We Better Know These
A 5-month-pregnant patient enters the clinic and states, “I have no money for any kind of vitamins, and I have never taken any.” What is the nurse’s initial intervention?
A. Refer the patient to social services
B. Check the patient’s hemoglobin and hematocrit
C. Start the patient on folic acid.
D. Screen the patient for fetal neural tube defects.
D. Screen the patient for fetal neural tube defects.
A child has been prescribed activated charcoal. What is the likely reason this is being ordered?
A. Ingestion of a toxic substance
B. Severe vomiting
C. Nausea
D. Motion sickness
A. Ingestion of a toxic substance
A contraindication for a patient requesting diphenhydramine treatment is
A. Drowsiness
B. Glaucoma
C. Pruritus
D. Urticaria
B. Glaucoma
A nurse is reviewing ethical concepts. Which statement should the nurse identify as best describing the term autonomy?
A. Showing respect for the person
B. Speaking for the patient when the patient needs a voice
C. Making decision for the patient regarding health care dilemmas
D. The patient’s right to self-determination
D. The patient’s right to self-determination
A nurse is working with a patient in the setting of goals related to compliance with medication regimen. Which goal statement reflects best practice?
A. The patient will document on a daily basis that prescribed medications were taken.
B. The patient will be able to state the clinical indications for each medication that was ordered by the end of the teaching session.
C. The patient will fill the prescription for each medication at the pharmacy.
D. The patient will take the medication as ordered
B. The patient will be able to state the clinical indications for each medication that was ordered by the end of the teaching session.
A patient diagnosed with an atonic bladder and a peptic ulcer is prescribed bethanechol. What is the nurse’s best intervention?
A. Inform the patient that the medication must be taken on an empty stomach
B. Teach the patient to take the medication with a full glass of water.
C. Administer the medication only after meals.
D. Hold the medication and call the health care provider.
D. Hold the medication and call the health care provider.
A patient has arrived at the emergency department and requires immediate surgery. He has been receiving heparin. Which intervention is essential?
A. Teach the patient about the phenytoin
B. Administer protamine sulfate
C. Assess the INR before surgery
D. Administer vitamin K
B. Administer protamine sulfate
A patient has hypocalcemia caused by parathyroid hormone deficiency. Which medication will the nurse anticipate giving to this patient?
A. Calcitonin
B. Calcitriol
C. Calcium
D. Vitamin D
B. Calcitriol
A patient is admitted to the emergency department with an overdose of benzodiazepine. Which antidote should the nurse expect to administer?
A. Flumazenil
B. Naloxone
C. Naltrexone
D. Ramelteon
A. Flumazenil
A patient is ordered a schedule III drug. The patient asks the nurse what the schedule designation means. The nurse explains to the patient that schedule drugs are classified according to the
A. risk for toxicity.
B. potential for abuse.
C. adverse effects.
D. pain relief provided
B. potential for abuse.
A patient is prescribed cyclobenzaprine for relief of muscles spasms. What does the nurse instruct the patient to avoid while taking cyclobenzaprine?
A. Beer
B. Coffee
C. Grape juice
D. Orange juice
A. Beer
A patient is receiving warfarin for a chronic condition. Which patient statement requires immediate action by the nurse?
A. “I will avoid contact sports.”
B. “I will take my medication in the early evening each day.”
C. “I will increase dark-green, leafy vegetables in my diet.”
D. “I will contact my health care provider if I develop excessive bruising.”
C. “I will increase dark-green, leafy vegetables in my diet.”
A patient presents to the ED with a rapid, thready pulse, which is too fast to count. The patient is diagnosed with PSVT. The nurse will expect the provider to order which medication to treat this condition?
A. Adenosine
B. Albuterol
C. Atropine
D. Theophylline
A. Adenosine
A patient receiving a unit of red blood cells suddenly develops shortness of breath, chills, and fever. What will the nurse do first?
A. Reassure the patient that this is an expected reaction.
B. Notify the health care provider while a peer monitors the blood transfusion
C. Discontinue the infusion
D. Decrease the infusion rate and reassess the patient in 15 min.
C. Discontinue the infusion
A patient recently returned to the United States and complains of fever, chills, sweating and flu-like symptoms. Which is the priority intervention?
A. Assess whether the patient has traveled out of the country to a malaria-endemic area
B. Complete a culture and sensitivity test
C. Immediately administer antibiotic therapy
D. Complete COVID-19 test and quarantine patient until results are available
A. Assess whether the patient has traveled out of the country to a malaria-endemic area
A patient who is experiencing chest pain and shortness of breath is brought to the emergency department. The nurse assesses a heart rate of 98 beats per minute, bilateral lung crackles, and an oxygen saturation of 93%. What drug will the nurse expect to administer initially to this patient?
A. Albuterol
B. Aspirin
C. Nitroglycerin
D. Oxygen
D. Oxygen
A patient with a history of burning upon urination is prescribed nitrofurantoin to treat a urinary tract infection. Which information should the nurse include in the patient’s teaching plan?
A. Restrict fluid intake.
B. Take nitrofurantoin with an antacid.
C. Urine may turn brown
D. Assess fingerstick blood sugar.
C. Urine may turn brown
A patient with hypophosphatemia should eat a diet with which foods?
A. Water, juice, and green-leafy vegetables
B. Whole-grain cereals, nuts, milk, and meat
C. Sugar-free candy, juice, and cheeses
D. Bananas, green-leafy vegetables, and oysters
B. Whole-grain cereals, nuts, milk, and meat
A patient with vitamin D deficiency is at risk for
A. Excessive weight gain
B. Photosensitivity
C. Bone fractures
D. Insomnia
C. Bone fractures
A pregnant patient complains of constipation and has not had a bowel movement in 5 days. What is the nurse’s first intervention?
A. Administer Metamucil
B. Administer docusate sodium.
C. Assess the patient’s fluid intake.
D. Increase the patient’s dietary fiber.
C. Assess the patient’s fluid intake.
A pregnant patient is receiving magnesium sulfate to inhibit uterine contractions. The patient develops depressed reflexes and confusion. What is the nurse’s priority action?
A. Administer atropine IV
B. Administer calcium gluconate
C. Administer epinephrine
D. Administer protamine sulfate.
B. Administer calcium gluconate
In developing a plan of care for a patient receiving morphine sulfate, which nursing diagnosis is a priority?
A. Nausea related to medication profile side effect
B. Risk for injury related to central nervous system side effects
C. Impaired gas exchange related to respiratory depression
D. Constipation related to gastrointestinal side effects
C. Impaired gas exchange related to respiratory depression
Patient testing reveals ocular hypertension, the nurse will anticipate administering which medication?
A. Calcium-channel blocker
B. Thiazide diuretic
C. Mannitol
D. Beta blocker combination
C. Mannitol
The charge nurse is observing the new nurse in administering medication to children on the unit. Which intervention would indicate a need for additional teaching?
A. The new nurse asks the parents to leave the room during medication administration.
B. The new nurse checks the order regarding dosage and route prior to administration.
C. The new nurse questions the parents about the existence of allergies.
D. The new nurse returns 30 minutes after administration to evaluate drug effects.
A. The new nurse asks the parents to leave the room during medication administration.
The clinic nurse is reviewing medication instructions with a patient taking nicotine replacement gum for smoking cessation. Which statement by the patient indicates a need for additional teaching by the nurse?
A. “I will continue to use birth control while taking this drug.”
B. “I will not drink or eat while chewing the gum.”
C. “I can continue to smoke a cigarette once in a while when taking this drug.”
D. “While chewing the gum, I will periodically hold the gum between my cheek and teeth.”
C. “I can continue to smoke a cigarette once in a while when taking this drug.”
The mineral chromium can be implemented into which patient's plan of care to improve treatment outcomes?
A. 18 year-old cancer patient
B. 34 year-old type II diabetes patient
C. 10 year-old influenza patient
D. 56 year-old HIV patient
B. 34 year-old type II diabetes patient
The nurse assesses a patient taking phenytoin and finds gingival hyperplasia. What is the nurse’s priority action?
A. Instruct the patient on oral hygiene
B. Call for a consult with a dentist.
C. Call the health care provider.
D. Hold the next dose of the drug.
A. Instruct the patient on oral hygiene
The nurse is administering nitroglycerin at 10 mcg/min. The patient continues to complain of chest pain. What is the nurse’s priority action?
A. Perform an electrocardiogram (ECG)
B. Stop the infusion.
C. Increase the infusion by 5 mcg/min
D. Call the health care provider
C. Increase the infusion by 5 mcg/min
The nurse is assessing a patient who is taking furosemide. The patient’s potassium level is 3.4 mEq/L; chloride is 90 mmol/L, and sodium is 140 mEq/L. Based on the nurse’s understanding of the laboratory results, what prescribed therapy can the nurse anticipate administering?
A. Mix 40 mEq of potassium in 250 mL D5W and infuse rapidly.
B. Administer sodium polystyrene sulfonate.
C. Administer 2 mEq potassium chloride per kilogram per day IV.
D. Administer calcium acetate, two tablets three times per day
C. Administer 2 mEq potassium chloride per kilogram per day IV.
The nurse is caring for a patient who is prescribed propranolol. Which assessment finding if identified by the nurse will reveal if the medication is having a therapeutic effect?
A. Lung sounds are clear.
B. Sinus rhythm noted.
C. Blood pressure is 127/75 mm Hg.
D. Strong peripheral pulses noted
C. Blood pressure is 127/75 mm Hg.
The nurse is caring for a patient who is taking a first-generation antihistamine. What is the most important information for the nurse to teach the patient?
A. “Do not take this medication for more than 2 days.”
B. “Do not drive after taking this medication.”
C. “Make sure you drink a lot of liquids while on this medication.”
D. “Take this medication on an empty stomach.”
B. “Do not drive after taking this medication.”
The nurse is caring for a patient who is taking rifampin. The patient has a heart rate of 90 beats/min, blood pressure of 100/89 mm Hg, and red-orange urine. What is the nurse’s best action?
A. Document the findings and teach the patient.
B. Call the health care provider.
C. Collect a urine culture
D. Discard the first void and start a 24-hour urine collection.
A. Document the findings and teach the patient.
The nurse is caring for a patient with a history of alcoholism who is undergoing long-term alcohol treatment. Which intervention is the highest priority?
A. Ensuring the patient knows all alcohol must be avoided when taking disulfiram
B. Teaching the patient about flumazenil
C. Monitoring the patient with methadone administration
D. Administering propranolol daily
A. Ensuring the patient knows all alcohol must be avoided when taking disulfiram
The nurse is reading a medication order and is not sure of the drug’s name. What action will the nurse perform first?
A. Look up the generic name of the medication.
B. Call the pharmacy
C. Call the health care provider.
D. Ask the patient what medications he or she was taking at home.
C. Call the health care provider.
The nurse is teaching the patient how to administer insulin. What information is essential to include in the plan?
A. “For the most consistent absorption, inject the insulin into the abdomen.”
B. “Avoid administering the insulin into your arm.”
C. “Inject the insulin at a 30-degree angle between the fat and muscle.”
D. “Do not mix any insulins in the same syringe.”
A. “For the most consistent absorption, inject the insulin into the abdomen.”
The nurse treating an HIV patient recognizes the dark blue lesions on the patient's skin as
A. Tuberulosis infection
B. Kaposi sarcoma
C. Thrush
D. Toxoplasmosis
B. Kaposi sarcoma
The patient is admitted with an acetaminophen overdose. In addition to monitoring liver function results, the nurse would anticipate administering which of the following?
A. Naloxone
B. Activated charcoal
C. Acetylcysteine
D. An antacid
C. Acetylcysteine
What nursing diagnosis is a priority for a patient receiving desmopressin (DDAVP)?
A. Risk for injury
B.Alteration in comfort
C. Fluid volume excess
D. Knowledge deficit
C. Fluid volume excess
Which answer choice best describes the contagious period of the common cold?
A. 1-4 days following onset of symptoms
B. 1-4 days before onset of symptoms
C. Starting at day 7 of infection
D. The common cold is contagious only as the patient exhibits symptoms
B. 1-4 days before onset of symptoms
Which assessment is most important for the nurse to monitor in a patient receiving an opioid analgesic?
A. Blood pressure
B. Heart rate
C. Mental status
D. Respiratory rate
D. Respiratory rate
Which of the following is a principle of immunosuppression?
A. Monotherapy reduces risk of organ rejection
B. Multiple drug therapy reduces risk of drug toxicity
C. Drugs which increase T-cell response reduce rejection
D. Drugs that activate lymphocytes reduce risk of rejection.
B. Multiple drug therapy reduces risk of drug toxicity
Which statement indicates to the nurse that the patient understands sublingual nitroglycerin medication instructions?
A. “I will take up to five doses every 3 min for chest pain.”
B. “I can chew the tablet for the quickest effect.”
C. “I will keep the tablets locked in a safe place until I need them.”
D. “I should sit or lie down after I take a nitroglycerin tablet to prevent dizziness.”
D. “I should sit or lie down after I take a nitroglycerin tablet to prevent dizziness.”