1. A 72 year-old client is scheduled to have a cardioversion. A nurse reviews the client’s medication administration record. The nurse should notify the health care provider if the client received which medication during the preceding 24 hours?
A. digoxin (Lanoxin)
B. diltiazam (Cardizem)
C. nitroglycerine ointment
D. metoprolol (Toprol XL)
A. digoxin (Lanoxin)
B. diltiazam (Cardizem)
C. nitroglycerine ointment
D. metoprolol (Toprol XL)
The correct answer is A: digoxin (Lanoxin) Digoxin increases ventricular irritability and increases the risk of ventricular fibrillation following cardioversion. The other medications do not increase ventricular irritability
2. Which of these clients, who all have the findings of a board-like abdomen, would the nurse suggest that the health care provider examine first?
A) An elderly client who stated that "My awful pain in my right side suddenly stopped about 3 hours ago."
B) A pregnant woman of 8 weeks newly diagnosed with an ectopic pregnancy
C) A middle-aged client admitted with diverticulitis and has taken only clear liquids for the past week
D) A teenager with a history of falling off a bicycle and did not hit the handle bars
The correct answer is A: An elderly client who stated that "My awful pain in my right side suddenly stopped about 3 hours ago." This client has the highest risk for hypovolemic and septic shock since the appendix has most likely ruptured as based on the history of the pain suddenly stopping over three hours ago. Being elderly, there is less reserve for the body to cope with shock and infection over long periods. The others are at risk for shock also. However, given that they fall in younger age groups, they would more likely be able to tolerate an imbalance in circulation. A common complication of falling off a bicycle is hitting the handle bars in the upper abdomen often on the left, resulting in a ruptured spleen.
3. The nurse manager informs the nursing staff at morning report that the clinical nurse specialist will be conducting a research study on staff attitudes toward client care. All staff are invited to participate in the study if they wish. This affirms the ethical principle of
The correct answer is D: Autonomy Individuals must be free to make independent decisions about participation in research without coercion from others.
4. Which statement made by a nurse about the goal of total quality management or continuous quality improvement in a health care setting is correct?
A) “It is to observe reactive service and product problem solving."
B) Improvement of the processes in a proactive, preventive mode is paramount.
C) A chart audits to finds common errors in practice and outcomes associated with goals.
D) A flow chart to organize daily tasks is critical to the initial stages.
The correct answer is B: Improvement of the processes in a proactive, preventive mode is paramount. Total quality management and continuous quality improvement have a major goal of identifying ways to do the right thing at the right time in the right way by proactive problem-solving.
5. A client with chronic obstructive pulmonary disease (COPD) and a history of coronary artery disease is receiving Aminophylline, 25mg/hour. Which one of the following findings by the nurse would require immediate intervention?
A) Decreased blood pressure and respirations.
B) Flushing and headache.
C) Restlessness and palpitations.
D) Increased heart rate and blood pressure.
The correct answer is C: Restlessness and palpitations. Side effects of Aminophylline include restlessness and palpitations
6. When teaching a client about the side effects of fluoxetine (Prozac), which of the following will be included?
A) Tachycardia blurred vision, hypotension, anorexia
B) Orthostatic hypotension, vertigo, reactions to tyramine rich foods
C) Diarrhea, dry mouth, weight loss, reduced libido
D) Photosensitivity, seizures, edema, hyperglycemia
The correct answer is C: Diarrhea, dry mouth, weight loss, reduced libido Commonly reported side effects for fluoxetine (Prozac) are diarrhea, dry mouth, weight loss and reduced libido
7. The nurse is preparing to administer a tube feeding to a post-operative client. To accurately assess for agastostomy tube placement, the priority is to
A) Auscultate the abdomen while instilling 10 cc of air into the tube
B) Place the end of the tube in water to check for air bubbles
C) Retract the tube several inches to check for resistance
D) Measure the length of tubing from nose to epigastrium
The correct answer is A: Auscultate the abdomen while instilling 10 cc of air into the tube If a swoosh of air is heard over the abdominal cavity while instilling air into the gastric tube, this indicates that it is accurately placed in the stomach. The feeding can begin after assessing the client for bowel sounds
8. Which of these questions is priority when assessing a client with hypertension?
A) "What over-the-counter medications do you take?"
B) "Describe your usual exercise and activity patterns."
C) "Tell me about your usual diet."
D) "Describe your family's cardiovascular history."
The correct answer is A: "What over-the-counter medications do you take?" Over-the-counter medications, especially those that contain cold preparations can increase the blood pressure to the point of hypertension.
9. The nurse is teaching parents of a 7 month-old about adding table foods. Which of the following is anappropriate finger food?
A) Hot dog pieces
B) Sliced bananas
C) Whole grapes
The correct answer is B: Sliced bananas Finger foods should be bite-size pieces of soft food such as bananas. Hot dogs and grapes can accidentally be swallowed whole and can occlude the airway. Popcorn is too difficult to chew at this age and can irritate the airway if swallowed
10. Client is ordered warfarin sodium (Coumadin) to be continued at home. Which focus is critical to be included in the nurse’s discharge instruction?
A) Maintain a consistent intake of green leafy foods
B) Report any nose or gum bleeds
C) Take Tylenol for minor pains
D) Use a soft toothbrush
The correct answer is B: Report any nose or gum bleeds The client should notify the health care provider if blood is noted in their stools or urine, or any other signs of bleeding occ
11. The nurse is assessing a comatose client receiving gastric tube feedings. Which of the following assessments requires an immediate response from the nurse?
A) Decreased breath sounds in right lower lobe
B) Aspiration of a residual of 100cc of formula
C) Decrease in bowel sounds
D) Urine output of 250 cc in past 8 hours
The correct answer is A: Decreased breath sounds in right lower lobe
The most common problem associated with enteral feedings is atelectasis. Maintain client at 30 degrees during feedings and monitor for signs of aspiration. Check for tube placement prior to each feeding or every 4 to 8 hours if continuous feeding
12. The nurse is talking with the family of an 18 months-old newly diagnosed with retinoblastoma. A priority in communicating with the parents is
A) Discuss the need for genetic counseling
B) Inform them that combined therapy is seldom effective
C) Prepare for the child's permanent disfigurement
D) Suggest that total blindness may follow surgery
The correct answer is A: Discussing the need for genetic counseling The hereditary aspects of this disease are well documented. While the parents focus on the needs of this child, they should be aware that the risk is high for future offspring
13. The nurse is performing an assessment on a client who is cachectic and has developed an enterocutaneous fistula following surgery to relieve a small bowel obstruction. The client's total protein level is reported as 4.5. Which of the following would the nurse anticipate?
A) Additional potassium will be given IV
B) Blood for coagulation studies will be drawn
C) Total parenteral nutrition (TPN) will be started
D) Serum lipase levels will be evaluated
The correct answer is C: Total parenteral nutrition (TPN) will be started The client is not absorbing nutrients adequately as evidenced by the cachexia and low protein levels. (A normal total serum protein level is 6.0-8.0.) TPN will maintain a positive nitrogen balance in the client who is unable to digest and absorb nutrients adequately.
14. The nurse is teaching about nonsteroidal anti-inflammatory drugs to a group of arthritic clients. To minimize the side effects, the nurse should emphasize which of the following actions?
A) Reporting joint stiffness in the morning
B) Taking the medication 1 hour before or 2 hours after meals
C) Using alcohol in moderation unless driving
D) Continuing to take aspirin for short term relief
The correct answer is B: Taking the medication 1 hour before or 2 hours after meals Taking the medication 1 hour before or 2 hours after meals will result in a more rapid effect.
15. Which approach is a priority for the nurse who works with clients from many different cultures?
A) Speak at least 2 other languages of clients in the neighborhood
B) Learn about the cultures of clients who are most often encountered
C) Have a list of persons for referral when interaction with these clients occur
D) Recognize personal attitudes about cultural differences and real or expected biases
Your response was "A". The correct answer is D: Recognize personal attitudes about cultural differences and real or expected biases The nurse must discover personal attitudes, prejudices and biases specific to different cultures. Sensitivity to these will affect interactions with clients and families across cultures.
16. A 35-year-old client of Puerto Rican-American descent is diagnosed with ovarian cancer. The client states “I refuse both radiation and chemotherapy because they are 'hot.'” The next action for the nurse to take is to
The correct response is "D".
A) Document the situation in the notes
B) Report the situation to the health care provider
C) Talk with the client's family about the situation
D) Ask the client to talk about the concerns about the "hot" treatments
The correct answer is D: Ask the client to talk about the concerns about the "hot" treatments The "hot-cold" system is found among Mexican-Americans, Puerto Ricans, and other Hispanic-Latinos. Most foods, beverages, herbs, and medicines are categorized as hot or cold, which are symbolic designations and do not necessarily indicate temperature or spiciness. Care and treatment regimens can be negotiated with clients within this framework.
17. During a routine check-up, an insulin-dependent diabetic has his glycosylated hemoglobin checked. The results indicate a level of 11%. Based on this result, what teaching should the nurse emphasize?
a. Rotation of injection sites
b. Insulin mixing and preparation
c. Daily blood sugar monitoring
d. Regular high protein diet
The correct answer is C: Daily blood sugar monitoring Normal hemoglobin A1C (glycosylated hemoglobin) level is 7 to 9%. Elevation indicates elevated glucose levels over time.
18. The nurse is assigned to care for 4 clients. Which of the following should be assessed immediately after hearing the report?
A) The client with asthma who is now ready for discharge
B) The client with a peptic ulcer who has been vomiting all night
C) The client with chronic renal failure returning from dialysis
D) The client with pancreatitis who was admitted yesterday
The correct answer is B: The client with a peptic ulcer who has been vomiting all night A perforated peptic ulcer could cause nausea, vomiting and abdominal distention, and may be a life threatening situation. The client should be assessed immediately and findings reported to the health care provider
19. To prevent drug resistance common to tubercle bacilli, the nurse is aware that which of the following agents are usually added to drug therapy?
A) Anti-inflammatory agent
B) High doses of B complex vitamins
C) Aminoglycoside antibiotic
D) Two anti-tuberculosis drugs
The correct answer is D: Two anti-tuberculosis drugs Resistance of the tubercle bacilli often occurs to a single antimicrobial agent. Therefore, therapy with multiple drugs over a long period of time helps to ensure eradication of the organism.
20. While assessing the vital signs in children, the nurse should know that the apical heart rate is preferred until the radial pulse can be accurately assessed at about what age?
A) 1 year of age
B) 2 years of age
C) 3 years of age
D) 4 years of age
The correct answer is B: 2 years of age A child should be at least 2 years of age to use the radial pulse to assess heart rate.