Pharmacology
A client with acute myelocytic leukemia is being treated with busulfan. Which laboratory value would the nurse specifically monitor during treatment with this medication?
1. Clotting time
2. Uric acid level
3. Potassium level
4. Blood glucose level
What is 2
Busulfan can cause an increase in the uric acid level. Hyperuricemia can produce uric acid nephropathy, renal stones, and acute kidney injury. Options 1, 3, and 4 are not specifically related to this medication.
The school nurse is performing pediculosis capitis (head lice) assessments. Which assessment finding indicates that a child has a "positive" head check for lice?
1. Maculopapular lesions behind the ears
2. Lesions in the scalp that extend to the hairline or neck
3. White flaky particles throughout the entire scalp region
4. White sacs attached to the hair shafts in the occipital area
What is 4
Pediculosis capitis is an infestation of the hair and scalp with lice. The nits are visible and attached firmly to the hair shaft near the scalp. The occiput is an area in which nits can be seen. Maculopapular lesions behind the ears or lesions that extend to the hairline or neck are indicative of an infectious process, not pediculosis. White flaky particles are indicative of dandruff.
The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement?
1. Setting limits on the client's behavior
2. Asking the client to leave the group session
3. Asking another nurse to escort the client out of the group session
4. Telling the client that they will not be able to attend any future group sessions
What is 1
Manic clients may be talkative and can dominate group meetings or therapy sessions by their excessive talking. If this occurs, the nurse initially would set limits on the client's behavior. Initially, asking the client to leave the session or asking another person to escort the client out of the session is inappropriate. This may agitate the client and escalate the client's behavior further. Barring the client from group sessions is also an inappropriate action because it violates the client's right to receive treatment and is a threatening action.
A client brought to the emergency department states that he has accidentally been taking 2 times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action?
1. Prepare to administer an antidote.
2. Draw a sample for type and crossmatch and transfuse the client.
3. Draw a sample for an activated partial thromboplastin time (aPTT) level.
4. Draw a sample for prothrombin time (PT) and international normalized ratio (INR).
What is 4
The action that the nurse should take is to draw a sample for PT and INR level to determine the client's anticoagulation status and risk for bleeding. These results will provide information as to how to best treat this client (e.g., if an antidote such as vitamin K or a blood transfusion is needed). The aPTT monitors the effects of heparin therapy.
The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm?
1. Placing cool compresses on the affected arm
2. Elevating the affected arm on a pillow above heart level
3. Avoiding arm exercises in the immediate postoperative period
4. Maintaining an intravenous site below the antecubital area on the affected side
What is 2
Following mastectomy, the arm should be elevated above the level of the heart. Simple arm exercises should be encouraged. No blood pressure readings, injections, intravenous lines, or blood draws should be performed on the affected arm. Cool compresses are not a suggested measure to prevent lymphedema from occurring.
The home health care nurse is visiting a client with coronary artery disease with elevated triglyceride levels and a serum cholesterol level of 398 mmol/L). The client is taking cholestyramine, and the nurse teaches the client about the medication. Which statement by the client indicates the need for further teaching?
1. "Constipation and bloating might be a problem."
2. "I'll continue to watch my diet and reduce my fats."
3. "Walking a mile each day will help the whole process."
4. "I'll continue my nicotinic acid from the health food store."
What is 4
Nicotinic acid, even an over-the-counter form, should be avoided because it may lead to liver abnormalities. All lipid-lowering medications also can cause liver abnormalities, so a combination of nicotinic acid and cholestyramine resin needs to be avoided. Constipation and bloating are the 2 most common adverse effects. Walking and the reduction of fats in the diet are therapeutic measures to reduce cholesterol and triglyceride levels.
The mother of an 8-year-old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the right side and that ibuprofen is not effective. Which instruction should the nurse provide to the mother?
1. Increase the dose of ibuprofen.
2. Increase the frequency of ibuprofen.
3. Encourage the child to lie on the left side.
4. Encourage the child to lie on the right side.
What is 4
Pneumonia is an inflammation of the pulmonary parenchyma or alveoli, or both, caused by a virus, mycoplasmal agents, bacteria, or aspiration of foreign substances. Splinting of the affected side by lying on that side may decrease discomfort. It would be inappropriate to advise the mother to increase the dose or frequency of the ibuprofen. Lying on the left side would not be helpful in alleviating discomfort.
The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." Which is the most helpful response by the nurse?
1. "Why don't you tell your spouse about this?"
2. "What do you find difficult about this situation?"
3. "This is not the best time to make that decision."
4. "I agree with you. You should get out of this situation."
What is 2
The most helpful response is one that encourages the client to solve problems. Giving advice implies that the nurse knows what is best and can foster dependency. The nurse should not agree with the client, and the nurse should not request that the client provide explanations.
The nurse is preparing to care for a client who has returned to the nursing unit following cardiac catheterization performed through the femoral vessel. The nurse checks the primary health care provider's (PHCP's) prescription and plans to allow which client position or activity following the procedure?
1. Bed rest in high-Fowler's position
2. Bed rest with bathroom privileges only
3. Bed rest with head elevation at 60 degrees
4. Bed rest with head elevation no greater than 30 degrees
What is 4
After cardiac catheterization, the extremity into which the catheter was inserted is kept straight for 4 to 6 hours. The client is maintained on bed rest for 4 to 6 hours (time for bed rest may vary depending on the PHCP's preference and on whether a vascular closure device was used), and the client may turn from side to side. The head is elevated no more than 30 degrees (although some PHCPs prefer a lower position or the flat position) until hemostasis is adequately achieved.
The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement?
1. "I will wash my face with cotton pads."
2. "I'll have to start chewing on my unaffected side."
3. "I should rinse my mouth if toothbrushing is painful."
4. "I'll try to eat my food either very warm or very cold."
What is 4
Facial pain can be minimized by using cotton pads to wash the face and using room temperature water. The client should chew on the unaffected side of the mouth, eat a soft diet, and take in foods and beverages at room temperature. If brushing the teeth triggers pain, an oral rinse after meals may be helpful instead.
A client with acquired immunodeficiency syndrome who is taking zidovudine 200 mg orally 3 times daily has severe neutropenia noted on follow-up laboratory studies. The nurse interprets that which change is likely to occur at this point?
1. The medication dose probably will be reduced.
2. Prednisone probably will be added to the medication regimen.
3. Epoetin alfa probably will be added to the medication regimen.
4. The medication probably will be discontinued until laboratory results indicate bone marrow recovery.
What is 4
Zidovudine is a nucleoside-nucleotide reverse transcriptase inhibitor. Hematological monitoring should be done every 2 weeks in the client taking zidovudine. If severe anemia or severe neutropenia develops, treatment should be discontinued until evidence of bone marrow recovery is noted. If anemia or neutropenia is mild, a reduction in dosage may be sufficient. The administration of prednisone may further alter the immune function. Epoetin alfa is administered to clients experiencing anemia.
The clinic nurse reviews the record of an infant and notes that the primary health care provider has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek health care for the infant?
1. Diarrhea
2. Projectile vomiting
3. Regurgitation of feedings
4. Foul-smelling, ribbon-like stools
What is 4
Hirschsprung's disease is a congenital anomaly also known as congenital aganglionosis or aganglionic megacolon. It occurs as the result of an absence of ganglion cells in the rectum and other areas of the affected intestine. Chronic constipation beginning in the first month of life and resulting in pellet-like or ribbon-like stools that are foul-smelling is a clinical manifestation of this disorder. Delayed passage or absence of meconium stool in the neonatal period is also a sign. Bowel obstruction, especially in the neonatal period; abdominal pain and distention; and failure to thrive are also clinical manifestations. Options 1, 2, and 3 are not associated specifically with this disorder.
A client who is exhibiting psychotic behaviors is admitted to the psychiatric unit. In developing a plan of care, the nurse should identify which as the priority client problem?
1. Disturbed thought processes
2. Lack of knowledge about the behavior
3. Inability to care for self with bathing procedures
4. Altered nutrition: inadequate consumption of food
What is 1
Psychosis is defined as a state in which a client's mental capacity to recognize reality and communicate and relate to others is impaired, thus interfering with the client's capacity to deal with life's demands. Disturbed thought processes generally indicate a state of increased anxiety in which hallucinations and delusions prevail. Although self-care and inadequate nutrition are important, the correct option is specific to the client and has priority. Lack of knowledge is not a priority at this time.
The nurse is caring for a client with a nasogastric (NG) tube who has a prescription for NG tube irrigation once every 8 hours. To maintain homeostasis, which solution should the nurse use to irrigate the NG tube?
1. Tap water
2. Sterile water
3. 0.9% sodium chloride
4. 0.45% sodium chloride
What is 3
Homeostasis is maintained by irrigating with an isotonic solution, such as 0.9% sodium chloride. Tap water, sterile water, and 0.45% sodium chloride are hypotonic solutions.
A client with diabetes mellitus who takes insulin is seen in the health care clinic. The client tells the clinic nurse that after the insulin injection, the insulin seems to leak through the skin. The nurse would appropriately determine the problem by asking the client which question?
1. "Are you rotating the injection site?"
2. "Are you aspirating before you inject the insulin?"
3. "Are you using a 1-inch needle to give the injection?"
4. "Are you placing an air bubble in the syringe before injection?"
What is 1
The client should be instructed that insulin injection sites should be rotated within 1 anatomical area before moving on to another area. This rotation process promotes uniform absorption of insulin and reduces the chances of irritation. The remaining options are not associated with the condition (skin leakage of insulin) presented in the question.
A 2-year-old with Pneumocystis jiroveci pneumonia is to begin treatment with highly active antiretroviral therapy (HAART). The nurse anticipates that the primary health care provider will prescribe which combination?
1. One immunoglobulin and one nucleoside analogue
2. Two nucleoside analogues and one protease inhibitor
3. Two protease inhibitors and one broad-spectrum antibiotic
4. One nucleoside reverse transcriptase inhibitor and one non-nucleoside reverse transcriptase inhibitor
What is 2
Pneumocystis jiroveci pneumonia (PCP) is a fungal infection and is a common opportunistic infection in the client with acquired immunodeficiency syndrome. HAART consists of the combination of 2 nucleoside analogues, which target viral replication during the reverse transcription phase of the cell cycle, and a protease inhibitor, which targets viral replication at a different phase. The remaining options are incorrect descriptions of combination therapies.
An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in which best position at this time?
1. Prone position
2. On the stomach
3. Left lateral position
4. Right lateral position
What is 3
A cleft lip is a congenital anomaly that occurs as a result of failure of soft tissue or bony structure to fuse during embryonic development. After cleft lip repair, the nurse avoids positioning an infant on the side of the repair or in the prone position because these positions can cause rubbing of the surgical site on the mattress. The nurse positions the infant on the side lateral to the repair or on the back upright and positions the infant to prevent airway obstruction by secretions, blood, or the tongue. From the options provided, placing the infant on the left side immediately after surgery is best to prevent the risk of aspiration if the infant vomits.
During the admission assessment process, the nurse observes that a client diagnosed with paranoid schizophrenia has multiple dental caries and mouth ulcers. The client denies oral pain or difficulty eating and does not present any concern over the nurse's finding. The nurse recognizes the client's response as most likely the result of which client factor?
1. Apathy
2. Impaired pain perception
3. Distrust of authority figures
4. Poor verbal communication skills
What is 2
Commonly, schizophrenia's effect on the pain center in the brain results in poor pain recognition. The client is likely not experiencing oral pain to the degree that may be felt by the individual who does not have schizophrenia. Although the remaining options may be general factors affecting this client's perceptions and personal interactions, they are not related to the pain perception threshold.
A client with a history of atrial fibrillation is brought to the emergency department and states that he has accidentally been taking 2 times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action?
1. Prepare to administer an antidote.
2. Draw a sample for type and crossmatch and transfuse the client.
3. Draw a sample for an activated partial thromboplastin time (aPTT) level.
4. Draw a sample for prothrombin time (PT) and international normalized ratio (INR).
What is 4
The action that the nurse should take is to draw a sample for PT and INR level to determine the client's anticoagulation status and risk for bleeding. These results will provide information as to how to best treat this client (e.g., if an antidote such as vitamin K or a blood transfusion is needed). The aPTT monitors the effects of heparin therapy.
The nurse is monitoring a client with cirrhosis of the liver for signs of hepatic encephalopathy. Which assessment finding would the nurse note as an early sign of hepatic encephalopathy?
1. Restlessness
2. Presence of asterixis
3. Complaints of fatigue
4. Decreased serum ammonia levels
What is 2
Asterixis is a flapping tremor of the hand that is an early sign of hepatic encephalopathy. The exact cause of this disorder is not known, but abnormal ammonia metabolism may be implicated. Increased serum ammonia levels are thought to interfere with normal cerebral metabolism. Tremors and drowsiness also would be noted.
Propofol is being administered to induce sedation in a client who is intubated and is being mechanically ventilated. The nurse should monitor for which adverse effect during infusion of the medication?
1. Itching
2. Skin redness
3. Elevated triglyceride levels
4. Signs of respiratory depression
What is 4
Propofol is an anesthetic agent that is used to provide continuous sedation in a client receiving mechanical ventilation. Adverse effects include respiratory depression and cardiovascular depression. Itching, skin redness, and elevated triglyceride levels are possible side effects, not adverse effects.
The nurse is teaching the parents of a child with growth hormone deficiency about preparing synthetic growth hormone and administering it to the child. Which statement, if made by the parents, would indicate an understanding of the procedure?
1. "We will rotate injection sites."
2. "We will give the injection weekly on Monday."
3. "We will administer the injection every morning."
4. "We will store the mixed growth hormone in the medicine cabinet."
What is 1
Synthetic growth hormone comes in a powdered form that must be diluted for administration. It is given as a subcutaneous injection 6 or 7 times per week as prescribed at bedtime. Parents are taught that, once diluted, the hormone preparation is to be stored at 36º to 46º F (refrigerated). Injection sites should be rotated, which will direct you to the correct option.
The nurse who is reviewing the record of a client admitted to the mental health unit notes that the client was admitted by voluntary status. Based on this fact, what assumption can the nurse make about the client?
1. The admission will last at least 21 days.
2. The client is not a danger to himself or to anyone else.
3. The admission is being financed by a third-party payer.
4. The client has the right to demand and obtain release from the hospital.
What is 4
Generally, voluntary admission is sought by the client or the client's family by written application to the facility. Voluntary clients have the right to demand and obtain release from the hospital. The remaining options are not necessarily true when considering a voluntary admission.
The nurse is creating a plan of care for a client receiving enteral feedings. Which client problem is the highest priority?
1. Diarrhea
2. Nutrition
3. Aspiration
4. Deficient fluid volume
What is 3
Any condition in which gastrointestinal motility is slowed or esophageal reflux is possible places the client at risk for aspiration. Diarrhea and nutrition may be appropriate problems, but they are not of highest priority. Deficient fluid volume is not likely to occur in this client.
The nurse is performing an admission assessment on a client diagnosed with paronychia. The nurse should plan to assess which part of the integumentary system first?
1. Nails
2. Hair follicles
3. Pilosebaceous glands
4. Epithelial layer of skin
What is 1
Paronychia is a fungal infection that most often is caused by Candida albicans. This results in inflammation of the nail fold, with separation of the fold from the nail plate. The affected area generally is tender to touch and has purulent drainage. Disorders of the hair follicles include folliculitis, furuncles, and carbuncles. Disorders of the pilosebaceous glands include acne vulgaris and seborrheic dermatitis. A variety of disorders may involve the epithelial skin layer.