Silvestri401-500

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PN Comprehensive Review CD Questions 401-500 401. A client with tuberculosis is being started on antituberculosis therapy with isoniazid (INH). The nurse reviews the client’s health care record to be sure that which of the following baseline studies have been completed before giving the client the first dose? 1. Coagulation times 2. Electrolytes 3. Serum creatinine 4. Liver enzymes Answer: 4 Rationale: Isoniazid therapy can cause an elevation of hepatic enzymes and hepatitis. Therefore liver enzymes are monitored when therapy is initiated and during the first 3 months of therapy. They may be monitored longer in the client who is over age 50 or abuses alcohol. Options 1, 2, and 3 are not specifically related to the administration of this medication. Test-Taking Strategy: Focus on the name of the medication. Recalling that this medication can be toxic to the liver 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/Implementation Content Area: Adult Health/Respiratory Reference: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 944. 402. A nurse is monitoring the respiratory status of the client who has suffered a fractured rib. The nurse monitors the client and understands that which manifestation is unrelated to the rib fracture? 1. Pain, especially with inspiration 2. Slow, deep respirations 3. Splinting or guarding the chest 4. Bruising over the fracture area Answer: 2 Rationale: Rib fractures are a common injury, especially in the older client, and result from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness that is localized at the fracture site and is exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Test-Taking Strategy: Use the process of elimination and note the key word unrelated. This word indicates a false response question, and you need to select the incorrect manifestation. Knowing that fractured ribs can cause pain and bruising helps you to eliminate options 1 and 4 first. To select between options 2 and 3, recalling that pain causes shallow, guarded respirations helps you to choose option 2 as the unrelated finding. Review the clinical manifestations in rib fractures if you had difficulty with this

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question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Respiratory Reference: Linton, A. & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 487. 403. A nurse is admitting a client to the nursing unit who is suspected of having tuberculosis. The nurse plans to admit the client to a room that has: 1. Ultraviolet light and three air exchanges per hour 2. Ten air exchanges per hour and venting to the outside 3. Venting to the outside and ultraviolet light 4. Venting to the outside, six air exchanges per hour, and ultraviolet light Answer: 4 Rationale: The client is admitted to a private room that has at least six air exchanges per hour, and which has negative pressure in relation to surrounding areas. The room should be vented to the outside and should have ultraviolet lights installed. Test-Taking Strategy: Begin to answer this question by recalling the specific requirements of physical facilities that are used in the care of clients with TB. Knowing that the air must vent to the outside helps to eliminate option 1. Knowing that ultraviolet light is useful in killing these organisms helps you to eliminate option 2. To select between the last two options, it is necessary to know that there must be an airflow system that allows for at least six air exchanges per hour. Review care to the client hospitalized with TB 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/Respiratory Reference: Christensen, B. & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 375. 404. A client with human immunodeficiency virus (HIV) who has contracted tuberculosis (TB) asks the nurse how long the medication therapy lasts. The nurse responds that the duration of therapy would most likely be for at least: 1. Six total months and at least 1 month after cultures convert to negative 2. Six total months and at least 3 months after cultures convert to negative 3. Nine total months and at least 3 months after cultures convert to negative 4. Nine total months and at least 6 months after cultures convert to negative Answer: 4 Rationale: The client with tuberculosis who is coinfected with HIV requires that antituberculosis therapy last longer than usual. The prescription is usually for a total of 9 months and at least 6 months after sputum cultures convert to negative. Test-Taking Strategy: Use the process of elimination. Knowing that the client with HIV requires longer therapy helps you to eliminate options 1 and 2 first. To select between the last two options, it is necessary to recall that sputum culture must be negative for 6

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months before terminating medication therapy because of the immunosuppressed status of the client. Review the guidelines related to medication therapy in the client with TB 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/Immune Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 375. 405. Morphine sulfate is being administered to a client with cancer. The nurse is monitoring the client for signs of overdose related to this medication therapy. Which of the following findings if noted in the client would require notification of the registered nurse? 1. Blood pressure 110/70 mm Hg 2. Apical rate of 72 beats/min 3. Temperature of 98.6° F 4. Respirations of 10 breaths/min Answer: 4 Rationale: Before an opioid is administered, respiratory rate, blood pressure, and pulse rate should be determined. The registered nurse is notified immediately if the respiratory rate is at or below 12 breaths per minute, if the blood pressure is significantly below the pretreatment value, or if the pulse rate is significantly above or below the pretreatment value. The registered nurse would then contact the physician. Test-Taking Strategy: Knowledge regarding normal vital sign measurements will assist in directing you to the correct option. Additionally, knowing that morphine sulfate primarily affects the respiratory rate will assist in directing you to option 4. 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/Evaluation Content Area: Pharmacology Reference: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 250. 406. A nurse is collecting data from a client who is experiencing the typical clinical manifestations of tuberculosis (TB). The nurse would expect the client to report having symptoms of fatigue and cough that have been present for: 1. A day or two 2. Almost a week 3. One to 2 weeks 4. Several weeks to months Answer: 4 Rationale: The client with tuberculosis may report symptoms that have been present for weeks or even months. The symptoms may include fatigue, lethargy, chest pain, anorexia

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and weight loss, night sweats, low grade fever, and cough with mucoid or blood-streaked sputum. It may be the production of blood-tinged sputum that finally forces some clients to seek care. Test-Taking Strategy: To answer this question, it is necessary to be familiar with the usual clinical manifestations of TB. Even without specific knowledge, you may be able to determine the correct answer by knowing that TB is an insidious health problem, which is hard to eradicate. It makes sense that if clients reported it early, it would not be the increasingly prominent health problem that it is. Review the clinical manifestations of TB if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Respiratory Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 602. 407. A client who is human immunodeficiency virus (HIV) positive has had a Mantoux test. The results show a 7-mm area of induration. The nurse evaluates that this result is: 1. Negative 2. Borderline 3. Uncertain 4. Positive Answer: 4 Rationale: The client with HIV is considered to have positive results on Mantoux testing with an area of 5 mm of induration or greater. The client without HIV has positive test results with induration greater than 10 mm or 15 mm if the client is at low risk. The client with HIV is immunosuppressed, making a smaller area of induration a positive test result for this type of client. It is also possible for the client infected with HIV to have false-negative readings because of the immunosuppression factor. Test-Taking Strategy: Use the process of elimination to answer the question. Begin by eliminating options 2 and 3 because they are similar. Remembering that the client with HIV is immunosuppressed will assist in directing you to option 4, the correct option. Review the procedures for interpreting the results of this test if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Immune Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 374. 408. A client has an order to receive purified protein derivative (PPD) 0.1 mL intradermally (Mantoux test). The nurse prepares to administer the PPD and obtains a tuberculin syringe with a 26-gauge, ⅝-inch needle, knowing that the needle will be inserted: 1. Almost parallel to the skin with bevel side up

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2. At a 45-degree angle with bevel side down 3. Almost parallel to the skin with bevel side down 4. At a 30-degree angle with bevel side down Answer: 1 Rationale: A Mantoux test is administered by giving 0.1 mL of purified protein derivative (PPD) intradermally. This involves drawing the medication into a tuberculin syringe with a 25- to 27-gauge, ⅝-inch needle. The injection is given by inserting the needle as close as possible to a parallel position with the skin and with the needle bevel facing up. This results in formation of a wheal when administered correctly. Test-Taking Strategy: Use the process of elimination, remembering that the bevel side is up during the administration of PPD. This will assist in directing you to the correct option. Also note that options 2, 3, and 4 are similar in that they indicate administration with the bevel side down. Review the procedure for administering this test if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Respiratory Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 766. 409. Cycloserine (Seromycin) is added to the medication regimen for a client with tuberculosis. Which of the following would the nurse suggest to include in the client teaching plan regarding this medication? 1. It is necessary to take the medication before meals. 2. It is necessary to return to the clinic weekly for serum drug levels. 3. It is not necessary to call the physician if a skin rash occurs. 4. It is not necessary to restrict alcohol intake with this medication. Answer: 2 Rationale: Cycloserine is an antitubercular medication that requires weekly serum drug level determinations to monitor for the potential of neurotoxicity. Serum drug levels less than 30 mg/mL reduce the incidence of neurotoxicity. The medication needs to be taken after meals to prevent gastrointestinal irritation. The client needs to be instructed to notify the physician if a skin rash or early signs of central nervous system toxicity are noted. Alcohol needs to be avoided because it increases the risk of seizure activity. Test-Taking Strategy: Use the process of elimination and general medication guidelines to eliminate options 3 and 4. From this point, knowing that the medication level needs to be monitored will assist you in selecting the correct option. If you had difficulty with this question, review this medication. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Respiratory References: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 947. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St.

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Louis: Mosby, p. 1054. 410. A nurse is assisting in providing a class to new mothers on newborn care. In teaching umbilical cord care, the nurse makes which suggestion to the new mothers? 1. If triple dye has been applied to the cord, it is not necessary to do anything else to it. 2. Apply alcohol to the cord ensuring that all areas around the cord are cleaned two to three times a day. 3. Gently apply alcohol to the cord, being careful not to move the cord because it will cause the newborn pain. 4. All that is necessary is to wash the cord with antibacterial soap, allowing it to air-dry one time a day. Answer: 2 Rationale: The cord and base should be cleaned with alcohol two to three times per day. The steps are to lift the cord, wipe around the cord starting at the top and wiping around it, clean the base of the cord, and fold the diaper below the umbilical cord to allow the cord to air-dry. Continuation of cord care is necessary until the cord falls off within 7 to 14 days. The baby does not feel pain in this area. Water and soap are not necessary; in fact the cord should be kept from getting wet. Test-Taking Strategy: Use the process of elimination. Recalling that alcohol is used to cleanse the cord will assist in eliminating options 1 and 4. From the remaining options, recall that this procedure is not painful. Review the principles related to cord care 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, pp. 154, 156. 411. A nurse’s assignment is to visit a new mother at home who was recently discharged from the hospital. What finding would the nurse expect to note in a healthy breastfeeding mother and newborn? 1. A mother breast-feeding with the newborn in a tummy-to-tummy position every 3 to 4 hours without signs of cracked nipples; the baby demonstrates bursts of sucking followed by a pause and swallow 2. A mother breast-feeding the newborn with the newborn’s head turned toward her breast, with the body flat in her arms; mother with sore nipples and newborn with a suck blister, and wetting three to four diapers a day 3. A mother complaining of breast engorgement, breast-feeding every 6 to 8 hours, with the newborn demonstrating difficulty in latching on to the breast 4. A mother with cracked nipples feeding the newborn with a supplemental bottle Answer: 1 Rationale: The baby should be positioned completely facing the mother with head, neck, and spine aligned. Poor positioning increases the number of attempts for latching on. Options 2, 3, and 4 all identify complications (sore nipples, breast engorgement, cracked nipples).

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Test-Taking Strategy: Use the process of elimination and focus on the issue, normal findings. Option 2 is incorrect because it demonstrates improper positioning. Options 3 and 4 are the result of improper positioning. Additionally, options 2, 3, and 4 all identify complications (sore nipples, breast engorgement, cracked nipples). Option 1 is the only option that identifies a normal expectation. Review breast-feeding techniques if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 180. 412. In caring for a preterm newborn’s skin, the nurse must understand the special characteristics that exist. These include a: 1. Thin and gelatinous skin with decreased amounts of subcutaneous fat and an open posture 2. Thin and gelatinous skin with a flexed posture and decreased subcutaneous fat 3. Thin and gelatinous skin with a flexed posture and increased amounts of brown fat 4. Fine downy hair on a thin epidermal and dermal layer with flexed posture and increased amount of brown fat Answer: 1 Rationale: The skin of a newborn plays a significant role in thermoregulation and as a barrier against infection. The skin is immature in contrast to a term newborn. The skin of a preterm newborn is thin and gelatinous. There are decreased amounts of subcutaneous fat, brown fat, and glycogen stores. In addition, preterm newborns lose heat because of the high body surface area in relation to their weight and because their posture is more relaxed with less flexion. For these reasons, preterm newborns are less able to generate heat. This places the preterm newborn at risk for increased heat loss and increased fluid requirements. Test-Taking Strategy: Use the process of elimination. Options 2, 3, and 4 are incorrect. Preterm newborns have open posture (option 1), which contributes to heat loss. Also, they have decreased amounts of subcutaneous and brown fat. Option 4 is partially correct in that the newborn may have fine downy hair, but the remainder of this option is incorrect. Review the characteristics of a preterm newborn 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 Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 306. 413. A nurse is caring for a newborn who has hyperbilirubinemia. Which of the following actions is recommended for a newborn that is being breast-fed and who has

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hyperbilirubinemia? 1. Alternate feeding with supplemental formula. 2. Stop breast-feeding for 48 hours and have the mother pump the breasts. 3. Add additional feedings with bottled glucose. 4. Increase the frequency of breast-feeding. Answer: 4 Rationale: The greater the number of breast-feedings, the lower the bilirubin. Breastfeeding should be initiated early and frequently. Supplementation with water does not reduce hyperbilirubinemia. Water, glucose, or formula supplements should be discouraged. Test-Taking Strategy: Use the process of elimination. Options 1 and 2 are incorrect because these options do not encourage continuation of breast-feeding and can cause nipple confusion in the newborn. Option 3 is incorrect. Bilirubin is excreted in the stool, and the addition of bottled glucose will only cause an increase in urination. Review this disorder if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum References: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 300. Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 312. 414. A nurse observes slight facial jaundice in a 2-day-old full-term neonate. The nurse interprets this finding using which of the following guidelines? 1. Facial jaundice is common from birth to 5 days old. 2. Bilirubin is produced at minimal rates in the neonate immediately following delivery. 3. Jaundice is visible on the skin of a neonate at bilirubin levels from 4 to 6 mg/dl, which are not abnormal in a 2-day-old neonate. 4. The neonate possesses an adequate supply of liver enzymes to conjugate excess bilirubin following delivery. Answer: 3 Rationale: Neonatal bilirubin levels below 12 mg/dl on the second to seventh day following birth are considered normal in the full-term neonate. The amount of the enzyme necessary for the conjugation of bilirubin may be decreased. Additionally the delayed passage through the gastrointestinal tract and the rapid production of bilirubin from the breakdown of excess fetal red blood cells may lead to rising levels of unconjugated bilirubin and jaundice in the neonate. Test-Taking Strategy: A thorough understanding of the principles of normal physiological jaundice in the full-term neonate is necessary to answer this question correctly. Remember neonatal bilirubin levels below 12 mg/dl on the second to seventh day following birth are considered normal in the full-term neonate. If you had difficulty with this question, review the content related to normal physiological jaundice. Level of Cognitive Ability: Analysis

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Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Postpartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 312. 415. A nursing student is preparing to instill a medication into the eyes of a newborn as a preventive measure against ophthalmic neonatorum. The nursing instructor asks the student to identify the medication for the prophylaxis of ophthalmic neonatorum and gonococcal infection. The student correctly replies by telling the instructor that this medication is: 1. Erythromycin 2. Neomycin 3. Penicillin 4. Silver nitrate Answer: 1 Rationale: Erythromycin ophthalmic 0.5% ointment is a broad spectrum antibiotic and is used prophylactically to prevent ophthalmic neonatorum, an eye infection acquired from the baby’s passage through the birth canal. Ophthalmic neonatorum is caused mostly by the presence of gonococci and/or chlamydia. Infection from these organisms can cause blindness or serious eye damage. Erythromycin is effective against both chlamydia and gonococci. None of the other medications are effective against both bacteria. Test-Taking Strategy: Knowledge of newborn care and the prevention of ophthalmic neonatorum are necessary to answer this question. Remember erythromycin ophthalmic 0.5% ointment is a broad spectrum antibiotic and is used prophylactically to prevent ophthalmic neonatorum. Review this content and newborn care if you had difficulty with this question. Level of Cognitive Ability: Comprehension 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, p. 159. 416. A nurse reinforces discharge instructions to the mother of a 5-day-old postterm newborn who required ventilatory support for 3 days for meconium aspiration. Which of the following statements indicates that the mother needs further teaching? 1. “If my baby’s hands and feet are blue in color, it usually means that they are cold.” 2. “My baby should be drinking 2½ to 3 oz every 4 hours.” 3. “I understand that my baby will be susceptible to respiratory infections throughout all of his childhood.” 4. “A bluish discoloration around my baby’s mouth is a sign of lack of oxygen.” Answer: 3 Rationale: Option 3 is not true for the postterm newborn. Once the meconium aspiration syndrome is resolved, the newborn should be cared for as any other newborn. Options 1, 2, and 4 are true statements and reflect understanding of discharge instructions.

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Test-Taking Strategy: Use the process of elimination and note the key words needs further teaching. These words indicate a false response question and that you need to select the incorrect client statement. Noting that option 3 contains the absolute word “all” will assist in directing you to this option. Review home care instructions for the postterm newborn 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: Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternalnewborn nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 605-606, 844-846. 417. A nurse is assisting in collecting data on a large-for-gestational-age (LGA) newborn. Which technique would the nurse use to check for evidence of birth trauma? 1. Palpate the clavicles for a fracture 2. Listen to the heart for a cardiac defect 3. Blanch the skin for evidence of jaundice 4. Perform Ortolani maneuver for hip dislocation Answer: 1 Rationale: Because of the neonate’s large size, there is an increased risk for shoulder dystocia. This may result in fractured clavicles and/or brachial plexus palsy. Other complications related to birth trauma include facial paralysis, phrenic nerve palsy, depressed skull fractures, hematomas, and bleeding. Option 2 is not related to birth trauma. Option 3 would not be present initially. Hip dislocation is congenital and is not caused by birth trauma. Test-Taking Strategy: Use the process of elimination and focus on the issue of the question, checking for birth trauma. Think of trauma as an injury. Option 1 is the only option that identifies an injury. Review the techniques for checking for birth trauma if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 742. 418. A nurse reviews the arterial blood gas report on a newborn with respiratory distress syndrome (RDS) who was recently weaned from the ventilator and placed in an oxygen hood at 50% oxygen. The results indicate a pH of 7.25, PaO2 80 mm Hg, PaCO2 50 mm −

Hg, and HCO 3 24 mEq. The nurse evaluates the blood gas report as indicating: 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis Answer: 1 Rationale: In normal acid-base balance, the pH is 7.35 to 7.45. Normal PaO2 is 80 to

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100 mm Hg and normal PaCO2 is 35 to 45 mm Hg. A decreased pH with an increased PaCO2 indicates a respiratory acidosis. Respiratory alkalosis is defined as a pH above 7.45 and a PaCO2 below 35 mm Hg. Metabolic acidosis exists with a pH below 7.35 and −

a HCO 3 below 22 mEq/L. Metabolic alkalosis is defined as a pH above 7.45, along with −

−

a HCO 3 above 27 mEq/L. Normal HCO 3 is 22 to 27 mEq/L. Test-Taking Strategy: This question requires knowledge about arterial blood gas interpretation. Recalling that a low pH indicates acidosis assists in eliminating options 2 and 4. From the remaining options, recalling that in a respiratory condition the PaCO2 moves in an opposite direction as the pH will direct you to option 1. Review the procedure for interpreting blood gases if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Postpartum Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 1083, 1190. 419. A nurse reviews the results of a bilirubin level on a 2-day-old jaundiced term newborn. The results indicate a total bilirubin level of 7.2 mg/dl. The newborn’s mother verbalizes concern over the bilirubin results. After interpreting the bilirubin results, the nurse’s response would include an explanation that the bilirubin level is: 1. Within acceptable ranges 2. Indicative of Rh incompatibility 3. Lower than normal for the newborn’s age 4. Indicative of a need for phototherapy Answer: 1 Rationale: Many newborns exhibit jaundice in the newborn period. Total bilirubin levels tend to peak on the second and third day after birth. These levels are between 5 and 10 mg/dl in the healthy newborn. Option 2 is not correct because the range given is not elevated for a 2-day-old newborn, and there is no data to support an Rh incompatibility. Term newborns are not treated with phototherapy until their bilirubin is above 12 mg/dl. Test-Taking Strategy: Knowledge regarding normal bilirubin levels and expected levels in a 2-day-old jaundiced term newborn is required to answer this question. Remember many newborns exhibit jaundice in the newborn period, and total bilirubin levels tend to peak on the second and third day after birth. Review these levels 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 References: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 312. Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 968.

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420. A client with a diagnosis of a recurrent major depression who is exhibiting psychotic features is admitted to the mental health unit. In an attempt to create a safe environment for the client, the nurse most importantly designs a plan of care that deals specifically with the client’s: 1. Altered thought processes 2. Potential lack of appetite 3. Inability to care for self 4. Lack of knowledge regarding the depression Answer: 1 Rationale: A recurrent major depression with psychotic features alerts the nurse that care must be planned to address both the major depression and the psychosis. Psychosis is defined as a state in which a person’s mental capacity to recognize reality, communicate, and relate to others is impaired, thus interfering with the person’s capacity to deal with life’s demands. Altered thought processes can include the presence of hallucinations and delusions. Test-Taking Strategy: Focus on the diagnosis of the client and use the process of elimination. Note the key words psychotic features to assist in directing you to option 1. Additionally, there is no data in the question that relates to the items in options 2, 3, or 4. Review the needs of the client who is exhibiting psychotic features if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Reference: Stuart, G., & Laraia, M. (2005). Principles & practice of psychiatric nursing (8th ed.). St. Louis: Mosby, pp. 112, 335. 421. A 30-week-gestation prenatal client with complaints of painless vaginal bleeding comes to the labor and birthing department of the hospital. The nurse prepares the client for which expected diagnostic procedure? 1. Pelvic examination 2. Chorionic villi sampling 3. Amniocentesis 4. Contraction stress test Answer: 4 Rationale: A client with painless vaginal bleeding is at risk for going into labor, and a contraction stress test is indicated. The concern is that fetal oxygenation is only marginally adequate when the uterus is at rest; it may be decreased further during uterine contractions. Options 2 and 3 are not appropriate at this time. A pelvic examination is contraindicated when there is vaginal bleeding. Test-Taking Strategy: Use the process of elimination focusing on the client’s symptoms and the purposes of the specific diagnostic tests identified in the options. Noting that the client has vaginal bleeding will assist in eliminating options 1, 2, and 3. Review care to the pregnant client who is bleeding vaginally if you had difficulty with this question.

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Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 70. 422. A client with tuberculosis will be treated with isoniazid and rifampin (Rifadin). The nurse is preparing instructions for the client regarding these medications. Which statement would the nurse plan to provide to the client? 1. “You must discontinue the medication if gastrointestinal (GI) irritation occurs.” 2. “You must take the medication with meals.” 3. “The entire year-long course of the medication needs to be completed.” 4. “Fluids must be increased while taking this medication to prevent renal failure.” Answer: 3 Rationale: The client needs to be instructed that the entire year-long course of the medication needs to be completed. It is preferable to take the medication 1 hour before or 2 hours after meals. If GI irritation occurs, the medication should not be discontinued, and in this situation a small amount of food may be taken to reduce the irritation. It is not necessary to increase fluids during this medication therapy. Test-Taking Strategy: Use the process of elimination to answer the question. Note that options 1, 3, and 4 contain the absolute words “must.” Review the client teaching points related to these medications if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Teaching/Learning Content Area: Pharmacology Reference: McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, pp. 1056-1057, 1060. 423. Schizophrenia is diagnosed in a client. The nurse is asked to assist in preparing a nursing care plan for the client. In the planning, the nurse understands that it is most important that: 1. Allowing the client to set the goals for the plan of care is a priority 2. Until the client's thinking is cleared, the nurse may need to assist the client with grooming and nutrition 3. Refraining from pointing out the inconsistencies of the client's communication is essential to initial treatment 4. Letting the client act out and using the quiet room and restraints will be required initially Answer: 2 Rationale: As the nurse plans care for the schizophrenic client, it is important to understand the client's developmental stage and ability to accept the disease. Because of the severe decompensation in thinking, the client lacks insight and may not even acknowledge illness. In the acute phase, the nurse will take the lead in planning for the client's basic human needs, such as nutrition, hygiene, sleep, and activities of daily living (ADL). Options 1, 3, and 4 are incorrect. Test-Taking Strategy: Focus on the client’s diagnosis and use the process of elimination.

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Using Maslow’s Hierarchy of Needs theory and recalling that it is important to assist the client in meeting basic needs will direct you to option 2. Review care to the client with schizophrenia if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 345. 424. A psychiatric clinical nurse specialist tells a nursing student that the technique of paradoxical intention is being planned to treat a client who experiences panic attacks. The student understands that which of the following describes the intervention that the nurse employs for the client? 1. Having the client confront the anxiety provoking stimuli and providing support during the episode 2. Using progressive relaxation toward the client's anxiety and pairing relaxation with the gradual exposure to reduce the client's anxiety 3. Presenting the anxiety provoking stimuli without any preparation of the client and having the client remain exposed until the anxiety subsides 4. Instructing the client to hyperventilate to create a panic attack Answer: 4 Rationale: In cognitive behavioral therapy, the client with panic attacks will receive a mix of cognitive restructuring, exposure therapy, and paradoxical intention. In paradoxical intention, the client is instructed by the therapist to hyperventilate to cause a panic attack. When this occurs, the nurse teaches the client to stop struggling to prevent the anxiety by a variety of coping mechanisms. This assists the client to regain an internal locus of control or feeling of empowerment or mastery regarding the anxietyprovoking issue, situation, or person. Test-Taking Strategy: This question tests your knowledge of the cognitive behavioral therapies that are used to treat clients who suffer from panic attacks. Option 1 describes a type of exposure therapy. Option 2 describes systematic desensitization, another type of exposure therapy. Option 3 describes flooding, which is probably the most intensive therapy. Note the relation between the words “paradoxical intention” in the question and the description in option 4. Review the components of paradoxical intention if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health References: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 185. Stuart, G., & Laraia, M. (2005). Principles & practice of psychiatric nursing (8th ed.). St. Louis: Mosby, p. 281. 425. A nurse is inserting soft contact lenses into the eyes of a client. The nurse tells the

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client to look: 1. Straight ahead 2. Downward and outward 3. Upward and outward 4. Downward and inward Answer: 1 Rationale: When inserting contact lenses for a client, the nurse tells the client to look straight ahead. This applies to both rigid and soft contact lenses. The other options are incorrect. Test-Taking Strategy: Use basic principles of eye care to answer this question. Visualize each of the eye positions in the options to assist in answering the question. Review this procedure 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: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 297-298. 426. A nurse is reviewing the arterial blood gas results of an assigned client. Which of the following arterial blood gases indicates metabolic alkalosis? 1. pH of 7.35, pCO2 of 50 mm Hg, HCO3− of 32 mEq/L 2. pH of 7.45, pCO2 of 35 mm Hg, HCO3− of 22 mEq/L 3. pH of 7.38, pCO2 of 45 mm Hg, HCO3− of 32 mEq/L 4. pH of 7.48, pCO2 of 40 mm Hg, HCO3− of 36 mEq/L Answer: 4 Rationale: In a metabolic alkalosis, the pH is elevated along with the bicarbonate level. Option 4 is the only option that reflects these values. Test-Taking Strategy: Use the process of elimination. Remember that when an alkalotic condition exists, the pH will be elevated. Next, recall that in a metabolic condition, the HCO3− will move in the same direction as the pH. The only option that represents these conditions is option 4. Review the process of blood gas analysis if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Respiratory Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 430. 427. A nursing student is caring for a client scheduled for cataract surgery. The student reviews the preoperative orders with the nursing instructor and notes that cyclopentolate (Cyclogyl) eye drops are prescribed to be administered preoperatively. The nursing instructor asks the student about the action of the eye drops. The student appropriately

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responds by telling the instructor that the action of these eye drops is to: 1. Provide the necessary lubrication to the operative eye 2. Initiate miosis in the operative eye 3. Dilate the pupil of the operative eye 4. Constrict the pupil of the operative eye Answer: 3 Rationale: Cyclopentolate (Cyclogyl) is a rapidly acting mydriatic and cycloplegic medication. It is effective in 25 to 75 minutes, and accommodation returns in 6 to 24 hours. Cyclopentolate (Cyclogyl) is used for preoperative mydriasis to dilate the eye. Options 1, 2, and 4 are incorrect actions for use of this medication. Test-Taking Strategy: Use the process of elimination. Options 2 and 4 identify similar information and are eliminated first. Remember miosis refers to a constricted pupil. Note that the question identifies a client being prepared for eye surgery. The pupil would need to be dilated for the surgical procedure. Review the action and purpose of this medication if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Eye Reference: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 1104. 428. A nurse in a long-term care facility is admitting a client. During data collection, the nurse discovers that the client has glaucoma and is taking pilocarpine hydrochloride (Isopto-Carpine). The nurse checks the medication supply to ensure that which of the following medications are available in the event of systemic toxicity caused by the pilocarpine hydrochloride? 1. Naloxone hydrochloride (Narcan) 2. Cyclopentolate (Cyclogyl) 3. Disulfiram (Antabuse) 4. Atropine sulfate Answer: 4 Rationale: Systemic absorption of pilocarpine hydrochloride can produce toxicity and includes manifestations of vertigo, bradycardia, tremors, hypotension, syncope, cardiac dysrhythmias, and seizures. Atropine sulfate must be available in the event of systemic toxicity. Naloxone hydrochloride is an opioid antagonist used to reverse narcotic-induced respiratory depression. Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication used preoperatively for eye procedures. Disulfiram is an alcohol deterrent used in the management of alcoholism in selected clients. Test-Taking Strategy: Knowledge regarding antidotes related to various medications is required to answer this question. Recalling the classifications of the medications presented in the options will assist in directing you to the correct option. Review these medications if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning

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Content Area: Pharmacology Reference: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 1102. 429. A nurse provides instructions to a client who has been prescribed betaxolol (Betoptic) eye drops for the treatment of glaucoma. The nurse instructs the client regarding the administration of the medication and about the importance of returning to the clinic for monitoring of the: 1. Presence of a positive Homans’ sign 2. Blood pressure and apical pulse 3. Blood glucose level 4. Presence of Trousseau’s sign Answer: 2 Rationale: Betaxolol is an antiglaucoma medication and a beta-adrenergic blocker. Hypotension manifested as dizziness, nausea, diaphoresis, headache, fatigue, constipation and diarrhea are systemic effects of the medication. Nursing interventions include monitoring the blood pressure for hypotension and assessing the pulse for strength, weakness, irregular rate, and bradycardia. The nurse also monitors bowel activity and assesses for the evidence of congestive heart failure (CHF) as manifested by dizziness, night cough, peripheral edema, and distended neck veins. Monitoring intake and output and for an increase in weight and a decrease in urine output may also be indicative of CHF. A blood glucose is unrelated to the use of this medication as is the presence of Homans’ or Trousseau’s sign. A positive Homans’ sign indicates the presence of deep vein thrombosis. A positive Trousseau’s sign indicates a calcium imbalance. Test-Taking Strategy: Focus on the name of the medication and recall that medication names that end with the letters “lol” are beta-blockers, and that these types of medications are frequently used to treat hypertension. Also use the ABCs, airway, breathing, and circulation to direct 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. 120. 430. A nurse is assisting in caring for a client with a respiratory tract infection who is receiving intravenous tobramycin sulfate (Tobrex). The nurse is instructed to monitor for adverse effects from the medication. The nurse understands that which of the following findings is indicative of an adverse effect from this medication? 1. Vomiting 2. Nausea 3. Hypotension 4. Vertigo Answer: 4 Rationale: Ringing in the ears and vertigo are two symptoms that may indicate

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dysfunction of the eighth cranial nerve. Ototoxicity is a frequent adverse effect of therapy with the aminoglycosides and could result in permanent hearing loss. If this occurred, the physician would be notified. Nausea, vomiting, and hypotension are rare side effects of the medication. Test-Taking Strategy: Use the process of elimination and note the key words adverse effect. Answer this question by recognizing that tobramycin is an aminoglycoside, and that ototoxicity is a frequent adverse effect of therapy with the aminoglycosides. Review the adverse and side 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 Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 1047. 431. A nurse is assisting in preparing a plan of care for a client with acquired immunodeficiency syndrome (AIDS) who will be receiving ganciclovir (Cytovene). Which priority intervention will be included in the plan of care? 1. Monitor for signs of hyperglycemia 2. Administer the medication without food 3. Instruct the client to use an electric razor for shaving 4. Administer the medication with an antacid Answer: 3 Rationale: Ganciclovir causes neutropenia and thrombocytopenia as the most frequent side effects. For this reason, the nurse monitors the client for signs and symptoms of bleeding and implements the same precautions that are used for a client receiving anticoagulant therapy. Thus the client should be instructed to use an electric rather than a straight razor for shaving. The medication does not have to be taken on an empty stomach or without food. Additionally the medication does not have to be taken with an antacid, and an antacid may affect absorption. The medication may cause hypoglycemia, but not hyperglycemia. Test-Taking Strategy: Use the process of elimination. Options 2 and 4 can be eliminated first because they are similar and indicate administering the medication with another substance. From the remaining options, noting the key word priority and recalling that the medication can cause bleeding from thrombocytopenia will assist in directing you to option 3. Review the nursing implications related to this medication 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, pp. 484-485. 432. A postpartum nurse is caring for a client following a cesarean birth who received epidural analgesia. The client is lethargic and is exhibiting signs of respiratory

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depression. The nurse suspects that the respiratory depression is due to the epidural analgesia. The nurse notifies the registered nurse immediately and prepares the client for the administration of: 1. Betamethasone (Celestone) 2. Morphine sulfate 3. Meperidine hydrochloride (Demerol) 4. Naloxone (Narcan) Answer: 4 Rationale: Narcotics are used for epidural analgesia. An adverse reaction of epidural analgesia is a delayed respiratory depression. Respirations are monitored for 24 hours after administration of epidural analgesia. Naloxone is a narcotic antagonist, which reverses the effects of narcotics and is given if respirations fall below 6 to 8 per minute. Morphine sulfate and meperidine hydrochloride are narcotics and are contraindicated because no other narcotics are to be administered during the first 24 hours. Betamethasone is a corticosteroid administered to enhance fetal lung maturity. Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 4 first because they are similar and are both narcotics. Focusing on the medication name in option 1 and recalling that medication names that end with the letters “sone” are corticosteroids will assist in eliminating this option. Review the purpose and actions of the medications presented in the options if you had difficulty with this question. Level of Cognitive Ability: Analysis 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. 749. 433. A nurse is assisting in caring for a client who is receiving amphotericin B (Fungizone) intravenously (IV) to treat disseminated candidiasis. The nurse reviews the plan of care and implements which of the following during the administration of the medication? 1. Monitors for hypothermia 2. Monitors for hyperglycemia 3. Monitors urinary output 4. Monitors blood pressure Answer: 3 Rationale: Amphotericin B is a toxic medication, which can produce symptoms during administration, such as chills, fever, headache, vomiting, and impaired renal function. The medication is also very irritating to the IV site, commonly causing thrombophlebitis. The nurse administering this medication watches for all of these problems. Options 1, 2, and 4 are not specifically related to the administration of this medication. Test-Taking Strategy: Knowledge of this potent medication is necessary to answer this question accurately. Recalling that the medication can be toxic to the kidneys directs you to option 3. Review nursing care related to the administration of this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis

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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. 65. 434. A nursing student is assigned to care for a 30-week-gestation woman who is admitted to the maternity unit in preterm labor. Betamethasone (Celestone) is prescribed to be administered to the mother. The nursing instructor asks the student about the purpose of the medication. Which statement by the student indicates an understanding of the purpose of this medication? 1. “This medication will stop the premature uterine contractions.” 2. “This medication will delay delivery.” 3. “This medication will promote fetal lung maturity.” 4. “This medication will prevent membrane rupture.” Answer: 3 Rationale: Betamethasone, an anti-inflammatory corticosteroid, is given to increase the surfactant level and increase fetal lung maturity, reducing the incidence of respiratory distress syndrome of the newborn. Surfactant production does not become stable until after 32-weeks of gestation, and if adequate amounts of surfactant are not present in the lungs, respiratory distress and death is a possible consequence. Delivery of the baby needs to be delayed for at least 48 hours after administration of betamethasone to allow time for the lungs to mature. Options 1, 2, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 2 first because they are similar and both relate to stopping labor. Knowing that respiratory distress syndrome of the newborn caused by immature lungs is a major problem of prematurity, and therefore a major concern, will assist in directing you to the correct option from the remaining options. Review the purpose of this medication if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Pharmacology Reference: Skidmore-Roth, L. (2005). Mosby’s drug guide for nurses (6th ed.). St. Louis: Mosby, p. 97. 435. A nurse is providing instructions to a mother regarding the administration of eardrops to her infant. The nurse observes the mother administer the drops and determines that the mother is performing the procedure correctly if the mother: 1. Pulls up and back on the auricle and directs the solution toward the wall of the ear canal 2. Pulls down and back on the auricle and directs the solution onto the eardrum 3. Pulls down and back on the earlobe and directs the solution toward the wall of the canal 4. Pulls up and back on the earlobe and directs the solution toward the wall of the

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canal Answer: 3 Rationale: The infant should be turned on the side with the affected ear uppermost. With the nondominant hand, the mother pulls down and back on the earlobe while resting the wrist of the dominant hand on the infant’s head. The medication is administered by aiming it at the wall of the canal rather than directly onto the eardrum. The infant should be held or positioned with the affected ear uppermost for 10 to 15 minutes to retain the solution. In the adult, the auricle is pulled up and back to straighten the auditory canal. Test-Taking Strategy: Use the process of elimination. Option 1 is eliminated because it is the adult procedure. Basic safety principles related to the administration of ear medications should assist in eliminating option 2. Visualizing the procedures identified in the remaining options will assist in directing you to the correct option. It would be difficult to pull up and back on an earlobe therefore eliminate option 4. Review the procedure for administering ear medications in an infant and adult if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 652. 436. A client with rheumatoid arthritis has been taking acetylsalicylic acid (ASA) (aspirin) more frequently than prescribed because the arthritis has been causing more discomfort than usual. The client complains of joint pain and has an elevated temperature. The nurse is concerned about the possibility of aspirin toxicity and asks the client which question that may confirm this suspicion? 1. “Are you having any diarrhea?” 2. “Are you constipated?” 3. “Do you have any ringing in the ears?” 4. “Do you have any double vision?” Answer: 3 Rationale: Mild intoxication with ASA is called salicylism and is commonly experienced when the daily dosage is more than 4 g. Tinnitus (ringing in the ears) is the most frequent effect noted with intoxication. Options 1, 2, and 4 are unrelated to aspirin toxicity. Test-Taking Strategy: Note that the question refers to aspirin intoxication. Eliminate options 1 and 2 because they are similar and relate to gastrointestinal symptoms. Knowledge regarding toxicity related to ASA (aspirin) is required to assist in directing you to option 3. Remember tinnitus (ringing in the ears) is the most frequent effect noted with intoxication. Review the toxic effects of aspirin 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.

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Philadelphia: W.B. Saunders, p. 88. 437. A nurse administers scopolamine as prescribed to a client in preparation for surgery. The nurse monitors the client for side effects related to the administration of this medication. Which of the following would the nurse determine is an expected side effect of this medication? 1. Increased urinary output in the Foley catheter bag 2. Client complaints of feeling sweaty 3. Client complaints of a dry mouth 4. Pupillary constriction on neurological examination Answer: 3 Rationale: Scopolamine is an anticholinergic medication that causes the frequent side effects of dry mouth, urinary retention, decreased sweating, and dilation of the pupils. The other options are incorrect. Test-Taking Strategy: To answer this question accurately, it is necessary to be familiar with this medication and its uses. Recalling that scopolamine is an anticholinergic medication and recalling the effects of anticholinergics will direct you to option 3. Review the action 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. 962. 438. Sucralfate (Carafate) 1 g four times daily has been prescribed for a client with a diagnosis of gastric ulcer, and the nurse provides instructions to the client regarding administration of the medication. Which statement by the client indicates an understanding of the use of the medication? 1. “I need to take the medication with my meals and again at bedtime.” 2. “I need to take the medication 1 hour after meals and again at bedtime.” 3. “I need to take the medication every 6 hours around the clock.” 4. “I need to take the medication 1 hour before my meals and at bedtime.” Answer: 4 Rationale: This medication is timed to allow it to form a protective coating over the gastric ulcer before food intake stimulates gastric acid production and mechanical irritation. Therefore the medication should be scheduled for administration 1 hour before meals and at bedtime. The other options are incorrect. Test-Taking Strategy: Use the process of elimination. Focusing on the diagnosis in the question will assist in directing you to option 4. It would seem most reasonable that medication should be administered before food with this diagnosis. 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

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Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 994. 439. Psyllium (Metamucil) is prescribed for a client with a cardiac disorder to facilitate defecation and prevent straining with bowel movements. The nurse provides instructions to the client regarding administration of the medication. Which statement by the client indicates an understanding of the use of the medication? 1. “I need to mix the medication with custard.” 2. “I should decrease the amount of fiber in my diet when I take this medication.” 3. “I should mix the medication with a full glass of water.” 4. “I need to decrease my fluid intake following administration of the medication.” Answer: 3 Rationale: Metamucil is a bulk-forming laxative. It should be taken with a full glass of water or juice (not custard), followed by another glass of liquid. This will help prevent impaction of the medication in the stomach or small intestine. Both fiber in the diet and fluid intake should not be decreased unless specifically prescribed by the physician. Test-Taking Strategy: Focus on the action of the medication and the information identified in the question to assist in eliminating options 2 and 4. Recalling that this medication is supplied in a dry form will assist in eliminating 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: 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. 908. 440. Metoclopramide (Reglan) four times daily has been prescribed for a client with reflux esophagitis, and the nurse provides instructions to the client regarding administration of the medication. Which statement by the client indicates an understanding of the use of the medication? 1. “I need to take the medication 1 hour after each meal and at bedtime.” 2. “I need to take the medication with every meal and at bedtime.” 3. “I need to take the medication 30 minutes before meals and at bedtime.” 4. “I need to take the medication every 6 hours spaced evenly around the clock.” Answer: 3 Rationale: Metoclopramide stimulates activity of the upper gastrointestinal tract. The client should be taught to take this medication 30 minutes before meals and at bedtime. This allows the medication time to begin working before the client takes in food, which requires digestion and movement. Options 1, 2, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination and focus on the client’s diagnosis. Remember that if the medication is used to treat reflux esophagitis, it must be taken before meals. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity 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. 699. 441. A nurse is assisting in preparing a plan of care for a client who will be receiving an infusion of ritodrine (Yutopar) to prevent premature delivery. Which of the following does the nurse suggest to include in the plan of care for the client? 1. Monitor for fluid volume excess 2. Monitor for fluid volume deficit 3. Monitor for hypoglycemia 4. Monitor for hypertension Answer: 1 Rationale: Intravenous ritodrine can cause pulmonary edema in some clients. The client should be monitored for fluid overload. If pulmonary edema develops, the infusion should be discontinued and standard treatment implemented. The client is also at risk for hypotension and hyperglycemia during infusion of this medication. Test-Taking Strategy: Knowledge regarding the adverse effects associated with ritodrine is required to answer this question. Noting that options 1 and 2 are opposite problems may indicate that one of these options is correct. Remember intravenous ritodrine can cause pulmonary edema in some clients. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology Reference: McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 912. 442. A client is scheduled for an intravenous pyelogram and has been instructed to take liquid magnesium citrate on the day before the scheduled procedure. The client asks the nurse about the administration procedure for this medication. Which of the following instructions will the nurse provide to the client? 1. “Take the medication on ice.” 2. “Take the medication with apple juice only.” 3. “Take the medication with a full glass of water.” 4. “Take the medication at room temperature.” Answer: 1 Rationale: Magnesium citrate is available as an oral solution. It is used commonly as a laxative before or following certain diagnostic studies. It should be served on ice and should not be allowed to stand for prolonged periods. This would reduce the carbonation and make the solution even less palatable. Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 3 first noting that liquid magnesium citrate is prescribed, and adding additional liquid will make it difficult to consume. From the remaining options, it is necessary to know that it should be given cold rather than at room temperature to enhance palatability. Review this medication if you had difficulty with this question.

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Level of Cognitive Ability: Application 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. 660. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 218. 443. A nurse is reviewing the laboratory results of a client receiving chemotherapy. The nurse prepares to initiate neutropenic precautions when the nurse notes which of the following laboratory results? 1. A white blood cell (WBC) count of 2000/μL 2. A platelet count of 100,000 cells/μL 3. A clotting time of 10 minutes 4. An ammonia level of 20 mcg/dl Answer: 1 Rationale: The normal WBC is 5000 to 10,000/μL. When the WBC count drops, neutropenic precautions need to be implemented. This includes protective isolation measures to protect the client from infection. Bleeding precautions need to be initiated when the platelet count drops. Bleeding precautions include avoiding all trauma, such as rectal temperatures or injections. The normal platelet count is 150,000 to 450,000 cells/μL. The normal clotting time is 8 to 15 minutes. The normal ammonia value is 15 to 45 mcg/dl. Test-Taking Strategy: Knowledge regarding normal laboratory values and the significance of the specific laboratory tests is required to answer the question. Options 3 and 4 identify normal laboratory values. To select between the remaining options, correlate a low WBC count with the need for neutropenic precaution and a low platelet count with the need for bleeding precautions. Review neutropenic precautions if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Pharmacology References: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 392. Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 253. 444. Cyclophosphamide (Cytoxan) is prescribed for a client with a diagnosis of breast cancer. The nurse has provided instructions to the client regarding the medication. Which statement by the client indicates an understanding of this chemotherapeutic regimen? 1. “I need to take the medication with food.” 2. “I need to avoid salt while taking this medication.”

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3. “I need to eat a banana and drink a glass of orange juice every day.” 4. “I need to increase my fluid intake to 2000 to 3000 mL daily.” Answer: 4 Rationale: Hemorrhagic cystitis is a toxic effect that can occur with the use of cyclophosphamide (Cytoxan). The client needs to be instructed to drink copious amounts of fluid during the administration of this medication. Clients should also monitor urine output for hematuria. The medication should be taken on an empty stomach, unless gastrointestinal upset occurs. Hyperkalemia can result from the use of the medication therefore the client would not be encouraged to increase potassium intake (bananas and orange juice). The client would not be instructed to alter their sodium intake. Test-Taking Strategy: Focus on the name of the medication. Correlate cyclophosphamide with hemorrhagic cystitis to direct you to option 4. Review the adverse 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 Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 272. 445. A client with carcinoma is admitted to the hospital for a chemotherapy treatment with intravenous bleomycin sulfate (Blenoxane). The nurse assisting in caring for the client understands that during administration of the bleomycin sulfate, which of the following would receive the highest priority? 1. Checking the peripheral pulses 2. Monitoring the heart rate 3. Monitoring the level of consciousness 4. Monitoring the respiratory status Answer: 4 Rationale: Bleomycin sulfate is an antineoplastic medication that can cause interstitial pneumonitis that can progress to pulmonary fibrosis. Pulmonary function studies along with hematological, hepatic, and renal function tests need to be monitored. The nurse needs to monitor the respiratory status for dyspnea and rales that indicate pulmonary toxicity. The medication needs to be discontinued immediately if pulmonary toxicity occurs. Test-Taking Strategy: Note the key words “highest priority.” Eliminate options 1 and 2 first because they are similar in nature. From this point, use the ABCs, airway, breathing, and circulation and select option 4 because it relates to airway. 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 Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 132.

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446. A student nurse is caring for a client with lung cancer receiving chemotherapy. The client is receiving a high dose of methotrexate (Folex). The student nurse informs the nursing instructor that leucovorin (Citrovorum Factor, folinic acid) is also prescribed for the client. The instructor asks the student about the purpose of the leucovorin. Which statement by the student indicates a need to further research the purpose of the medication? 1. “It preserves normal cells.” 2. “It promotes DNA synthesis.” 3. “It is also known as leucovorin rescue.” 4. “Leucovorin bypasses the metabolic block caused by methotrexate.” Answer: 2 Rationale: High concentrations of methotrexate cause harm and damage to normal cells. To save normal cells, leucovorin is given. This is known as leucovorin rescue. Leucovorin bypasses the metabolic block caused by methotrexate, thereby permitting normal cells to synthesize. It should be noted that leucovorin rescue is potentially hazardous. Failure to administer leucovorin in the right dose at the right time can be fatal. Test-Taking Strategy: Note the key words indicates a need to further research. These words indicate a false-response question, and that you need to select the incorrect student statement. Eliminate options 1 and 4 first because they are similar. Additionally, note the similarity between the words “leucovorin” in the question and in options 3 and 4. If you had difficulty with this question, review leukovorin rescue. 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. 623. 447. A client with tuberculosis is receiving cycloserine (Seromycin Pulvules) 250 mg orally twice daily. The nurse instructs the client to return to the clinic in 1 week for a blood test to measure the serum concentration of the medication. Which of the following instructions would the nurse provide to the client regarding this blood test? 1. “Take the morning dose and the blood test will be drawn 2 hours after the dose.” 2. “Hold the morning dose on the day of the scheduled blood test.” 3. “Hold the evening dose before the blood test and the dose scheduled for the morning of the test.” 4. “Double the dose on the evening before the test and hold the morning dose on the day of the test.” Answer: 1 Rationale: Cycloserine is an antitubercular medication that requires weekly serum drug level determinations to monitor for the potential of neurotoxicity and other adverse effects. Peak concentrations measured 2 hours after dosing should be 25 to 35 mcg/mL. Options 2, 3, and 4 are incorrect. Test-Taking Strategy: Knowledge regarding the toxicity associated with this medication and the serum drug levels that determine the therapeutic dosage is required to answer the

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question. Use general principles related to medication administration to eliminate options 3 and 4. From the remaining options, it is necessary to know that the blood is drawn 2 hours after dosing. Review this medication if you are unfamiliar with it. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Reference: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 947. 448. Metaproterenol (Alupent), two puffs, and beclomethasone (Vanceril), two puffs by metered dose inhaler, have been prescribed for the client with chronic obstructive pulmonary disease. The nurse caring for the client provides instructions regarding administration of the medication. Which statement by the client indicates an understanding of how to take these medications? 1. “I will take the two puffs of the beclomethasone first and then the two puffs of the metaproterenol.” 2. “I will take the two puffs of the metaproterenol first and then the two puffs of the beclomethasone.” 3. “I will alternate a single puff of each, beginning with the beclomethasone.” 4. “I will alternate a single puff of each, beginning with the metaproterenol.” Answer: 2 Rationale: Metaproterenol is an adrenergic type of bronchodilator. Beclomethasone is a glucocorticoid. Bronchodilators are always administered before glucocorticoids when both are to be given on the same time schedule. This allows for widening of the air passages by the bronchodilator, which then makes the glucocorticoid more effective. Options 1, 3, and 4 are incorrect. Test-Taking Strategy: Note the key words indicates an understanding. To answer this question correctly, it is necessary to know two different things. First you must know that a bronchodilator is always given before a glucocorticoid. This would allow you to eliminate options 3 and 4 since you would not alternate the medications. To select between options 1 and 2, it is necessary to know that metaproterenol is a bronchodilator, whereas beclomethasone is a glucocorticoid. Remember that medication names that end with the letters “sone” are bronchodilators. Review client instructions related to the use of inhaled medications 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: McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 715. 449. A client who is taking theophylline (Theo-Dur) reports to the health care clinic as scheduled to have a serum theophylline level drawn. The blood is drawn, and the laboratory calls the nurse and reports the results as 10 mcg/mL. The client asks the nurse what this figure means. The nurse accurately responds by stating this level is:

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1. At the low end of the therapeutic range 2. In the middle of the therapeutic range 3. At the top of the therapeutic range 4. In excess of the therapeutic range Answer: 1 Rationale: The normal therapeutic range for theophylline levels is 10 to 20 mcg/mL. A level above 20 mcg/mL is considered toxic. The value of 20 mcg/mL places the client at the top of the therapeutic range. The value of 10 mcg/mL places the client at the low end of the therapeutic range. Test-Taking Strategy: Specific knowledge regarding the therapeutic range for this medication is required to answer this question. Remember that the normal therapeutic range for theophylline levels is 10 to 20 mcg/mL. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 1040. 450. A client arrives at the emergency room with an acetaminophen (Tylenol) overdose. Acetylcysteine (Mucomyst) is prescribed to be administered to the client immediately. The nurse prepares to administer the medication by which of the following routes? 1. Orally 2. Via nebulizer 3. Intravenous 4. Subcutaneously Answer: 1 Rationale: Acetylcysteine can be given orally or by nasogastric tube to treat acetaminophen overdose or it may be given by inhalation for use as a mucolytic. Before giving the medication as an antidote to acetaminophen, the nurse ensures that the client’s stomach is empty through emesis or gastric lavage. The solution is diluted in cola, water, or juice to make the solution more palatable. It is then administered orally or by nasogastric tube. Test-Taking Strategy: Use the process of elimination and knowledge regarding this medication. Begin to answer this question by eliminating options 3 and 4. Then recall that this medication is not given by the inhalation route to treat acetaminophen overdose. Additionally, knowing that the solution must be diluted forces you to choose option 1 as correct. Review the administration of this medication as an antidote for acetaminophen overdose if you had difficulty with this question. Level of Cognitive Ability: Analysis 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. 9.

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451. A hospitalized client with allergic asthma has been started on cromolyn sodium (Intal) inhaler. The nurse assists in preparing a plan of care and includes monitoring for undesirable side effects associated with the use of this medication. The nurse places the highest priority on monitoring for which of the following? 1. Constipation 2. Hypotension 3. Cough 4. Bronchospasm Answer: 4 Rationale: The most common undesired clinical responses associated with inhalation therapy of cromolyn sodium are bronchospasm, cough, nasal congestion, throat irritation, and wheezing. Clients receiving this medication orally may experience pruritis, nausea, diarrhea, and myalgia. Test-Taking Strategy: Note the key words highest priority. Use the ABCs, airway, breathing, and circulation to select the correct option. Although cough is also an undesirable side effect, option 4 most clearly addresses airway and is the highest priority. Review the adverse effects of 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: McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 724. 452. A nurse is collecting data on a client admitted to the hospital with a diagnosis of a respiratory infection unresponsive to oral antibiotics. The nurse discovers that the client has a history of bronchial asthma and has been taking zafirlukast (Accolate). The nurse assists to develop a plan of care for the client and suggests that a priority includes monitoring: 1. Platelet counts 2. Gastric pH 3. Liver function tests 4. Urinary output Answer: 3 Rationale: Zafirlukast is a leukotriene receptor antagonist that is used in the prophylaxis and chronic treatment of bronchial asthma. It is used with caution in clients with impaired hepatic function. Liver function laboratory values should be obtained as a baseline and should be monitored during administration of the medication. Options 1, 2, and 4 are not specifically related to the use of this medication. Test-Taking Strategy: Focus on the name of the medication and note the key word priority. Recalling that this medication would affect hepatic function 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/Planning

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Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 1125. 453. A nurse is providing instructions to a client taking ethambutol (Myambutol) about the medication. The nurse instructs the client to contact the physician immediately if which of the following occur? 1. Distressing gastrointestinal effects (GI) side effects 2. Hearing disturbances 3. Orange colored urine 4. Visual disturbances Answer: 4 Rationale: Ethambutol causes optic neuritis, which decreases visual acuity and the ability to discriminate between the colors red and green. This poses a potential safety hazard when driving a motor vehicle. The client is taught to report this symptom immediately. The client is also taught to take the medication with food if GI upset occurs. Impaired hearing results from antitubercular therapy with streptomycin. Orange-red discoloration of secretions occurs with rifampin (Rifadin). Test-Taking Strategy: Use the process of elimination. Option 1 is the least likely symptom to report; rather, it should be managed by taking the medication with food. Thus this option may be eliminated first. To select from the other options, it is necessary to know that this medication causes optic neuritis and causes difficulty with red-green discrimination. If this question was difficult, review antitubercular medications since the incorrect options for this question are typical side effects of other antitubercular medications. Level of Cognitive Ability: Application 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. 412. 454. A client with rheumatoid arthritis is told that treatment for the disorder will include the administration of gold therapy. In preparation for the treatment, which of the following medications would the nurse anticipate would be prescribed for the client? 1. Auranofin (Ridaura) 2. Fludarabine (Fludara) 3. Prednisone (Deltasone) 4. Pentostatin (Nipent) Answer: 1 Rationale: Auranofin is a gold preparation used in rheumatoid arthritis. It is used in the management of rheumatoid arthritis in those individuals with insufficient therapeutic response to nonsteroidal anti-inflammatory drugs (NSAIDs). Fludarabine and pentostatin are antineoplastic agents. Prednisone is a corticosteroid. Test-Taking Strategy: Use the process of elimination. Option 3 can be easily eliminated knowing that this medication is a corticosteroid. From the remainder of the options, it is

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necessary to know the classifications of these medications. Review these medications if you had difficulty with this question. Level of Cognitive Ability: Analysis 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. 98. 455. Baclofen (Lioresal) is prescribed for a client with a spinal cord injury who is experiencing muscle spasms, and the nurse prepares a list of the associated side effects of the medication and reviews the list with the client. Which side effects if identified by the client indicates a need for further instructions? 1. Photosensitivity 2. Slurred speech 3. Nasal congestion 4. Tremors Answer: 1 Rationale: Side effects of baclofen include drowsiness, dizziness, weakness, and nausea. Occasional side effects include headache, paresthesia of the hands and feet, constipation or diarrhea, anorexia, hypotension, confusion, and nasal congestion. Paradoxical central nervous system excitement and restlessness can occur along with slurred speech, tremor, dry mouth, nocturia, and impotence. Photosensitivity is not a side effect of this medication. Test-Taking Strategy: Note the key words need for further instructions in the stem of the question. These words indicate a false-response question, and that you need to select the incorrect client statement. Eliminate options 2 and 4 first because both are neurological signs. From the remaining options, it is necessary to know that photosensitivity is not an associated side effect of the medication. If you had difficulty with this question, review the side effects related to baclofen. 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. 108. 456. Aminophylline (Theophylline) is being administered to a client with acute bronchitis. The nurse planning care for the client understands that the primary action of this medication is to: 1. Promote expectoration 2. Suppress the cough 3. Relax smooth muscles of the bronchial airway 4. Prevent infection Answer: 3 Rationale: Aminophylline is a bronchodilator that directly relaxes the smooth muscles of

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the bronchial airway. Options 1, 2, and 4 are not direct actions of this medication. Test-Taking Strategy: Focus on the name of the medication. Recalling that bronchodilator medication names end with the letters “line” will assist in directing you to the correct option. Review the primary action of this medication if you had difficulty with this question. Level of Cognitive Ability: Comprehension 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. 51. 457. A nurse is providing instructions to a client who will be taking phenytoin (Dilantin) for seizure control. Which statement will the nurse make to the client regarding the administration of this medication? 1. “If you have difficulty swallowing the capsules, open them and mix the contents with applesauce.” 2. “You need to cancel your next dentist visit and plan dentist appointments yearly rather than twice a year.” 3. “If you miss a dose of medication, wait until the next dose and take both doses.” 4. “If a sore throat develops, it is necessary to notify the physician.” Answer: 4 Rationale: Phenytoin it an anticonvulsant. Gingival hyperplasia, bleeding, and swelling and tenderness of the gums can occur with the use of this medication. The client needs to be taught good oral hygiene, gum massage, and the need for regular dentist visits. The client should not miss medication doses because this could precipitate a seizure. Capsules should not be chewed or broken, and they must be swallowed. The client needs to be instructed to report a sore throat, fever, glandular swelling, or any skin reaction because this indicates hematological toxicity. Test-Taking Strategy: Use general medication guidelines in selecting the correct option. Eliminate option 1 recalling that phenytoin capsules should not be broken. Eliminate option 3 because the client needs to be encouraged to take medications on time. Recalling that gingival hyperplasia can occur with the use of this medication or that hematological toxicity can occur will assist in directing you to the correct option from those remaining. Review the side effects related to phenytoin 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. 858. 458. A client with a history of seizures is taking phenytoin (Dilantin) for seizure control. The client arrives at the health care clinic, and a serum phenytoin drug level is drawn. The laboratory calls the nurse and reports a result of 10 mcg/mL. The nurse interprets

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that this value indicates: 1. An inadequate drug level 2. The low end of therapeutic range 3. The high end of therapeutic range 4. A toxic level Answer: 2 Rationale: The therapeutic serum drug level range for phenytoin is 10 to 20 mcg/mL. A laboratory result of 10 mcg/mL is at the low end of the therapeutic range. Test-Taking Strategy: Knowledge regarding the therapeutic serum range of this medication is required to answer the question. A helpful hint may be to remember that the theophylline therapeutic range and the acetaminophen (Tylenol) therapeutic range is the same as the phenytoin therapeutic range. Remembering this may assist you when answering questions related to these three medications. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 869. 459. A nurse reviews the laboratory results of a client with trigeminal neuralgia who is being treated with carbamazepine (Tegretol) 400 mg orally daily. The client’s white blood cell (WBC) count is 3000/μL, blood urea nitrogen (BUN) is 15 mg/dl, sodium is 140 mEq/L, and uric acid is 5.0 ng/dl. The nurse would notify the physician that: 1. The BUN is elevated indicating nephrotoxicity 2. The WBC is low indicating a blood dyscrasia 3. The sodium level is low indicating an electrolyte imbalance 4. The uric acid level is elevated indicating the risk for renal calculi Answer: 2 Rationale: Adverse effects of carbamazepine appear as blood dyscrasias, including aplastic anemia, agranulocytosis, thrombocytopenia, leukopenia, cardiovascular disturbances, thrombophlebitis, dysrhythmias, and dermatological effects. Options 1, 3, and 4 are incorrect because the laboratory values identified in the question for these specific tests are within normal range. Test-Taking Strategy: Use the process of elimination and knowledge regarding normal laboratory values to answer the question. If you are familiar with normal laboratory values, you will easily be able to eliminate options 1, 3, and 4. Review the signs of adverse reactions related to 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. 166.

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Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, p. 940. 460. A nurse is assisting in preparing a plan of care for a client with a diagnosis of cancer who is receiving morphine sulfate 10 mg subcutaneously every 3 to 4 hours for pain. The nurse suggests including which priority nursing action in the plan of care for this client? 1. Encourage the client to cough and deep breath 2. Encourage increased fluids 3. Monitor the client’s temperature 4. Monitor the urine output Answer: 1 Rationale: Morphine sulfate suppresses the cough reflex. Clients need to be encouraged to cough and deep breathe to prevent complications related to the use of this medication. Although options 2, 3, and 4 may be a component of the plan of care for this client, option 1 identifies the priority nursing action. Test-Taking Strategy: Note the key words priority nursing action. Recalling that morphine sulfate suppresses the cough reflex and the respiratory reflex will direct you to the correct option. Additionally, use the ABCs, airway, breathing, and circulation. This will easily direct you to option 1. Review the effects of this medication 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. 734. 461. A nurse is assisting in preparing a plan of care for a client with renal colic who is receiving meperidine hydrochloride (Demerol) for pain. The nurse includes in the plan of care to monitor for which side effect of this medication? 1. Urinary retention 2. Bradycardia 3. Hypertension 4. Increased respirations Answer: 1 Rationale: Side effects of this medication include respiratory depression, orthostatic hypotension, tachycardia, drowsiness and mental clouding, constipation, and urinary retention. Test-Taking Strategy: Knowledge regarding the side effects associated with narcotic analgesics will assist you in answering the question. With this question, you can associate the client’s diagnosis with the correct option because both are renal system related. If you had difficulty with this question, review the side effects of this medication. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning

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Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 675. 462. A nurse is providing instructions to a client who is taking codeine sulfate for severe back pain. The nurse tells the client to: 1. Increase fluid intake 2. Maintain a low-fiber diet 3. Avoid all exercise to prevent light-headedness 4. Avoid the use of stool softeners to prevent diarrhea Answer: 1 Rationale: Codeine sulfate can cause constipation. The client is instructed to increase fluid intake to prevent constipation. Options 2, 3, and 4 are incorrect because they do not address the side effects associated with the use of this medication. Although lightheadedness can occur with the use of this medication, all exercise is not avoided. It is important that the client ambulate frequently. Test-Taking Strategy: Use the process of elimination in answering the question. Remember that codeine sulfate can cause constipation. Review the side effects of 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. 254. 463. A client with a spinal cord injury has been experiencing discomfort caused by spasticity, and dantrolene (Dantrium) is prescribed for the client. Before initiating therapy, the nurse anticipates that which of the following will be prescribed? 1. Blood pressure measurements 2. Renal function studies 3. Liver function studies 4. Otoscopic examination Answer: 3 Rationale: Dantrolene can cause liver damage and the nurse should monitor the liver function studies. Baseline liver function studies are done before therapy starts, and regular liver function studies are performed throughout therapy. Dantrolene is discontinued if no relief of spasticity is achieved in 6 weeks. Options 1, 2, and 4 are not specifically related to the administration of this medication. Test-Taking Strategy: Use the process of elimination. Recalling that this medication is hepatotoxic 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

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Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 286. 464. A nurse has reinforced discharge instructions to a mother of a child who is taking tetracycline hydrochloride (Achromycin) to treat Rocky Mountain spotted fever (RMSF). Which statement by the mother indicates the best understanding regarding the administration of the medication? 1. “I need to give the medication with water.” 2. “I need to give the medication with milk.” 3. “I need to mix the medication in a Styrofoam glass with water.” 4. “I need to use a straw when I give the medication.” Answer: 4 Rationale: Because tetracycline hydrochloride can cause staining of the teeth, straws should be used, and the mouth should be rinsed after administration. Option 3 is not necessary. The medication should be administered 1 hour before or 2 hours after the administration of milk. Option 1 is accurate, but the best measure is to administer the medication with a straw. Test-Taking Strategy: Focus on the medication. Recalling that tetracycline can cause staining of the teeth will direct you to option 4. If you had difficulty with this question, review the client teaching points related to the administration of this medication. Level of Cognitive Ability: Comprehension 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. 997. 465. A nurse has reinforced discharge instructions to a client with multiple sclerosis who is receiving baclofen (Lioresal). Which statement by the client indicates an understanding of the medication? 1. “I need to restrict my fluid intake while I take this medication.” 2. “If I experience fatigue, I need to notify the physician.” 3. “I need to stop the medication if diarrhea occurs.” 4. “I need to watch for urinary retention.” Answer: 4 Rationale: Baclofen is a central nervous (CNS) depressant. It is not necessary to restrict fluids, but the client should be warned that urinary retention can occur. Fatigue is related to a CNS effect that is most intense during the early phase of therapy and diminishes with continued medication use. It is not necessary that the client notify the physician. Constipation rather that diarrhea is an adverse effect of baclofen. Additionally the client should be cautioned against the use of alcohol and other CNS depressants since baclofen potentiates the depressant activity of these agents. Test-Taking Strategy: Use the process of elimination. Recalling that baclofen is a CNS depressant will direct you to option 4. If you were unsure of the correct answer, use general principles related to medication administration to assist in selecting the correct

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option. Review the client teaching points related to this medication if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity 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. 512. 466. A nurse employed in the emergency room is preparing to administer syrup of ipecac to a 7-month-old child. The nurse prepares 5 mL of the syrup and administers one half of a glass of water following administration of the ipecac syrup. Which of the following expected response would the nurse expect to occur? 1. Vomiting 2. Diarrhea 3. Increased level of consciousness 4. Elevated blood pressure Answer: 1 Rationale: Syrup of ipecac is a medication that may be prescribed for the induction of emesis. It is indicated following ingestion of some poisons. It is contraindicated following ingestion of strong acids or bases. It is also contraindicated for clients who are comatose, delirious, or experiencing convulsions. The dose for children under 1 year of age is 5 to 10 mL followed by one half to one glass of water. Diarrhea may occur as a side effect of the medication, as can sedation. Blood pressure is not related to administration of this medication. Test-Taking Strategy: Use the process of elimination and note the key words “expected response.” Eliminate option 2 because diarrhea is a side effect of the medication. Eliminate option 4 because an elevated blood pressure is unrelated to the administration of this medication. From the remaining options, recalling that an oral medication would not be given if the child is not alert would assist in directing you to option 1. 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. 584. 467. L-asparaginase (Elspar) is administered to a client with acute lymphocytic leukemia. The nurse assisting in caring for the client is monitoring for adverse effects related to the medication. Which of the following, if noted on data collection, would indicate toxicity related to the administration of this medication? 1. Altered coagulation blood studies 2. Decreased white blood cell count 3. Oral ulcerations 4. Alopecia

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Answer: 1 Rationale: L-asparaginase can cause severe adverse effects, however the spectrum of toxicity differs from that of other anticancer medications. By inhibiting protein synthesis, the medication can cause coagulation deficiencies and injury to the liver, pancreas, and kidneys. Symptoms of central nervous system depression ranging from confusion to coma can occur. Nausea and vomiting can be intense and may limit the dose that can be tolerated. In contrast to most anticancer medications, L-asparaginase does not depress the bone marrow, nor does it cause alopecia, oral ulceration, or intestinal ulceration. Test-Taking Strategy: Use the process of elimination. Recalling that the toxicity associated with this medication is different from most anticancer medications will assist in directing you to option 1. Review the toxic 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 Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, pp. 85-86. 468. Cisplatin (Platinol) is administered to a client with a diagnosis of testicular cancer. The nurse assisting in caring for the client is monitoring for adverse effects related to the medication. Which of the following if noted in the client would indicate an adverse effect related to the administration of this medication? 1. Increased platelet count 2. Diarrhea 3. Tinnitus 4. Elevated white blood cell count Answer: 3 Rationale: Cisplatin is a medication that kills cells primarily by forming cross-links between and within strands of DNA. Its principle indication for use is to treat testicular cancer. Other indications include carcinomas of the ovary, bladder, head, and neck. It can cause damage to the kidneys. Other adverse effects include neurotoxicity, bone marrow depression, and toxicity to the ear that manifests as tinnitus and high frequency hearing loss. Nausea and vomiting can be severe beginning 1 hour after administration and persisting for 1 to 2 days. Test-Taking Strategy: Use the process of elimination. Eliminate option 4 first because the white blood cell count is likely to decrease rather than increase. Next eliminate option 1, knowing that the platelet count is likely to decrease rather than increase. From the remaining options, recalling that toxicity to the ear is associated with the use of this medication 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/Evaluation Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005.

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Philadelphia: W.B. Saunders, p. 233. 469. Ifosfamide (Ifex) is prescribed for a client with a diagnosis of germ cell cancer of the testes. The nurse assisting in caring for the client would anticipate that which of the following would be prescribed to be administered concurrently during the administration of this antineoplastic medication? 1. Mesna (Mesnex) 2. Cisplatin (Platinol) 3. Prednisone (Deltasone) 4. Melphalan (Alkeran) Answer: 1 Rationale: Ifosfamide is an antineoplastic medication used to treat refractory germ cell cancer of the testes. It is a derivative of cyclophosphamide (Cytoxan). Dose-limiting toxicity of bone marrow depression and hemorrhagic cystitis is minimized by concurrent therapy with mesna and by extensive hydration of at least 2 L of oral or IV fluids daily. Mesna is the antidote specific to this medication. Test-Taking Strategy: Knowledge regarding the adverse effects related to the administration of ifosfamide is required to answer this question. If you are unfamiliar with these toxic effects and with the antidote associated with the administration of this antineoplastic agent, review this content. Level of Cognitive Ability: Analysis 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. 555. 470. A nurse is reinforcing instructions to a client with a diagnosis of scabies regarding the administration of crotamiton (Eurax). Which statement by the client indicates an understanding regarding the application of this medication? 1. “I will apply the application to my entire body and leave on for 24 hours followed by a cleansing bath.” 2. “I will massage the medication into the skin from my chin downward and apply a second application in 24 hours, followed by a cleansing bath 48 hours after the second application.” 3. “I should apply the medication to my entire body avoiding the skin folds and creases and wash it off in 12 hours.” 4. “I should apply the medication to my entire body washing it off after 2 hours.” Answer: 2 Rationale: The client is instructed to massage the medication into the skin of the entire body starting with the chin and working downward. The head and face are treated only if needed. Special attention should be given to skin folds and creases. Contact with eyes, mucous membranes, and any region of inflammation should be avoided. A second application is made 24 hours after the first. A cleansing bath should be taken 48 hours after the second application, and if needed treatment can be repeated in 7 days. Test-Taking Strategy: Read each option carefully and use the process of elimination.

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Eliminate options 1 and 4 because of the words “entire body.” Eliminate option 3 because skin folds and creases would not be avoided. Review client teaching points related to this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Reference: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 1055. 471. A client taking metronidazole (Flagyl) for the treatment of trichomoniasis vaginalis calls the nurse employed in the physician’s office and is concerned because the color of the urine is very dark. Which of the following information would the nurse provide to the client? 1. Report to the clinic to see the physician immediately. 2. Discontinue the medication. 3. The darkening of the urine is a harmless side effect. 4. Increase fluid intake. Answer: 3 Rationale: Metronidazole can produce a variety of untoward effects, but these rarely require termination of treatment. Harmless darkening of the urine may occur, and the client should be forewarned of this effect. The nurse would not instruct the client to discontinue the medication. It is not necessary that the client see the physician. Increasing fluid intake is a good health measure, but will not prevent this side effect from occurring. Test-Taking Strategy: Focus on the data in the question. Eliminate option 1 because of the word “immediately.” Use general medication guidelines to eliminate option 2. From the remaining options, recalling the harmless side effects of this medication will direct you to option 3. Review the side effects of 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: Skidmore-Roth, L. (2005). Mosby’s drug guide for nurses (6th ed.). St. Louis: Mosby, p. 560. 472. A client with acquired immunodeficiency syndrome (AIDS) is taking zidovudine (Retrovir) 200 mg orally three times daily. The client reports to the health care clinic for follow-up blood studies, and the results of the blood studies indicate severe neutropenia. Which of the following would the nurse anticipate to be prescribed for the client? 1. Reduction in the medication dosage 2. Discontinuation of the medication 3. The administration of prednisone (Deltasone) concurrent with the therapy 4. Administration of epoetin alfa (Epogen) Answer: 2

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Rationale: Hematological monitoring should be done every 2 weeks in the client taking zidovudine. If severe anemia or severe neutropenia develops, treatment should be discontinued until there is evidence of bone marrow recovery. If anemia or neutropenia is mild, a reduction in dosage may be sufficient. The administration of prednisone may further alter the immune function. Epoetin alfa is given to clients experiencing anemia. Test-Taking Strategy: Knowledge regarding the adverse effects related to the administration of zidovudine is required to answer this question. Focus on the key words “severe neutropenia” to assist in directing 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/Planning Content Area: Adult Health/Immune Reference: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, pp. 988, 1018. 473. A client with acquired immunodeficiency syndrome is taking didanosine (Videx). The client calls the nurse at the physician’s office and reports nausea, vomiting, and abdominal pain. Which of the following instructions would the nurse provide to the client? 1. “This is an expected side effect of the medication.” 2. “Come to the office to be seen by the physician.” 3. “Take crackers and milk with the administration of the medication.” 4. “Decrease the dose of the medication until the next physician’s visit.” Answer: 2 Rationale: Pancreatitis, which can be fatal, is the major dose-limiting toxicity associated with the administration of didanosine. Clients should be monitored for indications of pancreatitis, which include increased serum amylase in association with increased serum triglycerides, decreased serum calcium, and nausea, vomiting, or abdominal pain. If evolving pancreatitis is diagnosed, the medication should be discontinued. The client should be seen by the physician. Test-Taking Strategy: Focus on the data in the question. Recalling that nausea, vomiting, and abdominal pain are signs of pancreatitis and that pancreatitis is associated with the use of this medication should direct you to the correct option. Review the adverse effects of 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: Adult Health/Immune Reference: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 1018. 474. A client with acquired immunodeficiency syndrome reports to the clinic for a follow-up examination. The client is taking zalcitabine (Hivid). Which of the following questions would the nurse ask to determine the presence of an adverse effect associated with the use of this medication?

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1. “Are you having any diarrhea?” 2. “Do you have any numbness or burning sensations in your arms or legs?” 3. “Are you having any ringing in you ears?” 4. “Do you have any burning on urination?” Answer: 2 Rationale: Peripheral neuropathy is an adverse effect associated with the use of zalcitabine. It manifests initially as numbness and burning sensations in the extremities. These symptoms may progress to sharp shooting pain and severe continuous burning if the medication is not discontinued. The pain of severe neuropathy requires narcotic analgesics for control. Clients should be informed about the early symptoms of neuropathy and instructed to report them immediately. Neuropathy will reverse slowly if the medication is withdrawn early, but may become irreversible if the medication is continued. Options 1, 3, and 4 are unrelated to the adverse effects associated with the use of this medication. Test-Taking Strategy: Knowledge regarding the adverse effects associated with the use of zalcitabine is required to answer this question. Recalling that peripheral neuropathy is an adverse effect will direct you to option 2. 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: Adult Health/Immune Reference: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 1018. 475. Indinavir (Crixivan) is prescribed for a client with human immunodeficiency virus (HIV). The nurse has provided instructions to the client regarding the administration of the medication. Which of the following if stated by the client indicates an adequate understanding of the use of this medication? 1. “I need to take the medication with my large meal of the day.” 2. “I need to store the medication in the refrigerator.” 3. “I need to take the medication with water but on an empty stomach.” 4. “I need to take the medication with a high-fat snack.” Answer: 3 Rationale: To maximize absorption, the medication should be administered with water on an empty stomach. The medication can be taken 1 hour before a meal or 2 hours after a meal, or it can be administered with skim milk, coffee, tea, or a low-fat meal, such as corn flakes with skin milk and sugar. It is not to be administered with a large meal. The medication should be stored at room temperature and protected from moisture because moisture can degrade the medication. Test-Taking Strategy: Use the process of elimination. Options 1 and 4 can be eliminated first because they are similar. From the remaining options, it is necessary to know that this medication is stored at room temperature. Review client teaching points related to this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity

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Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Immune Reference: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 1020. 476. A nurse is assigned to care for a client with herpes simplex virus (HSV) who is receiving acyclovir (Zovirax). The nurse is monitoring for adverse effects of the medication. Which of the following laboratory results would the nurse specifically monitor to identify an adverse effect associated with the use of this medication? 1. White blood cell count 2. Red blood cell count 3. Blood urea nitrogen (BUN) 4. Platelet count Answer: 3 Rationale: The most common reaction related to the administration of this medication is phlebitis and inflammation at the intravenous site of infusion. Reversible nephrotoxicity manifested as elevations in serum creatinine and blood urea nitrogen also occurs in some clients. The cause of nephrotoxicity is the deposition of acyclovir in the renal tubules. The risk of renal injury is increased by dehydration and by the use of other nephrotoxic medications. Test-Taking Strategy: Use of the process of elimination and knowledge regarding the adverse effects related to the administration of this medication are required to answer this question. Knowing that nephrotoxicity is an adverse effect will direct you to option 3. Review the adverse effects of acyclovir if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Immune Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 12. 477. A nurse is preparing to administer ribavirin (Vibrazole) to a child with respiratory syncytial virus (RSV). The pharmacy dispenses the medication as a powder. The nurse prepares to administer the medication by: 1. Mixing the medication in formula and administering it orally to the child 2. Mixing the medication in sterile saline and administering it by subcutaneous injection 3. Mixing the medication in sterile water and administering it by intramuscular injection 4. Aerosol administration Answer: 4 Rationale: Ribavirin is active against (RSV), influenza virus types A and B, and herpes simplex virus. It is administered by oral inhalation, and the medication is absorbed from the lungs and achieves high concentrations in respiratory tract secretions and erythrocytes. It is not administered orally, subcutaneously, or intramuscularly. Test-Taking Strategy: Knowledge regarding the administration of this medication is required to answer this question. Remember that this medication is administered by aerosol administration. Review the procedure for administering this medication if you

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had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology Reference: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 979. 478. A pilocarpine ocular system (Ocusert Pilo-20) system is prescribed for the client with glaucoma. The nurse provides instructions to the client regarding the medication. Which statement by the client indicates an understanding of the use of this medication? 1. “I should apply ½ inch into my eye at bedtime.” 2. “I should check my eye each morning to make sure that the medication system is in place.” 3. “I should apply 1 drop of the solution four times a day.” 4. “I need to replace the ocular system every 48 hours.” Answer: 2 Rationale: The pilocarpine ocular system consists of a bilayered membrane surrounding a reservoir of pilocarpine solution. The tiny unit is placed in the conjunctival sac after which pilocarpine is slowly released. A replacement unit should be installed once a week. Since the unit may fall out during sleep, clients are advised to check each morning for its presence. Test-Taking Strategy: Knowledge regarding the pilocarpine ocular system is required to answer this question. Knowing that the system remains in the eye for a period of 1 week will assist in directing you to the correct option. If you had difficulty with this question, review this treatment for glaucoma. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Eye Reference: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 1102. 479. Latanoprost (Xalatan) drops are prescribed for the client with glaucoma. The client returns to the health care clinic for evaluation. Which of the following findings if noted in the client indicate a side effect associated with the use of these eye drops? 1. Periorbital edema 2. Brown pigmentation of the iris 3. Elevated blood pressure 4. Cardiac dysrhythmias Answer: 2 Rationale: Latanoprost is a topical medication used to lower intraocular pressure in clients with open angle glaucoma and ocular hypertension. The most significant side effect is heightened brown pigmentation of the iris. Other side effects include blurred vision, burning, stinging, conjunctival hyperemia, and punctate keratopathy. The heightened pigmentation stops progressing when the medication is discontinued, but does

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not regress. Options 1, 3, and 4 are inaccurate and not associated side effects of the medication. Test-Taking Strategy: Knowledge regarding the effects of this medication is required to answer this question. Remember that the most significant side effect of this medication is heightened brown pigmentation of the iris. Review these side effects if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Eye Reference: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 1101. 480. A client with a burn injury is scheduled for a heterograft. The nurse is preparing the client for the skin grafting, and the client asks the nurse what “heterograft” means. The appropriate response to the client is: 1. “It is skin from another species.” 2. “It is skin from a cadaver.” 3. “It is skin from the burned client.” 4. “It is skin from a skin bank.” Answer: 1 Rationale: Biological dressings are obtained from living or deceased humans (homograft or allograft) or animals (heterograft or xenograft). A heterograft is skin from another species. The most commonly used type of heterograft is pigskin because of its relative compatibility with human skin. A homograft is skin from another human, which is usually obtained from a cadaver and is provided through a skin bank. Test-Taking Strategy: Use the process of elimination. Note that options 2, 3, and 4 all refer to donor skin from the human species. Option 1, the correct option, identifies skin from a different species. Review the various types of skin grafts 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/Integumentary References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 1459-1460. Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, pp. 528-529. 481. A nurse is assisting in caring for a client who sustained a traumatic head injury following a motor vehicle accident. The nurse documents that the client is exhibiting decerebrate posturing. The nurse bases this documentation on which observation? 1. Extension of the extremities and pronation of the arms 2. Flexion of the extremities and pronation of the arms 3. Upper extremity flexion with lower extremity extension

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4. Upper extremity extension with lower extremity flexion Answer: 1 Rationale: Decerebrate posturing (abnormal extension), which is associated with dysfunction in the brainstem area, consists of extension of the extremities and pronation of the arms. Posturing is a late sign of deterioration in the client’s neurological status and warrants immediate physician notification. Test-Taking Strategy: Knowledge regarding the findings noted in posturing is required to answer this question. Remember that decerebrate posturing (abnormal extension) consists of extension of the extremities and pronation of the arms. Review this abnormal neurological finding if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 383. 482. A client with diabetes mellitus calls the clinic nurse to report that the blood glucose level is 150 mg/dl. After obtaining further data from the client, the nurse determines that the client ate lunch approximately 2 hours ago. The nurse would interpret these results to be: 1. Normal 2. Lower than the normal value 3. Slightly higher than the normal value 4. A value that indicates immediate physician notification Answer: 3 Rationale: Normal fasting blood glucose values range from 70 to 120 mg/dl. The 2-hour postprandial blood glucose level should be less than 140 mg/dl. In this situation, the blood glucose value was 150 mg/dl 2 hours after the client ate, which is slightly elevated above normal. This value does not require physician notification. Test-Taking Strategy: Focus on the data in the question. Noting that the client ate 2 hours before the blood test will direct you to the correct option. If you had difficulty with this question, review normal blood glucose and 2-hour postprandial blood glucose values. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Endocrine Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 599. 483. A client was admitted to a medical unit because the client suddenly experienced total deafness. The client undergoes numerous testing to determine the cause of the deafness. All test results are negative, and there seems to be no organic reason why this client cannot hear. On further review of the client’s record, the nurse notes that the client became deaf after witnessing a murder. Based on this data and the results of the diagnostic tests, the nurse suspects that the client may be experiencing:

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1. Psychosis 2. A conversion disorder 3. A dissociative disorder 4. Repression Answer: 2 Rationale: A conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. It is thought to be an expression of a psychological need or conflict. In this scenario, the client witnessed a murder that was so psychologically painful that the client became deaf. Psychosis is a state in which a person’s mental capacity to recognize reality, communicate, and relate to others is impaired, thus interfering with the person’s capacity to deal with life demands. A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness. Test-Taking Strategy: Knowledge regarding defense mechanisms is required to answer the question. The key to the answer lies in the fact that the client evidences no organic reason to account for the deafness, hence, a conversion disorder. If you had difficulty with this question, review the manifestations associated with a conversion disorder. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, pp. 229-230. 484. Arterial blood gases (ABG) are obtained on a client with pneumonia. The ABG −

results are pH, 7.50; PCO2, 30 mm Hg; HCO 3 , 20 mEq/L; PO2, 75 mm Hg; SaO2, 90%. The nurse interprets these results and determines that which of the following acid-base conditions exists? 1. Respiratory alkalosis 2. Metabolic acidosis 3. Respiratory acidosis 4. Metabolic alkalosis Answer: 1 Rationale: Normal pH is 7.35 to 7.45. Normal PCO2 is 35 to 45 mm Hg. Remember that when a respiratory condition exists, an opposite effect will be found between the pH and the PCO2. In respiratory alkalosis, the pH will be elevated and the PCO2 level decreased. Test-Taking Strategy: Remember that in acidosis the pH is decreased, and in alkalosis the pH is elevated. Therefore eliminate options 2 and 3. Noting that the PCO2 is low will assist in directing you to option 1. Review ABG values if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Respiratory

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Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 245. 485. A nurse is admitting a client to the nursing unit who is scheduled for several diagnostic tests. When obtaining a medication history, the nurse discovers that the client is taking tacrolimus (Prograf) daily. On further data collection, the nurse would expect to note that the client: 1. Has a history of coronary artery disease 2. Has a history of hypertension 3. Had an allogenic liver transplant 4. Had an ileal conduit created Answer: 3 Rationale: Tacrolimus is an immunosuppressant medication used in the prophylaxis of organ rejection in clients receiving allogenic liver transplants. It should be used concurrently with adrenal corticosteroids. It may also be used in clients receiving kidney, bone marrow, heart, pancreas, and small bowel transplants. Options 1, 2, and 4 are not associated with this use of this medication. Test-Taking Strategy: Use the process of elimination. Use your knowledge of medical terminology to help you select the correct option. If you remember that “pro” means “for” and “graf” means “graft,” you will know that the action of Prograf is to prevent transplant rejection. 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 Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 1002. 486. A nurse is monitoring a client receiving torsemide (Demadex) 5 mg orally daily. Which of the following would indicate to the nurse that a therapeutic effect has occurred? 1. A blood pressure of 128/80 mm Hg 2. The presence of dependent edema 3. A sodium level of 130 mEq/L 4. A potassium level of 3.1 mEq/L Answer: 1 Rationale: Torsemide is a loop diuretic used primarily in the treatment of hypertension. It may be used alone or in combination with other antihypertensives. It may also be used in the treatment of edema associated with congestive heart failure (CHF), renal disease, or hepatic cirrhosis. Overdose of the medication produces acute, profound water loss, volume and electrolyte depletion, dehydration, decreased blood volume, and circulatory collapse. The presence of edema would not indicate a therapeutic effect. The normal sodium level is 135 to 145 mEq/L, and the normal potassium level is 3.5 to 5.1 mEq/L. Options 3 and 4 indicate abnormal electrolyte values. Test-Taking Strategy: Note the key words therapeutic effect. Knowledge of the action of torsemide and of normal laboratory values is required to answer this question. Option 1 is the only option that identifies a normal finding. Review the action of this medication if

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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. 1059. 487. A nurse is caring for a client who was told that he had Bell’s palsy 1 week ago. Which of the following data would indicate a potential complication associated with Bell's palsy? 1. Partial facial paralysis 2. Excessive tearing 3. Negative outcomes on the electromyography 4. The ability to taste food Answer: 2 Rationale: Complications of Bell's palsy include abnormal regeneration of the nerve; “crocodile tears” (autonomic fibers reconnect to the lacrimal duct instead of the salivary glands so that the client experiences excessive tearing while eating); abnormal facial movements caused by reinnervation of inappropriate muscles; and spasms, atrophy, and contractures caused by incomplete motor fiber reinnervation. Partial facial paralysis is a factor indicating recovery. Negative outcomes on the electromyography performed 1 week after symptom onset indicates that nerve regeneration is present (negative test result indicates a positive prognostic outcome). Tasting food 1 week after symptom onset indicates a good prognosis for recovery. Test-Taking Strategy: Focus on the key word complication. Partial facial paralysis is a factor indicating recovery, whereas total facial paralysis indicates a poor prognosis. Negative outcomes on the electromyography indicate a positive prognostic outcome. Tasting food 1 week after symptom onset indicates a good prognosis for recovery. Review the complications associated with Bell’s palsy if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, pp. 16051606. 488. Fluoxetine hydrochloride (Prozac) is prescribed for a client being treated for depression, and the nurse provides instructions to the client regarding the medication. Which statement by the client would indicate that the client understands this medication therapy? 1. “I will need a stronger dose if I don’t feel results in a few days.” 2. “If I don’t feel better in 1 week, I should stop the medication.” 3. “If my mouth becomes dry, I should stop the medication.” 4. “It takes approximately 2 to 4 weeks before improvement is noted.”

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Answer: 4 Rationale: The time frame in which the therapeutic effects of fluoxetine hydrochloride are seen is usually 2 to 4 weeks after initiation of therapy. It is important to advise clients to comply with the prescribed regimen so that therapeutic levels are maintained. Dry mouth is a side effect of the medication, and the client should be instructed to relieve the dry mouth by chewing sugarless gum or sipping tepid water. Test-Taking Strategy: Note the key words client understands. Eliminate options 2 and 3 because the client should not stop medication without consulting the health care provider. Next eliminate option 1, knowing that it will take longer than a few days for effectiveness to occur. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial 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. 453. 489. A nurse is caring for a client who received electroconvulsive therapy (ECT) for a major depressive disorder. On data collection, the nurse notes that the client’s blood pressure is elevated at 160/100 mm Hg. Based on this finding, the appropriate nursing action would be to: 1. Document the blood pressure 2. Reassess the blood pressure in 30 minutes 3. Notify the registered nurse 4. Lower the head of the bed Answer: 3 Rationale: The major side effects of ECT are confusion, disorientation, and memory loss. An elevation in blood pressure would not be an anticipated side effect and would be a cause for concern. If hypertension occurred following ECT, the nurse would notify the registered nurse who would then notify the physician. Options 1, 2, and 4 are incorrect nursing actions. Test-Taking Strategy: Use the process of elimination and knowledge of ECT and its side effects to assist you in answering this question. Eliminate option 4 first because this action may cause a further increase in blood pressure. When selecting from the remaining options, noting that the blood pressure is elevated and is higher than the normal range should assist in directing you to option 3. Review the adverse effects of ECT if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 218. 490. A nurse is caring for a hospitalized client following cystoscopy and is monitoring for signs of complications associated with the procedure. Which of the following, if

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noted in the first few hours following the procedure, indicates the need to notify the registered nurse? 1. Pink-tinged urine 2. Yellow-colored urine 3. Clear urine 4. Bloody urine with clots Answer: 4 Rationale: The client may have clear, yellow, or pink-tinged urine after cystoscopy. Bloody urine with clots is always an abnormal finding and should be reported immediately. Test-Taking Strategy: Use the process of elimination. Begin to answer this question by eliminating options 2 and 3 since these are normal findings. Eliminate option 1 next, knowing that minor trauma from the procedure could cause blood-tinged urine to occur. Remember that bloody urine with clots indicates active, current bleeding. Review postprocedure expected findings if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Renal Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 450. 491. A nurse is admitting a client to the nursing unit who has returned from the postanesthesia care unit following prostatectomy. The client has a three-way Foley catheter with continuous bladder irrigation. The nurse would maintain the flow rate of the continuous bladder infusion to maintain a urine output that is: 1. Red 2. Yellow with small clots 3. Colorless 4. Pale yellow or slightly pink Answer: 4 Rationale: Bladder irrigant is not infused at a preset rate, but rather it is increased or decreased to maintain urine that is clear or pale yellow or that has just a slight pink tinge. The infusion rate should be increased if the drainage is red or if clots are seen. Correspondingly the rate can be slowed slightly if the returns are as clear as water. Test-Taking Strategy: Begin to answer this question by eliminating option 2 as the least realistic of all the urine characteristics described in the options. You would then eliminate options 1 and 3 as reflecting inadequate and excessive flow, respectively. This leaves option 4 as the correct option. With proper flow rate of bladder irrigant, the urine should be pale yellow or pale pink. Review care to the client receiving continuous bladder irrigation 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/Renal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical

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management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 1023-1024. 492. A nurse is collecting data on a client suspected of having Alzheimer's disease. The priority data would focus on which of the following characteristic of this disease? 1. Recent memory loss 2. Difficulty in performing new tasks 3. Problems with concrete thinking 4. Problems with hearing and discriminating the spoken word from other sounds Answer: 1 Rationale: Dementia is the hallmark of Alzheimer's disease. Recent memory loss is one characteristic. Others include problems with abstract thinking, problems with speech (not hearing), and difficulty in performing familiar tasks. Test-Taking Strategy: Focus on the client’s diagnosis. Recalling that recent memory loss is associated with this disease will direct you to option 1. Review Alzheimer's disease if you have difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 633. 493. A nurse is providing instructions to a client with a diagnosis of rheumatoid arthritis (RA) who is receiving acetylsalicylic acid (ASA [aspirin])), 5 g orally daily. Which of the following if stated by the client would indicate an understanding of the instructions? 1. “I should notify the physician if I get any ringing in my ears.” 2. “A slow pulse might indicate a reaction to the medication.” 3. “If I have joint pain, I need to notify the physician.” 4. “If I have discomfort with exercise, I need to stop the medication.” Answer: 1 Rationale: ASA is a nonsteroidal anti-inflammatory medication. Adverse reactions include gastrointestinal bleeding and/or gastric mucosal lesions, ringing in the ears (tinnitus), and generalized pruritus. Headache, dizziness, flushing, tachycardia, hyperventilation, sweating, and thirst also are adverse reactions. Options 2, 3, and 4 are incorrect client statements. Test-Taking Strategy: Use the process of elimination. Eliminate option 3 first recalling that one of the primary complaints of clients with RA is joint pain, which is one of the reasons that ASA would be prescribed. Next eliminate option 4 because discomfort with exercise is expected with RA and ASA is administered to alleviate this discomfort. Remembering that this medication can cause ototoxicity will assist in directing you to the correct option from those remaining. 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/Evaluation

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Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 88. 494. A nurse is collecting data on a client with a diagnosis of peptic ulcer disease. Which of the following data is least likely associated with the development of this disease? 1. History of tarry black stools 2. History of alcohol abuse 3. History of gastric pain 2 to 4 hours after meals 4. History of the use of acetaminophen (Tylenol) for pain and discomfort Answer: 4 Rationale: Unlike acetylsalicylic acid (ASA [aspirin]), acetaminophen has little effect on platelet function, does not affect bleeding time, and generally produces no gastric bleeding. The data in options 1, 2, and 3, if reported by the client, indicate risk factors associated with peptic ulcer disease. Test-Taking Strategy: Use the process of elimination and note the key words least likely. Options 1 and 3 are signs and symptoms of peptic ulcers. Because alcohol may irritate the stomach mucosa, a history of alcohol abuse is often seen in clients with peptic ulcer disease. This leaves option 4 as the correct answer to this question. Review the risk factors associated with peptic ulcer disease if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Gastrointestinal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 186. 495. A child is to be admitted to the orthopedic unit following a Harrington rod insertion for the treatment of scoliosis. The nurse is assisting in preparing a plan of care for the child. The nurse plans to monitor which priority item in the immediate postoperative period? 1. Pain level 2. Capillary refill, sensation, and motion in all extremities 3. Ability to turn using the log-roll technique 4. Ability to flex and extend the lower extremities Answer: 2 Rationale: When the spinal column is manipulated during surgery, altered neurovascular status is a possible complication; therefore neurovascular assessments, including circulation, sensation, and motion, should be done every 2 hours. Level of pain and ability to flex and extend the lower extremities are important postoperative assessments, but not the priorities of the options provided. Log rolling would be performed by nurses. Test-Taking Strategy: Use the ABCs, airway, breathing, and circulation to answer this question. Option 2 addresses circulatory status. Review postoperative care following Harrington rod insertion if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity

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Integrated Process: Nursing Process/Planning Content Area: Child Health References: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 582. Wong, D., & Hockenberry, M. (2003). Nursing care of infants and children (7th ed.). St. Louis: Mosby, pp. 1812-1813. 496. A nurse is assisting in preparing a plan of care for a child who will be returning from surgery following the application of a hip spica cast. Which of the following would be the priority in the plan of care for this child upon return from the procedure? 1. Elevate the head of the bed 2. Turn the child on the right side 3. Check circulation 4. Abduct the hips using pillows Answer: 3 Rationale: During the first few hours after a cast is applied, the primary concern is swelling that may cause the cast to produce a tourniquet-like effect and restrict circulation. Therefore circulatory assessment is a priority. Elevating the head of the bed of a child in a hip spica would cause discomfort. Using pillows to abduct the hips is not necessary because a hip spica immobilizes the hip and the knee. Turning the child side to side at least every 2 hours is important because it allows the body cast to dry evenly and prevents complications related to immobility; however, it is not as important as checking circulation. Test-Taking Strategy: Use the process of elimination and note the key word priority. Use the ABCs, airway, breathing, and circulation, to answer this question. Option 3 addresses circulatory status. Review care to the child following the application of a hip spica cast if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Child Health Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 1409. 497. A nurse is caring for a client who has tuberculosis (TB). Rifampin (Rifadin), 600 mg by mouth daily, is prescribed for the client. The nurse provides instructions to the client regarding the administration of this medication. Which of the following statements by the client indicates an understanding of the instructions? 1. “I need to limit alcohol intake.” 2. “I will need to take the medication for months.” 3. “I need to take the medication with meals.” 4. “I need to call the physician if the color of my urine turns red-orange.” Answer: 2 Rationale: The client needs to avoid alcohol while taking this medication. The medication should be taken on an empty stomach with 8 oz of water 1 hour before or 2 hours after meals. The client should be told that urine, feces, sweat, and tears may turn

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red-orange. The client should also be instructed that doses should not be skipped, and the medication needs to be taken as prescribed for the full length of therapy, which may range from 6 to 9 months up to 1 year. The nurse should note any elevation of the alkaline phosphatase, which would indicate possible hepatotoxicity. Test-Taking Strategy: Use the process of elimination. Eliminate option 1 first, using basic principles related to medication therapy. Knowledge that medication therapy for TB is prescribed for months to a year or more will assist you in eliminating options 3 and 4 and direct you to option 2. Review pharmacological therapy for TB 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: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 951. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 1060. 498. A client had a Miller-Abbott tube inserted 24 hours ago. The nurse is asked to check the client to determine whether the tube is in the appropriate location at this time. Which of the following findings would indicate adequate location of the tube? 1. The aspirate from the tube has a pH of 7.45 2. The aspirate from the tube has a pH of 6.5 3. Bowel sounds are absent 4. The tube can be palpated to the right of the umbilicus Answer: 1 Rationale: The Miller-Abbott tube is a nasoenteric tube that is used to decompress the intestine (to correct a bowel obstruction). The end of the tube should be located in the intestine. The pH of the gastric fluid is acidic, and the pH of the intestinal fluid is 7 or higher if the tube is adequately located. Location of the tube can also be determined by x-ray examination. Options 3 and 4 are incorrect and would not determine adequate location of the tube. Test-Taking Strategy: The issue of the question is specific content regarding the client with a Miller-Abbott tube with regard to placement and location of the tube. Knowing that this tube should be located in the intestine and recalling that intestinal contents are alkaline will easily direct you to option 1. Review the purpose of a Miller-Abbott tube and the nursing care of a client with this tube if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Gastrointestinal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 660-662. 499. A nurse is monitoring a client receiving spironolactone (Aldactone) 50 mg by mouth daily. Which of the following would indicate to the nurse that the client is

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experiencing a side effect related to the medication? 1. A potassium level of 5.2 mEq/L 2. A sodium level of 140 mEq/L 3. Client complaints of constipation 4. Client complaints of dry skin Answer: 1 Rationale: Spironolactone is a potassium-sparing diuretic. Side effects include hyperkalemia, dehydration, hyponatremia, and lethargy. Although the concern with most diuretics is hypokalemia, this medication is potassium sparing, which means that the concern with the administration of this medication is hyperkalemia. The normal sodium level is 135 to 145 mEq/L, and the normal potassium level is 3.5 to 5.1 mEq/L. Additional side effects include nausea, vomiting, cramping, diarrhea, headache, ataxia, drowsiness, confusion, and fever. Dry skin is unrelated to the administration of this medication. Test-Taking Strategy: Use the process of elimination. Remember that most diuretics produce hypokalemia; however, the potassium-sparing diuretics cause hyperkalemia, particularly in clients on potassium supplements and clients with renal insufficiency. If you had difficulty with this question, review those medications in the classification of potassium-sparing diuretics. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 887. Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 985. 500. A nurse is monitoring a client with a C5 spinal cord injury for spinal shock. Which of the following findings would be unassociated with spinal shock in this client? 1. Bowel sounds are absent. 2. The client’s abdomen is distended. 3. Respiratory excursion is diminished. 4. The blood pressure rises when the client sits up. Answer: 4 Rationale: During the period of areflexia that characterizes spinal shock, the blood pressure may fall when the client sits up. The bowel and bladder often become flaccid, may become distended, and fail to empty spontaneously. Bowel sounds would be absent. Accessory muscles of respiration may become areflexic as well, diminishing respiratory excursion and oxygenation. Test-Taking Strategy: Use the process of elimination and note the key word unassociated. This word indicates a false-response question and that you need to select the incorrect finding. Recalling that in spinal shock the blood pressure may fall when the client sits up will direct you to the correct option. Review these signs if you had difficulty with this question. Level of Cognitive Ability: Analysis

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Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 650. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 439.