Pharmacology
The senior nursing student is assigned to care for a client with severe preeclampsia who is receiving an intravenous infusion of magnesium sulfate. The co-assigned registered nurse asks the student to describe the actions and effects of this medication. Which statement, if made by the student, indicates the need for further teaching?
1. "It decreases the frequency and duration of uterine contractions."
2. "It increases acetylcholine, blocking neuromuscular transmission."
3. "It decreases the central nervous system activity, acting as an anticonvulsant."
4. "It produces flushing and sweating due to decreased peripheral blood pressure."
What is 2
Magnesium sulfate produces flushing and sweating because of decreased peripheral blood pressure. It decreases the frequency and duration of uterine contractions and decreases central nervous system activity, acting as an anticonvulsant. Magnesium sulfate decreases (not increases) acetylcholine, blocking neuromuscular transmission.
The nurse has just assisted a client back to bed after a fall. The nurse and primary health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next?
1. Reassess the client.
2. Conduct a staff meeting to describe the fall.
3. Document in the nurse's notes that an incident report was completed.
4. Contact the nursing supervisor to update information regarding the fall.
What is 1
After a client's fall, the nurse must frequently reassess the client because potential complications do not always appear immediately after the fall. The client's fall should be treated as private information and shared on a "need to know" basis. Communication regarding the event should involve only the individuals participating in the client's care. An incident report is a problem-solving document; however, its completion is not documented in the nurse's notes. If the nursing supervisor has been made aware of the incident, the supervisor will contact the nurse if status update is necessary.
The nurse is conducting a prepared childbirth class and is instructing pregnant women about the method of effleurage. The nurse instructs the women to perform the procedure by doing which action?
1. Contracting and then consciously relaxing different muscle groups
2. Massaging the abdomen during contractions, using both hands in a circular motion
3. Instructing her partner to stroke or massage a tightened muscle by the use of touch
4. Contracting an area of the body, such as an arm or leg, and then concentrating on letting tension go from the rest of the body
What is 2
Effleurage is massage of the abdomen during contractions. Women learn to do effleurage using both hands in a circular motion. Progressive relaxation involves contracting and then consciously releasing different muscle groups. Touch relaxation helps the woman to learn to loosen taut muscles when she is touched by her partner. Neuromuscular disassociation helps the woman to relax her body even when 1 group of muscles is strongly contracted. In this procedure, the woman contracts an area such as an arm or leg and then concentrates on letting tension go from the rest of the body.
The nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire, but despite the client's efforts, the neighbor died. Which action should the nurse take to enable the client to work through the meaning of the crisis?
1. Identifying the client's ability to function
2. Identifying the client's potential for self-harm
3. Inquiring about the client's feelings that may affect coping
4. Inquiring about the client's perception of the cause of the neighbor's death
What is 3
The client must first deal with feelings and negative responses before the client is able to work through the meaning of the crisis. Option 3 pertains directly to the client's feelings. Options 1, 2, and 4 do not directly address the client's feelings.
The nurse is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which beverage should the nurse instruct the client to select from the menu?
1. Tea
2. Cola
3. Coffee
4. Raspberry juice
What is 4
A client with a diagnosis of MI should not consume caffeinated beverages. Caffeinated products can produce a vasoconstrictive effect, leading to further cardiac ischemia. Coffee, tea, and cola all contain caffeine and need to be avoided in the client with MI.
The nurse is teaching a client who is being started on imipramine about the medication. The nurse should inform the client to expect maximum desired effects at which time period following initiation of the medication?
1. In 2 months
2. In 2 to 3 weeks
3. During the first week
4. During the sixth week of administration
What is 2
The maximum therapeutic effects of imipramine may not occur for 2 to 3 weeks after antidepressant therapy has been initiated. Options 1, 3, and 4 are incorrect time periods.
The ambulatory care nurse is providing home care instructions to the client after an arthroscopy of the knee. Which statement by the client indicates a need for further instruction?
1. "I should elevate my knee while sitting."
2. "I can apply heat to the site if it becomes uncomfortable."
3. "I should avoid excessive use of the joint for several days."
4. "I should return to the primary health care provider for suture removal in about 7 days."
What is 2
Ice is applied to the affected joint for pain and swelling, and analgesics are administered as prescribed. The application of heat may cause swelling and discomfort. After arthroscopy the client is instructed to avoid excessive use of the joint for several days, to elevate the knee while sitting, to avoid twisting the knee, and to return for suture removal in about 7 days.
A pregnant 39-week-gestation client arrives at the labor and delivery unit in active labor. On confirmation of labor, the client reports a history of herpes simplex virus (HSV) to the nurse, who notes the presence of lesions on inspection of the client's perineum. Which should be the nurse's initial action?
1. Perform an abdominal scrub on the client.
2. Prepare the delivery room for a vaginal delivery.
3. Explain to the client why a cesarean delivery is necessary.
4. Call the primary health care provider to obtain a prescription for an antiviral medication.
What is 3
Because neonatal infection of HSV is life-threatening, prevention of neonatal infection is critical. Current recommendations state that a cesarean delivery within 4 hours after labor begins or membranes rupture is necessary if visible lesions are present on the woman's perineum. An abdominal scrub will be necessary eventually for the cesarean delivery but should not be the nurse's initial action. Antiviral medications are used to control symptoms, not to eradicate the infection. At this phase in the client's pregnancy, the focus is on preventing transmission to the fetus rather than controlling the symptoms of HSV.
A client with obsessive-compulsive disorder (OCD) who continually cleans the bathroom becomes enraged with the roommate for using the bar of bathing soap for cleaning the bathroom. The client begins to yell and slaps the roommate. Which action should the nurse take first?
1. Restrain the client.
2. Fill out an incident report.
3. Remove both clients to a separate, safe location.
4. Call the hospital risk management department.
What is 3
The first responsibility of the nurse is to provide for the safety of all clients. Only option 3 provides for the needs of both clients identified in the question. The other actions are either contraindicated (option 1), have lesser priority (option 2), or may not be indicated depending on the level of injury to the second client (option 4).
When obtaining assessment data from a client with a microcytic normochromic anemia, which should the nurse question the client about?
1. Folic acid intake
2. Dietary intake of iron
3. A history of gastric surgery
4. A history of sickle cell anemia
What is 2
Microcytic normochromic anemias involve the presence of small, pale-colored red blood cells. Causes are iron deficiency anemia, thalassemia, and lead poisoning. The only choice that fits this description is option 2. Folic acid deficiency is caused by macrocytic normochromic cells; these are large red blood cells. Gastric surgery can result in vitamin B12 deficiency. Sickle cell anemia results in sickled cells and erythrocyte destruction.
Following kidney transplantation, cyclosporine is prescribed for a client. Which laboratory result would indicate an adverse effect from the use of this medication?
1. Hemoglobin level of 14.0 g/dL (140 mmol/L)
2. Creatinine level of 0.6 mg/dL (53 mcmol/L)
3. Blood urea nitrogen level of 25 mg/dL (8.8 mmol/L)
4. Fasting blood glucose level of 99 mg/dL (5.5 mmol/L)
What is 3
Cyclosporine is an immunosuppressant. Nephrotoxicity can occur from the use of cyclosporine. Nephrotoxicity is evaluated by monitoring for elevated blood urea nitrogen and serum creatinine levels. The normal blood urea nitrogen level is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). The normal creatinine level for a male is 0.6 to 1.2 mg/dL (53 to 106 mcmol/L) and for a female is 0.5 to 1.1 mg/dL (44 to 97 mcmol/L). Cyclosporine can lower complete blood cell count levels. A normal hemoglobin is 14 to 18 g/dL (140 to 180 mmol/L) for a male and 12 to 16 g/dL (120 to 160 mmol/L) for a female. A normal hemoglobin is not an adverse effect. Cyclosporine does affect the glucose level. The normal fasting glucose is 70 to 99 mg/dL (3.9–5.5 mmol/L).
The nurse is admitting to the hospital a client with a diagnosis of Guillain-Barré syndrome. The nurse knows that if the disease is severe, the client will be at risk for which acid-base imbalance?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis
What is 3
Guillain-Barré is a neuromuscular disorder in which the client may experience weakening or paralysis of the muscles used for respiration. This could cause the client to retain carbon dioxide, leading to respiratory acidosis and ventilatory failure as the paralysis develops. Therefore, the remaining options are incorrect.
The nurse is reviewing the record of a newborn infant in the nursery and notes that the primary health care provider (PHCP) has documented the presence of a cephalohematoma. Based on this documentation, what should the nurse expect to note on assessment of the infant?
1. A suture split greater than 1 cm
2. A hard, rigid, immobile suture line
3. Swelling of the soft tissues of the head and scalp
4. Edema resulting from bleeding below the periosteum of the cranium
What is 4
A cephalohematoma indicates edema resulting from bleeding below the periosteum of the cranium. It does not cross the suture line. It is most likely to be caused by ruptured blood vessels from head trauma during birth. The lesion develops within 24 to 48 hours after birth and may take 2 to 3 weeks to resolve. A suture split greater than 1 cm may indicate increased intracranial pressure. A hard, immobile suture may be associated with premature closure or craniosynostosis and should be investigated further. Edema of cranial tissues identifies a caput succedaneum.
The nurse is monitoring a client with a diagnosis of depression. Which behavior observed by the nurse indicates that suicide precautions should be instituted for this client?
1. The client refuses to attend group therapy.
2. The client asks to meet with a lawyer to take care of unfinished business.
3. The client has an argument with her significant other during visiting hours.
4. The client swears at her roommate because she takes too much time in the bathroom.
What is 2
Warning signs of suicide include talking about suicide, preoccupation with death and dying, behavioral changes, giving away special possessions and making arrangements to take care of unfinished business, decreased appetite, difficulty with sleep, and a loss of interest in usual activities. The remaining behaviors deal with anger and "acting-out" behaviors.
A client exhibits a purplish bruise to the skin after a fall. The nurse would document this finding in the health record most accurately using which term?
1. Purpura
2. Petechiae
3. Erythema
4. Ecchymosis
What is 4
Ecchymosis is a type of purpuric lesion, also known as a bruise. Purpura is an umbrella term that incorporates ecchymoses and petechiae. Petechiae are pinpoint hemorrhages and are another form of purpura. Erythema is an area of redness on the skin.
A client in the hospital emergency department who received nitroglycerin for chest pain has obtained relief but now complains of a headache. The nurse should interpret that this client is most likely experiencing which condition?
1. An allergic reaction to nitroglycerin
2. An expected medication side effect
3. An early sign of tolerance to the medication
4. A warning that the medication should not be used again
What is 2
Headache is a frequent side effect of nitroglycerin, resulting from its vasodilator action. It often subsides as the client becomes accustomed to the medication and is effectively treated with acetaminophen. The other options are incorrect interpretations.
The client is suspected of having a skeletal muscle disorder. Which isoenzyme value reported with the creatine kinase (CK) level should the nurse assess for elevation?
1. MM
2. MB
3. BB
4. MS
What is 1
CK is a cellular enzyme that can be fractionated into 3 isoenzymes. The MM band reflects CK from skeletal muscle. This band would be elevated in skeletal muscle disease. The MB band reflects CK from myocardial muscle. The BB band reflects CK from the brain. There is no MS band.
During the intrapartum period, the nurse is caring for a client with sickle cell disease. The nurse ensures that the client receives adequate intravenous fluid intake and oxygen consumption to achieve which outcome?
1. Stimulate the labor process.
2. Prevent dehydration and hypoxemia.
3. Avoid the necessity of a cesarean section.
4. Eliminate the need for analgesic administration.
What is 2
A variety of conditions, including dehydration, hypoxemia, infection, and exertion, can stimulate the sickling process during the intrapartum period. Maintaining adequate intravenous fluid intake and the administration of oxygen via face mask will help to ensure a safe environment for maternal and fetal health during labor. These measures will not stimulate the labor process, avoid the necessity of a cesarean section, or eliminate the need for analgesic administration.
The nurse is working with a victim of rape in a clinic setting and assists in developing a plan of care for the client. Which is an inappropriate short-term initial goal?
1. Physical wounds will heal.
2. The client will participate in the treatment plan.
3. The client will verbalize feelings about the event.
4. The client will resolve feelings of fear and anxiety related to the rape trauma.
What is 4
The appropriate short-term initial goal is the client will resolve feelings of fear and anxiety related to the rape trauma. Short-term goals would include the beginning stages of dealing with the rape trauma. Clients will be expected initially to keep appointments, participate in care, begin to explore feelings, and begin to heal physical wounds that were inflicted at the time of the rape.
The nurse is assessing the renal function of a client at risk for acute kidney injury. After noting the amount of urine output and urine characteristics, the nurse proceeds to assess which as the best indirect indicator of renal status?
1. Blood pressure
2. Apical heart rate
3. Jugular vein distention
4. Level of consciousness
What is 1
The kidneys normally receive 20% to 25% of the cardiac output, even under conditions of rest. For kidney function to be optimal, adequate renal perfusion is necessary. Perfusion can best be estimated by the blood pressure, which is an indirect reflection of the adequacy of cardiac output. The heart rate affects the cardiac output but can be altered by factors unrelated to kidney function. Jugular vein distention and level of consciousness are unrelated items.
The nurse determines the client needs further instruction on cimetidine if which statements were made? Select all that apply.
1. "I will take the cimetidine with my meals."
2. "I'll know the medication is working if my diarrhea stops."
3. "My episodes of heartburn will decrease if the medication is effective."
4. "Taking the cimetidine with an antacid will increase its effectiveness."
5. "I will notify my primary health care provider if I become depressed or anxious."
6. "Some of my blood levels will need to be monitored closely since I also take warfarin for atrial fibrillation."
What is 1, 2, and 4
Cimetidine, a histamine (H2)-receptor antagonist, helps alleviate the symptom of heartburn, not diarrhea. Because cimetidine crosses the blood–brain barrier, central nervous system side and adverse effects, such as mental confusion, agitation, depression, and anxiety, can occur. Food reduces the rate of absorption, so if cimetidine is taken with meals, absorption will be slowed. Antacids decrease the absorption of cimetidine and should be taken at least 1 hour apart. If cimetidine is concomitantly administered with warfarin therapy, warfarin doses may need to be reduced, so prothrombin and international normalized ratio results must be followed.
The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply.
1. Nausea
2. Confusion
3. Bradypnea
4. Tachycardia
5. Hyperkalemia
6. Lightheadedness
What is 1, 2, 4, and 6
Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. Hyperventilation (tachypnea) occurs. Bradypnea describes respirations that are regular but abnormally slow. Hyperkalemia is associated with acidosis.
The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment findings indicate to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)? Select all that apply.
1. The client has a history of intravenous drug use.
2. The client has a significant other who is heterosexual.
3. The client has a history of sexually transmitted infections.
4. The client has had one sexual partner for the past 10 years.
5. The client has a previous history of gestational diabetes mellitus.
What is 1 and 3
HIV is transmitted by intimate sexual contact and the exchange of body fluids, exposure to infected blood, and passage from an infected woman to her fetus. Clients who fall into the high-risk category for HIV infection include individuals who have used intravenous drugs, individuals who experience persistent and recurrent sexually transmitted infections, and individuals who have a history of multiple sexual partners. Gestational diabetes mellitus does not predispose the client to HIV. A client with a heterosexual partner, particularly a client who has had only one sexual partner in 10 years, does not have a high risk for contracting HIV.
Which are appropriate interventions for caring for the client undergoing alcohol withdrawal? Select all that apply.
1. Monitor vital signs.
2. Maintain an NPO status.
3. Provide a safe environment.
4. Address hallucinations therapeutically.
5. Provide stimulation in the environment.
6. Provide reality orientation as appropriate.
What is 1, 3, 4, and 6
When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming himself or herself or others. The nurse would provide a low-stimulation environment to maintain the client in as calm a state as possible. The nurse would monitor the vital signs closely and report abnormal findings. The nurse would frequently reorient the client to reality and would address hallucinations therapeutically. Adequate nutritional and fluid intake must be maintained.
A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply.
1. Administer stool softeners as prescribed.
2. Instruct the client to limit fluid intake to avoid urinary retention.
3. Encourage a high-fiber diet to promote bowel movements without straining.
4. Apply cold packs to the anal-rectal area over the dressing until the packing is removed.
5. Help the client to a Fowler's position to place pressure on the rectal area and decrease bleeding.
What is 1, 3, and 4
Nursing interventions after a hemorrhoidectomy are aimed at management of pain and avoidance of bleeding and incision rupture. Stool softeners and a high-fiber diet will help the client avoid straining, thereby reducing the chances of rupturing the incision. An ice pack will increase comfort and decrease bleeding. Options 2 and 5 are incorrect interventions.