Med Administration
A nurse is preparing to administer an opioid analgesic to a patient following surgery. The patient has a history of substance abuse. Which of the following actions should the nurse prioritize before administering the medication?
A. Administer the medication as prescribed, as it is needed for pain management
B. Assess the patient’s pain level and history of substance abuse to make an informed decision
C. Withhold the medication and notify the healthcare provider immediately
D. Administer a reduced dose of the opioid and observe the patient’s response
Correct Answer: B. Assess the patient’s pain level and history of substance abuse to make an informed decision
Rationale: Assessing the patient’s pain level and history of substance abuse is essential in determining the safest course of action for pain management and preventing potential misuse or complications.
A nurse is assessing a patient who has been receiving enteral feedings through a nasogastric (NG) tube for 7 days. Which of the following findings should prompt the nurse to hold the feeding and notify the provider?
A. Residual volume of 50 mL
B. Serum potassium level of 4.0 mEq/L
C. Abdominal distention and decreased bowel sounds
D. Mild nausea after feeding
Correct Answer: C. Abdominal distention and decreased bowel sounds
Rationale: Abdominal distention and decreased bowel sounds may indicate feeding intolerance or potential complications such as ileus. Feeding should be held and the provider notified for further evaluation.
A nurse is assessing a postoperative patient for signs of deep vein thrombosis (DVT). Which of the following findings is most indicative of a DVT?
A. Cyanosis of the affected limb
B. Swelling and tenderness of the affected leg
C. Elevated heart rate and fever
D. Bilateral pedal edema without tenderness
Correct Answer: B Swelling and tenderness of the affected leg
Rationale: Swelling and tenderness of the affected leg are classic signs of DVT, and require immediate intervention to prevent complications like pulmonary embolism.
A nurse is creating a care plan for a patient with chronic heart failure. The patient’s goal is to maintain an independent lifestyle while managing their symptoms. Which of the following interventions would best support this goal?
A. Recommend long-term bed rest to reduce cardiac workload
B. Teach the patient to monitor daily weight and report any sudden changes
C. Schedule frequent hospital visits to ensure ongoing monitoring of cardiac status
D. Suggest complete elimination of all physical activity to prevent exacerbation
Correct Answer: B Teach the patient to monitor daily weight and report any sudden changes
Rationale: Teaching the patient to monitor daily weight is crucial for early detection of fluid retention, which can prevent exacerbations and allow the patient to maintain independence while managing heart failure.
When collaborating with the healthcare team, a nurse observes that the patient is not following their prescribed treatment plan. What is the most professional and ethical response?
A. Discuss the patient’s noncompliance with the healthcare provider and recommend discontinuing the treatment
B. Reflect on potential barriers to adherence and involve the patient in the care plan discussion
C. Report the patient’s noncompliance to the supervisor for further action
D. Reassure the patient that noncompliance is common and does not need to be addressed further
Correct Answer: B Reflect on potential barriers to adherence and involve the patient in the care plan discussion
Rationale: The nurse should consider factors contributing to nonadherence (such as health literacy, cultural differences, or misunderstanding) and work with the patient to adjust the care plan and address barriers to adherence.
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A nurse is evaluating a patient’s response to a new medication for hypertension. Which of the following outcomes best indicates the medication’s effectiveness?
A. The patient verbalizes understanding of hypertension and its treatment
B. The patient’s blood pressure consistently measures within the target range
C. The patient reports a reduction in headache frequency
D. The patient shows improved physical endurance and exercise tolerance
Correct Answer: B. The patient’s blood pressure consistently measures within the target range
Rationale: The primary outcome for assessing the effectiveness of hypertension treatment is whether the patient’s blood pressure reaches and stays within the target range.
A patient with chronic kidney disease is prescribed a low-protein diet. What is the most appropriate intervention to ensure the patient adheres to the dietary restriction?
A. Provide a list of low-protein foods and encourage the patient to follow it strictly
B. Educate the patient on the effects of excessive protein intake on kidney function
C. Refer the patient to a nutritionist for a personalized meal plan
D. Provide the patient with protein supplements to ensure adequate nutrition
Correct Answer: B. Educate the patient on the effects of excessive protein intake on kidney function
Rationale: Educating the patient about the direct effects of excessive protein on kidney function helps them understand the importance of adherence to the diet, which improves long-term health outcomes.
8. When assessing a patient with a history of ischemic stroke, which of the following findings would indicate a potential complication that requires immediate intervention?
A. Slight difficulty with fine motor skills
B. Increased lethargy and a decreased level of consciousness
C. Mild facial droop that resolves with the patient’s movement
D. Report of headache, but no changes in vital signs
Correct Answer: B. Increased lethargy and a decreased level of consciousness
Rationale: Increased lethargy and a decreased level of consciousness can be signs of a secondary stroke or other acute neurological complications, requiring immediate intervention.
A nurse is developing a care plan for a postoperative patient at risk for deep vein thrombosis (DVT). Which of the following interventions should be prioritized during the planning phase?
A. Administer prescribed anticoagulants as ordered
B. Encourage ambulation and leg exercises as soon as possible
C. Apply sequential compression devices (SCDs) immediately upon admission
D. Increase the patient’s fluid intake to reduce blood viscosity
Correct Answer: B. Encourage ambulation and leg exercises as soon as possible
Rationale: Early ambulation and leg exercises are the most effective non-pharmacological interventions for preventing DVT. They improve circulation and reduce the risk of clot formation.
Which of the following reflects the ethical principle of justice in nursing practice?
A. Ensuring that every patient receives the same level of care regardless of socioeconomic status
B. Giving priority to the most critically ill patients first
C. Advocating for patients to receive the best care available, regardless of cost
D. Making care decisions based on personal values and beliefs
Correct Answer: A Ensuring that every patient receives the same level of care regardless of socioeconomic status
Rationale: The ethical principle of justice involves ensuring fairness in the distribution of resources and care, treating all patients equitably.
A nurse is preparing to administer medications via a patient’s nasogastric (NG) tube. Which of the following actions demonstrates correct technique?
A. Crush all medications and mix together in 30 mL of water
B. Mix medications with enteral feeding formula to ease administration
C. Administer each medication separately, flushing between each one
D. Use cold water to flush the tube to prevent drug breakdown
Correct Answer: C Administer each medication separately, flushing between each one
Rationale: Each medication should be administered separately with flushing in between to prevent drug interactions and clogging of the NG tube. Water should be room temperature.
A patient with liver cirrhosis has developed ascites. Which of the following dietary modifications should the nurse recommend?
A. Increase protein
B. Limit fluid intake to 3 liters per day
C. Restrict sodium intake
D. Encourage high-fiber foods
Correct Answer: C. Restrict sodium intake
Rationale: Sodium restriction is essential for managing ascites in liver cirrhosis, as it helps control fluid retention.
A nurse is caring for a patient with a history of asthma who is experiencing an exacerbation. The healthcare provider orders a bronchodilator. Which of the following should the nurse assess first before administering the medication?
A. Oxygen saturation levels
B. Heart rate and blood pressure
C. Respiratory rate and lung sounds
D. Blood glucose levels
Correct Answer: C Respiratory rate and lung sounds
Rationale: Assessing the respiratory rate and lung sounds is crucial to determine the severity of the exacerbation and to monitor for any adverse effects after administering the bronchodilator.
After implementing an educational intervention on wound care for a patient with a diabetic foot ulcer, the nurse needs to evaluate the effectiveness of the teaching. Which outcome would best indicate successful learning?
A. The patient is able to verbalize the steps of proper wound care
B. The patient agrees to adhere to the prescribed treatment plan
C. The patient demonstrates proper wound cleaning and dressing change independently
D. The patient shows improvement in their blood glucose levels
Correct Answer: C. The patient demonstrates proper wound cleaning and dressing change independently
Rationale: The patient demonstrating the ability to perform the wound care independently indicates that learning has occurred and that the patient can manage their own care effectively.
When mentoring a new nurse, which of the following behaviors best demonstrates the mentor’s role in fostering professional development?
A. Correcting the new nurse’s errors immediately without further discussion
B. Providing constructive feedback while offering support and guidance
C. Allowing the new nurse to handle difficult situations alone to build confidence
D. Discouraging questions to allow the new nurse to learn independently
Correct Answer: B Providing constructive feedback while offering support and guidance
Rationale: A mentor’s role is to provide support, guidance, and constructive feedback to help the new nurse develop professionally while enhancing their skills and confidence.
A nurse is reviewing discharge instructions with a patient who has been prescribed a loop diuretic. Which of the following adverse effects should the patient be taught to monitor for?
A. Hypokalemia
B. Hypertension
C. Hypernatremia
D. Bradycardia
Correct Answer: A Hypokalemia
Rationale: Loop diuretics can cause significant potassium loss, so patients should be instructed to monitor for signs and symptoms of hypokalemia.
A nurse is caring for a patient receiving total parenteral nutrition (TPN). Which of the following is the most critical complication the nurse should monitor for?
A. Hypoglycemia
B. Hypokalemia
C. Hypernatremia
D. Infection
Correct Answer: D Infection
Rationale: Infection, particularly catheter-related bloodstream infections, is a major complication of TPN due to the central venous access route.
A nurse is assessing a patient with suspected fluid volume overload. Which of the following findings would the nurse expect?
A. Flattened neck veins and dry mucous membranes
B. Decreased blood pressure and weak peripheral pulses
C. Bounding pulse, crackles in lungs, and peripheral edema
D. Increased hematocrit and concentrated urine
Correct Answer: C. Bounding pulse, crackles in lungs, and peripheral edema
Rationale: Fluid volume overload presents with signs such as bounding pulse, pulmonary crackles, and edema due to excess intravascular and interstitial fluid.
A nurse is evaluating the effectiveness of an educational intervention on smoking cessation for a patient with chronic obstructive pulmonary disease (COPD). Which of the following is the best indicator of successful learning?
A. The patient verbalizes understanding of the risks of smoking
B. The patient schedules a follow-up appointment with a smoking cessation counselor
C. The patient demonstrates the ability to use a nicotine patch as part of their treatment plan
D. The patient reports feeling motivated to quit smoking and sets a quit date
Correct Answer: D. The patient reports feeling motivated to quit smoking and sets a quit date
Rationale: The patient’s motivation to quit smoking and setting a quit date is the strongest indicator of successful learning and commitment to behavior change.
What is the most significant barrier to the nurse’s ability to perform the role of patient advocate?
A. Lack of knowledge about legal regulations
B. Limited access to the patient’s medical records
C. Conflicts between the patient’s wishes and the healthcare team’s recommendations
D. Inadequate support from the hospital administration
Correct Answer: C Conflicts between the patient’s wishes and the healthcare team’s recommendations
Rationale: Conflicts between the patient’s wishes and healthcare providers’ recommendations can be the most challenging barrier, requiring the nurse to advocate for the patient’s preferences while maintaining professional ethical standards.
A nurse is evaluating a patient’s response to a new prescription for warfarin. Which of the following lab results would indicate that the patient is at increased risk for bleeding?
A. Platelet count of 120,000/mm³
B. Prothrombin time (PT) of 18 seconds
C. Hemoglobin level of 13 g/dL
D. International normalized ratio (INR) of 2.5
Correct Answer: B. Prothrombin time (PT) of 18 seconds (normal 11-13 seconds)
Rationale: An elevated prothrombin time (PT) indicates impaired clotting ability, which increases the patient’s risk for bleeding, especially when taking anticoagulant therapy like warfarin.
A patient with a recent diagnosis of pancreatitis is receiving nutrition education. Which of the following dietary instructions should the nurse include?
A. "You should consume a low-fat diet to reduce pancreatic stimulation."
B. "Drink protein shakes to promote healing."
C. "Add more dairy products to improve calcium intake."
D. "You can resume a normal diet once your pain decreases."
Correct Answer: A "You should consume a low-fat diet to reduce pancreatic stimulation."
Rationale: A low-fat diet helps reduce pancreatic enzyme secretion, which is important in the management and recovery from pancreatitis. High-fat foods can trigger flare-ups.
A nurse is assessing a patient admitted with suspected stroke. Which of the following assessment findings requires immediate intervention?
A. Facial drooping on the right side
B. Slurred speech
C. Sudden confusion
D. Respiratory rate of 8 breaths per minute
Correct Answer: D Respiratory rate of 8 breaths per minute
Rationale: While all findings indicate stroke symptoms, a respiratory rate of 8 is life-threatening and requires immediate intervention to maintain oxygenation and prevent hypoxia.
A nurse is providing care to a patient who has been prescribed an anticoagulant after a recent deep vein thrombosis. Which of the following interventions is essential in the implementation phase to prevent bleeding complications?
A. Instruct the patient to take aspirin daily for enhanced anticoagulation
B. Educate the patient about signs of bleeding and the importance of regular lab work
C. Advise the patient to stop taking the anticoagulant if they experience any bruising
D. Limit the patient’s physical activity to prevent falls and injury
Correct Answer: B. Educate the patient about signs of bleeding and the importance of regular lab work
Rationale: Educating the patient on recognizing signs of bleeding and the need for regular monitoring ensures safety and prevents bleeding complications while on anticoagulation therapy.
In the role of patient advocate, a nurse learns that a patient’s family has requested not to discuss a terminal diagnosis with the patient. The nurse believes the patient has the right to know. What is the most appropriate action for the nurse to take?
A. Discuss the matter with the healthcare provider to understand the reasoning behind the family’s request
B. Respect the family’s wishes and refrain from discussing the diagnosis with the patient
C. Follow the patient’s expressed wishes, and encourage the family to support the patient’s right to know
D. Notify the ethics committee immediately to address the disagreement
Correct Answer: C Follow the patient’s expressed wishes, and encourage the family to support the patient’s right to know
Rationale: The nurse’s role is to advocate for the patient’s autonomy while ensuring that the family is involved in supporting the patient’s decision-making. The nurse should facilitate communication between the patient and family to respect the patient’s wishes.