Pharmacology
Your pregnant client has a new order for medication. What principle should you apply to this new medication?
A. The fact that drugs classified as categories C, D and X are contraindicated for women who are pregnant.
B. The fact that drugs classified as categories A, B and C are contraindicated for women who are pregnant.
C. The fact that drugs classified as categories C, D and E are contraindicated for women who are pregnant.
D. The fact that drugs classified as categories C, D and Z are contraindicated for women who are pregnant.
Correct Response: A
Drugs classified as categories C, D and X are contraindicated for women who are pregnant because of the risks associated with these categories in terms of the developing fetus when these medications cross the placental barrier.
Pharmacology
The nurse is completing a percutaneous endoscopic gastrostomy (PEG) feeding on a patient who had the PEG tube placed one week ago. The nurse notices that the tube has dislodged. What is the priority action?
A. Apply sterile gloves and reinsert the PEG tube into the existing tract immediately.
B. Prepare to insert a Foley catheter into the PEG tube incision site.
C. Immediately notify the primary care provider who placed the PEG tube.
D. Obtain a nasogastric tube (NGT) for medications and feedings.
Immediately notify the primary care provider who placed the PEG tube, to make primary physician aware and immediate replacement.
Basic Care and Comfort
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD).
➤Select the 4 findings that are consistent with COPD.
A. Barrel Chest
B. Fever
C.Weight loss
D. Productive cough
E. Fatigue
Answers: Barrel-chest
Anteroposterior-transverse chest ratio 1:1, also called barrel-chest, and a classic assessment finding of a client with COPD. Since the lungs are constantly overfilled with air, the rib cage becomes accustomed to staying partially open at all times.
Weight loss
Weight loss is a common assessment finding of the client with COPD. The client can often get short of breath, even with minimal exertion, causing little nutritional intake.
Productive cough
A productive cough is an expected assessment finding in a client with COPD. The client can cough up clear, white, yellow, green, or frothy sputum.
Fatigue
Fatigue is a common finding with clients with COPD. Since the client has impaired gas exchange, the body has a shortage of oxygen and carbon dioxide builds up, also causing fatigue.
A wife drives her husband to the Emergency Department because he complained of "terrible heartburn." He tells the nurse that he also has crushing chest pain with more discomfort in his left arm. The nurse knows that his symptoms are likely consistent with which diagnosis
A. Cardiac tamponade
B. Myocardial infarction
C. Gastroesophageal reflux
D. Gastrointestinal bleed
Answer: Myocardial infarction.
Use the mnemonic PULSE = Persistent chest pain, Upset stomach, nausea, vomiting, Lightheadedness, dizziness, Shortness of breath, and Excessive sweating. The classic signs and symptoms of myocardial infarction include a feeling of indigestion or heartburn, a crushing pressure or pain in the chest, pain extending down the left arm, shortness of breath, nausea and a cold sweat. Chest pain with gastroesophageal reflux is more of a burning sensation. Cardiac tamponade is a life-threatening emergency characterized by bulging neck veins and muffled heart sounds. Gastrointestinal bleed does not usually present with chest pain although shortness of breath may be noted.
Which of the following is not considered one of the “Ten Rights of Medication Administration”?
A. The “right” verification
B. The “right” to refuse.
C. The “right” documentation
D. The “right” client education
Correct Response: A
The “right verification” is not one of the “Ten Rights of Medication Administration”. The verification of the doctor’s order for a medication is to confirm the right paint, medication, dose, route and time or frequency, it, in itself, is not one of the “10 Rights”.
The “Ten Rights of Medication Administration” are the right, or correct:
Pharmacology
Correct Response: A
Your first priority intervention is to immediately stop the flow of the intravenous antibiotic because it is highly likely that the signs of anaphylaxis have occurred as the result of the client’s adverse effect to this antibiotic.
The next thing that you would do is assess the client to determine their physical status and to provide necessary emergency measures, including CPR, if it is indicated. Later, you would notify the doctor about this adverse reaction.
A 50-year-old blind and deaf patient has been admitted to your floor. As the charge nurse, what is your primary responsibility for this patient?
A. Continually update the patient on the social environment
B. Provide a secure environment for the patient
C. Communicate with your supervisor and your patient safety concerns
D. Let others know the patient’s deficits
Answer: Provide a secure environment for the patient.
The American Disabilities Act (ADA) prohibits discrimination against anyone who has a disability; hospitals and Healthcare facilities must provide access and accommodations so that patients, visitors and staff are not at increased risk for injury .
A client with a diagnosis of possible appendicitis is a direct admit from the clinic. The nurse knows that a positive sign of appendicitis is?
A. Homans’
B. Murphy’s
C. Chadwick’s
D. Psoas
Answer: Psoas.
A positive psoas sign indicates the presence of inflammation of the psoas muscle. A positive Murphy's Sign indicates cholecystitis. A positive Homans’ sign is related to a deep vein thrombosis in a leg. A positive Chadwick sign is normal during pregnancy.
Which adverse effects should the nurse monitor for in a hospitalized patient with an order for aspirin 325 mg every 6 hours with a diagnosis of cluster headaches? Select all that apply.
A. The presence of dark melanin in the stool.
B. Decreased heart rate.
C. Increased ecchymosis noted on the extremities.
D. Increased blood pressure. Tinnitus noted on an exam.
Ask: Adverse effects of aspirin
Problem: aspirin (anti-platelet) easy bleeding, big risk for toxicity
Solution: adverse effects, things that are side effects, not normal, something that can harm the client.
Dark stools can indicate bleeding in the gastrointestinal. Bruising indicates bleeding from anti-platelets/ decreased clotting. Tinnitus can indicate toxicity within the kidneys and ears.
Pharmacology
As the nurse in an ambulatory care area, you see a new client enter with a cane that appears too short for the client. What should you do?
A. Place the client in a wheelchair to protect their safety in the clinic.
B. Remove the cane from the client to protect their safety.
C. Teach the client about the proper length of a cane.
D. Have the client use a wheelchair rather than the cane.
Correct Response: C
You should teach the client about the proper length of a cane. The proper length of the cane should be the length that only permits the client’s elbow to be slightly flexed. Some canes like a wooden cane are not adjustable to the client’s height and others can be adjusted to meet the height needs of the client.
You would not place the client in a wheelchair or ask the client to use a wheelchair and you would also not take the cane, which is their personal property, away from them. You would use this observation as a learning need assessment and, as such, you should teach the client about the proper length of a cane and help them to adjust the height of the cane if the client’s cane is a height adjustable one.
When assessing patients in the post-anesthesia care unit (PACU) , should the nurse first check the patients?
A. Level of consciousness
B. Ability to move
C. Respiratory status
D. Level of pain
Answer: Respiratory status.
The nurse should always begin by assessing the post operative patient's respiratory status. Breathing problems are the second most common problem in the PACU 9 nausea and vomiting are first). Immediate post anesthesia complications can include airway obstruction, pneumothorax, hypoventilation, or a pulmonary embolism.
The nurse reviews the daily lab results for a patient with a serious bacterial infection. When reporting the WBC differential to the patient's physician, the physician notes, "There's been a shift to the left." Does the nurse know what this means?
A. The infection has been resolved
B. The patient has acute leukemia
C. The infection is still progressing
D. The patient requires platelets
Answer: The infection is still progressing.
“Shift to the left” means that there is a shift in the WBC towards more immature neutrophil cells *(more bands and blasts). This shift is present in most bacterial infections. In the event of a bacterial infection, large numbers of neutrophils migrate from the blood to the infected site to destroy the invading microorganisms and thus protect the host. “Shift to the right” means that there has been a shift back to the normal differential .
A client with Addison disease presents with abdominal pain. The client experiences a decline in systolic blood pressure of 30 mm Hg, has a heart rate increase from 75 to 100/min and develops new confusion. Which action(s) should be implemented to prevent the Addisonian crisis? Select all that apply.
A. Give prescribed hydrocortisone 100 mg IVP.
B. Administer morphine 2 mg IVP every 2 hours for pain.
C. Begin potassium 40 mEq PO every 12 hours as prescribed.
D. Start an IV infusion of normal saline with 5% dextrose. Give Phenergan 12.5 mg IVP every 4 hours PRN nausea.
Ask: Actions to prevent this Addisonian crisis
Problem: client has Addison’s disease with abdominal pain, systolic blood pressure that is dropping by 30, heart rate increasing by 100 and they’re getting confused > Addison’s -add steroids, treat dehydration, dextrose IV
Solution: Interventions that the client needs right now
Give prescribed hydrocortisone 100 mg IVP, is a steroid. Start an IV infusion of normal saline with 5% dextrose, fluid and dextrose is needed to prevent dehydration and hypoglycemia.
Pharmacology
Which basic activity of daily living assistive device can be useful for the client who is affected with poor fine motor coordination?
A. Aphasia aid
B. A button hook.
C. Honey thickened liquid.
D. A word board.
Correct Response: B
The basic activity of daily living assistive device can be useful for the client who is affected with poor fine motor coordination is a button hook that would be used for the dressing activity of daily living.
An aphasia aid and a word board are assistive devices to facilitate communication when the client is affected with a communication deficit such as aphasia; and, lastly honey thickened liquids are indicated for clients with a swallowing disorder and they are not indicated for clients with poor fine motor coordination.
A pediatric nurse has been assigned to assist with a bone marrow biopsy for a 7-year-old girl. Conscious sedation will be used for the procedure. What is the nurse's primary responsibility?
A. Application of the topical anesthetic ointment
B. Monitoring the child during the procedure
C. Documentation of the entire process
D. Communication with the child's parents
Answer: Monitoring the child during the procedure.
Every procedure requires the one team member to be solely responsible for monitoring the patient. In this case the pediatric nurse will monitor the child's vital signs, reflexes, and response to the procedure. The nurse will not leave the patient to update any family member.
Following a patient's myocardial infarction, the nurse assesses the patient's electrocardiogram strip shown in the image. The nurse identifies the rhythm as?
A. Ventricular fibrillation
B. Sinus bradycardia
C. Sinus tachycardia
D. Atrial fibrillation
Answer: Sinus tachycardia is a rate over 100 beats per minute. The conduction and rhythm are normal. The P wave precedes the QRS complex, which is usually normal. following a myocardial infarction, sinus tachycardia should be quickly assessed and treated.
How many tablets should be administered daily using the below information? Doctor’s order: 200 mg of medication once a day Medication label: 1 tablet = 150 mg
A. 1.5 tablets
B. 1.25 tablets
C. 1.33 tablets
D. 1 tablet
Correct Response: C
You have to determine how many tablets the patient will take if the doctor has ordered 200 mg a day and the tablets are manufactured as 150 mg per tablet.
The mathematical rule for this type of calculation is:
Have/ Desire x Vehicle= X
This problem is calculated as shown below.
200 mg: X tablets = 150 mg: 1 tablet
Or as
200 mg = 150 mg
X tablets 1 tab
You will criss cross multiply the known numbers and then divide this product by the remaining number to solve for X, as below.
200 x 1 = 150 X
200/150 = 1.33 tabs rounded off to 1 1/3 tab
Pharmacology
Correct Response: C
You would document this client’s muscular strength as a 3 on a scale of 0 to 5.
Muscular strength is classified on a scale of zero to five, as below.
The clinic nurse is reviewing the urinalysis results of a new client. Which of the following values should be reported to the primary health care provider (PHCP)?
A. GLucose: 190 mg/dl
B. pH: 7.6
C. Clarity:Cloudy
D. Color: Deep amber
Answer: Glucose: 190 mg/dl.
The nurse should report the glucose level of 190 mg/dl. When blood glucose levels exceed 180 mg/dl, the proximal tubules become overwhelmed and cannot reabsorb the excess glucose. As a result glucose is excreted into the urine (glycosuria). The most common cause of glycosuria is diabetes mellitus, but elevations are also seen in pregnancy. The other values are within normal limits. Normal urinalysis values are as follows: Color: Yellow (light/pale to dark/deep amber) Clarity/Turbidity: Clear or cloudy. pH 4.5-8. Specific gravity 1.005-1.025. Glucose Less than or equal to 130, 18 less than or equal to 150 mg/dL.
When providing nutrition education for a newly diagnosed diabetic client, the nurse uses guidelines from the American Diabetes Association. What are their recommended proportions of nutrients?
A. 60% non-starchy vegetables, 20% protein, 20% carbohydrates
B. 50% non-starchy vegetables, 25% protein, 25% carbohydrates
C. 40% non-starchy vegetables, 35% protein, 25% carbohydrates
D. 70% non-starchy vegetables, 20% protein, 10% carbohydrates
Answer: 50% non-starchy vegetables, 25% protein, 25% carbohydrates.
The ADA Diabetic Plate Method includes 50% non-starchy vegetables, 25% protein, 25% carbohydrates and provides balanced nutrition to maintain blood glucose levels, enough protein to maintain body repair, and enough fat to ensure palatability. non-starchy vegetables are low in carbohydrates and high in fiber. examples can include broccoli, brussel sprouts, cauliflower, carrots, cucumber, and leafy greens. Lean protein includes fish, chicken, lean beef, soy products, eggs, and cheese. carbohydrate Foods include starchy vegetables, beans, fruit, yogurt, and milk. Clients should be advised to use a 9-in plate for their meals.