Pharmacology
A client has been given a prescription for sulfasalazine. Which allergy should the nurse assess for in the client prior to administration?
1. Sulfonamides or salicylates
2. Salicylates or acetaminophen
3. Shellfish or calcium channel blockers
4. Histamine receptor antagonists or beta blockers
What is 1
Sulfasalazine is a sulfonamide. The client who has been prescribed sulfasalazine should be checked for history of allergy to either sulfonamides or salicylates because the chemical composition of sulfasalazine and that of these medications are similar. The other options are not associated with an allergy to sulfasalazine.
The nurse reviews the primary health care provider's (PHCP's) prescriptions for a child with a streptococcal infection. The PHCP prescribes an antistreptolysin O titer. Based on this prescription, which diagnosis should the nurse suspect in the child?
1. Heart failure (HF)
2. Rheumatic fever (RF)
3. Aortic valve disease (AVD)
4. Pulmonic valve disease (PVD)
What is 2
A diagnosis of RF is confirmed by the presence of two major manifestations or one major and two minor manifestations from the Jones criteria. In addition, evidence of a recent streptococcal infection is confirmed by positive antistreptolysin O titer, Streptozyme slide tests, or anti-DNase B assays. An antistreptolysin O titer is not a specific laboratory test for the conditions identified in options 1, 3, and 4.
The spouse of an alcoholic client is attending a support group and says to the group members, "It's all very well for everyone to label me an enabler, but if I didn't call him in sick at work, he'd lose his job. Where would we be then?" Which statement by the nurse co-leader would be therapeutic?
1. "Does anyone in the group want to respond to that?"
2. "So you only call him in sick because you are worried about money?"
3. "Hasn't the group discussed this before? What conclusion did you all come to?"
4. "It is a difficult situation, but do you agree that enabling creates codependency?"
What is 4
The therapeutic response is the one that seeks clarification and assesses the client's understanding of the dynamics of codependency. The nurse should never belittle a client or inappropriately place the burden of responding on the group members. When the nurse changes the focus to money by reinterpreting the client's denial, the intervention is prematurely timed.
The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action?
1. Identify the types of accelerations.
2. Assess the baseline fetal heart rate.
3. Determine the intensity of the contractions.
4. Determine the frequency of the contractions.
What is 2
Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate can be identified if they occur. The intensity of contractions is assessed by an internal fetal monitor, not an external fetal monitor. Options 1 and 4 are important to assess, but not as the first priority. Fetal heart rate is evaluated by assessing baseline and periodic changes. Periodic changes occur in response to the intermittent stress of uterine contractions and the baseline beat-to-beat variability of the fetal heart rate.
The nurse is caring for a child who fractured the ulna bone and had a cast applied 24 hours ago. The child tells the nurse that the arm feels like it is falling asleep. Which nursing action is appropriate?
1. Encourage the child to keep the arm elevated.
2. Report the findings to the primary health care provider.
3. Document the findings and reassess the arm in 4 hours.
4. Tell the child that this is normal while the cast is drying.
What is 2
A child's complaint of pins and needles or of the extremity falling asleep needs to be reported to the primary health care provider. These complaints indicate the possibility of circulatory impairment and paresthesia. Paresthesia is a serious concern because paralysis can result if the problem is not corrected. The five Ps of vascular impairment are pain, pallor, pulselessness, paresthesia, and paralysis. Prompt intervention is critical if neurovascular impairment is to be prevented.
An ambulatory care client with allergic dermatitis has been given a prescription for a tube of diphenhydramine 1% to use as a topical agent. The nurse determines that the medication was effective if which finding was noted?
1. Nighttime sedation
2. Decrease in urticaria
3. Absence of ecchymosis
4. Healing of burned tissue
What is 2
Diphenhydramine reduces the symptoms of allergic reaction, such as itching or urticaria, when used as a topical agent on the skin. The oral form also has other uses, such as to provide mild nighttime sedation. It is not used to treat burns or ecchymosis.
The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy?
1. Restrict all visitors.
2. Restrict fluid intake.
3. Teach the client and family about the need for hand hygiene.
4. Insert an indwelling urinary catheter to prevent skin breakdown.
What is 3
In the neutropenic client, meticulous hand hygiene education is implemented for the client, family, visitors, and staff. Not all visitors are restricted, but the client is protected from persons with known infections. Fluids should be encouraged. Invasive measures such as an indwelling urinary catheter should be avoided to prevent infections.
A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a 2-bed room. A newly admitted client will be assigned to this client's room. Which client would be the best choice as a roommate for the client with anorexia nervosa?
1. A client with pneumonia
2. A client undergoing diagnostic tests
3. A client who thrives on managing others
4. A client who could benefit from the client's assistance at mealtime
What is 2
The client undergoing diagnostic tests is an acceptable roommate. The client with anorexia nervosa is most likely experiencing hematological complications, such as leukopenia. Having a roommate with pneumonia would place the client with anorexia nervosa at risk for infection. The client with anorexia nervosa should not be put in a situation in which the client can focus on the nutritional needs of others or be managed by others, because this may contribute to sublimation and suppression of personal hunger.
The nurse is monitoring a client who is in the active phase of labor. The client has been experiencing contractions that are short, irregular, and weak. Which type of labor dystocia should the nurse document that the client is experiencing?
1. Hypotonic
2. Precipitate
3. Hypertonic
4. Preterm labor
What is 1
Hypotonic labor contractions are short, irregular, and weak and usually occur during the active phase of labor. Precipitate labor is that which lasts in its entirety for 3 hours or less. Hypertonic dysfunction usually occurs during the latent phase of labor. Preterm labor is the onset of labor after 20 weeks of gestation and before the beginning of the 38th week of gestation.
The nurse notes documentation that a child is exhibiting an inability to flex the leg when the thigh is flexed anteriorly at the hip. Which condition does the nurse suspect?
1. Meningitis
2. Spinal cord injury
3. Intracranial bleeding
4. Decreased cerebral blood flow
What is 1
Meningitis is an infectious process of the central nervous system caused by bacteria and viruses. The inability to extend the leg when the thigh is flexed anteriorly at the hip is a positive Kernig's sign, noted in meningitis. Kernig's sign is not seen specifically with spinal cord injury, intracranial bleeding, or decreased cerebral blood flow.
A client with myasthenia gravis who is taking neostigmine is experiencing frequent exacerbations of myasthenic crisis and cholinergic crisis. The nurse teaches the client that it is most important that this medication be taken in which manner?
1. On time
2. On an empty stomach
3. Double-dosed if 1 dose is missed
4. Titrated for dosage, depending on symptoms
What is 1
The client should take neostigmine exactly on time. Taking the medication early or late could result in myasthenic or cholinergic crisis. Taking the medication on time is especially important for the client with dysphagia because the client may not be able to swallow the medication if it is given late. These clients are taught to set an alarm clock to remind them of dosage times. The medication should be administered with food or milk to minimize side and adverse effects. The client should never skip or double up on missed doses or titrate the dose, depending on symptoms. The client needs to take the medication exactly as prescribed.
A postoperative client with a large abdominal wound requiring frequent dressing changes is starting to develop skin irritation in the area where the dressing tape is applied to the skin. The nurse determines that the client would benefit most from which measure?
1. Obtaining a wound culture
2. The use of Montgomery straps
3. The use of hypoallergenic tape
4. Cleansing the irritated area with povidone-iodine
What is 2
The use of Montgomery straps is recommended to prevent skin breakdown with frequent dressing changes. They limit the friction and shear that could irritate skin with frequent removal and reapplication of tape. Hypoallergenic tape is used on clients with thin, fragile skin; clients whose skin is sensitive to standard tape; and clients who require less frequent dressing changes. Cleansing with povidone-iodine and obtaining a wound culture are not indicated.
An alcohol-troubled client says, "The 12 Steps of Alcoholics Anonymous (AA) meeting really upset me. I had to go for a drink after 1 hour with those people; they're fanatics!" Which statement by the nurse would be therapeutic?
1. "You think AA is for fanatics?"
2. "It sounds as if you look for any reason to drink!"
3. "Not any 1 strategy for remaining sober is best for everyone."
4. "I agree. AA is definitely not for you if you find it is a trigger to drink."
What is 3
The therapeutic statement is the one that does not cause a regressive struggle between nurse and client, which would result in dispute and another drinking excuse. By allowing the client to be in control, the nurse is able to reflect on the core problem and provide an opportunity to continue with the discussion about treatment options. The nurse should avoid confrontational statements, which can result in a regressive struggle. Agreeing with the client's rationalization is nontherapeutic. When the nurse paraphrases the statement regarding fanatics, the response becomes aggressive and sarcastic.
The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a loss of variability. What is the initial nursing action?
1. Turn the client on her side and administer oxygen by face mask at 8 to 10 L/min.
2. Turn the client on her back and administer oxygen by face mask at 8 to 10 L/min.
3. Turn the client on her side and administer oxygen by nasal cannula at 2 to 4 L/min.
4. Turn the client on her back and administer oxygen by nasal cannula at 2 to 4 L/min.
What is 1
If a fetal heart rate begins to slow or a loss of variability is observed, this could indicate fetal distress. To facilitate oxygen to the mother and her fetus, the client is turned to her side, which reduces the pressure of the uterus on the ascending vena cava and descending aorta. Oxygen at 8 to 10 L/min is applied to the mother by face mask.
The nurse is planning care for a child with hemolytic-uremic syndrome who has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to implement which measure?
1. Restrict fluids as prescribed.
2. Care for the arteriovenous fistula.
3. Encourage foods high in potassium.
4. Administer analgesics as prescribed.
What is 1
Hemolytic-uremic syndrome is thought to be associated with bacterial toxins, chemicals, and viruses that result in acute kidney injury in children. Clinical manifestations of the disease include acquired hemolytic anemia, thrombocytopenia, renal injury, and central nervous system symptoms. A child with hemolytic-uremic syndrome undergoing peritoneal dialysis because of anuria would be on fluid restriction. Pain is not associated with hemolytic-uremic syndrome, and potassium would be restricted, not encouraged, if the child is anuric. Peritoneal dialysis does not require an arteriovenous fistula (only hemodialysis).
A client with Parkinson's disease has begun therapy with levodopa/carbidopa. The nurse determines that the client understands the action of the medication if he or she verbalizes that results may not be apparent for how long?
1. 1 week
2. 24 hours
3. 2 to 3 days
4. 2 to 3 weeks
What is 4
Signs and symptoms of Parkinson's disease usually begin to resolve within 2 to 3 weeks of starting therapy, although in some clients marked improvement may not be seen for up to 6 months. The client needs to understand this concept to aid in compliance with medication therapy.
The nurse educator asks a student to list the 5 main categories of complementary and alternative medicine (CAM), developed by the National Center for Complementary and Alternative Medicine. Which statement, if made by the nursing student, indicates a need for further teaching regarding CAM categories?
1. "CAM includes biologically based practices."
2. "Whole medical systems are a component of CAM."
3. "Mind-body medicine is part of the CAM approach."
4. "Magnetic therapy and massage therapy are a focus of CAM."
What is 4
The 5 main categories of CAM include whole medical systems, mind-body medicine, biologically based practices, manipulative and body-based practices, and energy medicine. Magnetic therapy and massage therapy are therapies within specific categories of CAM.
The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action?
1. Adhering to the mandatory abuse-reporting laws
2. Notifying the caseworker of the family situation
3. Removing the client from any immediate danger
4. Obtaining treatment for the abusing family member
What is 3
Whenever an abused client remains in the abusive environment, priority must be placed on ascertaining whether the client is in any immediate danger. If so, emergency action must be taken to remove the client from the abusing situation. Options 1, 2, and 4 may be appropriate interventions, but are not the priority.
During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and teaches the client about proper nutrition to minimize this problem. Which client statement indicates an understanding of the proper nutrition to minimize this problem?
1. "I will drink 8 oz of water with each meal."
2. "I will eat 3 servings of cracked wheat bread each day."
3. "I will eat 2 saltine crackers before I get up each morning."
4. "I will eat fresh fruits and vegetables for snacks and for dessert each day."
What is 4
Fresh fruits and vegetables provide vitamins and minerals needed for healthy gums. Drinking water with meals has no direct effect on gums. Cracked wheat bread may abrade the tender gums. Eating saltine crackers can also abrade the tender gums.
The nurse reviews the record of a child who is suspected to have glomerulonephritis and expects to note which finding that is associated with this diagnosis?
1. Hypotension
2. Brown-colored urine
3. Low urinary specific gravity
4. Low blood urea nitrogen level
What is 2
Glomerulonephritis refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Gross hematuria resulting in dark, smoky, cola-colored, or brown-colored urine is a classic symptom of glomerulonephritis. Hypertension is also common. Blood urea nitrogen levels may be elevated. A moderately elevated to high urinary specific gravity is associated with glomerulonephritis.
A client is having the dosage of clonazepam adjusted. The nurse should plan to perform which action?
1. Weigh the client daily.
2. Institute seizure precautions.
3. Monitor blood glucose levels.
4. Observe for areas of ecchymosis.
What is 2
Clonazepam is a benzodiazepine that is used as an anticonvulsant. During initial therapy and during periods of dosage adjustment, the nurse should initiate seizure precautions for the client. Weight, glucose levels, and ecchymosis are unrelated to this medication.
A transgender client undergoing hormonal therapy is being seen by a primary health care provider (PHCP) in the clinic. The nurse notes new laboratory results in the client's chart. Which result has the highest priority of reporting to the PHCP?
1. Hematocrit 59% (0.59)
2. Sodium 145 mEq/L (145 mmol/L)
3. Potassium 3.5 mEq/L (3.4 mmol/L)
4. Blood urea nitrogen 10 mg/dL (3.6 mmol/L)
What is 1
Transgender persons taking hormone therapy must be monitored regularly by their PHCP due to associated complications and side effects. Polycythemia occurs from exogenous testosterone use. Normal hematocrit ranges are 37% to 52% (0.37 to 0.52 volume fraction). A hematocrit of 59% (0.59) indicates polycythemia. Normal sodium ranges are 135 to 145 mEq/L (135 to 145 mmol/L). Normal potassium ranges are 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Normal blood urea nitrogen (BUN) ranges are 10 to 20 mg/dL (3.6 to 7.1 mmol/L).
A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all my doctor's fault. I have done everything I've been asked to do!" Which nursing interpretation is best for this situation?
1. An expected coping mechanism
2. An ineffective defense mechanism
3. A need to notify the hospital lawyer
4. An expression of guilt on the part of the client
What is 1
The nurse needs to be aware of the effective and ineffective coping mechanisms that can occur in a client when loss is anticipated. The expression of anger is known to be a normal response to impending loss, and the anger may be directed toward the self, God or other spiritual being, or caregivers. Notifying the hospital lawyer is inappropriate. Guilt may or may not be a component of the client's feelings, and the data in the question do not indicate that guilt is present.
The nurse encourages a pregnant client who is human immunodeficiency virus (HIV) positive to immediately report any early signs of vaginal discharge or perineal tenderness to the primary health care provider. The client asks the nurse about the importance of this action, and the nurse responds by making which statement to the client?
1. "This is necessary to relieve your anxiety."
2. "This is necessary to eliminate the need for further uncomfortable screenings."
3. "This is necessary to minimize the financial cost of caring for an HIV-positive client."
4. "This is necessary to assist in identifying potential infections that may need to be treated."
What is 4
The HIV-compromised client may be at high risk for superimposed infections during pregnancy. These include, for example, Candida infections, genital herpes, and anogenital condyloma. Early reporting of signs and symptoms may alert the members of the health care team that further assessment and testing are needed to diagnose and manage additional maternal and fetal physiological risks. All other options do represent possible outcomes of this nursing intervention, but they are not the priority of care when promoting maternal-fetal well-being.
A mother arrives at the hospital emergency department with her child, in whom a diagnosis of epiglottitis is documented. Which prescription, if written by the primary health care provider, should the nurse question?
1. Obtain a throat culture.
2. Obtain axillary temperatures.
3. Administer humidified oxygen.
4. Administer acetaminophen for fever.
What is 1
The throat of a child with suspected epiglottitis should not be examined or cultured because any stimulation with a tongue depressor or culture swab could cause laryngospasm, thus completing airway obstruction. Humidified oxygen and antipyretics are components of management. Axillary rather than oral temperatures should be taken to avoid stimulation and resultant laryngospasm.