Pharmacology
A child with human immunodeficiency virus (HIV) infection is receiving zidovudine. Which finding indicates to the nurse that the child may be experiencing an adverse effect from the medication?
1. The child complains of pain in his lower legs.
2. The child's skin is pale and he is feeling tired.
3. The child has some swelling in the hands and around the ankles.
4. The child is clinging to his parents and won't allow them to leave.
What is 2
Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. Zidovudine effectively interferes with HIV replication but can cause bone marrow suppression. Anemia occurs most commonly after 4 to 6 weeks of therapy. Hematology studies need to be monitored for anemia and granulocytopenia. Tiredness and a pale color could indicate that the child is anemic. Complaints of pain is not associated with the medication but can be associated with the diagnosis; swelling is not usually a characteristic of the infection but could be an indication of an underlying problem. If the child is clinging to the parents, this could indicate fear but is not associated with an adverse effect of the medication.
The nurse is assessing a newborn with heart failure before administering the prescribed digoxin. In reviewing the laboratory data, the nurse notes that the newborn has a digoxin blood level of 1.6 ng/mL (2.05 mmol/L) and an apical heart rate of 90 beats/min. The mother also tells the nurse that the newborn just vomited her formula. Which intervention should the nurse take?
1. Retake the apical pulse.
2. Administer the medication.
3. Withhold the medication for 1 hour.
4. Withhold the medication and notify the primary health care provider.
What is 4
The apical pulse rate for a newborn is 120 to 160 beats/min. The therapeutic digoxin level ranges from 0.5 to 0.8 ng/dL (0.64 to 1.02 mmol/L). Because the apical rate is low and the digoxin blood level is elevated, indicating toxicity, the nurse would withhold the medication and notify the primary health care provider. Retaking the apical pulse is not indicated given the context of the other findings in this question. Administering the medication could potentially cause harm. Withholding the medication for 1 hour does not address the problem of toxicity.
A client who has shared with the group at a previous session now suddenly gets up and announces, "I'm leaving." How can the nurse initially meet the needs of both the client and the group?
1. Offer to go with the client to his room to talk.
2. Ask the client to refocus the group's discussion.
3. End the therapy session for everyone immediately.
4. Ask the client to stay and share what he is feeling.
What is 4
If a client attempts to leave a group session, ask the client what he is feeling and try to connect the behavior with a feeling. None of the other options encourages the sharing of the client's feelings.
A clinic nurse is assessing a client who has been on isoniazid for 6 months. Which client complaint should most concern the nurse?
1. Dry mouth
2. Cramping diarrhea
3. Frequent headaches
4. Difficulty tying shoes
What is 4
The client complaint that should most concern the nurse is difficulty tying shoes because this may indicate neuropathy. Dose-related peripheral neuropathy is one of the more common adverse effects of isoniazid. Dry mouth, cramping diarrhea, and frequent headaches are not concerns with administration of this medication.
A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristics? Select all that apply.
1. Lesion is painful to touch.
2. Lesion is highly metastatic.
3. Lesion is a nevus that has changes in color.
4. Skin under the lesion is reddened and warm to touch.
5. Lesion occurs in body areas exposed to outdoor sunlight.
What is 2 and 3
Melanomas are pigmented malignant lesions originating in the melanin-producing cells of the epidermis. Melanomas cause changes in a nevus (mole), including color and borders. This skin cancer is highly metastatic, and a person's survival depends on early diagnosis and treatment. Melanomas are not painful or accompanied by sign of inflammation. Although sun exposure increases the risk of melanoma, lesions may occur any place on the body, especially where birthmarks or new moles are apparent.
Atorvastatin has been prescribed for a client, and the client asks the nurse about the action of the medication. How should the nurse respond?
1. "It increases plasma cholesterol."
2. "It increases plasma triglycerides."
3. "It decreases low-density lipoproteins (LDLs)."
4. "It decreases high-density lipoproteins (HDLs)."
What is 3
Atorvastatin is a reductase inhibitor (HMG-CoA reductase inhibitor) that is used to treat hypercholesterolemia and hypertriglyceridemia. It decreases LDL cholesterol and plasma triglycerides and increases HDL cholesterol (the good cholesterol). The remaining options are not actions of this medication.
The nurse is monitoring a child with a brain tumor for complications associated with increased intracranial pressure. Which finding, if noted by the nurse, would indicate the presence of diabetes insipidus?
1. Weight gain
2. Hypertension
3. High urine output
4. Urine specific gravity greater than 1.030
What is 3
Diabetes insipidus (DI) can occur in a child with increased intracranial pressure. Weight gain, hypertension, and a urine specific gravity greater than 1.030 are indications of the syndrome of inappropriate antidiuretic hormone secretion, not DI. A high urine output would be indicative of DI.
The nurse has developed a plan of care for a client diagnosed with anorexia nervosa. Which client problem would the nurse select as the priority in the plan of care?
1. Disrupted appearance because of weight
2. Inability to feed self because of weakness
3. Pain because of an inflamed gastric mucosa
4. Nutritional imbalance because of lack of intake
What is 4
The priority client problem for the client with anorexia nervosa is lack of intake and nutritional imbalance since it is the basis of the condition. Although the problems identified in the other options may be considerations in the plan of care for the client with anorexia nervosa, nutritional imbalance is the priority.
The nurse is providing information to a client about a computed tomography (CT) scan of the head. Which statement should the nurse include when reviewing preparation for the CT with the client?
1. "You will need to stand up straight for the entire procedure."
2. "All scans require the injection of dye before the procedure."
3. "Each set of head scans takes less than 5 minutes to perform."
4. "You will need to remain on bed rest for 12 hours after the scan."
What is 3
For a CT scan of the head, the client lies on a movable table in a head-holding device. Each set of head scans takes less than 5 minutes to perform. An iodinated contrast medium may or may not be used. No special aftercare is indicated, so the client may resume the usual diet and activity afterward.
The registered nurse (RN) is educating a new nurse on mitral stenosis. Which statement by the new nurse indicates that the teaching has been effective?
1. "Left ventricle to aorta narrowing will impede flow of blood."
2. "Left atrium to left ventricle narrowing will impede flow of blood."
3. "Right atrium to right ventricle narrowing will impede flow of blood."
4. "Right ventricle to pulmonary artery narrowing will impede flow of blood."
What is 2
The mitral valve separates the left atrium from the left ventricle. The remaining options describe impeded flow due to aortic, tricuspid, and pulmonic stenosis, respectively.
A client with diabetes mellitus taking daily NPH insulin has been started on therapy with dexamethasone. The nurse anticipates that which adjustments in medication dosage will be made?
1. An increased dose of NPH insulin
2. A change to oral diabetic medications
3. A lower dose of dexamethasone than usual
4. An increase in the amount of daily dietary calories
What is 1
Dexamethasone is a glucocorticoid (corticosteroid) and therefore can elevate the blood glucose level. Diabetic clients may need their dosage of insulin or oral hypoglycemic medications increased during glucocorticoid therapy. This is most often a temporary change, needed to compensate for the actions of the medication. The client would not change to an oral diabetic medication if taking daily insulin. Additional calories would not be required. The client would not take a lower dose of dexamethasone than usual to compensate.
An infant is seen in the primary health care provider's office for complaints of projectile vomiting after feeding. Findings indicate that the child is fussy and is gaining weight but seems never to get enough to eat. Pyloric stenosis is suspected. Which prescription would the nurse anticipate having the highest priority in the care of this child?
1. Monitor intake and output.
2. Administer predigested formula.
3. Administer omeprazole before feeding.
4. Prepare the family for surgery for the child.
What is 4
Infants with projectile vomiting after feeding that are fussy should be suspected of pyloric stenosis. The treatment for this diagnosis is surgery. The other options are treatment measures that may be prescribed for gastroesophageal reflux.
A heroin-addicted client who is taking methadone hydrochloride discontinues the methadone without consulting the primary health care provider. The client says to the nurse, "I thought I didn't need the methadone after 1 year. I had a job and was even saving money. I can't believe I ruined everything." Which statement by the nurse is therapeutic?
1. "It sounds as if everything you do is either all or nothing."
2. "Talk to your counselor; maybe everything isn't ruined yet."
3. "You will need to restart your recovery starting from the beginning."
4. "We need to prepare you to recognize those things that trigger you to relapse."
What is 4
The therapeutic statement is the one that helps the client to reframe with more moderation. In reframing, the nurse focuses on the positive aspects of learning to overcome failure. The nurse must avoid being condescending or overly negative. The nurse uses an example of 1 support system that still exists to detour the faulty thinking. However, the nurse does not have the ability to know whether the counselor is supportive, so this is not the therapeutic statement.
The nurse is preparing a preoperative client for transfer to the operating room. The nurse should take which action in the care of this client at this time?
1. Ensure that the client has voided.
2. Administer all the daily medications.
3. Verify that the client has not eaten for the past 24 hours.
4. Have the client practice postoperative breathing exercises.
What is 1
The nurse should ensure that the client has voided if a Foley catheter is not in place. The nurse does not administer all daily medications just before sending a client to the operating room. Rather, the primary health care provider writes a specific prescription outlining which medications may be given with a sip of water. The time of transfer to the operating room is not the time to practice breathing exercises; this should have been done earlier. The client has nothing by mouth for 6 to 8 hours before surgery, not 24 hours.
The nurse is providing dietary instructions to a client with a diagnosis of irritable bowel syndrome. The nurse determines that education was effective if the client states the need to avoid which food?
1. Rice
2. Corn
3. Broiled chicken
4. Cream of wheat
What is 2
The client with irritable bowel should take in a diet that consists of 30 to 40 g of fiber daily because dietary fiber will help produce bulky, soft stools and establish regular bowel habits. The client should also drink 8 to 10 glasses of fluid daily and chew food slowly to promote normal bowel function. Foods that are irritating to the intestines need to be avoided. Corn is high in fiber but can be very irritating to the intestines and should be avoided. The food items in the other options are acceptable to eat.
The nurse is giving the client directions for proper use of aluminum hydroxide tablets. What should the nurse tell the client?
1. Swallow the tablets whole with a full glass of water.
2. Take the tablets at the same time as other medications.
3. Take each dose with a laxative to prevent constipation.
4. Chew the tablets thoroughly and follow with 4 oz of water.
What is 4
Aluminum hydroxide tablets should be chewed thoroughly before swallowing. This prevents them from entering the small intestine undissolved. They should not be swallowed whole. Antacids should be taken at least 1 hour apart from other medications to prevent interactive effects. Constipation is a side effect of the use of aluminum products, but it is not correct for the client to take a laxative with each dose. This promotes laxative abuse. The client should first try other means to prevent constipation.
The mother of an 8-year-old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the right side and that ibuprofen is not effective. Which instruction should the nurse provide to the mother?
1. Increase the dose of ibuprofen.
2. Increase the frequency of ibuprofen.
3. Encourage the child to lie on the left side.
4. Encourage the child to lie on the right side.
What is 4
Pneumonia is an inflammation of the pulmonary parenchyma or alveoli, or both, caused by a virus, mycoplasmal agents, bacteria, or aspiration of foreign substances. Splinting of the affected side by lying on that side may decrease discomfort. It would be inappropriate to advise the mother to increase the dose or frequency of the ibuprofen. Lying on the left side would not be helpful in alleviating discomfort.
The nurse caring for a client diagnosed with schizophrenia should include which interventions in the plan of care to assist in managing the client's concrete thinking?
1. Provide the client with written instructions regarding the routine of the unit.
2. Present verbal instructions regarding expectations in single, simple commands.
3. Assess the client's understanding of instructions by requiring restatement of expectations.
4. Incorporate family members in determining the emotional and physical needs of the client.
What is 2
A client with concrete thinking often has difficulty with multiple-step tasks and commands. The information should be provided in clear, concise, and single-focused commands to minimize client confusion and maximize understanding. The client may be incapable of processing information in written form and is not likely able to restate directions because of thought process dysfunction. These methods do not address the limitations of concrete thinking. Using family to help determine the client's needs may be an appropriate intervention, but this is not directed at minimizing the effect of the client's altered thought processes.
The nurse preceptor and the orientee note that the reticulocyte count for a client is increased. The preceptor determines that the orientee understands the significance of reticulocytes if the orientee makes which statement with regard to red blood cells (RBCs)?
1. "A reticulocyte is a mature RBC."
2. "A reticulocyte is an immature RBC."
3. "A reticulocyte is decreased whenever there is accelerated production of RBCs."
4. "A reticulocyte is increased when the bone marrow has slowed production of RBCs."
What is 2
The reticulocyte is an immature RBC. The reticulocyte count is increased any time there is an accelerated production of RBCs. It is decreased when the bone marrow has slowed production of RBCs.
The nurse has developed a plan of care for a client in traction and documents a problem of inability to perform self-care independently. The nurse evaluates the plan of care and determines that which observation indicates a successful outcome?
1. The client refuses care.
2. The client allows the family to assist in the care.
3. The client assists in self-care as much as possible.
4. The client allows the nurse to complete the care on a daily basis.
What is 3
A successful outcome for the problem of self-care is for the client to do as much of the self-care as possible. The nurse should promote independence in the client and allow the client to perform as much self-care as is optimal, considering the client's condition. The nurse would determine that the outcome is unsuccessful if the client refused care or allowed others to do the care.
The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instructions should the nurse provide? Select all that apply.
1. Sunscreen should be applied every 8 hours.
2. Use sunscreen when participating in outdoor activities.
3. Wear a hat, opaque clothing, and sunglasses when in the sun.
4. Avoid sun exposure in the late afternoon and early evening hours.
5. Examine your body monthly for any lesions that may be suspicious.
What is 2, 3, and 5
The client should be instructed to avoid sun exposure between the hours of brightest sunlight: 10 a.m. and 4 p.m. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities. The client should be instructed to examine the body monthly for the appearance of any cancerous or precancerous lesions. Sunscreen should be applied 30 minutes to 1 hour before sun exposure, and reapplied every 2 to 3 hours, and after swimming or sweating; otherwise, the duration of protection is reduced.
The nurse is conducting staff in-service training on von Willebrand's disease. Which should the nurse include as characteristics of von Willebrand's disease? Select all that apply.
1. Easy bruising occurs.
2. Gum bleeding occurs.
3. It is a hereditary bleeding disorder.
4. Treatment and care are similar to that for hemophilia.
5. It is characterized by extremely high creatinine levels.
6. The disorder causes platelets to adhere to damaged endothelium.
What is 1, 2, 3, 4, and 6
von Willebrand's disease is a hereditary bleeding disorder characterized by a deficiency of or a defect in a protein termed von Willebrand factor. The disorder causes platelets to adhere to damaged endothelium. It is characterized by an increased tendency to bleed from mucous membranes. Assessment findings include epistaxis, gum bleeding, easy bruising, and excessive menstrual bleeding. An elevated creatinine level is not associated with this disorder.
Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply.
1. Communicate expected behaviors to the client.
2. Ensure that the client knows that they are not in charge of the nursing unit.
3. Assist the client in identifying ways of setting limits on personal behaviors.
4. Follow through about the consequences of behavior in a nonpunitive manner.
5. Enforce rules by informing the client that he/she will not be allowed to attend therapy groups.
6. Have the client state the consequences for behaving in ways that are viewed as unacceptable.
What is 1, 3, 4, and 6
Interventions for dealing with the client exhibiting manipulative behavior include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear with the client regarding the consequences of exceeding the limits set; following through with the consequences in a nonpunitive manner; and assisting the client in identifying a means of setting limits on personal behaviors. Ensuring that the client knows that she or he is not in charge of the nursing unit is inappropriate; power struggles need to be avoided. Enforcing rules and informing the client that she or he will not be allowed to attend therapy groups is a violation of a client's rights.
The nurse in the ambulatory care department hears a client in the waiting room call out, "Help, fire!" The nurse rushes to the waiting room and finds the wastebasket on fire. Which action should the nurse take first?
1. Extinguish the fire.
2. Activate the fire alarm.
3. Confine the fire and then call 911.
4. Remove the client from the waiting room.
What is 4
The order of priority in the event of a fire is to rescue the clients in immediate danger. The next step is to activate the fire alarm. The fire is then confined by closing all doors, and last, the fire is extinguished.
A client has been diagnosed with pyelonephritis. The nurse interprets that which health problem has placed the client at risk for this disorder?
1. Diabetes mellitus
2. Orthostatic hypotension
3. Coronary artery disease
4. Intravenous (IV) contrast medium
What is 1
Pyelonephritis is most commonly caused by entry of bacteria, obstruction, or reflux. Risk factors associated with pyelonephritis include diabetes mellitus, hypertension, chronic renal calculi, chronic cystitis, overuse of analgesics, structural abnormalities of the urinary tract, presence of urinary stones, and indwelling or frequent urinary catheterization.