EAQ 1
A client is to receive a transfusion of packed red blood cells (PRBCs). Which solution would the nurse use to prime the blood intravenous (IV) tubing? A- Lactated Ringer solution B- 5% dextrose and water C- 0.9% normal saline D- 0.45% normal saline
C- 0.9% normal saline Blood and blood products for transfusion should be infused/diluted only with 0.9% normal saline solution. Solutions other than normal saline are incompatible and may cause RBC destruction by hemolysis.
Which adverse effect will the nurse instruct the client to anticipate when prescribed albuterol to relieve severe asthma?
Tremors Palpitations Albuterol's sympathomimetic effect causes central nervous system (CNS) stimulation, precipitating tremors, tachycardia, and palpitations. Lethargy is an adverse effect of medications that cause CNS depression, not CNS stimulation. Albuterol causes bronchodilation, not bronchoconstriction. Albuterol will cause tachycardia, not bradycardia.
Which reason would the nurse provide to a client who asks why blood tests are necessary after a health care provider prescribes peak and trough levels after initiation of intravenous antibiotic? A- "They determine if the dosage of the medication is adequate." B- "They detect if you are having an allergic reaction to the medication." C- "The tests permit blood culture specimens to be obtained when the medication is at its lowest level." D- "These allow comparison of your fever to changes in the antibiotic level."
A- "They determine if the dosage of the medication is adequate." Medication dose and frequency are adjusted according to peak and trough levels to enhance efficacy by maintaining therapeutic levels. Peak and trough levels reveal nothing about allergic reactions. Blood cultures are obtained when the client spikes a temperature; they are not related to peak and trough levels of an antibiotic. A sustained decrease in fever is the desired outcome, not a reduction just at peak serum levels of the medication.
Which statement regarding mealtime administration by a client who has arthritis and is prescribed corticosteroid medication indicates that the teaching was effective? A- "This will decrease gastric irritation." B- "This will serve as a reminder to take the medication." C- "The presence of food will enhance absorption." D- "The medication is ineffective in an acid medium."
A- "This will decrease gastric irritation." The presence of food limits the irritating effect of steroids on the gastric mucosa. Taking the medication at mealtime may help the client remember to take the medication, but it is not the reason for taking it with meals. Food does not increase or decrease absorption of steroids. The medication is not affected by an acid environment.
The nurse administers albuterol to a 4-year-old child. Which intervention would assist the nurse in evaluating the effectiveness of this medication? A- Auscultate breath sounds. B- Collect a sputum sample. C- Conduct a neurological examination. D- Palpate chest excursion.
A- Auscultate breath sounds. Albuterol is an adrenergic medication that stimulates beta-receptors, leading to relaxation of the smooth muscles of the airway. The lungs should be auscultated to evaluate the effectiveness of this medication. Albuterol does not affect the consistency of pulmonary secretions. Albuterol will not cause central nervous system stimulation. Albuterol does not affect intercostal contractility; chest excursion is not the appropriate assessment.
Which time would the nurse schedule the blood sample to be obtained when the primary health care provider prescribes trough levels of an antibiotic? A- Just before the medication is administered B- Between 30 and 60 minutes after the infusion is completed C- Six hours after the dose is completely infused D- In the morning before the client eats breakfast
A- Just before the medication is administered Trough levels are measured in relation to the time a medication is administered. The trough level for a medication is drawn just before a medication is given, when the medication's level is at its lowest. Any other time would be inaccurate for a medication's trough level. The medication's peak level is drawn 30 to 60 minutes after the infusion is completed. Whether the client eats breakfast does not affect this medication's trough levels, because it is an intravenous infusion.
Which process is responsible for the shift of body fluids associated with the intravenous administration of albumin? A- Osmosis B- Diffusion C- Active transport D- Hydrostatic pressure
A- Osmosis Albumin increases intravascular solute concentration. Osmosis is the movement of fluid from an area of lesser solute concentration to an area of greater solute concentration. Diffusion is the movement of particles across a semipermeable membrane from an area of greater concentration of particles to an area of lesser concentration of particles. In active transport, molecules move against a concentration gradient; this differs from diffusion and osmosis because metabolic energy is expended. Hydrostatic pressure, the pressure exerted within a closed system, is known as filtration force. Filtration is the passage of fluid through a material that prevents the passage of certain constituents; hydrostatic pressure moves fluid by pressure and concentration gradients.
An infant with congenital hypothyroidism receives levothyroxine for 3 months. Which finding would indicate to the nurse that the medication is effective? A- The infant is alert and interactive. B- The skin is cool to the touch. C- The baby's fine tremor has ceased. D- The baby's thyroid stimulating hormone level has increased.
A- The infant is alert and interactive. Infants with congenital hypothyroidism are lethargic, and may even need to be awakened and stimulated to nurse; therefore an infant who is alert and interacts appropriately for its age would demonstrate improvement. Cool skin is a clinical sign of hypothyroidism related to a slow basal metabolic rate. Fine hand tremor is related to hyperthyroidism and is not present in an infant with hypothyroidism, even one whose condition is being stabilized with levothyroxine. An increased thyroid stimulating hormone level would indicate inadequate treatment.
Which client statement indicates that the client understands the nurse's instructions about long-term steroid therapy? A- "My urine may become discolored." B- "I should avoid crowds in enclosed areas." C- "Weight loss can occur with this medication." D- "The medication should be taken between meals!"
B- "I should avoid crowds in enclosed areas." Crowds, especially in enclosed areas, can lead to infections when on steroids. Steroid therapy decreases lymphocytes, resulting in depressed immunity and a greater risk for infection. Steroids have no effect on urine color. Sodium is retained, resulting in fluid retention and weight gain. Steroids increase production of hydrochloric acid and should be taken with food or an antacid to prevent ulcer formation.
A 6-year-old child with asthma is prescribed an inhaled corticosteroid. The nurse would conclude the parent understands teaching about the medication side effects when the mother makes which statement? A- ''I'll watch for frequent urination." B- "I'll check for white patches in the mouth." C- "'Il be alert for short episodes of not breathing." D- "I'll monitor for an increased blood glucose level."
B- "I'll check for white patches in the mouth." Oral candidiasis is a potential side effect of inhaled steroids because of steroids' anti-inflammatory effect; the child should be taught to rinse the mouth after each inhalation. Frequent urination is not a side effect of steroid therapy. Apneic episodes are not a side effect of steroid therapy. Hyperglycemia is not a side effect of inhaled steroid therapy; it may occur when steroids are administered for a systemic effect.
Which instruction would the nurse teach a client with the diagnosis of Graves' disease regarding propylthiouracil (PTU)? A- "Increase sources of calcium." B- "Observe for signs of infection. C- "Take the medication through a straw." D- "Wear sunglasses when exposed to sunlight."
B- "Observe for signs of infection. PTU may lower the white blood cell count, making the client prone to infection. PTU does not cause hypocalcemia. Taking the medication through a straw is necessary with iodine preparations to prevent staining of the teeth; however, PTU does not contain iodine. PTU does not cause photophobia.
Which step would the nurse anticipate taking first when providing emergency care for a client who develops anaphylaxis after being stung by multiple bees? A- Administer oxygen (0 2) for saturation less than 90% B- Administer epinephrine C- Administer 50 mg diphenhydramine IM D- Monitor for the development of toxic venom effects
B- Administer epinephrine The first step in emergency care in a client stung by a bee is to administer epinephrine to alleviate the symptoms of severe allergic reactions such as wheezing, facial swelling, and respiratory distress. Administer O 2if O,saturation is less than 90% or client is experiencing respiratory distress. The nurse would then administer 50 mg diphenhydramine IM. The client who has sustained multiple stings is observed in an emergency care setting for several hours (hospital care) to monitor for the development of toxic effects from the venom.
A child with type 1 diabetes is receiving 15 units of regular insulin and 20 units of NPH insulin at 7:00 AM each day. Which time would the nurse anticipate a hypoglycemic reaction from the NPH insulin to occur? A- Before noon B- In the afternoon C- Within 30 minutes D- During the evening
B- In the afternoon NPH insulin is an intermediate-acting insulin that peaks approximately 6 to 8 hours after administration. It was administered at 7:00 AM, so between 1:00 PM and 3:00 PM is when the nurse would anticipate that a hypoglycemic reaction would occur. Noon is when a reaction from a short-acting insulin is expected. Short-acting insulin peaks 2 to 4 hours after administration. Within 30 minutes of administration is when a reaction from a rapid-acting insulin is expected. Rapid-acting insulin peaks 30 to 60 minutes after administration. During the evening or nighttime is when a reaction from a long-acting insulin is expected. Long-acting insulin has a small peak 10 to 16 hours after administration.
Which information from the client's history would the nurse identify as a risk factor for developing osteoporosis? A- Takes estrogen therapy B- Receives long-term steroid therapy C- Has a history of hypoparathyroidism D- Engages in strenuous physical activity
B- Receives long-term steroid therapy Increased levels of steroids will accelerate bone demineralization. Estrogen promotes deposition of calcium into bone which may prevent, not cause, osteoporosis. Hyperparathyroidism, not hypoparathyroidism, accelerates bone demineralization. Weight-bearing that occurs with strenuous activity promotes bone integrity by preventing bone demineralization.
When a client is seen in the emergency department with sudden onset severe dyspnea, coughing, and wheezes, which prescribed treatment would the nurse administer first? A- Inhaled corticosteroid B- Normal saline infusion C- Albuterol via nebulizer D- Intravenous methylprednisolone
C- Albuterol via nebulizer The client symptoms suggest acute asthma attack or anaphylaxis. Inhaled bronchodilators like albuterol act within a few minutes to relax bronchospasm, decrease bronchiolar inflammation, and dilate bronchioles. Inhaled corticosteroids are not rapidly acting and can be given after inhaled bronchodilators. Normal saline would be needed, but the nurse would not wait to give the bronchodilator while infusing saline. Intravenous corticosteroids like methylpred nisolone take several hours to be effective and would not be the priority treatment.
Which insulin will the nurse prepare for the emergency treatment of ketoacidosis? A- Glargine B- NPH insulin C- Insulin aspart D- Insulin detemir
C- Insulin aspart Insulin aspart is a rapid-acting insulin (within 10-20 minutes) and is used to meet a client's immediate insulin needs. Glargine is a long-acting insulin, which has an onset of 1.5 hours; for diabetic ketoacidosis, the individual needs rapid-acting insulin. NPH insulin is an intermediate-acting insulin, which has an onset of 1 to 2 hours; for diabetic ketoacidosis, the individual needs rapid-acting insulin. Insulin detemir is a long-acting insulin; for diabetic ketoacidosis, the individual needs rapid-acting insulin.
Which action of propylthiouracil (PTU) will the nurse include when teaching a client with hyperthyroidism? A- Increases the uptake of iodine B- Causes the thyroid gland to atrophy C- Interferes with the synthesis of thyroid hormone D- Decreases the secretion of thyroid-stimulating hormone (TSH)
C- Interferes with the synthesis of thyroid hormone PTU, used in the treatment of hyperthyroidism, blocks the synthesis of thyroid hormones by preventing iodination of tyrosine. Propylthiouracil does not increase the uptake of iodine. lodine solutions reduce the size and vascularity of the thyroid gland. TSH, secreted by the anterior pituitary, is not affected by propylthiouracil.
Which action will a nurse take when a male client receiving prolonged steroid therapy complains of being thirsty and urinating frequently? A- Have the client assessed for an enlarged prostate B- Obtain a urine specimen from the client to test for ketonuria C- Perform a finger stick to test the client's blood glucose level D- Assess the client's lower extremities for presence of pitting edema
C- Perform a finger stick to test the client's blood glucose level The client has signs of an increased serum glucose level, which may result from steroid therapy; testing the blood glucose level is a method of gathering more data. The symptoms are not those of benign prostatic hyperplasia. The blood glucose level, not the amount of ketones in the urine, should be assessed. The symptoms presented are not those of fluid retention but of hyperglycemia.
Which intravenous fluid is a hypertonic solution? A- Ringer solution B- 5% dextrose in water C- Lactated Ringer solution D- 5% dextrose in normal saline
D- 5% dextrose in normal saline An isotonic solution has the same osmolarity as body fluids. A hypertonic solution has a higher osmolarity than body fluids; it pulls fluid from cells, causing them to shrink and the extracellular space to expand. The hypertonic solution (5% dextrose in normal saline) provides 586 mOsm/kg. Ringer and Lactated Ringer [273 mOsmol/kg] are isotonic, whereas 5% dextrose in water [252 mOsmol/kg]) is slightly hypotonic.
The nurse educator is providing information about different insulin types. Which type of insulin can be safely mixed with regular human insulin in the same syringe? A- Insulin glargine B- Insulin detemir C- Insulin lispro mix 75/25 D- Isophane insulin neutral protamine hagedorn (NPH)
D- Isophane insulin neutral protamine hagedorn (NPH) Isophane insulin NPH is safe to mix with regular human insulin. No other insulin type should be mixed with insulin glargine, insulin detemir, or insulin lispro mix 75/25.
Which side effect would the nurse assess for in a child receiving prednisone? A- Alopecia B- Anorexia C- Weight loss D- Mood changes
D- Mood changes Mood swings may result from steroid therapy. Alopecia does not result from steroid therapy. An increased appetite, not anorexia, results from steroid therapy. Weight gain, not weight loss, results from steroid therapy.
Which rationale describes why steroids are administered to a client scheduled for a bilateral adrenalectomy? A- To foster accumulation of gylcogen in the liver B- To increase the inflammatory action to promote healing C- To facilitate urinary excretion of salt and water after surgery D- To compensate for sudden lack of these hormones after surgery
D- To compensate for sudden lack of these hormones after surgery Adrenal steroids help an individual adjust to stress. Unless received from external sources, there is no hormone available to cope with surgical stresses after an adrenalectomy. Glucose stores (glycogen) will be used by the body to adapt to surgery. Insulin is the hormone that facilitates conversion of glucose to glycogen. Steroids do not increase inflammatory reactions. Steroids will result in fluid retention, not loss.
Which manifestations of surgically induced hypothyroidism might the client exhibit after a thyroidectomy?
Fatigue Dry skin Fatigue results from the decreased metabolic rate associated with hypothyroidism. Dry skin is caused by decreased glandular function. Insomnia is associated with hyperthyroidism (not hypothyroidism) because of the increased metabolic rate. Lethargy, not excitability, is associated with hypothyroidism because of the decreased metabolic rate. Weight gain, not loss, is associated with hypothyroidism because of the decreased metabolic rate. Intolerance to heat is associated with hyperthyroidism, not hypothyroidism.
A client is diagnosed with hyperthyroidism and is treated with I-131. Before discharge the nurse teaches the client to observe for signs and symptoms of therapy-induced hypothyroidism. Which signs and symptoms would be included in the teaching?
Fatigue Dry skin Progressive weight gain Fatigue is caused by a decreased metabolic rate associated with hypothyroidism. Dry skin most likely is caused by decreased glandular function associated with hypothyroidism. Progressive weight gain is associated with hypothyroidism in response to a decrease in the metabolic rate because of insufficient thyroid hormone. Insomnia is associated with hyperthyroidism, not hypothyroidism, in response to an increase in the metabolic rate because of excessive thyroid hormone. Intolerance to heat is associated with hyperthyroidism, not hypothyroidism, in response to an increase in the metabolic rate because of excessive thyroid hormone.
When preparing to safely administer medications to newborns, it is important for the nurse to recognize which factors as contributors to reduced renal medication excretion?
Renal blood flow Glomerular filtration Active tubular secretion In newborns, renal blood flow, glomerular filtration, and active tubular excretion contribute to reduction of renal medication excretion. Bladder capacity is not associated with the reduction of renal excretion in newborns. The nephron is a structural and functional unit of the kidneys.
