Unit 14
A nurse is reviewing the medication administration record for a client with a recent head injury and increased intracranial pressure (ICP). The client is reporting severe pain. Which analgesic order should the nurse question?
a) Intravenous ketamine
b) Intramuscular hydromorphone
c) Intravenous morphine sulfate
d) Oral codeine with acetaminophen
c) Intravenous morphine sulfate
A nurse is planning care for a client receiving external beam radiation to the chest for lung cancer. Which instruction regarding skin care is most appropriate?
a) "Apply a thick layer of petroleum jelly to the treatment area before each session."
b) "Use a gentle, metal-free moisturizer on the skin and pat the area dry after washing."
c) "Scrub the area daily with an antibacterial soap to prevent infection."
d) "Expose the skin to air but cover it with a scented talc powder to keep it dry."
b) "Use a gentle, metal-free moisturizer on the skin and pat the area dry after washing."
A nurse is caring for a client receiving cisplatin (Platinol). Which assessment finding is most critical for the nurse to report to the provider?
a) Client report of tinnitus.
b) Nausea and vomiting 1 hour after infusion.
c) Urine output of 20 mL/hr.
d) A white blood cell count at the low end of normal.
c) Urine output of 20 mL/hr.
A nurse is administering mannitol (Osmitrol) IV to a client with increased intracranial pressure (ICP). Which finding would indicate a therapeutic effect of the medication?
a) Increased level of consciousness.
b) Decreased serum osmolality.
c) Increased blood pressure.
d) Decreased urine output.
a) Increased level of consciousness.
A client receiving a heparin infusion has an activated partial thromboplastin time (aPTT) of 110 seconds. The nurse assesses the client and notes bruising on the arms and blood oozing from the IV site. Which order should the nurse anticipate from the healthcare provider?
a) Administer Vitamin K IV.
b) Decrease the heparin infusion rate.
c) Administer protamine sulfate.
d) Administer a dose of enoxaparin SQ.
c) Administer protamine sulfate.
A client is brought to the emergency department with suspected opioid overdose and has a respiratory rate of 6 breaths/minute. The client is given a dose of IV naloxone (Narcan). Ten minutes later, the client is awake with a respiratory rate of 16 breaths/minute. What is the nurse's priority action? a) Prepare the client for discharge as the overdose has been successfully reversed.
b) Administer a dose of methadone to prevent withdrawal symptoms.
c) Continue to monitor the client's respiratory status and level of consciousness closely.
d) Insert a nasogastric tube in anticipation of giving activated charcoal.
c) Continue to monitor the client's respiratory status and level of consciousness closely.
A nurse is preparing to enter the room of a client with a temporary internal radiation (brachytherapy) implant for cervical cancer. Which action is a priority for the nurse's safety?
a) Turn on all the lights in the room to get a clear view of the patient.
b) Check the dosimeter badge to ensure it is correctly positioned on their uniform.
c) Bring the family into the room so they can receive instructions at the same time.
d) Plan to stay in the room for at least 30 minutes to provide comprehensive care.
b) Check the dosimeter badge to ensure it is correctly positioned on their uniform.
A client is receiving high-dose methotrexate (MTX). The nurse prepares to administer leucovorin. The nurse understands that leucovorin is given for which purpose?
a) To enhance the cytotoxic effects of methotrexate on cancer cells.
b) To prevent hemorrhagic cystitis.
c) To "rescue" normal cells from the toxic effects of methotrexate.
d) To treat methotrexate-induced nausea and vomiting.
c) To "rescue" normal cells from the toxic effects of methotrexate.
A client in the ICU has been on a high-dose propofol (Diprivan) infusion for 4 days. The nurse should be most concerned about which cluster of assessment findings?
a) Bradycardia, hypertension, and increased urine output.
b) Tachycardia, respiratory depression, and constipation.
c) Pain at the injection site, apnea, and hypotension.
d) Severe metabolic acidosis, hyperkalemia, and renal failure.
d) Severe metabolic acidosis, hyperkalemia, and renal failure.
A nurse is providing discharge teaching to a client going home on enoxaparin (Lovenox) injections. Which statement by the client indicates a need for further education?
a) "I will have my blood drawn regularly to check my aPTT level."
b) "I will be careful to avoid taking aspirin or other antiplatelet drugs."
c) "My dose is based on my weight."
d) "I will inject this medication into the fatty tissue of my abdomen.
a) "I will have my blood drawn regularly to check my aPTT level."
A nurse is preparing to administer a fentanyl transdermal patch to a client reporting severe, chronic pain. The nurse should confirm which of the following before applying the patch?
a) The client has not eaten a meal in the last two hours.
b) The client is already receiving and tolerant to other opioid therapy.
c) The client has a history of postoperative shivering.
d) The client has never taken an opioid medication before.
b) The client is already receiving and tolerant to other opioid therapy.
A client is undergoing Total Body Irradiation (TBI) in preparation for a bone marrow transplant. The nurse should prioritize interventions for which of the following expected, severe side effects?
a) Peripheral neuropathy
b) Myelosuppression
c) Hand-foot syndrome
d) Constipation
b) Myelosuppression
A nurse is administering vincristine (Oncovin) IV. The IV site becomes swollen and painful. What is the nurse's priority action?
a) Apply cold packs to the site to reduce absorption.
b) Stop the infusion and apply warm compresses.
c) Continue the infusion but at a slower rate.
d) Administer the antidote, dexrazoxane (Zinecard).
b) Stop the infusion and apply warm compresses.
A client is brought to the emergency department in status epilepticus. The nurse anticipates administering which medication as the drug of choice for this condition?
a) phenytoin (Dilantin)
b) gabapentin (Neurontin)
c) lorazepam (Ativan)
d) lamotrigine (Lamictal)
c) lorazepam (Ativan)
A client presents to the emergency department with symptoms of an acute thrombotic stroke that began 90 minutes ago. The CT scan rules out a hemorrhage. The nurse would anticipate the administration of which medication?
a) eptifibatide (Integrilin)
b) alteplase (Activase)
c) aminocaproic acid (Amicar)
d) Heparin IV infusion
b) alteplase (Activase)
A client who received multiple doses of meperidine (Demerol) for postoperative pain begins to experience tremors and has a seizure. The nurse anticipates that administering an opioid antagonist like naloxone will have what effect?
a) It will reverse both the respiratory depression and the seizure activity.
b) It will worsen the seizure activity by causing acute withdrawal.
c) It will reverse the respiratory depression but not the seizure activity.
d) It will have no effect on either respiratory depression or seizures
c) It will reverse the respiratory depression but not the seizure activity.
A client receiving daily external radiation therapy reports overwhelming fatigue. What is the nurse's best response?
a) "Fatigue is a sign that the radiation is not working and you should speak with your doctor."
b) "You should try to exercise vigorously every day to increase your energy levels."
c) "This is a very common side effect. Let's talk about balancing periods of rest and activity."
d) "This is an emotional response to your diagnosis, not a physical one."
c) "This is a very common side effect. Let's talk about balancing periods of rest and activity."
A client on long-term IV fluorouracil (5-FU) therapy reports tingling, redness, and swelling on the palms of their hands and soles of their feet. The nurse recognizes these symptoms as which of the following adverse effects?
a) Stevens-Johnson syndrome
b) Radiation recall phenomenon
c) Hand-foot syndrome
d) Peripheral neuropathy
c) Hand-foot syndrome
A nurse has just administered IV flumazenil (Romazicon) to a client who had respiratory depression after a procedure. The nurse should prioritize which of the following actions?
a) Monitor for the return of sedation and respiratory depression.
b) Prepare to administer a second dose in 30 minutes if needed.
c) Assess for signs of lidocaine toxicity.
d) Place the client in a quiet, dark room to prevent agitation.
a) Monitor for the return of sedation and respiratory depression.
A nurse is preparing to administer aminocaproic acid (Amicar) IV to a client. The nurse should question this order if the client has a history of which of the following conditions?
a) Hepatic cirrhosis
b) Bleeding from urinary tract
c) Aplastic anemia
d) Recent cardiac surgery
b) Bleeding from urinary tract
A nurse is administering IV hydromorphone (Dilaudid) to a client for severe pain. The nurse understands that compared to morphine, hydromorphone has which of the following properties?
a) It has a lower potency and a lower risk of respiratory depression.
b) It produces more nausea but less orthostatic hypotension.
c) It has a higher potency, requiring smaller doses for equivalent pain relief.
d) It is a second-line agent only used when morphine is contraindicated.
c) It has a higher potency, requiring smaller doses for equivalent pain relief.
A nurse is providing discharge instructions to a client who was treated with oral iodine-131 (I-131) for thyroid cancer. Which statement by the client indicates a need for further teaching?
a) "I will need to make sure my husband stays at least six feet away from me for the next few days." b) "I understand my pregnant daughter is not allowed to visit me during this time."
c) "It is okay for my 8-year-old grandson to visit as long as he doesn't hug me."
d) "I noticed the hospital staff wore dosimeter badges when they entered my room."
c) "It is okay for my 8-year-old grandson to visit as long as he doesn't hug me."
A postmenopausal woman with estrogen-receptive (ER) positive breast cancer is prescribed tamoxifen (Nolvadex). The nurse should instruct the client to promptly report which of the following symptoms?
a) Hot flashes
b) Vaginal dryness
c) Abnormal vaginal bleeding
d) Mild nausea
c) Abnormal vaginal bleeding
A nurse is providing education to a client newly prescribed phenytoin (Dilantin). Which statement by the client indicates an understanding of the teaching?
a) "If I develop a skin rash, I should treat it with over-the-counter cream."
b) "I will need to practice good oral hygiene, like brushing and flossing regularly."
c) "I can stop taking this medication as soon as I am seizure-free for a month."
d) "It is safe to switch between the brand name and generic versions of this drug."
b) "I will need to practice good oral hygiene, like brushing and flossing regularly."
A client is receiving an infusion of eptifibatide (Integrilin) after a percutaneous coronary intervention (PCI). The nurse knows this medication works by which of the following mechanisms?
a) Converting plasminogen to plasmin to dissolve the clot.
b) Inhibiting Vitamin K-dependent clotting factors.
c) Blocking glycoprotein IIb/IIIa receptors on platelets to reduce aggregation.
d) Selectively inhibiting Factor Xa in the coagulation cascade.
c) Blocking glycoprotein IIb/IIIa receptors on platelets to reduce aggregation.