Pharmacology
The nurse is monitoring a client with hypertension who is taking propranolol. Which assessment finding indicates a potential adverse complication associated with this medication?
1. Report of infrequent insomnia
2. Development of expiratory wheezes
3. A baseline blood pressure of 150/80 mm Hg after 2 doses of the medication
4. A baseline resting heart rate of 88 beats per minute followed by a resting heart rate of 72 beats per minute after 2 doses of the medication
What is 2
Audible expiratory wheezes may indicate a serious adverse reaction, bronchospasm. Beta blockers may induce this reaction, particularly in clients with chronic obstructive pulmonary disease or asthma. Normal decreases in blood pressure and heart rate are expected. Insomnia is a frequent mild side effect and should be monitored.
The nurse prepares a teaching plan for the mother of a child diagnosed with bacterial conjunctivitis. Which, if stated by the mother, indicates a need for further teaching?
1. "I need to wash my hands frequently."
2. "I need to clean the eye as prescribed."
3. "It is okay to share towels and washcloths."
4. "I need to give the eye drops as prescribed."
What is 3
Conjunctivitis is an inflammation of the conjunctiva. Bacterial conjunctivitis is highly contagious, and the nurse should teach infection control measures. These include good hand washing and not sharing towels and washcloths. Options 1, 2, and 4 are correct treatment measures.
What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session?
1. Ask the client to leave the group for this session only.
2. Refer the client to another group that includes other manic clients.
3. Tell the client to stop monopolizing in a firm but compassionate manner.
4. Thank the client for the input, but inform the client that others now need a chance to contribute.
What is 4
If a client is monopolizing the group, the nurse must be direct and decisive. The best action is to thank the client and suggest that the client stop talking and try listening to others. Although telling the client to stop monopolizing in a firm but compassionate manner may be a direct response, the correct option is more specific and provides direction for the client. The remaining options are inappropriate since they are not directed toward helping the client in a therapeutic manner.
The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply.
1. Respirations that are shallow
2. Respirations that are increased in rate
3. Respirations that are abnormally slow
4. Respirations that are abnormally deep
5. Respirations that cease for several seconds
What is 2 and 4
Kussmaul's respirations are abnormally deep and increased in rate. These occur as a result of the compensatory action by the lungs. In bradypnea, respirations are regular but abnormally slow. Apnea is described as respirations that cease for several seconds.
The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client?
1. Roast pork
2. Cheese omelet
3. Pasta with sauce
4. Tuna fish sandwich
What is 3
Cirrhosis is a chronic, progressive disease of the liver characterized by diffuse degeneration and destruction of hepatocytes. The serum ammonia level assesses the ability of the liver to deaminate protein byproducts. Normal reference interval is 10 to 80 mcg/dL (6 to 47 mcmol/L). Most of the ammonia in the body is found in the gastrointestinal tract. Protein provided by the diet is transported to the liver by the portal vein. The liver breaks down protein, which results in the formation of ammonia. Foods high in protein should be avoided since the client's ammonia level is elevated above the normal range; therefore, pasta with sauce would be the best selection.
The nurse is preparing a dose of 10 units of regular insulin and 35 units of NPH insulin for a client with type 1 diabetes mellitus. The nurse obtains an insulin syringe, gently rotates the insulin solutions, cleans the tops of the vials of insulin, and injects an amount of air equal to the dose prescribed into each vial. What is the next nursing action?
1. Draws up 10 units of regular insulin and checks the syringe contents with another nurse before drawing up the NPH insulin
2. Draws up 10 units of regular insulin, draws up 35 units of NPH insulin, and checks the syringe contents with another nurse
3. Draws up 35 units of NPH insulin and checks the syringe contents with another nurse before drawing up the regular insulin
4. Draws up 35 units of NPH insulin, draws up 10 units of regular insulin, and checks the syringe contents with another nurse
What is 1
Insulin dosages are verified by another nurse before administration. When 2 types of insulins are mixed, the doses must be verified after each is drawn up so as to verify the dosage for each one. The regular insulin is drawn into the syringe first.
A 1-year-old infant with a diagnosis of heart failure is prescribed digoxin. The nurse takes the apical pulse for 1 minute before administering the medication and obtains a result of 102 beats/minute. What is the nurse's best action?
1. Retake the apical pulse.
2. Withhold the medication.
3. Administer the medication.
4. Notify the primary health care provider.
What is 3
The apical pulse rate for a 1-year-old infant is 90 to 130 beats/min. Because the apical rate is normal, the remaining options are incorrect.
When a client is consistently 15 to 20 minutes late for weekly therapy sessions, the nurse attempts to best manage this behavior by implementing which intervention?
1. Ignoring the client's behavior
2. Telling the client that the sessions will be terminated
3. Arriving 15 minutes later than the scheduled time also
4. Asking the client if she or he is dealing with some new stressor
What is 4
If a client consistently demonstrates a behavior, such as arriving late for a scheduled meeting, the nurse should explore the reason for the behavior with the client. Ignoring the behavior is not a therapeutic or helpful nursing action. Terminating the meeting is inappropriate. Behavior that is similar to the client's behavior is nontherapeutic and inappropriate. It is most helpful to the client for the nurse to explore the reasons for the client's behavior.
The nurse is reviewing the laboratory test results for a client with a diagnosis of leukemia. The nurse notes that the granulocyte count is decreased. The nurse interprets that the client is at risk for which condition?
1. Anemia
2. Infection
3. Bleeding
4. Dehydration
What is 2
Granulocytes are blood cells that destroy bacteria. When granulocytes are decreased from normal, the risk of infection increases significantly. A decreased granulocyte count is not associated with anemia, bleeding, or dehydration.
The nurse is caring for a client with intracranial pressure (ICP) monitoring. Which intervention is appropriate to include in the plan of care?
1. Place the client in the modified left lateral recumbent position.
2. Change the drainage tubing every 48 hours.
3. Level the transducer at the lowest point of the ear.
4. Use strict aseptic technique when touching the monitoring system.
What is 4
Because there is a foreign body embedded in the client's brain, vigilant aseptic technique should be implemented. The modified left lateral recumbent position is a side-lying, flat position. With a client who has increased ICP, the head of the bed should be elevated at least 30 degrees to improve jugular outflow. The drainage tubing should not be routinely changed. It should remain for the duration of the monitoring. To obtain accurate ICP pressure readings, the transducer is zeroed at the level of the foramen of Monro, which is approximated by placing the transducer 1 inch above the level of the ear. Serial ICP readings should be done with the client's head in the same position.
Diclofenac is prescribed for a client with osteoarthritis. Which medication, if noted on the client's record, would alert the nurse to consult with the primary health care provider?
1. Phenytoin
2. Primidone
3. Acetaminophen
4. Warfarin sodium
What is 4
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID). Interactions may occur with the use of anticoagulants, and the nurse should consult with the primary health care provider about a potential medication interaction if an anticoagulant is prescribed. Phenytoin and primidone are anticonvulsant medications, and acetaminophen is a nonopioid analgesic. These medications are not contraindicated with diclofenac.
A child with sickle cell anemia who is in vaso-occlusive crisis is admitted to the hospital. Which primary health care provider prescription would assist in reversing the vaso-occlusive crisis?
1. Monitor pulse oximetry.
2. Begin intravenous fluids.
3. Administer oxygen by face mask.
4. Monitor vital signs and respiratory status.
What is 2
Increased fluid volume reduces the viscosity of the blood, preventing further vascular occlusion and further sickling caused by dehydration. Pulse oximetry and vital sign monitoring may be components of care, but they are actions that relate to monitoring the client versus treating. The intravenous fluids, however, will treat the condition. Vaso-occlusive crisis treatment includes analgesic and fluid administration. Oxygen may help relieve symptoms of respiratory distress, but analgesics and fluids treat the condition.
Which client's death was achieved by what is considered a soft suicide method?
1. Claimed to be going hunting and then shot himself while alone in the woods
2. Hung himself after becoming aware that he would be arrested for domestic violence
3. Sat in a running car parked in her locked garage to die of the carbon monoxide inhalation
4. Left a suicide note sharing that she was planning to jump off the bridge into a secluded part of the river
What is 3
Hard suicide methods include using a gun, jumping off a high place such as a bridge, hanging, and staging a car crash. Soft methods are those that are painless and include ingesting pills, or inhaling natural gas or carbon monoxide.
An 85-year-old client is hospitalized for a fractured right hip. During the postoperative period, the client's appetite is poor and the client refuses to get out of bed. Which nursing statement would be most appropriate to make to the client?
1. "We need to give you iodine to help in hemoglobin synthesis."
2. "It is important for you to get out of bed so that calcium will go back into the bone."
3. "We need to increase your calcium intake because you are spending too much time in bed."
4. "You need to remember to turn yourself in bed every 2 hours to keep from getting so stiff."
What is 2
Early ambulation in the postoperative period is important because if a client does not increase activity, the bones will suffer from loss of calcium. Iron, not iodine, is recommended for hemoglobin synthesis because oxygen is necessary for wound healing. Increasing calcium intake would cause elevated amounts of calcium in the blood, which could lead to kidney stones. Clients who are not turned in bed will develop pressure ulcers. An 85-year-old who is immobile needs to be turned every 2 hours by the nursing staff; clients should not be expected to turn themselves.
A nurse notes that a client with type 1 diabetes mellitus has lipodystrophy on both upper thighs. The nurse should ask the client if which measure is taken?
1. Rotating sites for injection
2. Administering the insulin at a 45-degree angle
3. Cleaning the skin with alcohol before each injection
4. Aspirating for blood before injection into the subcutaneous tissue
What is 1
Lipodystrophy (hypertrophy of subcutaneous tissue at the injection site) occurs in some clients with diabetes mellitus when injection sites are used for a prolonged period. Therefore, clients are instructed to adhere to a plan of rotating injection sites to avoid tissue changes. Angle of insulin administration, cleansing with alcohol, and aspiration do not produce this complication.
A client diagnosed with an anxiety disorder is prescribed buspirone orally. The client tells the nurse that it is difficult to swallow the tablets. Which is the best instruction to provide the client?
1. Crush the tablets before taking them.
2. Mix the tablet uncrushed in apple sauce.
3. Purchase the liquid preparation with the next refill.
4. Call the primary health care provider for a change in medication.
What is 1
Buspirone may be administered without regard to meals, and the tablets may be crushed. Mixing the tablet uncrushed in apple sauce will not ensure ease in swallowing. This medication is not available in liquid form. It is premature to advise the client to call the primary health care provider (PHCP) for a change in medication without first trying alternative interventions.
The nursing student is writing a plan of care for a child who presents with an acute head injury. The nursing instructor reviews the plan of care and praises the student for identifying which assessment as a priority?
1. Inspecting the scalp
2. Pupillary assessment
3. Airway and breathing
4. Palpating the child's head
What is 3
The first step in the emergency treatment of child with head injury includes the ABCs – airway, breathing, and circulation – assessments. The other assessments are included when evaluating a head injury, but the priority is ABC.
A client comes into the emergency department in a severe state of anxiety after a car crash. Which is the best nursing intervention at this time?
1. Remain with the client.
2. Put the client in a quiet room.
3. Teach the client deep breathing.
4. Encourage the client to talk about his or her feelings and concerns.
What is 1
If left alone, the severely anxious client may feel abandoned and become overwhelmed. Placing the client in a quiet room is also important, but the nurse must stay with the client. Teaching the client deep breathing or relaxation is not possible until the anxiety decreases. Encouraging the client to discuss concerns and feelings would not take place until the anxiety has decreased.
How should the nurse position the client for pericardiocentesis to treat cardiac tamponade?
1. Supine with slight Trendelenburg's position
2. Lying on the right side with a pillow under the head
3. Lying on the left side with a pillow under the chest wall
4. Supine with the head of the bed elevated at a 45- to 60-degree angle
What is 4
The client undergoing pericardiocentesis is positioned supine with the head of bed raised to a 45- to 60-degree angle. This places the heart in close proximity to the chest wall for easier insertion of the needle into the pericardial sac. Options 1, 2, and 3 are incorrect positions.
The clinic nurse notes that the primary health care provider has documented a diagnosis of herpes zoster (shingles) in the client's chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test?
1. Positive patch test
2. Positive culture results
3. Abnormal biopsy results
4. Wood's light examination indicative of infection
What is 2
With the classic presentation of herpes zoster, the clinical examination is diagnostic. However, a viral culture of the lesion provides the definitive diagnosis. Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the virus that causes chickenpox. A patch test is a skin test that involves the administration of an allergen to the surface of the skin to identify specific allergies. A biopsy would provide a cytological examination of tissue. In a Wood's light examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin.
A clinic nurse is assessing a client who has been on isoniazid for 6 months. Which client complaint should most concern the nurse?
1. Dry mouth
2. Cramping diarrhea
3. Frequent headaches
4. Difficulty tying shoes
What is 4
The client complaint that should most concern the nurse is difficulty tying shoes because this may indicate neuropathy. Dose-related peripheral neuropathy is one of the more common adverse effects of isoniazid. Dry mouth, cramping diarrhea, and frequent headaches are not concerns with administration of this medication.
The nurse is preparing to care for a child after a tonsillectomy. The nurse documents on the plan of care to place the child in which position?
1. Supine
2. Side-lying
3. High-Fowler's
4. Trendelenburg's
What is 2
A tonsillectomy is the surgical removal of the tonsils. The child should be placed in a prone or side-lying position after the surgical procedure to facilitate drainage. Options 1, 3, and 4 would not achieve this goal.
The nurse should monitor the client with a history of heroin addiction for which signs/symptoms of heroin withdrawal?
1. Constipation, insomnia, and hallucinations
2. Staggering gait, slurred speech, and violent outbursts
3. Nausea, vomiting, diarrhea, muscle aches, and diaphoresis
4. Decreased heart rate and blood pressure, and dry nose, mouth, and skin
What is 3
The client who is experiencing opioid withdrawal (e.g., from heroin) may experience dysphoric mood, nausea, vomiting, diarrhea, abdominal cramping, muscle aches, diaphoresis and piloerection, runny eyes (lacrimation) and nose (rhinorrhea), yawning, low-grade fever, restlessness, insomnia, anxiety, mydriasis, and increased pulse and blood pressure. Therefore, the other options are incorrect.
The nurse discovers a fire in the trash basket in a client's bathroom. The nurse assists the client out of the hospital room to a safe place, activates the fire alarm, and takes which action next?
1. Extinguishes the fire
2. Activates the fire alarm
3. Pulls the pin on the fire extinguisher
4. Closes the doors to the other clients' rooms
What is 4
In the event of a fire, the first priority is to rescue the client and protect the client from injury. The next priority is to activate the fire alarm and report the exact location of the fire to emergency personnel to aid in the rescue process. Next, the nurse would contain the fire by closing doors and placing towels under the doorways to prevent the spread of smoke. The nurse then would obtain the fire extinguisher, pull the pin, and extinguish the fire.
The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? Select all that apply.
1. Tremors
2. Weight loss
3. Feeling cold
4. Loss of body hair
5. Persistent lethargy
6. Puffiness of the face
What is 3, 4, 5, and 6
Feeling cold, hair loss, lethargy, and facial puffiness are signs of hypothyroidism. Tremors and weight loss are signs of hyperthyroidism.