Nutrition
A nurse is collecting data from a client who is receiving chemotherapy and is showing manifestations of malnutrition. Which of the following indicates a Vitamin C deficiency?
1. Dry, red conjunctiva
2. Swollen, bleeding gums
3. Inflammation of the tongue
4. Pale, brittle nails
2. Swollen bleeding gums
A nurse is caring for a client who has thrombophlebitis and is receiving a continuous infusion of heparin. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse make?
1) "It usually takes at least 2 to 3 days for heparin to dissolve a clot."
2) "The time it takes heparin to dissolve clots varies between clients."
3) "Heparin prevents new clots from forming rather than dissolving established clots."
4) "The time it takes for heparin to dissolve a clot depends on the size of the clot."
3) "Heparin prevents new clots from forming rather than dissolving established clots."
Answer Rationale:
Heparin is an anticoagulant that prevents the formation of new clots by blocking the conversion of prothrombin to thrombin and fibrinogen to fibrin. It does not dissolve established clots.
A nurse on a medical-surgical unit is assisting with the admission of a client who has vision loss. Which of the following actions is the nurse’s priority?
1) Instruct the client to use the call light when preparing to ambulate.
2) Remove clutter from the client’s room.
3) Encourage the client to feel the walls with her hands.
4) Describe the environment to the client.
4) Describe the environment to the client.
Answer Rationale:
The greatest risk to this client is injury from falling or colliding with objects in the environment she cannot see. Therefore, the priority action is to describe the new environment in detail to the client.
A nurse is reinforcing teaching about a tonometry examination with a client who has manifestations of glaucoma. Which of the following statements should the nurse include in the teaching?
1) "Tonometry is performed to evaluate peripheral vision."
2) "This test will diagnose the type of your glaucoma."
3) "Tonometry will allow inspection of the optic disc for signs of degeneration."
4) "This test will measure the intraocular pressure of the eye."
4) "This test will measure the intraocular pressure of the eye."
Answer Rationale:
A tonometry examination provides a precise and simple way to measure intraocular pressure. This is a component of a comprehensive eye examination and is crucial for clients who have glaucoma or who are at high risk for developing intraocular hypertension.
Based on a client's recent history, a nurse suspects that a client is beginning menopause. Which of the following questions should the nurse ask the client to help confirm the client is experiencing manifestations of menopause?
1) "Do you sleep well at night?"
2) "Have you been experiencing chills?"
3) "Have you experienced increased hair growth?"
4) "When did you begin your menses?"
1) "Do you sleep well at night?"
Answer Rationale:
Menopause causes vasomotor instability, which can cause night sweats and sleep disturbances. Therefore, this is an appropriate question for the nurse to ask.
A nurse is reinforcing teaching with a middle-age client who is at high risk for osteoporosis and is taking oral calcium gluconate. Which of the following instructions should the nurse include in the teaching?
1. Take the calcium supplement on an empty stomach
2. Take vitamin D supplements
3. Take the calcium supplement with whole grain cereal at breakfast
4. Take with zinc-rich foods
2) Take vitamin D supplements.
Answer Rationale:
The client who is at risk for bone loss should take supplemental calcium with vitamin D because vitamin D promotes calcium absorption.
A nurse is preparing to administer a client’s daily dose of NPH insulin at 0730. The nurse should expect this type of insulin to peak within which of the following timeframes after administration?
1. 30 min to an hour
2. 1-5 hours
3. 4-14 hours
4. 2-6 hours
3) 4 to 14 hr
Answer Rationale:
NPH insulin, an intermediate-acting insulin, peaks at 4 to 14 hr following administration.
A nurse is caring for an older adult client in a long-term care facility. Which of the following measures should the nurse take first when assisting with planning the client's care?
1) Explaining the roles of the RN, licensed practical nurse, and assistive personnel
2) Understanding the client's routine for his own care at home
3) Determining the client's mobility
4) Introducing health care team members to the client
3) Determining the client's mobility
Answer Rationale:
The greatest risk to this client is injury from moving without assistance if he has impaired mobility; therefore, the priority action is to collect data about the client’s mobility and need for assistance with transferring and ambulating.
A nurse is evaluating discharge instructions for a client following a right cataract extraction. Which of the following client statements indicates the teaching is effective?
1) "I will take a stool softener until my eye is healed."
2) "I will expect to have moderately severe pain for 1-2 days."
3) "I will refrain from cooking for 1 week."
4) "I will bend at the waist to tie my shoes."
1) "I will take a stool softener until my eye is healed."
Answer Rationale:
The client should avoid straining during bowel movements to prevent an increase in intraocular pressure.
A nurse in a provider’s officer is collecting date from a client who has ovarian cancer. Which of the following manifestations should the nurse expect?
1) Unexplained weight loss
2) Urinary retention
3) Diarrhea
4) Abdominal bloating
4) Abdominal bloating
Answer Rationale:
The nurse should expect the client who has ovarian cancer to manifest abdominal bloating.
A nurse is caring for a client who has a history of pancreatitis. Which of the following food choices should the client avoid?
1. Noodles
2. Vegetable soup
3. Baked fish
4. Cheddar cheese
4) Cheddar cheese
Answer Rationale:
A client who has pancreatitis should avoid foods high in fat. Because cheddar cheese is high in fat content, the client should avoid this food.
A nurse is caring for a client who is receiving IV tobramycin and has a prescription for peak and trough blood levels with the next dose scheduled for 1800. The nurse should expect the lab to draw blood samples at which of the following times?
1. 1400 & 2200
2. 1630 &1930
3. 1745 & 1830
4. 1100 & 1700
3) 1745 and 1830
Answer Rationale:
Timing of the peak and trough is based on the pharmacokinetics of absorption and the half-life of the medication. The trough level is the lowest serum level after the pharmacokinetic effects have taken place. Correct timing for the trough is just prior to administering the next dose. The peak is the highest serum level of the drug; if this level is too low, then the drug will not be effective. Correct timing for the peak is 30 min after the dose finishes infusing.
A nurse is preparing an in-service presentation about preventing health care-associated infections (HAIs). The nurse should include which of the following as a common cause of these infections?
1) Chlorhexidine washes
2) Urinary catheterization
3) Malnutrition
4) Multiple caregivers
2) Urinary catheterization
Answer Rationale:
Invasive nursing procedures are common causes of HAIs. These include urinary catheterization, IV infusions, and administration of parenteral medications.
A nurse is reinforcing teaching with a client who has been newly diagnosed with chronic open angle glaucoma. Which of the following statements by the client indicates an understanding of the teaching?
1) "When my vision improves, I will be able to stop taking the eye drops."
2) "If I forget to take my eye drops, I should wait until the next time they are due."
3) "I should call the clinic before taking any over-the-counter medications."
4) "Every two years I will need to have my vision checked by an eye doctor."
3) "I should call the clinic before taking any over-the-counter medications."
Answer Rationale:
Taking over-the-counter medications that dilate the pupil could cause the client who has chronic open angle glaucoma to experience an increase in intraocular pressure. The nurse should instruct the client to always check with the provider before using over-the-counter medications.
A nurse is reinforcing teaching to a client who is at high risk for breast cancer and is prescribed tamoxifen citrate for prophylaxis. Which of the following statements should the nurse make regarding adverse effects of the medication?
1) "Hot flashes are a common side effect of this drug."
2) "Take this drug in the morning, as it can cause insomnia."
3) "This drug will have to be taken for at least 6 months."
4) "You will need to take steps to prevent constipation while on this drug."
1) "Hot flashes are a common side effect of this drug."
Answer Rationale:
The nurse should instruct the client that hot flashes are a common adverse effect of tamoxifen.
A nurse is reinforcing discharge teaching with a client who has acute pancreatitis and a prescription for fat-soluble vitamin supplements. Which of the following supplements should the nurse include in the teaching?
1. Vitamin A
2. Vitamin B1
3. Vitamin C
4. Vitamin B12
1) Vitamin A
Answer Rationale:
The nurse should instruct the client that fat-soluble vitamins include vitamins A, D, E, and K.
A nurse is caring for a client who has a prescription for clopidogrel. Which of the following actions should the nurse plan to take?
1) Monitor the client for black, tarry stools
2) Initiate contact precautions.
3) Administer the medication with each meal.
4) Have suction equipment at the bedside
1) Monitor the client for black, tarry stools.
Answer Rationale:
Clopidogrel is an antithrombotic and antiplatelet medication; therefore, it poses a risk of serious bleeding. The nurse should monitor for signs of bleeding such as black, tarry stools and report these findings to the provider.
A nurse is evaluating an older adult client who is receiving end-of-life care and has Cheyne-Stokes respirations. Which of the following observations should the nurse identify as confirmation of this respiratory pattern?
1) Breathing ranging from very deep to very shallow with periods of apnea
2) Shallow breathing alternating with periods of apnea
3) Rapid respirations that are unusually deep and regular
4) An inability to breathe without dyspnea unless sitting upright
1) Breathing ranging from very deep to very shallow with periods of apnea
Answer Rationale:
This describes Cheyne-Stokes respirations, an indication that the client is approaching death.
A nurse is reinforcing preoperative teaching with a client who is scheduled for retinal detachment repair. Which of the following instructions should the nurse include in the teaching?
1) Keep both eyes patched.
2) Restrict head movement
3) Lie down as much as possible.
4) Apply cool compresses.
2) Restrict head movement.
Answer Rationale:
The client should restrict head and eye movement to prevent further detachment prior to surgery.
A school nurse is reinforcing teaching to a group of teenage clients about prevention of sexually transmitted infections (STIs). Which of the following practices is the most effective form of protection to include in the teaching?
1) The use of latex condoms
2) Avoiding sexual contact if a partner is known to have an STI
3) Vaccination against vaccine-preventable STIs
4) Limiting sexual partners
1) The use of latex condoms
Answer Rationale:
According to evidenced based practice, the nurse should reinforce to the teenage clients that the most effective form of protection against STIs is the use of latex condoms.
A nurse is reinforcing teaching with a client who has neutropenia as a result of radiation therapy for the treatment of lung cancer. Which of the following should the nurse plan to include in the teaching?
1. Increase fluid intake by drinking bottled water
2. A salad bar is a healthy choice when dining out.
3. Soft-boiled eggs are an appropriate source of protein
4. Eating at buffets is a good choice to increase caloric intake
1) Increase fluid intake by drinking bottled water.
Answer Rationale:
The client who has neutropenia is at risk for foodborne illness. Bottled water prevents the client’s exposure to pathogens that might be found in other water sources.
A nurse is reinforcing teaching with a client who has a new prescription for phenytoin. The nurse should recognize that which of the following statements by the client indicates a need for further teaching?
1) "I will notify my provider before taking any other medications."
2) "I have made an appointment to see my dentist next week."
3) "I will take this medication with meals."
4) "I'll be glad when my seizures stop so I can quit taking this medicine."
4) "I'll be glad when my seizures stop so I can quit taking this medicine."
Answer Rationale:
The client should not discontinue the phenytoin abruptly, because withdrawal from treatment can cause seizures to resume. Clients taking anticonvulsant medications often require them for life, and phenytoin should not be stopped unless indicated by the provider.
A nurse on a medical unit is caring for a client who requires seizure precautions. Which of the following interventions should the nurse contribute to the client’s plan of care?
1) Restrain the client as soon as seizure activity begins.
2) Keep the lights on when the client is sleeping.
3) Keep the client’s bed in the lowest position.
4) Have a padded tongue depressor available at the bedside.
3) Keep the client’s bed in the lowest position.
Answer Rationale:
Keeping the client’s bed in the lowest position is an important way to protect the client from injuries due to falling out of bed. Keeping a mattress on the floor can also help with this.
A nurse is collecting data from a client who has a possible cataract. Which of the following manifestations should the nurse expect the client to report?
1) Decreased color perception
2) Loss of peripheral vision
3) Bright flashes of light
4) Eyestrain
1) Decreased color perception
Answer Rationale:
Visual manifestations associated with cataracts can include decreased color perception and decreased visual acuity, even in daylight.
A nurse is reinforcing teaching with a client who has benign prostatic hypertrophy and has a new prescription for finasteride. Which of the following information should the nurse include in the teaching?
1) Avoid taking the medication with grapefruit juice.
2) Expect to experience a response from the medication in 1 week.
3) Decreased libido is an adverse effect of the medication.
4) Prostate-specific antigen (PSA) levels will increase while taking this medication.
3) Decreased libido is an adverse effect of the medication.
Answer Rationale:
The nurse should include in the teaching that the client may have decreased libido as an adverse effect of the medication because of the androgenic effect on the prostate.