Fundamentals

a nurse is preparing to administer the varicella vaccine to a young adult female who has not previously had chickenpox or this vaccine. the nurse should withhold the vaccine & collect additional data when the client makes which statement? a. "i am allergic to neomycin" b. "i am taking antibiotics for my acne" c. "my irritable bowel syndrome has been acting up the last few days" d. "i have been taking an oral contraceptive for the last 6 months"

a. "i am allergic to neomycin"

a nurse on medical-surgical unit is preparing to administer medications to a client. which of the following question should the nurse ask the client to verify the client's identity? a. "what is your name & birth?" b. "what is your room number & bed number?" c. "what's your doctors name?" d. "what is your diagnosis?"

a. "what is your name & birth?"

a nurse is reinforcing with a client who is to start therapy with a nitroglycerin transdermal patch. which of the following statements by the client indicates an understanding of the teaching? a. "while using the patch, i will be careful when rising from a chair" b. "i should leave the patch in place for 24 hrs" c. "i should apply the patch to the same location with each application" d. "i will apply a new patch if i have chest pain"

a. "while using the patch, i will be careful when rising from a chair"

a nurse is caring for a client who is receiving methylprednisolone. which of the following lab values should the nurse plan to monitor? (select all that apply) a. WBC b. serum potassium c. creatinine phosphokinase d. blood glucose e. amylase

a. WBC b. serum potassium d. blood glucose

a nurse is reviewing a client's medical history before administering hydromorphone for postoperative pain. the nurse should notify the provider of which of the following findings before administering this medication? a. benign prostatic hyperplasia b. history of hypertension c. rheumatoid arthritis d. allergy to aspirin

a. benign prostatic hyperplasia

a nurse is reviewing the medication administration record for a client who has anew prescription for tobramycin to treat a pulmonary infection. which of the following medications should the nurse identify as increasing the risk for ototoxicity while taking tobramycin? a. furosemide b. propranolol c. gabepentin d. guaifenesin

a. furosemide

a nurse is assisting with the admission of a client who reports muscle aches & pains associated with construction work. the provider suggests taking acetaminophen. the nurse should notify the provider about which of the following information obtained from the client? a. history of hepatitis b b. cigarette smoker c. history of hypertension d. allergy to sulfonamides

a. history of hepatitis b

a nurse is caring for a client who has schizophrenia & is to start therapy with risperidone. which of the following manifestation should the nurse monitor to determine whether the treatment is effective? a. improved social interactions b. decreased OC thoughts c. decreased hand tremors d. improved urinary control

a. improved social interactions

a nurse is reinforcing discharge teaching with a client who has DM II & a new prescription for metformin. the nurse should instruct the client to monitor which of the following manifestations as adverse effects of this medication? a. muscle pain b. fatigue c. weight gain d. constipation e. metallic taste

a. muscle pain b. fatigue e. metallic taste

a nurse is collecting data from a client who has hyperthyroidism & a new prescription for Propylthiouracil. the nurse should monitor the client for which of the following manifestation as an adverse effect? a. sore throat b. metallic taste c. mania d. urinary retention

a. sore throat

a nurse is collecting data from a client who recently began taking niacin to treat hyperlipidemia. the client report experiencing facial flushing after taking the medication. the nurse should expect the provider to make which of the following recommendations? a. take aspirin 30 min before taking the medication b. lie down for 30 min after taking the med c. take the medication on an empty stomach d. avoid caffeine while taking the medication

a. take aspirin 30 min before taking the medication

a nurse is collecting data from a client who has been taking levodopa/carbidopa. which of the following findings should indicate to the nurse that the medication is effective? a. the client is able to wash his face b. the client experiences fewer seizures c. the client report decreased heartburn d. the client is able to sleep through the night

a. the client is able to wash his face

a nurse is reinforcing dietary teaching with a client who has a new prescription for phenelzine. which of the following foods should the nurse include in the teaching as an appropriate food choice? a. yogurt b. avocado c. smoked salmon d. pepperoni

a. yogurt

a nurse is reinforcing teaching with a client who has a new prescription for timolol eye drops for glaucoma. which of the following client statements indicates an understanding of the teaching? a. "i will rub my eyes for 10 seconds after putting in the medication" b. "i will look up when putting the medication in my eyes" c. "i will clean my eyes from the outer edge toward the nose before putting in the medication" d. "i will close my eyes tightly after putting in the medication"

b. "i will look up when putting the medication in my eyes"

a nurse in a provider's office is reviewing the immunization records of a 12 month old infant who is immunocompromised. which of the following vaccines should the nurse identify as contraindicated for this client? a. hepatitis a b. MMR c. pneumococcal conjugate d. haemophilus b conjugate

b. MMR

a nurse is collecting data from a client who is taking exenatide to treat DM. for which of the following findings should the nurse withhold the exenatide dose & notify the provider immediately? a. loss of appetite b. abdominal pain c. muscle weakness d. heartburn

b. abdominal pain

a nurse is caring for a client who has genital herpes. which of the following medication should the nurse expect to administer? a. levofloxacin b. acyclovir c. ceftriaxone d. metronidazole

b. acyclovir

a nurse is caring for a client who is having an acute asthma attack. which of the following medications should the nurse administer first? a. beclomethasone b. albuterol c. cromolyn d. prednison

b. albuterol

a nurse is collecting data from a client who has bacterial pneumonia & is taking ceftriaxone. which of the following findings indicates a therapeutic effect of the medication? a. white blood cell count 10,500/mm b. clear, bilateral breath sounds c. heart rate 110/min d. tolerates small meal servings

b. clear, bilateral breath sounds

a nurse is collecting data from a client who is taking oral amoxicillin to treat a respiratory infection. the nurse should monitor the client for which of the following manifestation as an adverse effect of the medication? a. hearing loss b. diarrhea c. bruising d. tendonitis

b. diarrhea

a nurse is reviewing the medical administration record of a client who has a history of stevens-johnson syndrome when taking sulfamethoxazole-trimethoprim. which of the following medications should the nurse identify as contraindicated for this client? a. prednisone b. furosemide c. lansoprazole d. digoxin

b. furosemide

a nurse is assisting with the care of a client who is in preterm labor & is receiving magnesium sulfate by continuous IV infusion. which of the following indicates magnesium toxicity? a. urinary output 60 mL/hr b. hyporeflexia c. respirations 14/min d. tachycardia

b. hyporeflexia

a nurse is caring for a client who has kidney failure & has been taking epoetin alfa. which of the following is a therapeutic effect of this medication? a. decreased bun b. increased hub c. decreased leukocyte production d. increased platelet production

b. increased hub

a nurse is reinforcing teaching about immunization with a client who is pregnant. which of the following vaccines should the nurse include in the teaching as safe to administer during pregnancy? a. herpes zoster b. tetanus c. varicella d. mar

b. tetanus

a nurse is reinforcing teaching with a client who has a new prescription for vitamin b12 intranasal to treat malabsorption syndrome. which of the following instructions should the nurse include in the teaching? a. "take this medication once per day" b. "drink hot liquid after administering the medication" c. "massage your nose gently after medication administration" d. "store this medication in the refrigerator"

c. "massage your nose gently after medication administration"

a nurse if reinforcing discharge teaching with a client who has prescription for a metered dose inhaler. which of the following information should the nurse include in the teaching? a. "wait for 15 sec between each puff of the same medication" b. "hold your breath for 5 sec after inhaling the medication" c. "take a slow, deep breath lasting 3-5 sec after releasing the medication" d. "roll the canister between your hands for 10-15 sec to mix the medication"

c. "take a slow, deep breath lasting 3-5 sec after releasing the medication"

an older adult client who has terminal cancer reports pain level at 5 using a 0-10 pain scale. the client has a prescription for morphin e15 mg orally every 4 hrs. the client's children express concern that the client is receiving too much of the medication. which of the following responses should the nurse make? a. "clients who receive this medication orally have a lower risk for addiction" b. "additional doses will not be needed because this medication is given on a fixed schedule" c. "the dose should remain constant to prevent breakthrough pain" d. "we can switch from oral administration to rectal administration"

c. "the dose should remain constant to prevent breakthrough pain"

a nurse is reinforcing teaching about nicotine polacrilex gum with a client who smokes 3 packs of cigarettes per day. which of the following statements should the nurse include in the teaching? a. "you can drink caffeinated beverages while chewing gum" b. "you can chew 2 pieces of gum when you have the urge to smoke" c. "you should chew gum for 30 min before discarding" d. "you should wait 5 minutes after eating to chew the gum

c. "you should chew gum for 30 min before discarding"

a nurse is reviewing the medical record of a client who has a new prescription for dimenhydrinate to treat motion sickness. which of the following disorders in the client's medical record should the nurse report? a. major depressive disorder b. diabetes mellitus c. bengin prostatic hyperplasia d. menieres disease

c. bengin prostatic hyperplasia

a nurse is reinforcing teaching with a client who experiences migraine headache & has a new prescription for sumatriptan. the nurse should instruct the client to report which of the following manifestations to the provider as an adverse effect of this medication? a. insomnia b. photophobia c. chest tightness d. respiratory depression

c. chest tightness

a nurse is collecting data from a client who has multiple sclerosis & a new prescription for baclofen. which fo the following findings should the nurse identify as an adverse effect of this medication? a. diarrhea b. weight loss c. drowsiness d. hypertension

c. drowsiness

a nurse is collecting data from a client who has angina & has s a new prescription for sublingual nitroglycerin. which of the following manifestation should the nurse expect as an adverse effect? a. sob b. bradycardia c. headache d. double vision

c. headache

a nurse is caring for a client who has a 10 yr history of alcohol use disorder & is experiencing acute alcohol withdrawal. the nurse should identify which of the following interventions as the priority? a. suggest the client attend a support group b. administer naltrexone c. implement seizure precaution d. assist the client to identify triggers of alcohol use

c. implement seizure precaution

a nurse is collecting data from a client who is taking tobramycin. which of the following findings should the nurse report to the provider immediately? a. report of nausea b. fever c. oliguria d. report of headache

c. oliguria

a nurse is reinforcing teaching with a client who is newly diagnosed with hypertension & is taking metoprolol. the nurse should instruct the client to report which of the following manifestation to the provider as an adverse effect of this medication? a. tachycardia b. tinnitus c. peripheral edema d. urinary retention

c. peripheral edema

a nurse is monitoring a client who has just returned to the unit following surgery. the client received an initial dose of morphine 5 mg IV bolus for pain relief. which of the following adverse effects should the nurse report immediately to the provider? a. emesis b. sedation c. respiratory rate 11/min d. blood pressure 100/74

c. respiratory rate 11/min

a nurse is collecting data from a client who is taking lithium to treat bipolar disorder. which of the following findings should the nurse report to the provider? a. bloating b. WBC count 8,500/mm c. slurred speech d. sodium 140 mEq/L

c. slurred speech

a nurse is reinforcing teaching with a client who has a new prescription for a fluticasone inhaler. which of the following client statements indicates an understanding of the teaching? a. "i will administer 2 puffs of the medication consecutively" b. "i will use this inhaler if i feel an asthma attack coming on" c. "i will avoid intake of dairy products in my diet" d. "i will rinse my mouth after i use this inhaler"

d. "i will rinse my mouth after i use this inhaler"

a nurse is collecting data prior to administering digoxin to a client. for which of the following findings should the nurse withhold this medication & notify the provider? a. digoxin level 0.9 ng/mL b. blood pressure 142/80 c. potassium 4.4 mEq/L d. apical pulse 52/min

d. apical pulse 52/min

a nurse is monitoring a client who is 2 hr postoperative & has a prescription for opioid analgesics. which of the following actions provides the nurse with the priority data to determine the clients need for analgesia? a. observe the client for signs of restlessness b. monitor the client for facial grimacing c. watch the client for indications of decreased mobility d. ask the client to rate her pain level

d. ask the client to rate her pain level

a nurse is performing the third check before administering hydromorphone to a client. after opening the unit dose packet, the client tells the nurse he does not want to take the medication now. which of the following actions should the nurse take? a. complete an occurrence report of the incident b. encourage the client to take the medication c. leave the medication at the client's bedside in case he changes his mind d. dispose of the medication with a second nurse as a witness.

d. dispose of the medication with a second nurse as a witness.

a nurse erroneously administered zolpidem to the wrong client. which of the following actions should the nurse take when documenting the medication error? a. document the completion of the incident report in the medical record of the client who received the zolpidem b. administer a dose of naloxone to reverse the effects of the medication c. keep a copy of the incident report on the unit d. document the notification of the client's provider

d. document the notification of the client's provider

a nurse is reinforcing teaching with a client who is receiving enalapril 20 mg PO daily. the nurse should instruct the client to monitor which of the following adverse effects of this medication? a. hypokalemia b. blurred vision c. tremors d. dry cough

d. dry cough

a nurse is evaluating a client who is receiving amphotericin b via intermittent IV bolus. which of the following findings indicates an adverse reaction to this medication? a. serum potassium 5.6 mEq/L b. hematocrit 55% c. polyuria d. hypotension

d. hypotension

a nurse is reinforcing teaching with a client who has rheumatoid arthritis & a new prescription for methotrexate. which of the following information should the nurse include in the teaching? a. avoid grapefruit juice b. increase salt intake c. avoid aged cheese d. increase fluid intake

d. increase fluid intake

a nurse is caring for a client who is taking disulfiram & consumed alcohol 12 hr ago. which of the following adverse reactions is the priority finding to report to the provider? a. hyperemesis b. severe headache c. palpitations d. respiratory depression

d. respiratory depression

a nurse is reinforcing teaching with a client who has DM I & is learning to self-administer NPH insulin. which of the following client actions indicates an understanding of the teaching? a. the client shakes the insulin vial prior to drawing up the dose b. the client uses the tip of the plunger to measure the correct dose c. the client injects air into the vial after inverting it d. the client wipes the cap with alcohol prior to filling the syringe

d. the client wipes the cap with alcohol prior to filling the syringe

a nurse is collecting data from a client who has been taking digoxin for 1 month. the nurse should identify which of the following findings as a manifestation of digoxin toxicity? a. pulse rate of 100/min b. blood pressure 140/90 c. wheezing d. vomiting

d. vomiting