurse must emphasize to the client that they must call the physician to obtain a dosage increase when experiencing stressful situations. Abrupt withdrawal of this medication can result in Addisonian crisis. Although side effects are not severe at lower doses, side effects may be experienced with glucocorticoid administration. It is very unsafe to stop taking the medication without first consulting the physician. Test-Taking Strategy: Use the process of elimination recalling information about glucocorticoids and the stress response. The correct option makes the correlation between stress and the increased need for corticosteroids. If you had difficulty with this question, review the client teaching points related to glucocorticoids. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology References: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, pp. 641, 766. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 856. 1864. A client began taking amantadine hydrochloride (Symmetrel) approximately 2 weeks ago. The nurse determines that the medication is having a therapeutic effect if the client exhibited decreased: 1. White blood cell count 2. Voiding 3. Rigidity and akinesia
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4. Blood pressure Answer: 3 Rationale: Amantadine hydrochloride is an antiparkinson agent that potentiates the action of dopamine in the central nervous system. The expected effect of therapy is a decrease in akinesia and rigidity. Leukopenia, urinary retention, and hypotension are all adverse effects of the medication. Test-Taking Strategy: Focus on the name of the medication and recall that this medication is used to treat Parkinson’s disease. This will direct you to option 3 as the expected effect of the medication. Review the expected effects of this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 42. 1865. A nurse is caring for a restless client who keeps biting down on an orotracheal tube. The nurse uses which of the following to prevent the client from obstructing the airway with the teeth? 1. Nasal airway 2. Oral airway 3. Bite stick 4. Padded tongue blade Answer: 2 Rationale: An oral airway may be used to keep the client from biting down, occluding an orotracheal tube. A nasal airway is not used in conjunction with an oral endotracheal tube. A padded tongue blade or a bite stick may be used initially to open the mouth for easier insertion of an oral airway. Test-Taking Strategy: Visualize the use of each item in the options. Note the relation between “orotracheal” in the question and “oral airway” in the correct option. Review care to the client with an orotracheal tube if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Respiratory Reference: Potter, P., & Perry, A. (2003). Essentials for practice (5th ed.). St. Louis: Mosby, p. 662. 1866. A nurse performs a blood glucose test on a newborn infant whose mother has diabetes mellitus and obtains a reading of 50 mg/dl. The nurse determines that this result indicates: 1. Hypoglycemia 2. A normal level 3. Hyperglycemia 4. Hypotonia
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Answer: 2 Rationale: A normal blood glucose level for newborn infants is 40 mg/dl and higher. This places the finding noted in the question at a normal level; therefore neither hypoglycemia nor hyperglycemia is present. Hypotonia refers to muscle tone and is not associated with blood glucose screening. Test-Taking Strategy: Knowledge regarding the normal blood glucose level in a newborn infant is required to answer the question. Remember, the normal blood glucose level for newborn infants is 40 mg/dl and higher. This will direct you to option 2. Review this normal laboratory value if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum References: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 1058-1059. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 494. 1867. A client has been receiving nitrofurantoin sodium (Macrodantin). The nurse determines that the therapy is effective if which of the following is noted? 1. Cessation of cough 2. Absence of dysuria 3. Relief of chest pain 4. Decreased urge for cigarettes Answer: 2 Rationale: Nitrofurantoin sodium is an antibacterial medication and is used to treat acute urinary tract infection, or is used as chronic suppressive treatment of urinary tract infection. It is not effective with systemic bacterial infections. Since dysuria is a sign of a urinary tract infection, this is the only correct option. Test-Taking Strategy: Familiarity with the classification of this medication is needed to answer this question. Recalling that it is used to treat urinary tract infection will direct you to option 2. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 776. Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 937. 1868. Nifedipine (Procardia) has been prescribed for a client with Raynaud’s disease, and the nurse reinforces medication instructions with the client. Which statement by the client indicates a need for further instructions? 1. “I need to get up slowly when I change positions because the medicine causes hypotension.”
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2. “I will contact my doctor if I get short of breath.” 3. “I will call my doctor if I get headaches that worsen.” 4. “Nausea and drowsiness is expected and if it occurs I don’t really need to worry about it.” Answer: 4 Rationale: Nifedipine is a calcium antagonist that reduces smooth muscle contractility by inhibiting the movement of calcium ions in slow channels. Its side effects include headache, flushing, peripheral edema, and postural hypotension. Overdose of the medication produces nausea, drowsiness, confusion, and slurred speech. If signs of overdose occur, the physician is notified. Test-Taking Strategy: Use the process of elimination noting the key words need for further instructions. These words indicate a false response question and that you need to select the incorrect client statement. Eliminate option 1 first recalling the safety guidelines related to medication administration, specifically cardiac medications. From the remaining options, note that option 4 is the only option that does not address contacting the physician. If you had difficulty with this question, review the client teaching points and the side effects and adverse effects related to this medication. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2004). Saunders nursing drug handbook 2004. Philadelphia: W.B. Saunders, p. 729. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 600. 1869. A nurse notes that zidovudine (AZT) has recently been prescribed for the client. The client states, “I’ve been getting a little nauseous and I’ve had a couple of headaches since I started the AZT. Does this mean I can’t take the medicine?” The nurse makes which response to the client? 1. “These symptoms may become more tolerable as you adjust to ongoing therapy.” 2. “Don’t worry. There are so many other medications these days that the doctor can give you.” 3. “I know you’re worried that you won’t be able to take AZT, but you only have a slight neutropenia.” 4. “I do not see the need for you to worry because your neutrophil counts are well over 100.” Answer: 1 Rationale: The initial adverse effects of zidovudine (AZT) include headache, malaise, insomnia, rash, diarrhea, and fever. As AZT therapy proceeds, these symptoms become more tolerable. If anemia or neutropenia occurs, the medication will be discontinued or the therapy will be temporarily interrupted. Options 2, 3, and 4 do not address the client’s concerns. Test-Taking Strategy: Use the process of elimination, knowledge regarding this medication, and therapeutic communication techniques. Eliminate options 2, 3, and 4 because they all indicate telling the client “not to worry.” Review this medication if you had difficulty with
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this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology References: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 988. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 1034. 1870. Warfarin sodium (Coumadin) has been prescribed for the client, and the nurse teaches the client and family about the medication. Which statement by the client indicates that further teaching is necessary? 1. “I’ll use an electric shaver until the anticoagulant is discontinued.” 2. “I will buy a medication alert tag that indicates I’m on anticoagulants.” 3. “I will not take any over-the-counter medications except aspirin.” 4. “I won’t participate in games such as football anymore.” Answer: 3 Rationale: No over-the-counter medications of any kind should be ingested by a client who is taking anticoagulants. This is especially true of aspirin and/or aspirin-containing products (because of the potential to cause bleeding). Options 1, 2, and 4 are correct client statements. Electric shavers are less irritating to the skin than razors and less likely to cause a skin breakdown. Medication alert tags or bracelets should be worn. In addition, all clients should be taught to carry identification cards that list all of the medications currently being taken. Strenuous games such as contact sports that can cause bruising and skin breakdown are to be avoided. Test-Taking Strategy: Use the process of elimination noting the key words further teaching is necessary. These words indicate a false response question and that you need to select the incorrect client statement. Recalling that warfarin sodium is an anticoagulant and that anticoagulants can cause bleeding will direct you to option 3. If you had difficulty with this question, review the teaching points for clients taking anticoagulants. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 1123. 1871. A nurse has given medication instructions to a client beginning therapy with carisoprodol (Soma). The nurse determines that the client understands the effects of the medication if the client states to: 1. Expect muscle spasticity as a side effect 2. Take a missed dose when remembered, regardless of when the next dose is due 3. Avoid alcohol while taking this medication 4. Drive on city streets; avoid highway driving Answer: 3
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Rationale: Carisoprodol, a centrally-acting skeletal muscle relaxant, may cause central nervous system (CNS) side effects of drowsiness and dizziness. For this reason, the client avoids other CNS depressants, such as alcohol, while taking this medication. Driving or other activities requiring mental alertness are also avoided until the client’s reaction to the medication is known. The medication is used to reduce muscle spasticity and pain. Missed doses should be taken if remembered within 1 hour. Test-Taking Strategy: Use the process of elimination. Begin to answer this question by eliminating option 4, because driving is either indicated or not indicated. Knowing that this medication is a skeletal muscle relaxant helps you to eliminate option 1 next, since this medication relieves muscle spasms. From the remaining options, recalling that alcohol should not be taken while on any medication especially those that affect the CNS directs you to option 3. If you had difficulty with this question, review the teaching points related to this medication. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 514. 1872. Amantadine hydrochloride (Symmetrel) 100 mg orally twice daily has been prescribed for a client with Parkinson’s disease, and the nurse teaches the client about the medication. Which statement by the client indicates that further teaching is necessary? 1. “I’ll take this medication early in the morning and just before I go to bed.” 2. “I can empty the capsules into food or fluid to make swallowing easier.” 3. “I can get this medication in syrup form if I have difficulty swallowing.” 4. “I should see improvement in my condition in about 7 days.” Answer: 1 Rationale: Amantadine hydrochloride is administered twice a day, but the last dose should not be administered near bedtime since it may cause insomnia in some clients. Options 2, 3, and 4 are correct statements. Test-Taking Strategy: Note the key words further teaching is necessary. These words indicate a false response question and that you need to select the incorrect client statement. Recalling that this medication can cause insomnia will direct you to option 1. If you had difficulty with this question, review the nursing implications associated with its administration. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 44. 1873. A client is receiving sulfisoxazole (Gantrisin). The nurse determines the effectiveness of the therapy by monitoring the client’s: 1. Blood pressure
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2. Blood glucose level 3. Red blood cell count 4. White blood cell count Answer: 4 Rationale: Sulfisoxazole is an antiinfective used primarily to treat urinary tract infections. The effectiveness of the medication may be evaluated by monitoring the client’s white blood cell count, which should decrease to within normal limits with therapy. The client should also experience relief of symptoms. This medication is not used as an antihypertensive (option 1), hypoglycemic agent (option 2), or to treat anemia (option 3). Test-Taking Strategy: Focus on the name of the medication—sulfisoxazole. Recalling that most “sulfa” medications are antiinfectives will direct you to option 4. If you had difficulty with this question, review the action of this medication. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology References: Kee, J., & Hayes, E. (2003). Pharmacology: A nursing process approach (4th ed.). Philadelphia: W.B. Saunders, p. 427. Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 932. 1874. A client is receiving supplemental therapy with folic acid (Folate). The nurse evaluates the effectiveness of this therapy by monitoring the results of which of the following laboratory studies? 1. Complete blood cell count 2. Blood urea nitrogen level 3. Blood glucose level 4. Alkaline phosphatase level Answer: 1 Rationale: Folic acid is necessary for red blood cell production, and is classified as a vitamin and an antianemic. The effectiveness of therapy can be measured by monitoring the results of periodic complete blood cell counts, noting particularly the hematocrit level. Options 2, 3, and 4 are not associated with the use of this medication. Test-Taking Strategy: Focus on the name of the medication. Recalling that folic acid is a vitamin, which may be supplemented to treat anemia, will direct you to option 1. If you are not familiar with the effects of folic acid on the body, review this content. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 465. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 1164.
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1875. A client with a history of prostatic hypertrophy has been prescribed propantheline bromide (ProBanthine) for the treatment of peptic ulcer disease. The nurse determines that the client understands the medication instructions if the client states to report: 1. Abdominal cramping or diarrhea 2. Excessive salivation 3. Urinary hesitancy or retention 4. Excessive sweating Answer: 3 Rationale: Propantheline bromide is an anticholinergic medication that is used as an adjunct for therapy in peptic ulcer disease. It is also used as an antispasmodic agent. It should be used cautiously with prostatic hypertrophy, because the anticholinergic effects of the medication could cause exacerbation of symptoms, including urinary retention or hesitancy. Other side effects of the medication include constipation, dry mouth, and decreased sweating. Tachycardia is a common cardiovascular side effect. Test-Taking Strategy: Use the process of elimination recalling that this medication is an anticholinergic that causes urinary retention. Note the relation between “prostatic hypertrophy” in the question and “urinary hesitancy or retention” in the correct option. Review the side effects of this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology References: Kee, J., & Hayes, E. (2003). Pharmacology: A nursing process approach (4th ed.). Philadelphia: W.B. Saunders, p. 347. Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 119. 1876. A nurse has completed reinforcing client teaching about heart failure and prescribed medications that include digoxin (Lanoxin) and furosemide (Lasix). The nurse documents that the teaching goals have been met if the client states to report a: 1. Sudden increase in appetite 2. Weight gain of 2 to 3 pounds in a few days 3. Cough that accompanies a cold 4. High urine output during the day Answer: 2 Rationale: Clients with heart failure should immediately report weight gain, loss of appetite, shortness of breath with activity, edema, persistent cough, and nocturia. A high urine output is expected with these medications. A cough that accompanies a cold is normal. A sudden increase in appetite is insignificant. Test-Taking Strategy: Use the process of elimination. Option 1 is unrelated to the question and is eliminated first. Option 4 is expected with diuretic therapy. The client should report a persistent cough, not necessarily one that accompanies a cold. Option 2 would accompany fluid retention, and should be reported because it indicates a complication of heart failure. Review the expected effects of these medications and the signs and symptoms of heart failure if you had difficulty with this question. Level of Cognitive Ability: Analysis
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Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 480. 1877. A nurse is collecting data on a client with myasthenia gravis. The nurse determines that the client may be developing myasthenic crisis if the client states: l. “I took my pills late last night.” 2. “I can hardly think straight today.” 3. “I dropped one of my pills on the floor.” 4. “I can’t swallow very well today.” Answer: 4 Rationale: Because dysphagia is a classic sign of myasthenia gravis exacerbation, observing how a client is able to ingest food is an important assessment. Timing of this medication is of paramount concern. Although options 1, 2, and 3 may require further assessment, option 4 reflects the potential of developing myasthenic crisis. Test-Taking Strategy: Use the process of elimination focusing on the issue—that the client may be developing myasthenic crisis. Recalling that dysphagia is a classic sign of myasthenia gravis exacerbation will direct you to option 4. Review the clinical manifestations of myasthenic crisis if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 762. 1878. An 8-day-old infant is irritable, has a high-pitched persistent cry, and has a temperature of 99.4° F. The infant is also tachypneic and diaphoretic, continues to lose weight, and is hyperactive to environmental stimuli. The nurse determines that these behaviors may be consistent with: 1. Hypercalcemia 2. Drug withdrawal 3. Sepsis 4. Intraventricular hemorrhage Answer: 2 Rationale: Drug withdrawal causes a hyperactive response in the infant because of the increased central nervous system (CNS) stimulation (tachypnea, elevated temperature, increased use of calories). This response and the signs and symptoms of drug withdrawal seem to be most apparent at around 1 week of age. Hypercalcemia, sepsis, and intraventricular hemorrhage are characterized by symptoms of CNS depression. Test-Taking Strategy: Use the process of elimination focusing on the data in the question. Note the key word hyperactive in the question. This indicates CNS stimulation. Eliminate options 1, 3, and 4 because these conditions produce CNS depression. If you had difficulty with this question, review the signs and symptoms of drug withdrawal in
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the newborn infant. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 1075, 1077. 1879. A client received a dose of regular insulin (Humulin R) this morning at 7:00 AM . At what time would the nurse most likely anticipate the potential for a hypoglycemic reaction to occur? 1. 8:00 AM 2. 10:00 AM 3. Noon 4. 2:00 PM Answer: 2 Rationale: Humulin R is a rapid-acting insulin with a peak action of 2 to 4 hours after injection. Hypoglycemic reactions are most likely to occur during the peak action of insulin. This makes option 2 correct. Test-Taking Strategy: Use the process of elimination and knowledge regarding the general action (onset, peak, and duration) of rapid-acting insulin to answer the question. Remember that Humulin “R (regular)” indicates “rapid” and that the peak action occurs in 2 to 4 hours after injection. If you had difficulty with this question, review the characteristics of rapid-acting insulin. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 570. Kee, J., & Hayes, E. (2003). Pharmacology: A nursing process approach (4th ed.). Philadelphia: W.B. Saunders, p. 737. 1880. A nurse is preparing a postpartum client who had a cesarean delivery for discharge to home. Which statement by the client indicates a need for additional discharge preparation? 1. “I will lift nothing heavier than the baby for two weeks.” 2. “I can start doing abdominal exercises as soon as I get home.” 3. “If I develop a fever, I will call my doctor.” 4. “When getting out of bed, I will turn on my side and push up with my arms.” Answer: 2 Rationale: Abdominal exercises should not be started following abdominal surgery until 3 to 4 weeks postoperatively to allow for healing of the incision. Options 1, 3, and 4 reflect proper understanding of self-care after discharge. Test-Taking Strategy: Use the process of elimination noting the key words need for additional discharge preparation. These words indicate a false response question and
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that you need to select the incorrect client statement. Noting that the client had a cesarean delivery and recalling the general postoperative instructions related to abdominal surgery will direct you to option 2. Review home care instructions following cesarean delivery if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Maternity/Postpartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 1021. 1881. A nurse enters a new mother’s room and finds that the mother is crying and that the infant is undressed on the bed in front of the mother. The mother looks at the nurse and says, “I can’t even dress this baby!” After reassuring the client, the nurse determines that the most appropriate nursing action would be to: 1. Diaper the infant while it is lying on the bed 2. Place the infant back in the bassinet 3. Place the infant in the bassinet and take the infant back to the nursery 4. Have the mother place the infant in the bassinet and assist the mother in dressing the baby Answer: 4 Rationale: The infant needs to be placed in the bassinet for safety. The mother needs to be reassured that she can safely care for her infant, and the nurse should assist the mother in dressing the baby. Option 1 is incorrect because the infant needs to be placed in the bassinet for safety. Options 2 and 3 are incorrect because these actions do not address the mother’s needs. Option 4 is the only option that focuses on the mother’s feelings and needs and the safety of the infant. Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Note that option 4 is the only option that addresses both the infant and the mother. Review the psychosocial needs of a new mother if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Reference: Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternalnewborn nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 566-567. 1882. A client with acquired immunodeficiency syndrome (AIDS) has a low T4 count. The nurse initiates prophylactic treatment as prescribed with aerosolized pentamidine isethionate (NebuPent) and monitors for which expected outcome? 1. The client has a respiratory rate and depth within normal limits for activity level 2. Strict standard precautions were maintained 3. The client shows no weight loss 4. The client maintains serum sodium, potassium, calcium, and chloride values within normal ranges
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Answer: 1 Rationale: Aerosolized pentamidine is given prophylactically to clients with a T4 count below 200 to prevent Pneumocystis jiroveci pneumonia, which is the most common opportunistic infection that occurs in clients with AIDS. A respiratory rate and depth within normal limits for activity level would indicate that the client was not experiencing the respiratory difficulty that is associated with pneumonia. Standard precautions are always maintained on all clients. Although weight loss and electrolyte imbalance can occur in the client with AIDS, these options are not related to this medication. Test-Taking Strategy: Use the process of elimination and the ABCs—airway, breathing, and circulation. Option 1 relates to the respiratory status of the client. If you had difficulty with this question, review this medication. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 844. 1883. A client with type 1 diabetes mellitus takes NPH insulin every morning and checks the blood glucose level four times per day. The client tells the nurse that yesterday her late-afternoon blood glucose level was 60 mg/dl and that she “felt funny.” Which statement by the client would indicate an understanding of this occurrence? 1. “My blood glucoses are running low because I’m tired.” 2. “I forgot to take my usual afternoon snack yesterday.” 3. “I took less insulin this morning so I won’t feel funny today.” 4. “I don’t know why I have to check my blood glucose four times a day. That seems too much.” Answer: 2 Rationale: Hypoglycemia is a blood glucose level of 60 mg/dl or less. The causes are multiple, but in this case omitting the afternoon snack is the cause. Fatigue and selfadjustment of dose are incorrect options. Recommended blood glucose testing for the client with type 1 diabetes mellitus is at least four times a day. Test-Taking Strategy: Use the process of elimination and knowledge regarding the pathophysiology of diabetes mellitus. Noting that a blood glucose reading of 60 mg/dl indicates hypoglycemia and recalling the causes of hypoglycemia will direct you to option 2. If you had difficulty with this question, review the causes of hypoglycemia. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 571. 1884. A pregnant woman reports that she has just finished taking the prescribed antibiotics to treat her urinary tract infection. The mother expresses concern that her baby will be born with an infection. Which response would the nurse make to help
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reduce the maternal fears that the newborn will be born with an infection? 1. “Urinary infections during pregnancy are common. Your baby will be fine.” 2. “Your developing baby cannot acquire an infection from you during pregnancy.” 3. “Now that you have taken the medication as prescribed, we will continue to monitor you closely by repeating the urine culture before you leave today.” 4. “You shouldn’t worry about this since you received early prenatal care and are taking your prenatal vitamins.” Answer: 3 Rationale: Symptomatic bacteriuria has been associated with an increased risk of neonatal sepsis following delivery. Appropriate prenatal care of a client with a urinary tract infection includes antibiotic treatment and follow-up repeat urine cultures. Option 3 is the only therapeutic response and is the response that identifies accurate information. Test-Taking Strategy: Use the process of elimination and therapeutic communication techniques. Eliminate option 2 first because this response does not identify accurate information. Next eliminate options 1 and 4 because they provide false reassurances. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Application Clients Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Antepartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 422. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 723, 729. 1885. A nurse is collecting data from a human immunodeficiency virus (HIV) positive pregnant woman during gestational week 32. The nurse reviews the data and determines that which finding requires further follow-up? 1. Slight lower extremity edema 2. Increased shortness of breath and bilateral wheezes 3. Active fetal movement 4. Weight gain of 22 pounds Answer: 2 Rationale: Human immunodeficiency virus infection in a pregnant woman may cause both maternal and fetal complications. Fetal compromise can occur because of premature rupture of the membranes, preterm birth, or low birth weight. Potential maternal effects include an increased risk of opportunistic infections. Individuals in the later stages of HIV are further susceptible to other invasive conditions, such as tuberculosis and a wide variety of bacterial infections. The finding in option 2 can be indicative of an opportunistic infection and requires follow-up. Test-Taking Strategy: Note the key words requires further follow-up. These words indicate a false response question and that you need to select the abnormal finding. Eliminate options 1, 3, and 4 because these are normal findings. Additionally, use the ABCs—airway, breathing, and circulation—to direct you to the correct option. Review care to the HIV positive pregnant woman if you had difficulty with this question. Level of Cognitive Ability: Analysis
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Clients Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum References: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 203, 1065. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 729-730. 1886. A client with multiple sclerosis is receiving diazepam (Valium), and the home care nurse provides instructions to the client regarding the side effects of the medication. The nurse tells the client that which of the following is a side effect of this medication? 1. Insomnia 2. Incoordination 3. Inability to urinate 4. Increased salivation Answer: 2 Rationale: Incoordination and drowsiness are common side effects resulting from this medication. Options 1, 3, and 4 are unrelated to the use of this medication. Test-Taking Strategy: Use the process of elimination. Note that the question addresses a centrally-acting skeletal muscle relaxant. This will assist in directing you to option 2. If you had difficulty with this question, review the side effects associated with diazepam. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 315. 1887. A nurse palpates the anterior fontanelle of a neonate and notes that it feels soft. The nurse analyzes these data as indicative of: 1. Increased intracranial pressure (ICP) 2. Dehydration 3. Decreased ICP 4. A normal finding Answer: 4 Rationale: The anterior fontanelle is normally 2.5 to 5 cm in width and diamond-like in shape. It can be described as soft, which is normal, or full and bulging, which could be indicative of increased ICP. Conversely, a depressed fontanelle could mean that the neonate is dehydrated. Test-Taking Strategy: Use the process of elimination noting the key words feels soft in the question. Remember that the anterior fontanelle is soft in the neonate. If you had difficulty answering this question, review normal findings in a neonate. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum
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References: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 718. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 504. 1888. A nurse is preparing to administer digoxin (Lanoxin) to an adult client. The nurse checks which most important item before administering the medication? 1. Neurological signs 2. Blood pressure 3. Apical pulse rate 4. Level of consciousness Answer: 3 Rationale: Digoxin is a cardiac glycoside that is used to manage and treat heart failure and to control ventricular rates in clients with atrial fibrillation. Before administering the medication, the nurse needs to assess the apical heart rate for 1 minute. If the pulse rate is less than 60 beats per minute in an adult client, the nurse would withhold the medication and contact the physician because a low pulse rate may be an indication of toxicity. Options 1, 2, and 4 may be a component of the assessment depending on the client’s diagnosis. However, these assessments are not specifically associated with the use of digoxin. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 4 first because they are similar. From the remaining options, recalling that digoxin is a cardiac glycoside will direct you to option 3. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2004). Saunders nursing drug handbook 2004. Philadelphia: W.B. Saunders, p. 310. 1889. After a newborn infant undergoes circumcision, which of the following would the nurse include in the postprocedure plan of care? 1. Restricting oral intake for several hours 2. Ensuring informed consent is obtained from the parents 3. Restraining the infant on a Circumstraint board 4. Observing for bleeding and assessing for pain Answer: 4 Rationale: Following a circumcision, the nurse should observe for bleeding, which is the most common complication. A common protocol is to assess the site every hour for 8 to 12 hours. Assessing for pain by looking at the infant’s facial expressions, body movements, and character of crying will indicate the need to minimize or lessen pain. Nutrition is important. The informed consent is to be obtained before the procedure. Restraints are not necessary postprocedure. Test-Taking Strategy: Use the process of elimination noting the key words postprocedure. Options 1, 2, and 3 are nursing actions required before (options 1 and 2)
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and during (option 3) the procedure. Review postprocedure care following circumcision if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 168. 1890. A nurse is assisting in preparing a client for a cardiac catheterization. The nurse understands that it is most important to check the client for a history of: 1. Allergy to shellfish 2. Hypertension 3. Atrial fibrillation 4. Cigarette smoking Answer: 1 Rationale: Determination before the procedure that a client has allergies to seafood, iodine, or iodine contrast media may necessitate a skin test for allergy severity and the use of prophylactic antihistamines to prevent an allergic response to the contrast medium. The other options are important parts of the client’s history, but are not specific to a cardiac catheterization procedure. Test-Taking Strategy: Note the key words most important. These words indicate that more than one option may be correct but that you need to determine which option is the priority based on the data in the question. Recalling that the contrast medium used for cardiac catheterization usually has an iodine base and that the allergen in shellfish is usually iodine will direct you to option 1. Review preprocedure care for cardiac catheterization if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Delegating/Prioritizing Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 327. 1891. A student nurse is assigned to assist in caring for a client with acute pulmonary edema who is receiving digoxin (Lanoxin) and subcutaneous heparin therapy. The nursing instructor reviews the plan of care formulated by the student and tells the student that which intervention is unsafe? 1. Holding the digoxin for a heart rate less than 60 beats per minute 2. Administering the heparin with a 25-gauge needle 3. Restricting the client’s potassium intake 4. Encouraging the client to rest after meals Answer: 3 Rationale: Clients with acute pulmonary edema are on a sodium-restricted diet, not potassium-restricted. Restricting potassium intake makes the client more prone to digoxin toxicity. Digoxin should be held and the physician notified when the client’s
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heart rate is less than 60 beats per minute, unless otherwise ordered. Heparin should be administered with a 25- or 27-gauge needle to reduce tissue trauma. Resting after meals decreases the demands placed on the heart and should be encouraged. Test-Taking Strategy: Focus on the data in the question and note the key word unsafe. This word indicates a false response question and that you need to select the incorrect intervention. Noting the word “restricting” in option 3 will direct you to this option. If you had difficulty with this question, review care to the client with acute pulmonary edema. Level of Cognitive Ability: Analysis Client Needs: Safe, Effective Care Environment Integrated Process: Teaching/Learning Content Area: Leadership/Management Reference: Hodgson, B., & Kizior, R. (2004). Saunders nursing drug handbook 2004. Philadelphia: W.B. Saunders, p. 311. 1892. A nurse is assisting in planning care for a client with Hodgkin’s disease who is neutropenic due to radiation and chemotherapy. Which plan would be most effective in decreasing the risk of infection? 1. Limiting visitors to immediate family only 2. Providing a diet high in protein 3. Ensuring meticulous hand washing before caring for the client 4. Monitoring electrolyte levels daily Answer: 3 Rationale: Specific nursing management of the client undergoing treatment for Hodgkin’s disease focuses on the medication-induced side effects. Risk for infection is a significant consideration, and hand washing is the most effective means of decreasing risk of infection. Limiting visitors to immediate family only is not the best measure because an immediate family member could transmit an infection. Options 2 and 4 do not directly relate to infection. Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 4 because diet and electrolytes do not directly relate to infection. Limiting visitors to only immediate family is not the best measure because an immediate family member could transmit an infection. Review measures that decrease the risk of infection if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Adult Health/Oncology Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 281. 1893. A nurse is caring for a client who has undergone pelvic exenteration. In addressing psychosocial issues related to the surgery, which statement by the nurse would be most therapeutic? 1. “Would you like to talk?” 2. “How do you feel about your body?”
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3. “You are looking good today.” 4. “Will your family help you deal with this?” Answer: 2 Rationale: Postoperatively, a woman begins to deal with the trauma of the surgery by expressing grief about her mutilated body. Later, she may become depressed or withdrawn or even angry or hostile. The woman needs intense emotional support if she is to adapt to her altered body image and functions. Option 2 is the only option that addresses the client’s feelings. Test-Taking Strategy: Use therapeutic communication techniques. Open-ended questions are most therapeutic, so eliminate options 1 and 4. From the remaining options, option 2 is open-ended and focuses on the client’s feelings. Remember, focus on the client’s feelings first. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Caring Content Area: Adult Health/Oncology References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1074. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, pp. 437-440. 1894. A nurse is assisting in planning care for a client just admitted to the hospital with a diagnosis of cardiovascular insufficiency. The nurse would include as a priority: 1. Maintenance of good body alignment while on bed rest 2. Maintenance of as large a fluid intake as allowed 3. Family instruction on how to obtain medical assistance 4. The need to teach the client about medications Answer: 1 Rationale: Good body alignment promotes rest and relaxation and decreases the workload of the cardiovascular system. Adequate fluid intake is important, but a large fluid intake could stress the heart. Option 3 addresses the family, not the client. Option 4 is not a priority immediately after admission to the hospital. Test-Taking Strategy: Use the process of elimination. Eliminate option 3 because it does not address the client of the question. Eliminate option 2 next noting that it addresses large amounts of fluids. From the remaining options, focusing on the client’s diagnosis will direct you to option 1. Review care to the client with cardiovascular insufficiency if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Cardiovascular Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1659. 1895. A nurse is caring for a client who verbalizes a need to increase her self-esteem.
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The nurse plans to assist the client to achieve the goal of gaining self-esteem by encouraging the client to: 1. Institute measures to prevent tooth decay 2. Maintain a daily diary of negative feelings 3. Maintain a well-groomed appearance 4. Verbalize feelings of being unloved Answer: 3 Rationale: The client may demonstrate increased feelings of self-esteem through outward appearance. Options 2 and 4 focus on negative issues and should be avoided. Option 1 is indirectly related to self-esteem. Test-Taking Strategy: Use the process of elimination and focus on the issue of selfesteem. Eliminate options 2 and 4 because they focus on negative issues. From the remaining options, note that option 3 is directly related to self-esteem and is the umbrella (global) option. Review measures that increase self-esteem if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Reference: Keltner, N., Schwecke, L., & Bostro, C. (2003). Psychiatric nursing (4th ed.). St. Louis: Mosby, p. 356. 1896. A nurse is assisting in planning stress management strategies for the client with irritable bowel syndrome. Which suggestion would the nurse give to the client? 1. Try to avoid every possible stressful situation 2. Learn measures such as biofeedback or progressive relaxation 3. Limit exercise to reduce bowel stimulation 4. Rest in bed as much as possible Answer: 2 Rationale: Treatment for irritable bowel syndrome includes stress reduction measures such as biofeedback, progressive relaxation, and regular exercise. The client should also learn to limit own responsibilities. Other measures include increased fluid and fiber in the diet as prescribed, and antispasmodic or sedative medications as needed. Test-Taking Strategy: Use the process of elimination. Begin to answer this question by eliminating options 3 and 4 because they are similar. Next eliminate option 1, since the word “every” in the option is an absolute word. If you had difficulty with this question, review appropriate stress management techniques for the client with irritable bowel syndrome. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Gastrointestinal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 848. 1897. A nurse plans to change the dressing of the client who has had arterial bypass
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surgery. Which technique is most important for the nurse to follow? 1. Standard precautions 2. Aseptic technique 3. Clean technique 4. Reverse isolation technique Answer: 2 Rationale: Aseptic technique is important to reduce risk of infection. Standard precautions are important, but are not specific to this procedure. Reverse isolation is not necessary, and clean technique would place the client at risk for infection. Test-Taking Strategy: Focus on the issue—the most important technique to follow for the client who has had surgery. While standard precautions are important, they do not protect the client from infection. Focusing on the issue—preventing infection—will direct you to option 2. Review care to the client following surgery if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 786. 1898. A client has an inoperable abdominal aortic aneurysm (AAA). The nurse reinforces with the client about the need for: 1. Antihypertensives 2. Bed rest 3. Restricting fluids 4. Maintaining a low-fiber diet Answer: 1 Rationale: The medical treatment for AAA is controlling blood pressure. Hypertension creates added stress on the blood vessel wall, increasing the likelihood of rupture. There is no need for the client to restrict fluids or to have bed rest prescribed. A low-fiber diet is not helpful and will cause constipation. Test-Taking Strategy: Use the process of elimination. Recalling the relation between AAA and hypertension will direct you to option 1. If this question was difficult, review AAA and its treatment. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Cardiovascular Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, pp. 790-791. 1899. A nurse is assisting in developing a teaching plan for a pregnant client with diabetes mellitus. Which instruction is the priority for this client? 1. How to test for proteinuria
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2. How to check for and manage preterm bleeding 3. How to manage the discomfort of early labor 4. How to check for signs of hypoglycemia and the required treatment Answer: 4 Rationale: In diabetes mellitus, the pancreas does not produce enough insulin for necessary carbohydrate metabolism. The physiological changes of pregnancy drastically alter insulin requirements. Pregnant diabetic clients should be taught to monitor themselves for hypoglycemia to minimize potential maternal and fetal effects that result from hypoglycemia. Testing for proteinuria is important for the mother with pregnancyinduced hypertension. Management of preterm bleeding is taught to the mother with placenta previa. Managing the discomforts of early labor is important for all pregnant women. Test-Taking Strategy: Note the key word priority. Note the relation between “diabetes mellitus” in the question and “hypoglycemia” in the correct option. Review care to the pregnant client with diabetes mellitus if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Planning Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 229. 1900. A nurse is preparing to teach a new mother to breast-feed. Which factor is most important to promote an effective and positive learning experience? 1. Separation of infant and mother after birth is important to allow the mother to rest 2. Previous breast-feeding experience 3. A physician that encourages clients to breast-feed 4. A positive nurse-client relationship Answer: 4 Rationale: Because hospital stays are short, all contacts with the mother become teachable moments. A positive nurse-client relationship is a growth-fostering experience that will enhance the teaching/learning experience. Separation of the infant and mother decreases the chance of correct latch and suck in the immediate postpartum period. The infant should be placed at the breast immediately after delivery. The mother, not the physician, makes the decision regarding the method of feeding. Although previous breast-feeding experience is helpful, the most significant factor is the nurse-client relationship. Test-Taking Strategy: Use the process of elimination noting the key words most important. Focus on the issue—to promote an effective and positive learning experience —and note the relation of the issue and option 4. Review teaching/learning principles if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders,
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Comprehensive Review CD Questions 1801-1900 {COMP: No Equations/Formulas; No
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and the process of elimination to answer the question. Eliminate option 4 because of the word “injection” in the question. From the remaining options, recalling that the issue with this medication is to avoid staining the skin will direct you to option 1. Review the procedure for the administration of an iron injection if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Perry, A., & Potter, P. (2004). Clinical nursing skills & techniques (5th ed.). St. Louis: Mosby, p. 528. 1803. A nurse is assisting in developing a plan of care for the client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. Which nursing intervention would the nurse suggest including in the plan of care to manage this symptom? 1. Keep the call bell within reach for the client 2. Administer a sedative at bedtime 3. Administer an antipyretic at bedtime 4. Provide a back rub and comfort measures before bedtime Answer: 3 Rationale: For clients with AIDS who experience night fever and night sweats, it is useful to offer the client an antipyretic prior to bedtime. It is also helpful to keep a change of bed linens and nightclothes nearby for use. The pillow should have a plastic cover, and a towel may be placed over the pillowcase if there is profuse diaphoresis. The client should have liquids at the bedside to drink. Options 1, 2, and 4 are important interventions but they are unrelated to the issue of fever and night sweats. Test-Taking Strategy: Focus on the issue of the question—night fever and night sweats. Options 1, 2, and 4 are helpful and important interventions but do not address the issue of the question. Since night fever and sweats occur serially, it is most helpful to give the antipyretic before sleep as a prophylactic measure. Review nursing measures for the client with AIDS if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Immune Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 2395. 1804. A nurse is assisting in preparing a plan of care for the client with acquired immunodeficiency syndrome (AIDS) who has nausea. Which dietary measure would the nurse include in the plan? 1. Dairy products with each snack and meal 2. Red meat daily 3. Addition of spices to food to make the taste more palatable 4. Foods that are at a cool temperature
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Answer: 4 Rationale: The AIDS client experiencing nausea should avoid fatty products, such as diary products and red meat. Meals should be small and frequent to lessen the chance of vomiting. Spices and odorous foods should be avoided, since they aggravate nausea. Foods are best tolerated either cool or at room temperature. Test-Taking Strategy: Use knowledge related to the effects of AIDS on the gastrointestinal system to assist in answering the question. Additionally, general principles related to nutrition in a client with an immunosuppressive disorder will assist in directing you to option 4. Review these measures if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Immune Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 551. 1805. A perinatal client with a history of heart disease has been instructed on care at home. Which statement by the client would indicate that the client understands her needs? 1. “There is no restriction on people who visit me.” 2. “I should avoid stressful situations.” 3. “My weight gain is not important.” 4. “I should rest on my right side.” Answer: 2 Rationale: To avoid contracting infections, persons with active infections should not be allowed to visit the client. Stress causes increased heart workload. Too much weight gain causes an increase in body requirements and stress on the heart. Resting should be on the left side to promote blood return. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 3 because of the absolute words “no” and “not” used in these options, respectively. Recalling the concepts related to blood return during pregnancy will assist in eliminating option 4. If you had difficulty with this question, review care to the perinatal client with heart disease. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Antepartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 913. 1806. A hospital employee is removing trash from a nursing unit and accidentally pricks a finger with the needle that was discarded in the trash. The employee never received the hepatitis B vaccine and asks the nurse what can be given to him for protection. The nurse tells the hospital employee that which of the following will be administered? 1. Hepatitis B immune globulin and hepatitis B vaccine
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2. Hepatitis B immune globulin 3. Immune globulin 4. Hepatitis B vaccine Answer: 1 Rationale: Immune globulin is given prophylactically for hepatitis A. Hepatitis B immune globulin is indicated for persons exposed to the hepatitis B virus. Vaccination is effective for long-term prevention of hepatitis B in health care workers. Both the vaccine and the hepatitis B immune globulin may be given at the same time. Since the hospital employee was pricked by a needle from an unknown source, both vaccine and hepatitis B immune globulin will be administered. Test-Taking Strategy: Use the process of elimination. Noting that the question states that the client never received the hepatitis B vaccine will assist in eliminating options 2 and 3. From the remaining options, focus on the data in the question. Since the hospital employee was pricked by a needle from an unknown source, both hepatitis B immune globulin and hepatitis B vaccine need to be administered. Review hepatitis B immune globulin and hepatitis B vaccine if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 427, 13261327. 1807. A nurse is providing dietary instructions to a client with tuberculosis (TB). The nurse would specifically instruct the client to increase intake of which of the following food items in the daily diet? 1. Meats and citrus fruits 2. Cereals and broccoli 3. Eggs and bacon 4. Rice and fish Answer: 1 Rationale: The nurse teaches the client with TB to increase intake of protein, iron, and vitamin C. Foods rich in vitamin C include citrus fruits, berries, melons, pineapple, broccoli, cabbage, green peppers, tomatoes, potatoes, chard, kale, asparagus, and turnip greens. Food sources that are rich in iron include liver and other meats, from which 10% to 30% of available iron is absorbed. Less than 10% of iron is absorbed from eggs, and less than 5% is absorbed from grains and vegetables. Test-Taking Strategy: Recalling that the diet for the client with TB should be high in protein, vitamin C, and calories will assist in answering this question. It is also necessary to know which types of foods contain these various nutrients. If you had difficulty with this question, review these nutritional concepts for the client with TB. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Fundamental Skills
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Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 537. 1808. A nurse is providing dietary instructions to a client with renal calculi, and the laboratory analysis has revealed that the calculi are composed of uric acid. The nurse tells the client that it would be helpful to: 1. Include organ meat type foods in the diet 2. Increase intake of seafood in the diet 3. Increase intake of legumes in the diet 4. Increase intake of cranberries and citrus fruits Answer: 3 Rationale: Dietary instructions to the client with uric acid type stones include increasing legumes, green vegetables, and fruits (except prunes, grapes, cranberries, and citrus fruits) to increase the alkalinity of the urine. The client should also be instructed to decrease purine sources such as organ meats, gravies, red wines, goose, venison, and seafood. Test-Taking Strategy: Use the process of elimination and focus on the issue—a client with uric acid calculi. Recalling that the goal is to increase the alkalinity of the urine will assist in directing you to option 3. If you had difficulty with this question, review the dietary instructions associated with this type of renal calculi. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Peckenpaugh, N. (2003). Nutrition essentials and diet therapy (9th ed.). Philadelphia: W.B. Saunders, p. 301. 1809. A nurse is caring for a client with a nasogastric tube. Which observation is most reliable in determining that the tube is correctly placed? 1. The aspirate is dark green in color 2. The aspirate is negative for guaiac 3. The tube is inserted the length measured from the client’s ear to nose and from the nose to xiphoid process 4. The pH of the aspirate is 5 Answer: 4 Rationale: After a nurse inserts a nasogastric tube into a client, the correct location of the tube must be verified. The presence of blood (option 2) is unrelated to the location of the tube. Aspirate is dark green in color, and the tube is inserted the length measured from the client’s ear to nose and from the nose to the xiphoid process. However, testing the pH of the gastric fluid and determining its acidity most reliability verifies that the tube is correctly placed. Test-Taking Strategy: Use the process of elimination noting the key words most reliable. Eliminate option 2 because it is unrelated to the question. Although options 1 and 3 are accurate, testing the pH of the aspirate is most reliable in determining correct placement of the tube. If you had difficulty with this question, review nasogastric insertion and
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placement techniques. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills Reference: Christensen, B., & Kockrow, E. (2003). Foundations of nursing (4th ed.). St. Louis: Mosby, p. 479. 1810. A nurse is preparing to perform chest physiotherapy (CPT) on a client. Before determining the correct position to place the client, the nurse must ascertain: 1. The client’s capability for lung expansion 2. The lung areas involved 3. The client’s procedure for performing deep breathing techniques 4. The close proximity of the oxygen tank Answer: 2 Rationale: The goal of CPT is to mobilize secretions for improved respiratory function. The nurse must determine which areas of the lungs should be targeted for this technique. The client’s capability for lung expansion is secondary to the lung assessment. Deep breathing routines and oxygen use do not specifically relate to client positioning. Test-Taking Strategy: Use the process of elimination and focus on the issue—client positioning. Deep breathing routines and the close proximity of oxygen are unrelated to positioning the client; therefore eliminate options 3 and 4. Eliminate option 1 because lung expansion is secondary to the primary purpose (mobilization of secretions) of CPT. Review the procedure for performing CPT if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills References: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, pp. 672673. Potter, P., & Perry, A. (2003). Essentials for practice (5th ed.). St. Louis: Mosby, pp. 671, 833. 1811. A client is admitted to the hospital with a bowel obstruction secondary to a recurrent malignancy, and the physician plans to insert a Miller-Abbott tube. When the nurse tries to explain the procedure, the client interrupts the nurse and states, “I don’t want to hear about that. Just let the doctor do it.” Based on the client’s statement, the nurse determines that the best action is to: 1. Leave the room 2. Ask the client if he would like another nurse to care for him 3. Explain to the client that all clients have the right to know about medical procedures 4. Remain with the client and be silent Answer: 4 Rationale: The nurse needs to recognize that the client has a greater need for security and acceptance than education. In option 4, the nurse conveys acceptance of the client and
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uses the therapeutic tool of silence. Options 1, 2, and 3 block communication and do not address the client’s need. Test-Taking Strategy: Use the process of elimination and therapeutic communication techniques. The nursing actions in options 1, 2, and 3 will block communication. Remaining with the client (option 4) demonstrates acceptance. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 661. 1812. A nurse is evaluating the effectiveness of meperidine hydrochloride (Demerol) for pain management for a client in labor. The nurse determines that the medication is effective if the client exhibits: 1. Complete pain relief and a period of rest from labor contractions 2. Moderate pain relief while a progressive labor pattern continues 3. Moderate pain relief with increased amounts of bloody show 4. Contractions that are longer, stronger, and closer together Answer: 2 Rationale: Effective pain management during labor does not interrupt the labor process but does provide relaxation and moderate pain relief to the mother. Increased bloody show and increased intensity of the contractions are not indications of effective pain management. Test-Taking Strategy: Use the process of elimination to answer the question. Eliminate options 3 and 4 first because increased bloody show and increased intensity of the contractions are not indications of effective pain management. From the remaining options, the key words are progressive labor pattern continues. This should direct you to option 2. Review the effects of meperidine hydrochloride on the client in labor if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Intrapartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 500. 1813. A nurse is reading a client’s urinalysis report. The nurse interprets that which of the following items found on the report is considered abnormal? 1. Negative glucose 2. Positive protein 3. pH 6.0 4. Specific gravity 1.018 Answer: 2 Rationale: Urine has a pH range of 4.5 to 8 and a specific gravity ranging from 1.010 to
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1.025. Urine is typically screened for protein, glucose, ketones, bilirubin, casts, crystals, red blood cells, and white blood cells, all of which should be negative. Test-Taking Strategy: Focus on the issue—an abnormal report. Noting the word “positive” in option 2 will direct you to this option. If you had difficulty with this question, review normal urinalysis results. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 1117. 1814. A client with an endotracheal tube gets easily frustrated when trying to communicate personal needs to the nurse. The nurse determines that which of the following methods for communication may be the easiest for the client? 1. Have the family interpret needs 2. Use a picture or word board 3. Use a pad and paper 4. Devise a system of hand signals Answer: 2 Rationale: The client with an endotracheal tube in place cannot speak. The nurse devises an alternative communication system with the client. Use of a picture or word board is the simplest method of communication, because it requires only pointing at the word or object. A pad and pencil is an acceptable alternative, but it requires more client effort and more time. The use of hand signals may not be a reliable method, because it may not meet all needs, and is subject to misinterpretation. The family does not need to bear the burden of communicating the client’s needs, and they may not understand them either. Test-Taking Strategy: Use the process of elimination. Note the key words easily frustrated in the question and easiest in the stem of the question. Options 3 and 4 are obviously not the “easiest” and are therefore eliminated first. Since the family may not necessarily know what the client is trying to communicate, this option (option 1) could cause added frustration for the client. Review communication methods for the client with an endotracheal tube if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Fundamental Skills Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1893. 1815. A nurse is collecting data from a client seen in the health care clinic for the first time. When the nurse asks the client about current prescribed medications, the client tells the nurse that rosiglitazone maleate (Avandia) is taken daily. Based on this finding, the nurse elicits data from the client regarding the presence of which condition? 1. Asthma 2. Diabetes mellitus
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3. Emphysema 4. Chronic bronchitis Answer: 2 Rationale: Rosiglitazone maleate is an antidiabetic medication used for clients with type 2 diabetes mellitus, and the medication reduces the plasma glucose level. It is used as monotherapy or in combination with metformin (Glucophage) as an adjunct to diet and exercise. It is not used to treat respiratory conditions. Test-Taking Strategy: Use the process of elimination. Note the similarity between options 1, 3, and 4 in that they all identify a respiratory-related disorder. Review the action and use of this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 952. 1816. A nurse is assisting in preparing a teaching plan for a client who has just been given a prescription for pioglitazone (Actos). The nurse plans to provide instructions to the client about which of the following related to this medication? 1. Signs of hypoglycemia 2. The need to increase the daily intake of calories by 750 3. The need to take the medication 1 hour following a meal 4. Signs of anemia Answer: 1 Rationale: Pioglitazone is an antidiabetic medication used for clients with type 2 diabetes mellitus, and the medication reduces the plasma glucose level. It is used as monotherapy or in combination with a sulfonylurea, metformin (Glucophage), or insulin as an adjunct to diet and exercise. It should be taken 15 to 30 minutes before a meal. A prescribed diet is an essential component of treatment in a diabetic client, but the client is not told to increase calorie intake unless specifically prescribed by the physician. The client is instructed in the signs of hypoglycemia because this effect can occur with the use of antidiabetic medications. The client is also instructed regarding the intervention necessary if hypoglycemia occurs. Anemia is not associated with the use of this medication. Test-Taking Strategy: Use the process of elimination. Recalling that the medication is an antidiabetic will direct you to option 1. Review this medication and the associated client teaching points if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 864. 1817. A nurse is collecting data from a client who is taking pantoprazole (Protonix). The nurse determines that the medication is effective if the client states relief of:
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1. A nighttime cough 2. Heartburn 3. Constipation 4. Migraine headaches Answer: 2 Rationale: Pantoprazole is a gastric acid pump inhibitor that increases the gastric pH and reduces gastric acid production. It is used to treat gastric and duodenal ulcers and gastroesophageal reflux disease. It is not used to treat cough, constipation, or migraine headaches. Test-Taking Strategy: Note the name of the medication—pantoprazole. Remembering that medication names for acid pump inhibitors end with the suffix zole will direct you to option 2. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 825. 1818. Entacapone (Comtan) is prescribed for a client with a diagnosis of Parkinson’s disease. The nurse reinforces medication instructions to the client and tells the client that a frequent side effect is: 1. An elevation in blood pressure 2. Joint pain 3. Urine discoloration to dark yellow or orange 4. Pruritus Answer: 3 Rationale: Entacapone is an antiparkinsonian agent that is used in conjunction with levodopa to improve the quality of life in clients with Parkinson’s disease. A frequent side effect is urine discoloration to dark yellow or orange. Orthostatic hypotension is also a frequent side effect. Joint pains and pruritus are not associated with the use of this medication. Test-Taking Strategy: Specific knowledge regarding this medication is required to answer this question. Remember, a frequent side effect of entacapone is urine discoloration to dark yellow or orange. If you are unfamiliar with the side effects of this medication, review this content. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 378. 1819. A nurse employed in a neighborhood health care clinic notes that the physician has prescribed oseltamivir (Tamiflu). The nurse teaches the client specific home care measures knowing that this medication was prescribed to treat:
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1. A cold sore 2. Influenza virus 3. Herpes zoster 4. Varicella zoster Answer: 2 Rationale: Oseltamivir is an oral antiviral medication used to treat influenza A and B virus. It is not used to treat a cold sore, herpes zoster, or varicella zoster. Test-Taking Strategy: Use the process of elimination and knowledge regarding the action and use of this medication. Noting the name of the medication—Tamiflu—will assist in directing you to option 2. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 806. 1820. A priority for a client diagnosed with placental abruption is to minimize alterations in fetal tissue perfusion. The nurse determines that fetal tissue perfusion is adequate if which of the following is noted? 1. Decreased fetal heart rate variability 2. Presence of late decelerations 3. Presence of accelerations 4. Evidence of fetal bradycardia Answer: 3 Rationale: Accelerations are an indication of fetal well-being and an oxygenated fetal central nervous system. Bradycardia, late decelerations, and decreased variability are representative of decreased oxygenation of the fetus. Test-Taking Strategy: Use the process of elimination and knowledge regarding the indications of fetal well-being. Eliminate options 1, 2, and 4 knowing that accelerations are an indication of fetal well-being. If you had difficulty with this question, review the significance of bradycardia, late decelerations, and decreased variability in the fetus. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum References: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 876-877. Matteson, P. (2001). Women’s health during the childbearing years: A community-based approach. St. Louis: Mosby, p. 346. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 346. 1821. A cooperative, compliant adult client taking 600 mg of carbamazepine (Tegretol) twice daily experienced two seizures at home during the past 2 weeks. The nurse interprets this information as:
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1. A need to increase the dose of the medication 2. A possible hysterical response 3. Not unusual 4. A need for a second anticonvulsant medication to be added to the treatment plan Answer: 4 Rationale: Carbamazepine (Tegretol) is an anticonvulsant used to treat seizures. The maintenance daily dose is between 800 and 1200 mg. The goal of all therapy for clients with seizures is no seizure activity. Because this high dose of carbamazepine (Tegretol) is not controlling the seizures, the use of an additional anticonvulsant is warranted. Options 1, 2, and 3 are incorrect interpretations. Test-Taking Strategy: Use the process of elimination focusing on the issue—the need to control the seizures. This issue and noting the medication dose identified in the question will direct you to option 4. Review content regarding carbamazepine if you are unfamiliar with this medication. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 165. Kee, J., & Hayes, E. (2003). Pharmacology: A nursing process approach (4th ed.). Philadelphia: W.B. Saunders, p. 281. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 368. 1822. A client being discharged from the hospital with a diagnosis of gastric ulcer has an order for sucralfate (Carafate) 1 gram by mouth four times daily. The nurse interprets that the client understands proper use of the medication if the client states to take it: 1. Every 6 hours around the clock 2. One hour after meals and at bedtime 3. With meals and at bedtime 4. One hour before meals and at bedtime Answer: 4 Rationale: The medication should be scheduled for administration 1 hour before meals and at bedtime. This timing will allow the medication to form a protective coating over the ulcer before it becomes irritated by food intake, gastric acid production, and mechanical movement. The other options are incorrect. Test-Taking Strategy: Use the process of elimination. Recalling the action of this medication—to form a protective coating—will assist in directing you to the correct option. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2004). Saunders nursing drug handbook 2004. Philadelphia: W.B. Saunders, p. 940.
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1823. A client is to receive medication via patient-controlled analgesia (PCA), and the nursing instructor asks the nursing student caring for the client to describe the use of the PCA. The instructor determines that the student needs instructions about the PCA if the student stated that: 1. PCA enables the client to titrate analgesics 2. PCA delivers predetermined amounts of analgesia at present intervals 3. Clients using PCA initiate the infusion by programming a pump 4. A continuous intravenous (IV) solution is needed to keep the vein open between analgesia infusions Answer: 3 Rationale: Patient-controlled analgesia (PCA) involves the use of a programmed syringe pump that delivers predetermined amounts of analgesia at preset intervals. PCA enables the client to titrate analgesics to maintain a consistent serum level of the narcotic rather than experience the peaks and troughs that occur with PRN injections. The pump is programmed by nursing staff as prescribed by the physician. The client will have IV fluids infusing to keep the vein open between analgesia infusions. Test-Taking Strategy: Note the key words needs instructions. These words indicate a false response question and that you need to select the incorrect student statement. Try to visualize the PCA and its use by the client. Remembering that a client would not program the pump should direct you to the correct option for this question as stated. If you had difficulty answering this question, review the principles related to the PCA pump. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Leadership/Management References: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 595-597. Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 245. 1824. A nurse is employed in a newborn nursery. The nurse is aware that medication toxicity is more likely to occur in the neonate than in an adult because: 1. The lungs are not developed 2. The kidneys are smaller than adults 3. Cerebral function is not fully developed 4. The liver is immature Answer: 4 Rationale: The increased medication sensitivity of neonates and infants is due largely to the immature state of five pharmacokinetic processes. These include medication absorption, renal medication excretion, hepatic medication metabolism, protein binding of medication, and exclusion of medication from the central nervous system by the bloodbrain barrier. Test-Taking Strategy: Use the process of elimination focusing on the issue—medication toxicity in the neonate. Recalling the characteristics of a newborn or neonate will assist
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in answering the question. Also, note that the key word in the correct option is immature. If you had difficulty with this question, review the characteristics of a neonate. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology References: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 86. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 134. 1825. A nurse is reinforcing instructions to the spouse of a client who is taking tacrine (Cognex) for the management of moderate dementia associated with Alzheimer’s disease. The nurse tells the spouse which of the following? 1. If flu-like symptoms occur, it is necessary to notify the physician immediately 2. If a dose is missed, double up on the next dose 3. If a change in the color of the stools occurs, notify the physician 4. Do not administer food with the medication Answer: 3 Rationale: Tacrine (Cognex) may be administered between meals on an empty stomach, and if gastrointestinal upset occurs, it may be administered with meals. Flu-like symptoms without fever and gastrointestinal symptoms are frequent side effects that may occur with the use of the medication. The client or spouse should never be instructed to double the dose of any medication if it was missed, and the client and caregiver are instructed to notify the physician if nausea, vomiting, diarrhea, rash, jaundice, or changes in the color of the stool occur. This may be indicative of the potential occurrence of hepatitis. Test-Taking Strategy: Use the process of elimination. Eliminate option 2 first using general principles related to medication administration. From the remaining options, if you can recall that an adverse reaction associated with the use of the medication is hepatitis you will easily be directed to option 3. If you are unfamiliar with the use of this medication and its potential adverse reactions, review this content. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2004). Saunders nursing drug handbook 2004. Philadelphia: W.B. Saunders, p. 948. 1826. A client is admitted to the labor and delivery suite with an intrauterine fetal demise. A nurse determines that the discussion with the parents was most effective in preparing them for the delivery when the parents: 1. State they have no questions 2. Request to hold the infant following delivery 3. Are surprised by the appearance of the infant following delivery 4. Refuse a footprint and picture of the infant to take home
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Answer: 2 Rationale: The nurse should explain to the parents the expected events following delivery of the fetus and should tell the parents that they can hold their infant following delivery. Viewing and holding the dead infant can alleviate any negative images the mother or her partner may have. Providing a picture or other mementos will help preserve the memory of the infant. If the parents refuse a picture, most hospitals will keep a picture and copy of the footprints on file for parents to access later. Parents should be encouraged to verbalize their feelings, ask questions about the process, and make their own decisions about care as much as possible. Test-Taking Strategy: Use the process of elimination noting the key words most effective. Seek the option that identifies preparedness of the parents for delivery. Option 2 is the option that most clearly identifies this preparedness. Review care to the parents experiencing intrauterine fetal demise if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Caring Content Area: Maternity/Postpartum References: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 1165. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 648. 1827. In reviewing the admission assessment data and physician’s orders for a client with peptic ulcer disease, the nurse notes that the client has a history of renal disease. Based on these data, the nurse determines that the most likely antacid to be prescribed for this client is: 1. Aluminum hydroxide (Amphojel) 2. Magnesium oxide (Mag-Ox 400) 3. Aluminum and magnesium combination (Maalox) 4. Aluminum and calcium (Camalox) Answer: 1 Rationale: Aluminum hydroxide lowers serum phosphate levels by binding with dietary phosphorus to form insoluble aluminum phosphate. The phosphate is then excreted in the feces. Aluminum hydroxide will not affect the renal system as much as other antacids. The medications identified in options 2, 3, and 4 are partially excreted by the kidneys; therefore they may cause a problem in clients with renal disease. Test-Taking Strategy: Note that the client has a history of renal disease. Also note that options 2, 3, and 4 are similar and contain magnesium. Therefore eliminate these options. If you had difficulty with this question, review these medications. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 41. Kee, J., & Hayes, E. (2003). Pharmacology: A nursing process approach (4th ed.).
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Philadelphia: W.B. Saunders, p. 670. 1828. Dantrolene (Dantrium) is prescribed for a client with a spinal cord injury for discomfort due to spasticity. The nurse determines that toxicity is present when which of the following laboratory values is altered? 1. Sedimentation rate 2. White blood cell count 3. Liver function studies 4. Creatinine level Answer: 3 Rationale: The risk of hepatotoxicity can occur with dantrolene, and liver function studies need to be monitored while the client is taking this medication. The sedimentation rate measures the presence of inflammation and infection. The white blood cell count measures the body’s immune defense system. The creatinine level measures renal function. Test-Taking Strategy: Knowledge regarding the toxic effects of dantrolene is required to answer the question. Correlate this medication with the potential for hepatotoxicity to answer questions similar to this one. If you had difficulty with this question, review the toxic effects of dantrolene. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 286. 1829. A newborn infant receives naloxone (Narcan) to reverse opiate-induced respiratory depression that occurred following labor and delivery. The nurse continues to monitor the respiratory status of a newborn infant following the administration of this medication because: 1. The newborn infant may demonstrate a gradual reappearance of respiratory depression as the antagonist’s short-lived effects diminish 2. The newborn infant may have an underlying respiratory disorder 3. The effects of naloxone are long lasting 4. The use of naloxone in newborn infants is toxic Answer: 1 Rationale: Naloxone is a short-term opiate antagonist. It reverses the respiratory depression that can be exhibited in newborn infants whose mothers have been treated with opiates for the pain of labor and delivery. Because it is short acting, and the newborn’s liver is immature, respiratory depression may reoccur after the duration of effects of naloxone. Test-Taking Strategy: Knowledge regarding the effects of naloxone is required to answer the question. Remember, it is specifically used to reverse respiratory depression. Also note the relation of the words “respiratory depression” in the question and in the correct option. If you had difficulty with this question, review this medication. Level of Cognitive Ability: Analysis
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Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, pp. 748-750. 1830. A client is being treated with atenolol (Tenormin) for hypertension. The client tells the nurse, “I am very tired since I began taking the medication.” Based on the client’s statement, the nurse determines that which nursing diagnosis written in the client’s plan of care is appropriate? 1. Ineffective Airway Clearance 2. Decreased Cardiac Output 3. Ineffective Health Maintenance 4. Self Care Deficit Answer: 2 Rationale: Atenolol is a beta-blocker, causing a decrease in heart rate and blood pressure and a decrease in cardiac output. Fatigue is the most common side effect. If this interferes with client’s activity level, dosage can be adjusted to eliminate this side effect. The defining characteristics of decreased cardiac output include complaints of fatigue or weakness. There are no data in the question that relate to the nursing diagnoses Ineffective Airway Clearance, Ineffective Health Maintenance, or Self Care Deficit. Test-Taking Strategy: When the question asks for selection of an appropriate nursing diagnosis, focus on the data presented in the question and use these data to select the correct option. Focusing on the client’s statement and considering the action of this medication will direct you to option 2. Review the defining characteristics of Decreased Cardiac Output if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 317. Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 91. 1831. A nurse is caring for a client with Paget’s disease. The nurse understands that the client is receiving calcitonin (Calcimar) to: 1. Regulates serum calcium concentrations 2. Promote the excretion of calcium in the urine 3. Decrease gastrointestinal absorption of calcium 4. Increase bone metabolism Answer: 1 Rationale: Calcitonin works in conjunction with parathyroid hormone (PTH) to regulate calcium levels by decreasing the rate of bone reabsorption and regulating bone metabolism. Options 2, 3, and 4 are not the purposes for administering this medication to this client.
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Test-Taking Strategy: Knowledge related to the purpose and action of the medications used to treat Paget’s disease is required to answer this question. If you had difficulty with this question, review the action and purpose of calcitonin and the treatment for Paget’s disease. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 153. Kee, J., & Hayes, E. (2003). Pharmacology: A nursing process approach. (4th ed.). Philadelphia: W.B. Saunders, pp. 724, 726. 1832. A client receiving therapy with carbidopa/levodopa (Sinemet) is upset and tells the nurse that his urine has turned a darker color since beginning to take this medication. The client wants to discontinue its use. In formulating a response to the client’s concerns, the nurse interprets that this change is: 1. Indicative of developing toxicity 2. A sign of interaction with another medication 3. A harmless side effect of the medication 4. A result of taking the medication with milk Answer: 3 Rationale: With carbidopa/levodopa therapy, a darkening of the urine or sweat may occur. The client should be reassured that this is a harmless side effect of the medication, and its use should be continued. Options 1, 2, and 4 are incorrect. Test-Taking Strategy: Knowledge of the side effects of this medication is needed to answer this question. Remember, a darkening of the urine or sweat is a harmless side effect of the medication. If you had difficulty with this question, review the side effects of this medication. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 167. 1833. A client with a history of simple partial seizures is taking clorazepate (Tranxene). The client asks the nurse if there is a risk of addiction. The nurse’s response is based on the understanding that clorazepate: 1. Is not habit-forming either physically or psychologically 2. Leads to physical and psychological dependence with prolonged high-dose therapy 3. Leads to physical tolerance, but only after 10 or more years of therapy 4. Can result in psychological dependence only, due to the nature of the medication Answer: 2 Rationale: Clorazepate is classified as an anticonvulsant, antianxiety agent, and sedative/hypnotic (benzodiazepine). The medication can lead to physical or
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psychological dependence when there is prolonged therapy at high doses. For this reason, the amount of medication that is readily available to the client at any one time is restricted. Options 1, 3, and 4 are incorrect. Test-Taking Strategy: Focus on the name of the medication. Recalling that the medication is a benzodiazepine leads you to conclude that this medication can lead to physical as well as psychological dependence. If you had difficulty with this question, review this medication. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 248. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 338. 1834. A client who takes chlorothiazide (Diuril) every evening expresses frustration with the medication and wants to stop therapy. When the nurse explores the reasoning, the client says, “It keeps me up all night. I feel as though I should bring my pillow into the bathroom!” The nurse interprets that the client can best be assisted to successfully adapt to this therapy by: 1. Switching to a morning administration of the medication 2. Taking a sleep aid with the medication 3. Limiting oral fluids before bedtime 4. Asking the physician for a new brand of medication Answer: 1 Rationale: Diuretic therapy should be administered in the morning to cause the least disruption as possible in the client’s sleep cycle. Options 2, 3, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination. Look at the name of the medication and determine that it is a diuretic. Recalling that diuretics need to taken in the morning will direct you to option 1. Review the client teaching points related to this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Teaching/Learning Content Area: Pharmacology References: Kee, J., & Hayes, E. (2003). Pharmacology: A nursing process approach (4th ed.). Philadelphia: W.B. Saunders, p. 590. Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, pp. 405, 408. 1835. A nurse is scheduled to administer a dose of digoxin (Lanoxin) to a client with atrial fibrillation. The client has a potassium level of 4.6 mEq/L. The nurse interprets that the: 1. Dose should be omitted for that day 2. Client needs a dose of potassium before receiving the digoxin
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3. Dose should be withheld and the physician notified 4. Dose should be administered as prescribed Answer: 4 Rationale: Hypokalemia can make the client more susceptible to digoxin toxicity. The nurse monitors the results of potassium levels drawn on the client. The normal reference range of potassium for an adult is 3.5 to 5.1 mEq/L. If the potassium level is low, the dose is withheld and the physician is notified. In this situation, the dose should be administered as prescribed because the potassium level is within the normal range. Test-Taking Strategy: To answer this question correctly, you must know that hypokalemia potentiates digoxin toxicity, and normal potassium levels. Noting that the client’s potassium level is within normal limits will direct you to option 4. Review the normal potassium level and the nursing considerations related to the administration of digoxin if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 326. Kee, J., & Hayes, E. (2003). Pharmacology: A nursing process approach (4th ed.). Philadelphia: W.B. Saunders, p. 569. 1836. A client who was started on anticonvulsant therapy with clonazepam (Klonopin) tells the nurse of increasing clumsiness and unsteadiness since starting the medication. The client is visibly upset by these manifestations and asks the nurse what to do. The nurse’s response is based on the understanding that these symptoms: 1. Indicate that the client is experiencing a severe untoward reaction to the medication 2. Are most severe during initial therapy and decrease or disappear with long-term use 3. Are probably the result of an interaction with another medication 4. Usually occur when the client takes the medication with food Answer: 2 Rationale: Drowsiness, unsteadiness, and clumsiness are expected effects of the medication during early therapy. They are dose-related, and usually diminish or disappear altogether with continued use of the medication. It does not indicate that a severe untoward reaction is occurring. It is also unrelated to interaction with another medication. The client is encouraged to take this medication with food to minimize gastrointestinal upset. Test-Taking Strategy: Specific knowledge regarding this medication is needed to answer this question. Recalling that the effects described in the question occur early in the course of therapy and decrease or disappear with long-term use will direct you to option 2. If you had difficulty with this question, review this medication. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005.
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Philadelphia: W.B. Saunders, p. 245. 1837. A client has been prescribed cyclobenzaprine (Flexeril) in the treatment of painful muscle spasms accompanying a herniated intervertebral disk. The nurse would withhold the medication and question the order if the client had concurrent orders to take: 1. Furosemide (Lasix) 2. Valproic acid (Depakene) 3. Ibuprofen (Motrin) 4. Tranylcypromine (Parnate) Answer: 4 Rationale: The client should not receive cyclobenzaprine if the client has taken a monoamine oxidase (MAO) inhibitor such as tranylcypromine or phenelzine (Nardil) within the last 14 days. Otherwise, the client could experience hypertensive crisis, convulsions, or death. Options 1, 2, and 3 are not contraindicated with the use of this medication. Test-Taking Strategy: Knowledge regarding cyclobenzaprine and the contraindications in its use is required to answer the question. Remember that cyclobenzaprine is not taken with MAO inhibitors. If you had difficulty with this question, review this medication and the contraindications associated with its use. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 269. 1838. An infant is suspected to be human immunodeficiency virus (HIV) positive, and the nurse provides information to the parents about the care of their infant. Which of the following indicates to the nurse that the parents need further information about the care of their HIV positive infant? 1. The parents state they will not allow anyone with a cold to hold and kiss the baby 2. The parents are able to verbalize signs and symptoms of the infant’s failure to thrive 3. The parents ask for a prescription for an antiretroviral medication 4. The parents plan to use rice cereal to help with watery stools when they occur Answer: 4 Rationale: If an infant is having diarrhea, the parents need to seek medical attention because this could be the beginning of an opportunistic infection. Self-treatment is not encouraged. Asking for antiretroviral therapy, understanding signs and symptoms of failure to thrive, and being protective of an immunocompromised infant are evidence of understanding the needs of the infant. Test-Taking Strategy: Use the process of elimination noting the key words need further information. These words indicate a false response question and that you need to select the incorrect client statement. Recalling the signs of an opportunistic infection will direct you to option 4. If you had difficulty with this question, review parent education points for the newborn infant suspected to be HIV positive. Level of Cognitive Ability: Analysis
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Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Child Health References: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 689, 1066-1067. Matteson, P. (2001). Women’s health during the childbearing years: A community-based approach. St. Louis: Mosby, p. 692. 1839. A pregnant woman has tested positive for human immunodeficiency virus (HIV). The nurse reinforces information to the client about HIV and determines that additional information is necessary when the client states: 1. “Breast-feeding after delivery is best for my baby.” 2. “I can continue to hug and hold my other children.” 3. “It may be two years before I know if my baby has HIV.” 4. “My husband and I can still sleep together in the same bed.” Answer: 1 Rationale: Breast-feeding is contraindicated if the mother is positive for human immunodeficiency virus (HIV) because the virus may be spread to the infant in the breast milk. HIV is not spread through casual contact, so holding, hugging, and sleeping with other family members is not prohibited. A newborn may test positive for HIV for up to 2 years after birth because of placental transfer of maternal antibodies. It is vital that the nurse ascertains that the client has correct knowledge regarding the transmission of the disease and precautions necessary to prevent the spread of HIV. Test-Taking Strategy: Use the process of elimination noting the key words additional information is necessary. Recalling that HIV is spread by direct contact with infected body fluids will direct you to option 1. If you had difficulty with this question, review the methods of transmission of the HIV virus. Level of Cognitive Ability: Analysis Client Needs: Safe, Effective Care Environment Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum References: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 422. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 728. 1840. A client with congestive heart failure is being discharged home and will be taking furosemide (Lasix). The nurse determines that teaching has been effective if the client states which of the following? 1. “I will check my ankles every day for swelling.” 2. “I will take my pulse every day.” 3. “I will measure my urine output.” 4. “I will weigh myself every day.” Answer: 4 Rationale: A client taking furosemide (Lasix) must be able to monitor fluid status throughout therapy. Monitoring daily weight is the easiest and most accurate way to
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accomplish this. Options 1 and 3 are incorrect because of the difficulty of assessing fluid status accurately in this way. Additionally, in order for option 3 to be correct, fluid intake would need to be measured. Option 2 is incorrect and unrelated to the administration of furosemide. Test-Taking Strategy: Use the process of elimination. In client teaching questions, try to select the option that would be the easiest and most effective for a nurse to teach and for the client to understand. Remember, if you teach a client to do something that is too complicated, there will be no compliance. Option 4 provides the easiest and most accurate way to measure fluid status. If you had difficulty with this question, review the measures that will effectively determine a therapeutic response to furosemide. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 480. 1841. A client is being treated for heart failure and is receiving digoxin (Lanoxin). The client’s vital signs are blood pressure 85/50 mm Hg, pulse rate 96 beats per minute, respirations 26 breaths per minute. To evaluate the therapeutic effectiveness of this medication, the nurse would expect which of the following changes in the client’s vital signs? 1. Blood pressure 85/50 mm Hg, pulse rate 60 beats per minute, respirations 26 breaths per minute 2. Blood pressure 98/60 mm Hg, pulse rate 80 beats per minute, respirations 24 breaths per minute 3. Blood pressure 130/70 mm Hg, pulse rate 104 beats per minute, respirations 20 breaths per minute 4. Blood pressure 110/40 mm Hg, pulse rate 110 beats per minute, respirations 20 breaths per minute Answer: 2 Rationale: The main function of digoxin is inotropic. The increased myocardial contractility is associated with increased cardiac output, causing an increase in the blood pressure in a client with heart failure. Digoxin has a negative chronotropic effect (decreases heart rate) and will therefore cause a slowing of the heart rate. As cardiac output improves, there should be an improvement in respirations as well. Test-Taking Strategy: This question requires knowledge of the action of digoxin. Knowing that digoxin slows the heart rate will assist in eliminating options 3 and 4. Knowing that digoxin improves cardiac output will assist in eliminating option 1. This leaves option 2 as the correct option. If you had difficulty with this question, review the therapeutic effects of digoxin. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005.
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Philadelphia: W.B. Saunders, p. 326. Kee, J., & Hayes, E. (2003). Pharmacology: A nursing process approach (4th ed.). Philadelphia: W.B. Saunders, p. 569. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, pp. 540, 542. 1842. A client with a partial right adrenalectomy is placed on corticosteroid replacement therapy. Which of the following would indicate that the client is experiencing an adverse effect related to the pharmacological treatment? 1. Hypoglycemia 2. Hypotension 3. Dry mouth 4. Tarry stools Answer: 4 Rationale: Glucocorticoids increase gastric secretion, and this can result in peptic ulcers and gastrointestinal bleeding. Corticosteroids increase blood glucose levels. Hypotension and dry mouth are not side effects of corticosteroid therapy. Test-Taking Strategy: Knowledge regarding the adverse effects associated with corticosteroid therapy is required to answer this question. Remember, glucocorticoids can cause gastrointestinal bleeding. Review the adverse effects associated with corticosteroids if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology Reference: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 767. 1843. A client is being discharged following treatment for left ventricular heart failure. The nurse is teaching the client the purpose, actions, adverse effects, and use of digoxin (Lanoxin) 0.25 mg daily and hydrochlorothiazide (HydroDIURIL) 50 mg prescribed for daily use. Which statement by the client indicates that further discharge teaching is needed? 1. “I should decrease my intake of foods high in potassium, such as bananas.” 2. “I should take my radial pulse before taking these medications.” 3. “These medications will cause an increase in urine output.” 4. “These medications should be taken in the morning rather than in the evening.” Answer: 1 Rationale: Digoxin is a cardiac glycoside and hydrochlorothiazide is a diuretic. Clients on digoxin have an increased risk of digoxin toxicity from the potassium-depleting effect of hydrochlorothiazide. Therefore the diet should be high in potassium. The client should take their pulse before taking cardiac glycosides. A combined therapeutic effect of these medications is to increase urine output. The increased blood flow to the kidneys as a result of enhanced cardiac contractility from the digoxin will promote urinary output. Hydrochlorothiazide increases urine excretion of sodium and water by inhibiting sodium reabsorption in the nephron. For best therapeutic effects, these medications should be
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taken at the same time in the morning to avoid sleep disturbances from the need to urinate. Test-Taking Strategy: Note the key words further discharge teaching is needed. These words indicate a false response question and that you need to select the incorrect client statement. Recalling that potassium depletion can occur with the use of these medications will direct you to option 1. If you had difficulty with this question, review these medications. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Pharmacology References: Kee, J., & Hayes, E. (2003). Pharmacology: A nursing process approach (4th ed.). Philadelphia: W.B. Saunders, p. 570. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 541. 1844. A nurse is assisting in developing a plan of care for a pregnant client with acquired immunodeficiency syndrome (AIDS). The nurse determines that which of the following is the priority nursing diagnosis for this client? 1. Ineffective Health Maintenance 2. Risk for Infection 3. Disturbed Sensory Perception 4. Deficient Fluid Volume Answer: 2 Rationale: Acquired immunodeficiency syndrome decreases the body’s immune response, making the infected person susceptible to infections. AIDS affects helper T lymphocytes, which are vital to the body’s defense system. Opportunistic infections are a primary cause of death in persons infected with AIDS. Therefore preventing infection is a priority of nursing care. Although the nursing diagnoses in options 1, 3, and 4 may be a concern at some point in the care of the client, these are not the priority. Test-Taking Strategy: Note the key word priority. Use Maslow’s Hierarchy of Needs theory to eliminate options 1 and 3. From the remaining options, recalling that AIDS affects the body’s immune system will direct you to option 2. If you had difficulty with this question, review the priority concerns related to the client with AIDS. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing References: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 203. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 727. 1845. A nurse in the preoperative holding unit administers a dose of scopolamine to a client. The nurse monitors the client for which common side effect of the medication? 1. Dry mouth
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2. Pupillary constriction 3. Excessive urination 4. Diaphoresis Answer: 1 Rationale: Scopolamine is an anticholinergic medication that causes the frequent side effects of dry mouth, urinary retention, decreased sweating, and dilation of the pupils. Each of the incorrect options is the opposite of a side effect of this medication. Test-Taking Strategy: Use the process of elimination. Recalling that this medication is an anticholinergic will direct you to option 1. If the medication is unfamiliar to you, review its action and side effects. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2004). Saunders nursing drug handbook 2004. Philadelphia: W.B. Saunders, p. 908. 1846. A client is being discharged home following recovery from an anterior myocardial infarction with recurrent angina. The client will be taking diltiazem (Cardizem SR) two times daily, isosorbide dinitrate (Isordil) four times daily, and nitroglycerin (Nitrostat) sublingually as needed, and the nurse reinforces information to the client about the medications. Which statement by the client indicates that further teaching is needed about the medications? 1. “All three of these medications will help to decrease the intensity of my chest pain.” 2. “All three of these medications will increase blood flow to my heart.” 3. “I should notify my doctor immediately if I experience headaches with any of these medications.” 4. “I will store these medications in a cool place, away from light.” Answer: 3 Rationale: Because of the vasodilating effects of nitrates, headache is a common side effect. Medical attention is not needed unless the headaches increase in severity or frequency. All three medications are nitrates, which improve myocardial circulation by dilating coronary arteries and collateral vessels, thus increasing blood flow to the heart. These medications are used to help prevent the frequency, intensity, and duration of anginal attacks. Nitrates should be stored in a cool place and in a dark container. Heat and light cause these medications to break down and lose their potency. Test-Taking Strategy: Note the key words further teaching is needed. These words indicate a false response question and that you need to select the incorrect client statement. Recalling that these medications have a vasodilating effect and that headache is a common side effect will direct you to option 3. If you had difficulty with this question, review these medications. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005.
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Philadelphia: W.B. Saunders, p. 108. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 608. 1847. A nurse has reinforced instructions to a client with Parkinson’s disease who is taking carbidopa/levodopa (Sinemet). Which statement by the client indicates the need for further instruction? 1. “I will take the medication just before meals to avoid nausea.” 2. “I will eat lots of foods high in vitamin B6.” 3. “I will get up slowly to prevent dizziness.” 4. “I may need to take this medication for the rest of my life.” Answer: 2 Rationale: Foods high in vitamin B6 can counteract the effects of carbidopa/levodopa, and their intake should be limited. Options 1, 3, and 4 are accurate statements regarding this medication. Test-Taking Strategy: Note the key words need for further instruction. These words indicate a false response question and that you need to select the incorrect client statement. Remember, foods high in vitamin B6 can counteract the effects of this medication. If you had difficulty with this question, review this medication. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2004). Saunders nursing drug handbook 2004. Philadelphia: W.B. Saunders, p. 168. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 497. 1848. A client being seen in the clinic is taking phenytoin (Dilantin), and the client’s phenytoin blood level is within therapeutic range and the client’s seizures are controlled. Which of the following if observed by the nurse on data collection would require physician notification and possible discontinuation of the medication? 1. Diplopia 2. Bleeding gums 3. Mental impairment 4. Diffuse body rash Answer: 4 Rational e: Stevens-Johnson syndrome is a rash indicating an allergy, and if this occurs the physician needs to be notified for consideration of medication discontinuation. Options 1, 2, and 3 are also side effects of the medication, but may be reversed with medication dose alteration rather than medication discontinuation. Test-Taking Strategy: Note the key words possible discontinuation of the medication. Options 1, 2, and 3 require attention, but a rash indicates an allergic response and an allergy can be life-threatening. If you are unfamiliar with this medication, review this content.
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Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 856. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 361. 1849. A young pregnant woman with diabetes mellitus has lost 10 pounds during the first 15 weeks’ gestation. The client tells the nurse that, “I do not eat regular meals.” Based on the client’s statement, the nurse determines that the best response would be which of the following? 1. “If you do not eat regular meals you will hurt your baby.” 2. “Can you tell me more about what you are eating?” 3. “I’ll have the doctor review your diet history.” 4. “It does not matter anymore how much weight you gain.” Answer: 2 Rationale: It is important for the nurse to obtain additional information from the client. In option 2, the nurse is using the therapeutic communication tool of validation and clarification in order to obtain more information. The other options will block communication. Option 1 devalues the client and shows disapproval. Option 3 is avoiding the issue, and option 4 provides false reassurance. Test-Taking Strategy: Use therapeutic communication techniques. Note that option 2 is open-ended and will encourage communication. Additionally, option 2 identifies the process of gathering data, the first step in the nursing process. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Analysis Client’s Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Maternity/Antepartum References: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 889-890. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 707. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 437. 1850. A client with a thoracic spinal cord injury is receiving dantrolene sodium (Dantrium). Which statement by the client indicates to the nurse that the client is having an undesired medication effect? 1. “I’m feeling drowsy.” 2. “My legs are very relaxed.” 3. “I can’t seem to get enough to eat.” 4. “My urine has a bluish color.” Answer: 1
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Rationale: Drowsiness, diarrhea, and hepatotoxicity are the major adverse effects of this muscle relaxant, which is used to treat the chronic spasticity seen in spinal cord injury. The drowsiness may interfere with the client’s rehabilitation. Some clients have anorexia and hematuria. Test-Taking Strategy: Use the process of elimination focusing on the issue—an undesired medication effect. Option 2 is a desired effect, so eliminate this option. Options 3 and 4 are unrelated to this medication. Also remember that many medications cause nausea or gastric irritation, so option 3 could be eliminated, and very few medications cause blue urine, making option 4 incorrect. If you had difficulty with this question, review the undesired effects of this medication. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 285. 1851. A nurse is assisting in monitoring a client who received hydralazine hydrochloride (Apresoline) to treat autonomic dysreflexia. Which finding most accurately indicates that the medication is effective? 1. Muscle spasms subside 2. Blood pressure declines 3. Intensity of seizure activity declines 4. Client states that they feel better Answer: 2 Rationale: Hydralazine hydrochloride is a potent ganglionic blocking agent that will decrease the blood pressure by vasodilation. It may be given by slow intravenous push during an episode of extreme hypertension. Options 1, 3, and 4 are not intended effects of the medication. Test-Taking Strategy: Recalling that hydralazine hydrochloride is an antihypertensive agent will direct you to option 2. If you are unfamiliar with this medication, note the relation between the name of the medication and the action; in this case, Apresoline and pressure. If you had difficulty with this question, review the action of this medication. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 527. 1852. A client with acquired immunodeficiency syndrome (AIDS) has an opportunistic respiratory fungal infection and is receiving intravenous amphotericin B (Fungizone). The nurse assisting in caring for the client monitors for which sign that indicates an adverse effect of the medication? 1. Decreased urine output 2. Orange colored urine
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3. Pale colored stools 4. Jaundice Answer: 1 Rationale: Clients receiving amphotericin B may develop nephrotoxicity. Clients should be monitored for oliguria, hematuria, cloudy urine, decreased urine output, and elevated renal function laboratory values. Amphotericin B does not cause the urine to turn orange in color. Pale colored stools indicate hepatotoxicity as does jaundice; hepatotoxicity is not an adverse effect. Test-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 first because they both relate to hepatotoxicity. From the remaining options recalling that amphotericin B is nephrotoxic will direct you to the correct option. Review the adverse effects of this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 65. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 1015. 1853. A 38-week gestational pregnant woman arrives at the emergency department. She reports the presence of bright red vaginal bleeding and denies the presence of any pain. Based on this information, the nurse determines that the client may be experiencing: 1. The passage of the mucous plug 2. Abruptio placentae 3. Rupture of the amniotic sac 4. Placenta previa Answer: 4 Rationale: The primary symptom in placenta previa is painless vaginal bleeding in the second or third trimester of pregnancy. Passage of the mucous plug appears as pink or blood-tinged mucus. A ruptured amniotic sac would include findings such as watery vaginal drainage. Findings of abruptio placentae include dark red vaginal bleeding and abdominal pain. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 3 because these conditions would not produce bloody discharge. From the remaining options, it is necessary to recall the signs and symptoms of both placenta previa and abruptio placentae. Recalling that painless vaginal bleeding occurs in placenta previa will direct you to the correct option. If you had difficulty with this question, review the signs associated with both disorders. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum References: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 872.
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Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 672. 1854. A client informs the nurse that she has been taking acarbose (Precose) as prescribed. The nurse determines that a therapeutic effect of the medication has occurred if which of the following is noted? 1. A serum lipase level of 100 units/L 2. A 2-hour postprandial serum glucose level of 120 mg/dl 3. A sodium level of 140 mEq/L 4. A blood urea nitrogen (BUN) level of 15 mg/dl Answer: 2 Rationale: Acarbose is an oral antidiabetic medication used as an adjunct to diet to lower blood glucose levels in clients with non–insulin-dependent diabetes mellitus whose hyperglycemia cannot be managed by diet alone. All of the laboratory values presented in the options are within a normal value. Lipase level monitors pancreatic activity. Sodium is an electrolyte. The BUN measures renal function. A 2-hour postprandial serum glucose reading of 120 mg/dl would identify a therapeutic effect of the medication. Test-Taking Strategy: Focus on the name of the medication. If you are unfamiliar with this medication, note its name—Precose. This can provide you with a clue that the medication is administered prior to something. Knowing that antidiabetics are administered prior to the meal may assist in directing you to the correct option. Review the purpose of this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 4. Kee, J., & Hayes, E. (2003). Pharmacology: A nursing process approach (4th ed.). Philadelphia: W.B. Saunders, p. 746. 1855. A nurse employed in the emergency department receives a telephone call from the emergency alert system informing the department that a child who ingested a bottle of acetaminophen (Tylenol) is on route to the emergency department. The nurse prepares the room for the arrival of the child and checks the medication supply to determine if which medication that is the antidote is available? 1. Phytonadione (Vitamin K) 2. Protamine sulfate 3. Acetylcysteine (Mucomyst) 4. Pancreatin Answer: 3 Rationale: Acetylcysteine is the antidote for acetaminophen. Protamine sulfate is the antidote for heparin. Phytonadione is the antidote for warfarin sodium (Coumadin). Pancreatin is a pancreatic enzyme replacement or supplement. Test-Taking Strategy: Knowledge regarding the appropriate antidote for acetaminophen is required to answer the question. Remember, acetylcysteine is the antidote for
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acetaminophen. Review the various medication antidotes if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 9. 1856. A nurse is caring for a client who has been taking acetazolamide (Diamox) for glaucoma. The nurse reviews the assessment data documented in the client’s medical record and determines that a potential adverse effect of the medication may be occurring if which of the following is noted? 1. No change in the level of peripheral vision 2. Jaundice 3. Pupillary constriction in response to light 4. Tinnitus Answer: 2 Rationale: Acetazolamide is a carbonic anhydrase inhibitor used in the treatment of open-angle, secondary, or angle-closure glaucoma to reduce the rate of aqueous humor formation and to lower intraocular pressure. Adverse effects relate to nephrotoxicity, hepatotoxicity, and bone marrow depression. Jaundice is a sign of hepatotoxicity. A decrease in the level of peripheral vision would indicate a complication of glaucoma. Pupillary constriction in response to light is a normal response. Tinnitus is unrelated to this medication. Test-Taking Strategy: Focus on the issue—an adverse effect of the medication. Eliminate option 3 because this is a normal response. From the remaining options, remembering that nephrotoxicity, hepatotoxicity, and bone marrow depression indicate adverse effects will direct you to the correct option. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 10. Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 1103. 1857. A client reports to the clinic for follow-up after a 1-month treatment with acebutolol (Sectral). The nurse determines that a therapeutic effect of the medication has occurred if which of the following is noted? 1. A blood pressure of 130/84 mm Hg 2. An apical pulse rate of 88 beats per minute 3. Palpable peripheral pulses 4. Maintenance of desired weight
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Answer: 1 Rationale: Acebutolol is a beta-adrenergic blocker used primarily to manage mild to moderate hypertension or cardiac dysrhythmias. The expected therapeutic response is a controlled blood pressure within normal limits. Although a pulse rate of 88 beats per minute is also normal, no reference is made regarding the quality or regularity of the pulse. Options 3 and 4 are unrelated to the action of the medication. Test-Taking Strategy: Remember that medication names that end in the letters “lol” are beta blockers and that beta blockers lower blood pressure. This should assist in directing you to the correct option. Review this medication if you had difficulty with the question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 6. 1858. A nurse is caring for a client experiencing a partial placental abruption. The client is uncooperative and is refusing any interventions until her husband arrives at the hospital. The nurse analyzes the client’s behavior as most likely the result of: 1. Emotional immaturity 2. An undiagnosed psychiatric disorder 3. Acute anxiety and the need for support 4. A stubborn personality Answer: 3 Rationale: Any of the situations identified in the options may contribute to the reason for the client’s behavior, but the most likely reason is anxiety. Option 3 is the only option that supports the information identified in the question. The client may be anxious about the unknown effects of complications, and the presence of a support person while dealing with a crisis is crucial. There are no data in the question to support options 1, 2, and 4. Test-Taking Strategy: Use the process of elimination focusing on the data in the question. Noting the key words refusing any interventions until her husband arrives will direct you to option 3. Additionally, there are no data in the question to support options 1, 2, and 4. Review the psychosocial aspects of care for a client with a partial placental abruption if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum References: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 874-876. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 674. 1859. A nurse reinforces instructions to a client with myxedema about the dosage, method of administration, and side effects of levothyroxine sodium (Synthroid). Which statement by the client would indicate an understanding of the nurse’s instructions?
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1. “I can expect to have diarrhea, insomnia, and excessive sweating.” 2. “If I feel nervous or have tremors I should only take half the dose.” 3. “I should apply the topical patch to a nonhairy area.” 4. “I will report any episodes of palpitations, chest pain, or dyspnea.” Answer: 4 Rationale: A major concern when initiating thyroid hormone replacement therapy is that the dose may be too high, which can lead to cardiovascular problems. As a result, clients need to be aware of the early signs and symptoms of toxicity and that they must report these immediately to their physician. Diarrhea, insomnia, and excessive sweating are signs and symptoms of hyperthyroidism, and while they can occur with thyroid replacement therapy, they are not expected and should be reported. Tremors and nervousness are also signs of toxicity, which need to be reported. Clients should never take it upon themselves to adjust hormone dosage. Levothyroxine sodium is not administered topically. Test-Taking Strategy: Focus on the issue—an understanding of the nurse’s instructions. General principles related to medication therapy will assist in eliminating option 2. From the remaining options, focus on the name of the medication and recall the effects of thyroid replacement therapy. This will direct you to option 4. If you had difficulty with this question, review this medication. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 633. 1860. A client has a prescription for niacin (Nicobid, Niacor). The nurse determines that the client understands the importance of this therapy if the client verbalized the importance of periodic monitoring of: 1. Renal function studies 2. The serum cholesterol level 3. The blood urea nitrogen level 4. The creatinine level Answer: 2 Rationale: Niacin is used as adjunctive therapy in the management of hyperlipidemia. This is used in conjunction with a low-fat and low-cholesterol diet, exercise, and smoking cessation. Serum cholesterol and triglyceride levels are monitored periodically to assess the effectiveness of therapy. The laboratory studies in options 1, 3, and 4 assess renal function. Test-Taking Strategy: Use the process of elimination. Eliminate options 1, 3, and 4 because they are similar and assess renal function. Remember, niacin is used as adjunctive therapy in the management of hyperlipidemia. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation
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Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 766. 1861. A client with aldosteronism has been instructed on spironolactone (Aldactone) treatment. Which client statement indicates that the client needs further teaching about the medication? 1. “This medication will make me void frequently.” 2. “This medication will decrease my blood glucose.” 3. “My blood pressure should get back to normal.” 4. “My potassium level may increase.” Answer: 2 Rationale: Spironolactone is a potassium-sparing diuretic. It does not lower blood glucose level. Spironolactone counteracts the effect of aldosterone; it promotes sodium and water excretion, decreases circulating volume, and therefore decreases blood pressure and inhibits the excretion of potassium. Test-Taking Strategy: Note the key words needs further teaching. These words indicate a false response question and that you need to select the incorrect client statement. Recalling that this medication is a potassium-sparing diuretic and is prescribed for blood pressure control will direct you to option 2. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 985. 1862. A client with chronic atrial fibrillation is being started on quinidine sulfate (Quinidex Extentabs) as maintenance therapy for dysrhythmia suppression. The nurse determines that the client needs instruction about this medication if the client stated to: 1. Take the dose at the same time each day 2. Avoid chewing the sustained release tablets 3. Take the medication with food if gastrointestinal (GI) upset occurs 4. Stop taking the prescribed digoxin (Lanoxin) after starting this new medication Answer: 4 Rationale: Medication-specific teaching points for quinidine sulfate include the following: take the medication exactly as prescribed; do not chew the sustained release tablets; take the medication with food if GI upset occurs; wear a Medic-Alert bracelet or tag; and get periodic checks of heart rhythm and blood counts. This medication is initiated for atrial flutter or fibrillation only after being digitalized. Test-Taking Strategy: Note the key words needs instruction. These words indicate a false response question and that you need to select the incorrect client statement. Options 1 and 2 are general instructions for medication use and are therefore eliminated first. From the remaining options, remember that it is not usual practice to “stop taking” a “prescribed” medication. This will direct you to option 4. If you had difficulty with this
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question, review this medication. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, pp. 326, 918. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 553. 1863. Which statement indicates that a client with Addison’s disease knows how to safely manage a medication regimen that consists of daily doses of glucocorticoids? 1. “I will need to call my doctor for an increase in medication dose when I’m experiencing a lot of stress.” 2. “I should stop my medication if I begin to experience any unpleasant side effects.” 3. “The medication I am taking is very safe and does not cause side effects.” 4. “If I’m nauseated and can’t take my medicine for a few days, I can do without them.” Answer: 1 Rationale: The client with Addison’s disease will require lifelong replacement of adrenal hormones. The medications must be taken daily, and an alternate route of administration must be used if the client cannot take oral medications for any reason, such as nausea and vomiting. Additional doses of glucocorticoids will be needed during times of acute stress. The nurse must emphasize to the client that they must call the physician to obtain a dosage increase when experiencing stressful situations. Abrupt withdrawal of this medication can result in Addisonian crisis. Although side effects are not severe at lower doses, side effects may be experienced with glucocorticoid administration. It is very unsafe to stop taking the medication without first consulting the physician. Test-Taking Strategy: Use the process of elimination recalling information about glucocorticoids and the stress response. The correct option makes the correlation between stress and the increased need for corticosteroids. If you had difficulty with this question, review the client teaching points related to glucocorticoids. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology References: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, pp. 641, 766. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 856. 1864. A client began taking amantadine hydrochloride (Symmetrel) approximately 2 weeks ago. The nurse determines that the medication is having a therapeutic effect if the client exhibited decreased: 1. White blood cell count 2. Voiding 3. Rigidity and akinesia
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4. Blood pressure Answer: 3 Rationale: Amantadine hydrochloride is an antiparkinson agent that potentiates the action of dopamine in the central nervous system. The expected effect of therapy is a decrease in akinesia and rigidity. Leukopenia, urinary retention, and hypotension are all adverse effects of the medication. Test-Taking Strategy: Focus on the name of the medication and recall that this medication is used to treat Parkinson’s disease. This will direct you to option 3 as the expected effect of the medication. Review the expected effects of this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 42. 1865. A nurse is caring for a restless client who keeps biting down on an orotracheal tube. The nurse uses which of the following to prevent the client from obstructing the airway with the teeth? 1. Nasal airway 2. Oral airway 3. Bite stick 4. Padded tongue blade Answer: 2 Rationale: An oral airway may be used to keep the client from biting down, occluding an orotracheal tube. A nasal airway is not used in conjunction with an oral endotracheal tube. A padded tongue blade or a bite stick may be used initially to open the mouth for easier insertion of an oral airway. Test-Taking Strategy: Visualize the use of each item in the options. Note the relation between “orotracheal” in the question and “oral airway” in the correct option. Review care to the client with an orotracheal tube if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Respiratory Reference: Potter, P., & Perry, A. (2003). Essentials for practice (5th ed.). St. Louis: Mosby, p. 662. 1866. A nurse performs a blood glucose test on a newborn infant whose mother has diabetes mellitus and obtains a reading of 50 mg/dl. The nurse determines that this result indicates: 1. Hypoglycemia 2. A normal level 3. Hyperglycemia 4. Hypotonia
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Answer: 2 Rationale: A normal blood glucose level for newborn infants is 40 mg/dl and higher. This places the finding noted in the question at a normal level; therefore neither hypoglycemia nor hyperglycemia is present. Hypotonia refers to muscle tone and is not associated with blood glucose screening. Test-Taking Strategy: Knowledge regarding the normal blood glucose level in a newborn infant is required to answer the question. Remember, the normal blood glucose level for newborn infants is 40 mg/dl and higher. This will direct you to option 2. Review this normal laboratory value if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum References: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 1058-1059. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 494. 1867. A client has been receiving nitrofurantoin sodium (Macrodantin). The nurse determines that the therapy is effective if which of the following is noted? 1. Cessation of cough 2. Absence of dysuria 3. Relief of chest pain 4. Decreased urge for cigarettes Answer: 2 Rationale: Nitrofurantoin sodium is an antibacterial medication and is used to treat acute urinary tract infection, or is used as chronic suppressive treatment of urinary tract infection. It is not effective with systemic bacterial infections. Since dysuria is a sign of a urinary tract infection, this is the only correct option. Test-Taking Strategy: Familiarity with the classification of this medication is needed to answer this question. Recalling that it is used to treat urinary tract infection will direct you to option 2. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 776. Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 937. 1868. Nifedipine (Procardia) has been prescribed for a client with Raynaud’s disease, and the nurse reinforces medication instructions with the client. Which statement by the client indicates a need for further instructions? 1. “I need to get up slowly when I change positions because the medicine causes hypotension.”
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2. “I will contact my doctor if I get short of breath.” 3. “I will call my doctor if I get headaches that worsen.” 4. “Nausea and drowsiness is expected and if it occurs I don’t really need to worry about it.” Answer: 4 Rationale: Nifedipine is a calcium antagonist that reduces smooth muscle contractility by inhibiting the movement of calcium ions in slow channels. Its side effects include headache, flushing, peripheral edema, and postural hypotension. Overdose of the medication produces nausea, drowsiness, confusion, and slurred speech. If signs of overdose occur, the physician is notified. Test-Taking Strategy: Use the process of elimination noting the key words need for further instructions. These words indicate a false response question and that you need to select the incorrect client statement. Eliminate option 1 first recalling the safety guidelines related to medication administration, specifically cardiac medications. From the remaining options, note that option 4 is the only option that does not address contacting the physician. If you had difficulty with this question, review the client teaching points and the side effects and adverse effects related to this medication. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2004). Saunders nursing drug handbook 2004. Philadelphia: W.B. Saunders, p. 729. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 600. 1869. A nurse notes that zidovudine (AZT) has recently been prescribed for the client. The client states, “I’ve been getting a little nauseous and I’ve had a couple of headaches since I started the AZT. Does this mean I can’t take the medicine?” The nurse makes which response to the client? 1. “These symptoms may become more tolerable as you adjust to ongoing therapy.” 2. “Don’t worry. There are so many other medications these days that the doctor can give you.” 3. “I know you’re worried that you won’t be able to take AZT, but you only have a slight neutropenia.” 4. “I do not see the need for you to worry because your neutrophil counts are well over 100.” Answer: 1 Rationale: The initial adverse effects of zidovudine (AZT) include headache, malaise, insomnia, rash, diarrhea, and fever. As AZT therapy proceeds, these symptoms become more tolerable. If anemia or neutropenia occurs, the medication will be discontinued or the therapy will be temporarily interrupted. Options 2, 3, and 4 do not address the client’s concerns. Test-Taking Strategy: Use the process of elimination, knowledge regarding this medication, and therapeutic communication techniques. Eliminate options 2, 3, and 4 because they all indicate telling the client “not to worry.” Review this medication if you had difficulty with
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this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology References: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 988. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 1034. 1870. Warfarin sodium (Coumadin) has been prescribed for the client, and the nurse teaches the client and family about the medication. Which statement by the client indicates that further teaching is necessary? 1. “I’ll use an electric shaver until the anticoagulant is discontinued.” 2. “I will buy a medication alert tag that indicates I’m on anticoagulants.” 3. “I will not take any over-the-counter medications except aspirin.” 4. “I won’t participate in games such as football anymore.” Answer: 3 Rationale: No over-the-counter medications of any kind should be ingested by a client who is taking anticoagulants. This is especially true of aspirin and/or aspirin-containing products (because of the potential to cause bleeding). Options 1, 2, and 4 are correct client statements. Electric shavers are less irritating to the skin than razors and less likely to cause a skin breakdown. Medication alert tags or bracelets should be worn. In addition, all clients should be taught to carry identification cards that list all of the medications currently being taken. Strenuous games such as contact sports that can cause bruising and skin breakdown are to be avoided. Test-Taking Strategy: Use the process of elimination noting the key words further teaching is necessary. These words indicate a false response question and that you need to select the incorrect client statement. Recalling that warfarin sodium is an anticoagulant and that anticoagulants can cause bleeding will direct you to option 3. If you had difficulty with this question, review the teaching points for clients taking anticoagulants. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 1123. 1871. A nurse has given medication instructions to a client beginning therapy with carisoprodol (Soma). The nurse determines that the client understands the effects of the medication if the client states to: 1. Expect muscle spasticity as a side effect 2. Take a missed dose when remembered, regardless of when the next dose is due 3. Avoid alcohol while taking this medication 4. Drive on city streets; avoid highway driving Answer: 3
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Rationale: Carisoprodol, a centrally-acting skeletal muscle relaxant, may cause central nervous system (CNS) side effects of drowsiness and dizziness. For this reason, the client avoids other CNS depressants, such as alcohol, while taking this medication. Driving or other activities requiring mental alertness are also avoided until the client’s reaction to the medication is known. The medication is used to reduce muscle spasticity and pain. Missed doses should be taken if remembered within 1 hour. Test-Taking Strategy: Use the process of elimination. Begin to answer this question by eliminating option 4, because driving is either indicated or not indicated. Knowing that this medication is a skeletal muscle relaxant helps you to eliminate option 1 next, since this medication relieves muscle spasms. From the remaining options, recalling that alcohol should not be taken while on any medication especially those that affect the CNS directs you to option 3. If you had difficulty with this question, review the teaching points related to this medication. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 514. 1872. Amantadine hydrochloride (Symmetrel) 100 mg orally twice daily has been prescribed for a client with Parkinson’s disease, and the nurse teaches the client about the medication. Which statement by the client indicates that further teaching is necessary? 1. “I’ll take this medication early in the morning and just before I go to bed.” 2. “I can empty the capsules into food or fluid to make swallowing easier.” 3. “I can get this medication in syrup form if I have difficulty swallowing.” 4. “I should see improvement in my condition in about 7 days.” Answer: 1 Rationale: Amantadine hydrochloride is administered twice a day, but the last dose should not be administered near bedtime since it may cause insomnia in some clients. Options 2, 3, and 4 are correct statements. Test-Taking Strategy: Note the key words further teaching is necessary. These words indicate a false response question and that you need to select the incorrect client statement. Recalling that this medication can cause insomnia will direct you to option 1. If you had difficulty with this question, review the nursing implications associated with its administration. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 44. 1873. A client is receiving sulfisoxazole (Gantrisin). The nurse determines the effectiveness of the therapy by monitoring the client’s: 1. Blood pressure
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2. Blood glucose level 3. Red blood cell count 4. White blood cell count Answer: 4 Rationale: Sulfisoxazole is an antiinfective used primarily to treat urinary tract infections. The effectiveness of the medication may be evaluated by monitoring the client’s white blood cell count, which should decrease to within normal limits with therapy. The client should also experience relief of symptoms. This medication is not used as an antihypertensive (option 1), hypoglycemic agent (option 2), or to treat anemia (option 3). Test-Taking Strategy: Focus on the name of the medication—sulfisoxazole. Recalling that most “sulfa” medications are antiinfectives will direct you to option 4. If you had difficulty with this question, review the action of this medication. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology References: Kee, J., & Hayes, E. (2003). Pharmacology: A nursing process approach (4th ed.). Philadelphia: W.B. Saunders, p. 427. Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 932. 1874. A client is receiving supplemental therapy with folic acid (Folate). The nurse evaluates the effectiveness of this therapy by monitoring the results of which of the following laboratory studies? 1. Complete blood cell count 2. Blood urea nitrogen level 3. Blood glucose level 4. Alkaline phosphatase level Answer: 1 Rationale: Folic acid is necessary for red blood cell production, and is classified as a vitamin and an antianemic. The effectiveness of therapy can be measured by monitoring the results of periodic complete blood cell counts, noting particularly the hematocrit level. Options 2, 3, and 4 are not associated with the use of this medication. Test-Taking Strategy: Focus on the name of the medication. Recalling that folic acid is a vitamin, which may be supplemented to treat anemia, will direct you to option 1. If you are not familiar with the effects of folic acid on the body, review this content. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 465. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 1164.
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1875. A client with a history of prostatic hypertrophy has been prescribed propantheline bromide (ProBanthine) for the treatment of peptic ulcer disease. The nurse determines that the client understands the medication instructions if the client states to report: 1. Abdominal cramping or diarrhea 2. Excessive salivation 3. Urinary hesitancy or retention 4. Excessive sweating Answer: 3 Rationale: Propantheline bromide is an anticholinergic medication that is used as an adjunct for therapy in peptic ulcer disease. It is also used as an antispasmodic agent. It should be used cautiously with prostatic hypertrophy, because the anticholinergic effects of the medication could cause exacerbation of symptoms, including urinary retention or hesitancy. Other side effects of the medication include constipation, dry mouth, and decreased sweating. Tachycardia is a common cardiovascular side effect. Test-Taking Strategy: Use the process of elimination recalling that this medication is an anticholinergic that causes urinary retention. Note the relation between “prostatic hypertrophy” in the question and “urinary hesitancy or retention” in the correct option. Review the side effects of this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology References: Kee, J., & Hayes, E. (2003). Pharmacology: A nursing process approach (4th ed.). Philadelphia: W.B. Saunders, p. 347. Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 119. 1876. A nurse has completed reinforcing client teaching about heart failure and prescribed medications that include digoxin (Lanoxin) and furosemide (Lasix). The nurse documents that the teaching goals have been met if the client states to report a: 1. Sudden increase in appetite 2. Weight gain of 2 to 3 pounds in a few days 3. Cough that accompanies a cold 4. High urine output during the day Answer: 2 Rationale: Clients with heart failure should immediately report weight gain, loss of appetite, shortness of breath with activity, edema, persistent cough, and nocturia. A high urine output is expected with these medications. A cough that accompanies a cold is normal. A sudden increase in appetite is insignificant. Test-Taking Strategy: Use the process of elimination. Option 1 is unrelated to the question and is eliminated first. Option 4 is expected with diuretic therapy. The client should report a persistent cough, not necessarily one that accompanies a cold. Option 2 would accompany fluid retention, and should be reported because it indicates a complication of heart failure. Review the expected effects of these medications and the signs and symptoms of heart failure if you had difficulty with this question. Level of Cognitive Ability: Analysis
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Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 480. 1877. A nurse is collecting data on a client with myasthenia gravis. The nurse determines that the client may be developing myasthenic crisis if the client states: l. “I took my pills late last night.” 2. “I can hardly think straight today.” 3. “I dropped one of my pills on the floor.” 4. “I can’t swallow very well today.” Answer: 4 Rationale: Because dysphagia is a classic sign of myasthenia gravis exacerbation, observing how a client is able to ingest food is an important assessment. Timing of this medication is of paramount concern. Although options 1, 2, and 3 may require further assessment, option 4 reflects the potential of developing myasthenic crisis. Test-Taking Strategy: Use the process of elimination focusing on the issue—that the client may be developing myasthenic crisis. Recalling that dysphagia is a classic sign of myasthenia gravis exacerbation will direct you to option 4. Review the clinical manifestations of myasthenic crisis if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 762. 1878. An 8-day-old infant is irritable, has a high-pitched persistent cry, and has a temperature of 99.4° F. The infant is also tachypneic and diaphoretic, continues to lose weight, and is hyperactive to environmental stimuli. The nurse determines that these behaviors may be consistent with: 1. Hypercalcemia 2. Drug withdrawal 3. Sepsis 4. Intraventricular hemorrhage Answer: 2 Rationale: Drug withdrawal causes a hyperactive response in the infant because of the increased central nervous system (CNS) stimulation (tachypnea, elevated temperature, increased use of calories). This response and the signs and symptoms of drug withdrawal seem to be most apparent at around 1 week of age. Hypercalcemia, sepsis, and intraventricular hemorrhage are characterized by symptoms of CNS depression. Test-Taking Strategy: Use the process of elimination focusing on the data in the question. Note the key word hyperactive in the question. This indicates CNS stimulation. Eliminate options 1, 3, and 4 because these conditions produce CNS depression. If you had difficulty with this question, review the signs and symptoms of drug withdrawal in
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the newborn infant. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 1075, 1077. 1879. A client received a dose of regular insulin (Humulin R) this morning at 7:00 AM . At what time would the nurse most likely anticipate the potential for a hypoglycemic reaction to occur? 1. 8:00 AM 2. 10:00 AM 3. Noon 4. 2:00 PM Answer: 2 Rationale: Humulin R is a rapid-acting insulin with a peak action of 2 to 4 hours after injection. Hypoglycemic reactions are most likely to occur during the peak action of insulin. This makes option 2 correct. Test-Taking Strategy: Use the process of elimination and knowledge regarding the general action (onset, peak, and duration) of rapid-acting insulin to answer the question. Remember that Humulin “R (regular)” indicates “rapid” and that the peak action occurs in 2 to 4 hours after injection. If you had difficulty with this question, review the characteristics of rapid-acting insulin. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 570. Kee, J., & Hayes, E. (2003). Pharmacology: A nursing process approach (4th ed.). Philadelphia: W.B. Saunders, p. 737. 1880. A nurse is preparing a postpartum client who had a cesarean delivery for discharge to home. Which statement by the client indicates a need for additional discharge preparation? 1. “I will lift nothing heavier than the baby for two weeks.” 2. “I can start doing abdominal exercises as soon as I get home.” 3. “If I develop a fever, I will call my doctor.” 4. “When getting out of bed, I will turn on my side and push up with my arms.” Answer: 2 Rationale: Abdominal exercises should not be started following abdominal surgery until 3 to 4 weeks postoperatively to allow for healing of the incision. Options 1, 3, and 4 reflect proper understanding of self-care after discharge. Test-Taking Strategy: Use the process of elimination noting the key words need for additional discharge preparation. These words indicate a false response question and
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that you need to select the incorrect client statement. Noting that the client had a cesarean delivery and recalling the general postoperative instructions related to abdominal surgery will direct you to option 2. Review home care instructions following cesarean delivery if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Maternity/Postpartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 1021. 1881. A nurse enters a new mother’s room and finds that the mother is crying and that the infant is undressed on the bed in front of the mother. The mother looks at the nurse and says, “I can’t even dress this baby!” After reassuring the client, the nurse determines that the most appropriate nursing action would be to: 1. Diaper the infant while it is lying on the bed 2. Place the infant back in the bassinet 3. Place the infant in the bassinet and take the infant back to the nursery 4. Have the mother place the infant in the bassinet and assist the mother in dressing the baby Answer: 4 Rationale: The infant needs to be placed in the bassinet for safety. The mother needs to be reassured that she can safely care for her infant, and the nurse should assist the mother in dressing the baby. Option 1 is incorrect because the infant needs to be placed in the bassinet for safety. Options 2 and 3 are incorrect because these actions do not address the mother’s needs. Option 4 is the only option that focuses on the mother’s feelings and needs and the safety of the infant. Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Note that option 4 is the only option that addresses both the infant and the mother. Review the psychosocial needs of a new mother if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Reference: Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternalnewborn nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 566-567. 1882. A client with acquired immunodeficiency syndrome (AIDS) has a low T4 count. The nurse initiates prophylactic treatment as prescribed with aerosolized pentamidine isethionate (NebuPent) and monitors for which expected outcome? 1. The client has a respiratory rate and depth within normal limits for activity level 2. Strict standard precautions were maintained 3. The client shows no weight loss 4. The client maintains serum sodium, potassium, calcium, and chloride values within normal ranges
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Answer: 1 Rationale: Aerosolized pentamidine is given prophylactically to clients with a T4 count below 200 to prevent Pneumocystis jiroveci pneumonia, which is the most common opportunistic infection that occurs in clients with AIDS. A respiratory rate and depth within normal limits for activity level would indicate that the client was not experiencing the respiratory difficulty that is associated with pneumonia. Standard precautions are always maintained on all clients. Although weight loss and electrolyte imbalance can occur in the client with AIDS, these options are not related to this medication. Test-Taking Strategy: Use the process of elimination and the ABCs—airway, breathing, and circulation. Option 1 relates to the respiratory status of the client. If you had difficulty with this question, review this medication. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 844. 1883. A client with type 1 diabetes mellitus takes NPH insulin every morning and checks the blood glucose level four times per day. The client tells the nurse that yesterday her late-afternoon blood glucose level was 60 mg/dl and that she “felt funny.” Which statement by the client would indicate an understanding of this occurrence? 1. “My blood glucoses are running low because I’m tired.” 2. “I forgot to take my usual afternoon snack yesterday.” 3. “I took less insulin this morning so I won’t feel funny today.” 4. “I don’t know why I have to check my blood glucose four times a day. That seems too much.” Answer: 2 Rationale: Hypoglycemia is a blood glucose level of 60 mg/dl or less. The causes are multiple, but in this case omitting the afternoon snack is the cause. Fatigue and selfadjustment of dose are incorrect options. Recommended blood glucose testing for the client with type 1 diabetes mellitus is at least four times a day. Test-Taking Strategy: Use the process of elimination and knowledge regarding the pathophysiology of diabetes mellitus. Noting that a blood glucose reading of 60 mg/dl indicates hypoglycemia and recalling the causes of hypoglycemia will direct you to option 2. If you had difficulty with this question, review the causes of hypoglycemia. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 571. 1884. A pregnant woman reports that she has just finished taking the prescribed antibiotics to treat her urinary tract infection. The mother expresses concern that her baby will be born with an infection. Which response would the nurse make to help
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reduce the maternal fears that the newborn will be born with an infection? 1. “Urinary infections during pregnancy are common. Your baby will be fine.” 2. “Your developing baby cannot acquire an infection from you during pregnancy.” 3. “Now that you have taken the medication as prescribed, we will continue to monitor you closely by repeating the urine culture before you leave today.” 4. “You shouldn’t worry about this since you received early prenatal care and are taking your prenatal vitamins.” Answer: 3 Rationale: Symptomatic bacteriuria has been associated with an increased risk of neonatal sepsis following delivery. Appropriate prenatal care of a client with a urinary tract infection includes antibiotic treatment and follow-up repeat urine cultures. Option 3 is the only therapeutic response and is the response that identifies accurate information. Test-Taking Strategy: Use the process of elimination and therapeutic communication techniques. Eliminate option 2 first because this response does not identify accurate information. Next eliminate options 1 and 4 because they provide false reassurances. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Application Clients Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Antepartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 422. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 723, 729. 1885. A nurse is collecting data from a human immunodeficiency virus (HIV) positive pregnant woman during gestational week 32. The nurse reviews the data and determines that which finding requires further follow-up? 1. Slight lower extremity edema 2. Increased shortness of breath and bilateral wheezes 3. Active fetal movement 4. Weight gain of 22 pounds Answer: 2 Rationale: Human immunodeficiency virus infection in a pregnant woman may cause both maternal and fetal complications. Fetal compromise can occur because of premature rupture of the membranes, preterm birth, or low birth weight. Potential maternal effects include an increased risk of opportunistic infections. Individuals in the later stages of HIV are further susceptible to other invasive conditions, such as tuberculosis and a wide variety of bacterial infections. The finding in option 2 can be indicative of an opportunistic infection and requires follow-up. Test-Taking Strategy: Note the key words requires further follow-up. These words indicate a false response question and that you need to select the abnormal finding. Eliminate options 1, 3, and 4 because these are normal findings. Additionally, use the ABCs—airway, breathing, and circulation—to direct you to the correct option. Review care to the HIV positive pregnant woman if you had difficulty with this question. Level of Cognitive Ability: Analysis
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Clients Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum References: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 203, 1065. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 729-730. 1886. A client with multiple sclerosis is receiving diazepam (Valium), and the home care nurse provides instructions to the client regarding the side effects of the medication. The nurse tells the client that which of the following is a side effect of this medication? 1. Insomnia 2. Incoordination 3. Inability to urinate 4. Increased salivation Answer: 2 Rationale: Incoordination and drowsiness are common side effects resulting from this medication. Options 1, 3, and 4 are unrelated to the use of this medication. Test-Taking Strategy: Use the process of elimination. Note that the question addresses a centrally-acting skeletal muscle relaxant. This will assist in directing you to option 2. If you had difficulty with this question, review the side effects associated with diazepam. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 315. 1887. A nurse palpates the anterior fontanelle of a neonate and notes that it feels soft. The nurse analyzes these data as indicative of: 1. Increased intracranial pressure (ICP) 2. Dehydration 3. Decreased ICP 4. A normal finding Answer: 4 Rationale: The anterior fontanelle is normally 2.5 to 5 cm in width and diamond-like in shape. It can be described as soft, which is normal, or full and bulging, which could be indicative of increased ICP. Conversely, a depressed fontanelle could mean that the neonate is dehydrated. Test-Taking Strategy: Use the process of elimination noting the key words feels soft in the question. Remember that the anterior fontanelle is soft in the neonate. If you had difficulty answering this question, review normal findings in a neonate. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum
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References: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 718. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 504. 1888. A nurse is preparing to administer digoxin (Lanoxin) to an adult client. The nurse checks which most important item before administering the medication? 1. Neurological signs 2. Blood pressure 3. Apical pulse rate 4. Level of consciousness Answer: 3 Rationale: Digoxin is a cardiac glycoside that is used to manage and treat heart failure and to control ventricular rates in clients with atrial fibrillation. Before administering the medication, the nurse needs to assess the apical heart rate for 1 minute. If the pulse rate is less than 60 beats per minute in an adult client, the nurse would withhold the medication and contact the physician because a low pulse rate may be an indication of toxicity. Options 1, 2, and 4 may be a component of the assessment depending on the client’s diagnosis. However, these assessments are not specifically associated with the use of digoxin. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 4 first because they are similar. From the remaining options, recalling that digoxin is a cardiac glycoside will direct you to option 3. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2004). Saunders nursing drug handbook 2004. Philadelphia: W.B. Saunders, p. 310. 1889. After a newborn infant undergoes circumcision, which of the following would the nurse include in the postprocedure plan of care? 1. Restricting oral intake for several hours 2. Ensuring informed consent is obtained from the parents 3. Restraining the infant on a Circumstraint board 4. Observing for bleeding and assessing for pain Answer: 4 Rationale: Following a circumcision, the nurse should observe for bleeding, which is the most common complication. A common protocol is to assess the site every hour for 8 to 12 hours. Assessing for pain by looking at the infant’s facial expressions, body movements, and character of crying will indicate the need to minimize or lessen pain. Nutrition is important. The informed consent is to be obtained before the procedure. Restraints are not necessary postprocedure. Test-Taking Strategy: Use the process of elimination noting the key words postprocedure. Options 1, 2, and 3 are nursing actions required before (options 1 and 2)
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and during (option 3) the procedure. Review postprocedure care following circumcision if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 168. 1890. A nurse is assisting in preparing a client for a cardiac catheterization. The nurse understands that it is most important to check the client for a history of: 1. Allergy to shellfish 2. Hypertension 3. Atrial fibrillation 4. Cigarette smoking Answer: 1 Rationale: Determination before the procedure that a client has allergies to seafood, iodine, or iodine contrast media may necessitate a skin test for allergy severity and the use of prophylactic antihistamines to prevent an allergic response to the contrast medium. The other options are important parts of the client’s history, but are not specific to a cardiac catheterization procedure. Test-Taking Strategy: Note the key words most important. These words indicate that more than one option may be correct but that you need to determine which option is the priority based on the data in the question. Recalling that the contrast medium used for cardiac catheterization usually has an iodine base and that the allergen in shellfish is usually iodine will direct you to option 1. Review preprocedure care for cardiac catheterization if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Delegating/Prioritizing Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 327. 1891. A student nurse is assigned to assist in caring for a client with acute pulmonary edema who is receiving digoxin (Lanoxin) and subcutaneous heparin therapy. The nursing instructor reviews the plan of care formulated by the student and tells the student that which intervention is unsafe? 1. Holding the digoxin for a heart rate less than 60 beats per minute 2. Administering the heparin with a 25-gauge needle 3. Restricting the client’s potassium intake 4. Encouraging the client to rest after meals Answer: 3 Rationale: Clients with acute pulmonary edema are on a sodium-restricted diet, not potassium-restricted. Restricting potassium intake makes the client more prone to digoxin toxicity. Digoxin should be held and the physician notified when the client’s
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heart rate is less than 60 beats per minute, unless otherwise ordered. Heparin should be administered with a 25- or 27-gauge needle to reduce tissue trauma. Resting after meals decreases the demands placed on the heart and should be encouraged. Test-Taking Strategy: Focus on the data in the question and note the key word unsafe. This word indicates a false response question and that you need to select the incorrect intervention. Noting the word “restricting” in option 3 will direct you to this option. If you had difficulty with this question, review care to the client with acute pulmonary edema. Level of Cognitive Ability: Analysis Client Needs: Safe, Effective Care Environment Integrated Process: Teaching/Learning Content Area: Leadership/Management Reference: Hodgson, B., & Kizior, R. (2004). Saunders nursing drug handbook 2004. Philadelphia: W.B. Saunders, p. 311. 1892. A nurse is assisting in planning care for a client with Hodgkin’s disease who is neutropenic due to radiation and chemotherapy. Which plan would be most effective in decreasing the risk of infection? 1. Limiting visitors to immediate family only 2. Providing a diet high in protein 3. Ensuring meticulous hand washing before caring for the client 4. Monitoring electrolyte levels daily Answer: 3 Rationale: Specific nursing management of the client undergoing treatment for Hodgkin’s disease focuses on the medication-induced side effects. Risk for infection is a significant consideration, and hand washing is the most effective means of decreasing risk of infection. Limiting visitors to immediate family only is not the best measure because an immediate family member could transmit an infection. Options 2 and 4 do not directly relate to infection. Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 4 because diet and electrolytes do not directly relate to infection. Limiting visitors to only immediate family is not the best measure because an immediate family member could transmit an infection. Review measures that decrease the risk of infection if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Adult Health/Oncology Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 281. 1893. A nurse is caring for a client who has undergone pelvic exenteration. In addressing psychosocial issues related to the surgery, which statement by the nurse would be most therapeutic? 1. “Would you like to talk?” 2. “How do you feel about your body?”
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3. “You are looking good today.” 4. “Will your family help you deal with this?” Answer: 2 Rationale: Postoperatively, a woman begins to deal with the trauma of the surgery by expressing grief about her mutilated body. Later, she may become depressed or withdrawn or even angry or hostile. The woman needs intense emotional support if she is to adapt to her altered body image and functions. Option 2 is the only option that addresses the client’s feelings. Test-Taking Strategy: Use therapeutic communication techniques. Open-ended questions are most therapeutic, so eliminate options 1 and 4. From the remaining options, option 2 is open-ended and focuses on the client’s feelings. Remember, focus on the client’s feelings first. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Caring Content Area: Adult Health/Oncology References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1074. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, pp. 437-440. 1894. A nurse is assisting in planning care for a client just admitted to the hospital with a diagnosis of cardiovascular insufficiency. The nurse would include as a priority: 1. Maintenance of good body alignment while on bed rest 2. Maintenance of as large a fluid intake as allowed 3. Family instruction on how to obtain medical assistance 4. The need to teach the client about medications Answer: 1 Rationale: Good body alignment promotes rest and relaxation and decreases the workload of the cardiovascular system. Adequate fluid intake is important, but a large fluid intake could stress the heart. Option 3 addresses the family, not the client. Option 4 is not a priority immediately after admission to the hospital. Test-Taking Strategy: Use the process of elimination. Eliminate option 3 because it does not address the client of the question. Eliminate option 2 next noting that it addresses large amounts of fluids. From the remaining options, focusing on the client’s diagnosis will direct you to option 1. Review care to the client with cardiovascular insufficiency if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Cardiovascular Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1659. 1895. A nurse is caring for a client who verbalizes a need to increase her self-esteem.
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The nurse plans to assist the client to achieve the goal of gaining self-esteem by encouraging the client to: 1. Institute measures to prevent tooth decay 2. Maintain a daily diary of negative feelings 3. Maintain a well-groomed appearance 4. Verbalize feelings of being unloved Answer: 3 Rationale: The client may demonstrate increased feelings of self-esteem through outward appearance. Options 2 and 4 focus on negative issues and should be avoided. Option 1 is indirectly related to self-esteem. Test-Taking Strategy: Use the process of elimination and focus on the issue of selfesteem. Eliminate options 2 and 4 because they focus on negative issues. From the remaining options, note that option 3 is directly related to self-esteem and is the umbrella (global) option. Review measures that increase self-esteem if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Reference: Keltner, N., Schwecke, L., & Bostro, C. (2003). Psychiatric nursing (4th ed.). St. Louis: Mosby, p. 356. 1896. A nurse is assisting in planning stress management strategies for the client with irritable bowel syndrome. Which suggestion would the nurse give to the client? 1. Try to avoid every possible stressful situation 2. Learn measures such as biofeedback or progressive relaxation 3. Limit exercise to reduce bowel stimulation 4. Rest in bed as much as possible Answer: 2 Rationale: Treatment for irritable bowel syndrome includes stress reduction measures such as biofeedback, progressive relaxation, and regular exercise. The client should also learn to limit own responsibilities. Other measures include increased fluid and fiber in the diet as prescribed, and antispasmodic or sedative medications as needed. Test-Taking Strategy: Use the process of elimination. Begin to answer this question by eliminating options 3 and 4 because they are similar. Next eliminate option 1, since the word “every” in the option is an absolute word. If you had difficulty with this question, review appropriate stress management techniques for the client with irritable bowel syndrome. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Gastrointestinal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 848. 1897. A nurse plans to change the dressing of the client who has had arterial bypass
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surgery. Which technique is most important for the nurse to follow? 1. Standard precautions 2. Aseptic technique 3. Clean technique 4. Reverse isolation technique Answer: 2 Rationale: Aseptic technique is important to reduce risk of infection. Standard precautions are important, but are not specific to this procedure. Reverse isolation is not necessary, and clean technique would place the client at risk for infection. Test-Taking Strategy: Focus on the issue—the most important technique to follow for the client who has had surgery. While standard precautions are important, they do not protect the client from infection. Focusing on the issue—preventing infection—will direct you to option 2. Review care to the client following surgery if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 786. 1898. A client has an inoperable abdominal aortic aneurysm (AAA). The nurse reinforces with the client about the need for: 1. Antihypertensives 2. Bed rest 3. Restricting fluids 4. Maintaining a low-fiber diet Answer: 1 Rationale: The medical treatment for AAA is controlling blood pressure. Hypertension creates added stress on the blood vessel wall, increasing the likelihood of rupture. There is no need for the client to restrict fluids or to have bed rest prescribed. A low-fiber diet is not helpful and will cause constipation. Test-Taking Strategy: Use the process of elimination. Recalling the relation between AAA and hypertension will direct you to option 1. If this question was difficult, review AAA and its treatment. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Cardiovascular Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, pp. 790-791. 1899. A nurse is assisting in developing a teaching plan for a pregnant client with diabetes mellitus. Which instruction is the priority for this client? 1. How to test for proteinuria
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2. How to check for and manage preterm bleeding 3. How to manage the discomfort of early labor 4. How to check for signs of hypoglycemia and the required treatment Answer: 4 Rationale: In diabetes mellitus, the pancreas does not produce enough insulin for necessary carbohydrate metabolism. The physiological changes of pregnancy drastically alter insulin requirements. Pregnant diabetic clients should be taught to monitor themselves for hypoglycemia to minimize potential maternal and fetal effects that result from hypoglycemia. Testing for proteinuria is important for the mother with pregnancyinduced hypertension. Management of preterm bleeding is taught to the mother with placenta previa. Managing the discomforts of early labor is important for all pregnant women. Test-Taking Strategy: Note the key word priority. Note the relation between “diabetes mellitus” in the question and “hypoglycemia” in the correct option. Review care to the pregnant client with diabetes mellitus if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Planning Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 229. 1900. A nurse is preparing to teach a new mother to breast-feed. Which factor is most important to promote an effective and positive learning experience? 1. Separation of infant and mother after birth is important to allow the mother to rest 2. Previous breast-feeding experience 3. A physician that encourages clients to breast-feed 4. A positive nurse-client relationship Answer: 4 Rationale: Because hospital stays are short, all contacts with the mother become teachable moments. A positive nurse-client relationship is a growth-fostering experience that will enhance the teaching/learning experience. Separation of the infant and mother decreases the chance of correct latch and suck in the immediate postpartum period. The infant should be placed at the breast immediately after delivery. The mother, not the physician, makes the decision regarding the method of feeding. Although previous breast-feeding experience is helpful, the most significant factor is the nurse-client relationship. Test-Taking Strategy: Use the process of elimination noting the key words most important. Focus on the issue—to promote an effective and positive learning experience —and note the relation of the issue and option 4. Review teaching/learning principles if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders,
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