Pharmacology
Zafirlukast is prescribed for a client with bronchial asthma. Which laboratory test does the nurse expect to be prescribed before the administration of this medication?
1. Platelet count
2. Neutrophil count
3. Liver function tests
4. Complete blood count
What is 3
Zafirlukast is a leukotriene receptor antagonist used in the prophylaxis and long-term treatment of bronchial asthma. Zafirlukast is used with caution in clients with impaired hepatic function. Liver function laboratory tests should be performed to obtain a baseline, and the levels should be monitored during administration of the medication. It is not necessary to perform the other laboratory tests before administration of the medication.
The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which is the best position in which the nurse should place the client?
1. Side-lying on the operative side
2. On the nonoperative side with the legs abducted
3. Side-lying with the affected leg internally rotated
4. Side-lying with the affected leg externally rotated
What is 2
Positioning following a total hip replacement depends on the surgical techniques used, the method of implantation, the prosthesis, and the primary health care provider's PHCP's preference. Abduction is maintained when the client is in a supine position or positioned on the nonoperative side. Internal and external rotation, adduction, or side-lying on the operative side (unless specifically prescribed by the PHCP) is avoided to prevent displacement of the prosthesis.
Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply.
1. Communicate expected behaviors to the client.
2. Ensure that the client knows that he or she is not in charge of the nursing unit.
3. Assist the client in identifying ways of setting limits on personal behaviors.
4. Follow through about the consequences of behavior in a nonpunitive manner.
5. Enforce rules by informing the client that he or she will not be allowed to attend therapy groups.
6. Have the client state the consequences for behaving in ways that are viewed as unacceptable.
What is 1, 3, 4, and 6
Interventions for dealing with the client exhibiting manipulative behavior include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear with the client regarding the consequences of exceeding the limits set; following through with the consequences in a nonpunitive manner; and assisting the client in identifying a means of setting limits on personal behaviors. Ensuring that the client knows that he or she is not in charge of the nursing unit is inappropriate; power struggles need to be avoided. Enforcing rules and informing the client that he or she will not be allowed to attend therapy groups is a violation of a client's rights.
The client is being seen at 24 weeks' gestation at the prenatal clinic. At her last routine visit, the fundus was located at the umbilicus. Today, the fundus is measured and found to be 23 cm. How should the nurse interpret this finding?
1. Fundus is at the appropriate level.
2. Fundus is larger than expected height.
3. Fundus is smaller than expected height.
4. Growth pattern indicates intrauterine growth restriction (IUGR).
What is 1
At the previous routine visit at 20 weeks' gestation, the fundus was located at the umbilicus. For each subsequent week after 20 weeks, fundal height should increase by approximately 1 cm/week. At 24 weeks' gestation, the appropriate fundal height would be 24 cm plus or minus 2 cm. By 36 weeks' gestation, the fundus reaches its highest level at the xiphoid process.
A client is diagnosed as having a intestinal tumor. The nurse should monitor the client for which complications of this type of tumor? Select all that apply.
1. Flatulence
2. Peritonitis
3. Hemorrhage
4. Fistula formation
5. Bowel perforation
6. Lactose intolerance
What is 2, 3, 4, and 5
Complications of intestinal tumors include bowel perforation, which can result in hemorrhage and peritonitis. Other complications include bowel obstruction and fistula formation. Flatulence can occur but is not a complication; lactose intolerance also is not a complication of intestinal tumor.
Which is the nurse's priority assessment for monitoring for adverse effects for the client taking isoniazid?
1. Skin color
2. Urine color
3. Hydration status
4. Respiratory effort
What is 2
Isoniazid is an antituberculosis medication. The most serious adverse effect associated with isoniazid is hepatic injury, which on rare occasions has been fatal; therefore, monitoring of liver function tests and for signs and symptoms of liver injury is the priority. Dark urine is a sign of liver injury and the client should be taught to report this, and the nurse should assess for this. Skin color, hydration status, and respiratory effort are not directly related to adverse effects of this medication.
The nurse participating in a health fair is setting up a booth on prevention of human immunodeficiency virus (HIV) transmission. A poster is planned that will list sexual behaviors in 1 of 2 columns, "safe" and "not safe." Which behavior should the nurse place in the "not safe" column?
1. Abstinence
2. Mutual monogamy
3. Use of latex condoms
4. Use of natural skin condoms
What is 4
Abstinence is the safest way to avoid HIV infection. Another reliable method is participation in a mutually monogamous relationship. The use of latex condoms is considered safe because the latex prevents the transmission of HIV as long as the condom is used properly and remains in place. The use of natural skin condoms is not considered safe because the pores in the condom are large enough for the virus to pass through.
A client diagnosed with schizophrenia says to the nurse, "Will you protect me from the Grand Duchess?" and points to an older client who is sitting reading a book. Which statement is the therapeutic response by the nurse?
1. "Where is she? I'll talk to her."
2. "I can see no Grand Duchess. You will need to trust me on that."
3. "You will be safe here. Your thinking will be clearer after your medication starts to work."
4. "The Grand Duchess, huh? Well, I'm the Queen, and I will order her to stay away from you."
What is 3
The schizophrenic client is making a paranoid statement. It is important that the nurse provide the client with a supportive and protective intervention. The correct option is the only one that reflects a therapeutic technique, presents reality, and addresses safety. To ask, "Where is she? I'll talk to her" is not therapeutic because the nurse feeds into the client's psychosis by asking where the fantasy client is. To state that the nurse does not see the Grand Duchess and that the client needs to trust the nurse begins by presenting reality, but it does not demonstrate any real support for the client's concern with safety. To say that the nurse is the Queen and will order the Grand Duchess to stay away is sarcastic and belittling to the client.
A client in her second trimester of pregnancy is seen at the health care clinic. The nurse collects data from the client and notes that the fetal heart rate is 90 beats/minute. Which nursing action is appropriate?
1. Document the findings.
2. Notify the primary health care provider (PHCP).
3. Inform the client that everything is normal and fine.
4. Instruct the client to return to the clinic in 1 week for reevaluation of the fetal heart rate.
What is 2
The fetal heart rate should be 110 to 160 beats/minute during pregnancy. A fetal heart rate of 90 beats/minute (bradycardia) requires that the PHCP be notified and the client be evaluated further. The other options are inappropriate and delay necessary intervention.
The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply.
1. Loosening restrictive clothing.
2. Restraining the client's limbs.
3. Removing the pillow and raising padded side rails.
4. Positioning the client to the side, if possible, with the head flexed forward.
5. Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist.
What is 1, 3, and 4
Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising padded side rails in the bed, and placing the client on 1 side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible; protects the head from injury; and moves furniture that may injure the client.
The nurse is collecting data from a client with a history of renal transplantation. The nurse understands that which medication is the medication of choice for preventing organ rejection?
1. Probenecid
2. Prednisone
3. Indomethacin
4. Cyclosporine
What is 4
Cyclosporine is a powerful immunosuppressant and is the medication of choice for preventing organ rejection following allogenic transplantation. Prednisone is a glucocorticoid and may be administered concurrently with the cyclosporine. Probenecid is a uricosuric agent used to treat hyperuricemia. Indomethacin is a nonsteroidal anti-inflammatory agent.
Cardiac magnetic resonance imaging (MRI) is prescribed for a client. When providing teaching, what does the nurse include as one of the major advantages of this test?
1. It doesn't require any radiation.
2. It provides images in 1 to 2 planes.
3. It involves low-dose administered iodine.
4. It is a minimally invasive imaging technique.
What is 1
Cardiac MRI does not require any radiation to the client and is considered an extremely safe procedure. It does not involve any ionizing radiation and is a noninvasive, not minimally invasive, imaging technique. It also provides images in multiple planes with uniformly good resolution and not just in 1 to 2 planes.
Community mental health teams recognize that in the immediate postdisaster period, the most effective means of identifying individuals experiencing difficulty coping psychologically with the disaster is to take which action?
1. Establish a centrally located mental health disaster center.
2. Ask for referrals from local health care providers and clergy.
3. Station mental health professionals at established assistance centers.
4. Distribute fliers identifying the availability of psychological counseling.
What is 3
It is important for victims of traumatic experiences to be quickly and effectively identified, and for services to be promptly initiated. It is best that mental health professionals proactively go to places where the victims tend to gather, assess them for early symptoms of crisis, and offer to implement the appropriate services. The remaining options are passive in nature, relying on the victims to identify themselves and their needs.
An infant is born to a mother with hepatitis B. Which prophylactic measure is indicated for the infant?
1. Hepatitis B vaccine given within 24 hours after birth
2. Immune globulin (IG) given as soon as possible after delivery
3. Hepatitis B immune globulin (HBIG) given within 14 days after birth
4. Hepatitis B immune globulin (HBIG) and hepatitis B vaccine given within 12 hours after birth
What is 4
Both HBIG and the vaccine are given to infants with perinatal exposure to prevent hepatitis and achieve lifelong prophylaxis; they are administered within 12 hours after birth. IG is given to prevent hepatitis A.
A client is suspected of having systemic lupus erythematosus (SLE). On reviewing the client's record, the nurse should expect to note documentation of which characteristic sign of SLE?
1. Fever
2. Fatigue
3. Skin lesions
4. Elevated red blood cell count
What is 3
Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. The major skin manifestation of SLE is a dry, scaly, raised rash on the face known as the butterfly rash. Fever and fatigue may occur before and during exacerbation, but these signs and symptoms are vague. Anemia is most likely to occur in SLE.
The nurse is monitoring the laboratory test results for a client who is taking warfarin sodium after mechanical heart valve replacement. The nurse should expect the international normalized ratio (INR) for this client to be at what value in order to be therapeutic?
1. 0.2
2. 0.5
3. 1.0
4. 3.0
What is 4
The normal value for INR is 0.81 to 1.2 (0.81 to 1.2). The target INR or therapeutic level for a client receiving warfarin sodium is 2.5 to 3.5 (2.5 to 3.5).
A client is recovering from abdominal surgery and has a large abdominal wound. The nurse should encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing?
1. Milk
2. Oranges
3. Bananas
4. Chicken
What is 2
Citrus fruits and juices are especially high in vitamin C. Bananas are high in potassium. Meats and dairy products are 2 food groups that are high in the B vitamins.
Which statement indicates an understanding of the focus of milieu therapy?
1. "Milieu therapy provides a cognitive approach to changing behavior."
2. "A living, learning, or working environment is the focus of milieu therapy."
3. "Milieu therapy provides a behavior modification approach type of therapy."
4. "A behavioral approach to changing behavior is the focus of milieu therapy."
What is 2
Milieu therapy, or "therapeutic community," has as its focus a living, learning, or working environment. Such therapy may be based on any number of therapeutic modalities, from structured behavioral therapy to spontaneous, humanistically oriented approaches. Although milieu therapy may include behavioral approaches, its primary focus is described in the correct option.
The nurse evaluates the ability of a hepatitis B–positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn?
1. The mother requests that the window be closed before feeding.
2. The mother holds the newborn properly during feeding and burping.
3. The mother tests the temperature of the formula before initiating feeding.
4. The mother washes and dries her hands before and after self-care of her perineum and asks for a pair of gloves before feeding.
What is 4
Hepatitis B virus is highly contagious and is transmitted by direct contact with blood and body fluids of infected persons. The rationale for identifying childbearing clients with this disease is to provide adequate protection of the fetus and the newborn, to minimize transmission to other individuals, and to reduce maternal complications. The correct option provides the best evaluation of maternal understanding of disease transmission. Option 1 will not affect disease transmission since hepatitis B does not spread through airborne transmission. Options 2 and 3 are appropriate feeding techniques for bottle-feeding, but do not minimize disease transmission for hepatitis B.
A client with a spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. The nurse should perform which action?
1. Ask the family to deliver the care.
2. Leave the client alone until ready to participate.
3. Advise the client that rehabilitation progresses more quickly with cooperation.
4. Acknowledge the client's anger and continue to encourage participation in care.
What is 4
Adjusting to paralysis is physically and psychosocially difficult for the client and family. The nurse recognizes that the client goes through the grieving process in adjusting to the loss and may move back and forth among the stages of grief. The nurse acknowledges the client's feelings while continuing to meet the client's physical needs and encouraging independence. The family also is in crisis and needs the nurse's support and should not be relied on to provide care. The nurse cannot simply neglect the client until the client is ready to participate. Option 3 represents a factual but noncaring approach to the client and is not therapeutic.
Which supplies should the nurse obtain for the administration of ribavirin to a hospitalized child with respiratory syncytial virus (RSV)?
1. A mask and pair of goggles
2. Isolation gown and sterile gloves
3. An intravenous (IV) pole and hood
4. Intramuscular (IM) syringe and needle
What is 1
Ribavirin is administered via hood, face mask, or oxygen tent and is not administered by the IV or IM route. Some caregivers experience headaches, burning nasal passages and eyes, and crystallization of soft contact lenses as a result of administration of ribavirin. Specific to this medication is the use of goggles. A mask may be worn. A gown is not necessary. The medication used for the prevention of RSV is palivizumab, a monoclonal antibody, which is given monthly in an IM injection to prevent hospitalization associated with RSV.
What health effects best describe a client who is the victim of abuse or negligence? Select all that apply.
1. Depression
2. Chronic fatigue
3. Involuntary shaking
4. Motivation to persevere
5. Interrupted sleeping patterns
What is 1, 2, 3, and 5
Clients who are victims of abuse or neglect are prone to certain health effects; these effects may be physical, such as bruises, broken bones, chronic fatigue, or involuntary shaking. The victim may also experience mental effects, such as nightmares, anxiety, post-traumatic stress disorder (PTSD), depression, interrupted sleep patterns, and low self-esteem. Motivation to persevere is not a direct effect and can be a positive characteristic.
The nurse should monitor a client with a history of opioid abuse for which signs and symptoms associated with opioid withdrawal?
1. Increased appetite, irritability, anxiety, restlessness, and altered concentration
2. Tachycardia, mild hypertension and fever, sweating, nausea, vomiting, and marked tremor
3. Depression, high drug craving, fatigue, altered sleep patterns, hypertension, agitation, and paranoia
4. Increased pulse and blood pressure, low-grade fever, yawning, restlessness, anxiety, diarrhea, and mydriasis
What is 4
Opioids are central nervous system depressants. They generally cause drowsiness and the feeling of being out of touch with the world. Withdrawal occurs within 12 hours after the last dose. Option 4 identifies the signs and symptoms associated with opioid withdrawal. Option 1 describes cocaine withdrawal. Option 2 identifies signs associated with nicotine withdrawal. Option 3 describes alcohol withdrawal.
The nurse caring for a client with a diagnosis of subinvolution should recognize which conditions as causes of this diagnosis? Select all that apply.
1. Afterpains
2. Uterine infection
3. Increased estrogen levels
4. Increased progesterone levels
5. Retained placental fragments from delivery
What is 2 and 5
Infections and retained placental fragments are the primary causes of subinvolution. When either of these processes is present, the uterus has difficulty contracting. The presence of afterpains is an expected finding following delivery. Hormonal levels are not causes of subinvolution.
A client with chronic kidney disease (CKD) is prescribed aluminum hydroxide. Which information should the nurse include while instructing the client regarding the action of this medication?
1. It prevents ulcers.
2. It prevents constipation.
3. It promotes the elimination of potassium from the body.
4. It combines with phosphorus and helps eliminate phosphates from the body.
What is 4
Aluminum hydroxide may be prescribed for a client with CKD. It binds with phosphate in the intestines for excretion in the feces, thus lowering phosphorus levels. It can cause constipation, and it does not promote the elimination of potassium. It may be used in the treatment of hyperacidity associated with gastric ulcers, but this is not the purpose of its use in the client with renal failure.