Immune Question sets
46.Which age should the nurse consider safe to administer the hepatitis B vaccine? 1.At birth. 2.At age 12 months. 3.At age 6 years. 4.At age 18 years.
Answer: 1 Rationale: 1.Infants born to mothers who are positive for hepatitis B surface antigen(HBsAg) should receive hepatitis B immunization within 12 hours of birth. All infants should receive the vaccine prior to discharge, but they may receive the first dose at any time before 2 months old. 2. The injection series should be started by age 2 months. 3. The injection series should be started by age 2 months. 4. The injection series should be started by age 2 months.
42.The mother of a child scheduled to receive a measles, mumps, and rubella vaccination asks the nurse, "What could happen to my child if I don't let you give the vaccination?" Which statement is the nurse's best response? 1."If your child gets one of the diseases, it could lead to serious complications." 2."Your child will not be allowed to attend any public school in the country." 3."Nothing can happen to you or the child if you don't get the vaccination." 4."You sound worried. Have you heard of problems associated with the shot?"
Answer: 1 Rationale: 1.Potential complications of measles include blindness and deafness. Potential complications of mumps include aseptic meningitis; for adolescent and adult males, orchitis is another com-plication. Potential complications for rubella include arthritis in women and birth defects or miscarriage for pregnant women. 2. The public school system encourages all children to be immunized according to the Centers for Disease Control and Prevention guidelines, but there are exceptions. The nurse should know the requirements for the state where the nurse is practicing. 3.Immunizations prevent many illnesses. 4. This parent is asking for information, not a therapeutic conversation.
49.The parent of a child about to receive the intramuscular polio vaccine, inactivated poliovirus vaccine (IPV), asks the nurse "Why can't my child get the oral vaccine like I took when I was a child?" Which statement by the nurse is the best explanation to give the client? 1."I don't know why, but the manufacturer has stopped making the oral drug." 2."There were some cases of polio that developed from the oral vaccine." 3."I will check with your health-care provider and see about changing the order." 4."The intramuscular route is more effective in preventing polio than the oral route."
Answer: 2 Rationale: 1. The nurse should be aware of important information regarding the medications being administered so that the nurse can inform the clients. 2. The manufacture of the oral vaccine has been discontinued because several children developed polio from the live virus. The intramuscular vaccine is the only vaccine available. It is an inactivated form of the virus. 3.There is no reason to ask the HCP for a change of order. 4.Both vaccines prevented polio, but the oral route also caused polio in some children.
44.Which clients should the nurse question administering a live virus vaccine? Select all that apply. 1.The child who is afraid of needles and health-care personnel. 2.The child who lives with a grandparent undergoing chemotherapy. 3.The child who has not received an immunization previously. 4.The child whose parents are Jehovah's Witnesses. 5.The child on prednisone who is immunosuppressed.
Answer: 2, 5 Rationale: 1.Most children are afraid of being hurt by the injections, but this is not a reason to question administering the injection. 2. The child will shed the vaccine in the urine and feces. The grandparent is immunocompromised as a result of the chemotherapy and could become ill. This child should receive an inactivated vaccine. The nurse should question this vaccine. 3. This is a reason to give the vaccine, not question it. 4.Jehovah's Witnesses do not refuse vaccinations because of religious beliefs. 5. This child is immunocompromised and could become ill and should receive an inactivated vaccine.
45.The nurse is preparing to administer measles, mumps, and rubella vaccinations to a15-month-old child. Which description is the correct administration procedure? 1.Inject the medication into the dorso gluteal muscle. 2.Use the deltoid muscle for the injection. 3.Administer the medication into the vastus lateralis muscle. 4.Give subcutaneously in the abdomen.
Answer: 3 Rationale: 1. This is not a safe administration site for a15-month-old child. 2. This is not the best site for a toddler. 3.Infants and toddlers should receive intramuscular injections in the vastus lateralis muscle, the large muscle of the thigh. This muscle is large and away from any nerves that could be damaged by the injection. 4. The immunizations are given intramuscularly, not subcutaneously.
41.The nurse in the pediatrician's office is recording a child's immunizations. Which information is the nurse required to document? 1.The vaccinations the client should have received. 2.Centers for Disease Control and Prevention guidelines for the client. 3.The vaccination type, manufacturer, and lot number. 4.The date the next required vaccination should be administered.
Answer: 3 Rationale: 1. This may be important information to give to the parent, but it is not the legal requirement for documentation of immunizations. 2. This may be important information to give to the parent, but it is not the legal requirement for documentation of immunizations. 3. The National Childhood Vaccine Act of 1986 requires that a permanent record of the vaccinations a child receives be maintained. The required information is date of the vaccination; route and site of the vaccination; vaccine type, manufacturer, lot number, and expiration date; and the name, address, and title of the person administering the vaccination 4. This may be important information to give to the parent, but it is not the legal requirement for documentation of immunizations.
47.The clinic nurse is discussing immunizations with the parent of a male child diagnosed with type 1 diabetes mellitus. Which information should the nurse teach the client? 1.The child should not receive immunizations because of the diabetes. 2.The child is at greater risk of complications from immunizations. 3.The child will not mind the injections because he is used to them. 4.The child should receive a flu vaccination every year.
Answer: 4 Rationale: 1. The child has a chronic disease, and it is very important for the child to receive all immunizations. 2. The child is at greater risk of complications of the illnesses the immunizations prevent because of the diabetes. The child should receive all recommended immunizations. 3. The child does not "get used" to the needles, and the child likely will mind the injections. 4.Children with chronic illnesses are encouraged to receive a yearly flu vaccine.
73. The nurse is caring for a client who has been diagnosed as having an acute kidney injury. What diagnostic test is most effective in confirming this diagnosis? 1. Renal biopsy 2. Ultrasonography 3. Computed tomography scan 4. Magnetic resonance imaging
Correct answer: 1 Rationale: A renal biopsy is considered the best method for confirming intrarenal causes of acute kidney injury (AKI). Magnetic resonance imaging (MRI) and computed tomography (CT) scans contain contrast mediums that can be harmful to clients. An ultrasound study is not definitive and may not provide enough information.
93. The nurse is caring for a client with a diagnosis of Chlamydia. Because the client has a history of noncompliance with medication administration, the health care provider prescribes azithromycin. When educating the client about azithromycin, the nurse should make which statement? 1. "One dose of this medication will be needed." 2. "This medication is given only every 72 hours." 3. "You will need to take this medication every 6 hours." 4. "You will need to return tomorrow for your second dose."
Correct answer: 1 Rationale: Azithromycin is a macrolide antibiotic. The usual pharmacological treatment for urethral, cervical, or rectal chlamydial infections is doxycycline or azithromycin. Azithromycin is often prescribed when compliance may be a problem because only one dose is needed; however, expense is a concern with this medication. The responses in the remaining options are incorrect.
16. The nurse is caring for a client who is going to have arthrography with a contrast medium. Which assessment by the nurse would be of highest priority? 1. Allergy to iodine or shellfish 2. Whether the client wishes to void before the procedure 3. Ability of the client to remain still during the procedure 4. Whether the client has any remaining questions about the procedure
Correct answer: 1 Rationale: Because of the risk of allergy to contrast dye, the nurse places highest priority on assessing whether the client has an allergy to iodine or shellfish. The nurse also reinforces information about the test, assists the client to void before the procedure, and tells the client about the need to remain still during the procedure.
55. The home health nurse is visiting a client who has been started on therapy with clotrimazole. The nurse should monitor which item to monitor the effectiveness of this medication with each visit? 1. Rash 2. Fever 3. Pain relief 4. Sore throat
Correct answer: 1 Rationale: Clotrimazole is a topical antifungal agent used in the treatment of cutaneous fungal infections. The nurse monitors the effectiveness of this medication by noting the presence or absence of a skin rash, which is characteristic of this infection. Fever, pain relief, and sore throat are unrelated to the use of this medication.
86. A client has a prescription for ketoconazole. Which instruction should the nurse include in the client's teaching plan? 1. Avoid exposure to sunlight. 2. Take the medication with an antacid. 3. Take the medication on an empty stomach. 4. Limit alcohol consumption to 2 ounces per day.
Correct answer: 1 Rationale: Ketaconazole is an antifungal medication. The client also should avoid exposure to sunlight because the medication increases photosensitivity. Antacids should be avoided for 2 hours after ketoconazole is taken because gastric acid is needed to activate the medication; however, it should be taken with food. The client should avoid concurrent use of alcohol because the medication is hepatotoxic.
122. Ketoconazole is prescribed for an assigned client. The nurse prepares to administer the medication by which method? 1. With food 2. With an antacid 3. With 8 oz (235 ml) of water 4. On an empty stomach
Correct answer: 1 Rationale: Ketoconazole is an antifungal medication. It should be administered with food to minimize gastrointestinal irritation. The remaining options are incorrect. The medication requires acidity and should be administered at least 2 hours apart from an antacid.
74. A clinic nurse is reviewing the record of a client with a suspected diagnosis of pernicious anemia. The nurse anticipates that which diagnostic test will be prescribed by the client's health care provider? 1. Schilling test 2. Clotting time 3. Bone marrow biopsy 4. White blood cell differential
Correct answer: 1 Rationale: The Schilling test is used to determine the cause of vitamin B12 deficiency, which leads to pernicious anemia. This test involves the use of a small oral dose of radioactive B12, followed by a large nonradioactive intramuscular (IM) dose. The IM dose helps flush the oral dose into the urine if it was absorbed. A 24-hour urine collection is performed to measure the amount of radioactivity in the urine. Clotting time and a white blood cell differential count are not significantly related to pernicious anemia and would not be helpful in determining the diagnosis. A bone marrow biopsy is indicated in a client suspected of having leukemia.
85. A client is receiving tobramycin. The nurse evaluates that the medication therapy is effective if which laboratory test result is noted? 1. WBC count of 8000 mm3 (8 × 109/L) and a creatinine level of 0.9 mg/dL (79.5 mcmol/L) 2. Sodium level of 145 mEq/L (145 mmol/L)and chloride level of 106 mEq/L (106 mmol/L) 3. Sodium level of 140 mEq/L (140 mmol/L) and potassium level of 3.9 mEq/L (3.9 mmol/L) 4. White blood cell (WBC) count of 15,000 mm3 (15 × 109/L) and a blood urea nitrogen level of 38 mg/dL (13.7 mmol/L)
Correct answer: 1 Rationale: Tobramycin is an antibiotic (aminoglycoside) that causes nephrotoxicity and ototoxicity. The medication is working if the WBC count drops back into the normal range and kidney function remains normal. A WBC count of 15,000 mm3 (15 × 109/L) is elevated, indicating that infection is still present. The sodium, chloride, and potassium levels are all normal values and are unrelated to the effectiveness of this medication.
84. A client receiving a dose of intravenous vancomycin begins to experience chills, tachycardia, syncope, and flushing of the face and trunk. What is the nurse's best interpretation of these findings? 1. The medication is infusing too rapidly. 2. The client is allergic to the medication. 3. The client is experiencing upper airway obstruction. 4. The medication has interacted with another medication the client is receiving.
Correct answer: 1 Rationale: Vancomycin is an antibiotic. The client is experiencing manifestations of what is called "red neck syndrome." This is a response due to histamine release that occurs with rapid or bolus injection of this medication. The client may experience chills, fever, flushing of the face or trunk, tachycardia, syncope, tingling, and an unpleasant taste in the mouth. The corrective action is to administer the medication more slowly. An antihistamine such as diphenhydramine may be administered as well. Although the client can experience an allergic reaction to the medication, the manifestations in the question best describe "red neck syndrome." There is no indication that the client is experiencing an upper airway obstruction. In addition, there are no data in the question that indicate that the client is taking another medication.
56. Levofloxacin is prescribed for a client. While teaching the client about the medication, what should the nurse tell the client to take the medication with? 1. Water 2. An antacid 3. A zinc preparation 4. An iron supplement
Correct answer: 1 Rationale: Levofloxacin is a fluoroquinolone and should be administered with water. Antacids, zinc, and iron supplements decrease absorption and should be taken at least 4 hours before or 2 hours after the medication.
98. The nurse is presenting information on treatment of influenza and the use of oseltamivir. The nurse should provide which information on the use of oseltamivir? Select all that apply. 1. The incidence of flu complications is reduced. 2. Oseltamivir is effective for all types of influenza. 3. Dosing must begin within 2 days after symptom onset. 4. No interactions with other medications have been reported. 5. It is best to begin dosing within the first 12 hours after symptom onset. 6. Oseltamivir is highly toxic to the liver, and liver function studies must be performed.
Correct answer: 1, 2, 3, 4, 5 Rationale: Options 1 through 5 are correct. Oseltamivir is an antiviral medication that reduces complications of the flu and is effective for all flu types. Treatment must begin early, no later than 2 days after symptom onset, and preferably much sooner, even during the first 12 hours, because benefits decline greatly when treatment is delayed. It has no reported interactions with other medications. The only major side effects are nausea and vomiting. It is not toxic to the liver.
10. A stool smear for culture needs to be obtained from a client. What steps should the nurse plan to implement when obtaining the specimen? Select all that apply. 1. Wearing sterile gloves 2. Using a sterile container 3. Refrigerating the specimen 4. Sending the specimen directly to the laboratory 5. Positioning the client in a dorsal recumbent position
Correct answer: 1, 2, 4 Rationale: A stool smear specimen is obtained using sterile gloves and a sterile container. {It is very important to use a wooden applicator to put the stool in the sterile container; it is NOT necessary to obtain the first bowel movement of the day.} After obtaining the specimen, the stool is sent immediately to the laboratory. Storing a stool specimen for culture in a refrigerator is contraindicated because it can retard the growth of organisms. The client needs to be positioned in a lateral recumbent position to obtain the sample.
12. Ketoconazole is prescribed for a client. Which interventions should the nurse include when teaching the client about the medication? Select all that apply. 1. Avoid alcohol. 2. Restrict fluid intake. 3. Avoid exposure to the sun. 4. Prepare for periodic liver function studies. 5. Administer the medication with an antacid. 6. Administer the medication on an empty stomach.
Correct answer: 1, 3, 4 Rationale: Ketoconazole is an antifungal medication. There is no reason for the client to restrict fluid intake; in fact, this could be harmful to the client. The medication is hepatotoxic, and the nurse monitors liver function. It is administered with food (not on an empty stomach) and antacids are avoided for 2 hours after taking the medication to ensure absorption. The client is also instructed to avoid alcohol. In addition, the client is instructed to avoid exposure to the sun because the medication increases photosensitivity.
4. The nurse provides information to a client scheduled for a dual x-ray absorptiometry (DEXA) test. Which information should the nurse provide to the client? Select all that apply. 1. It is a painless test. 2. It emits slightly more radiation than a chest x-ray does. 3. Upper body clothing will need to be removed for testing. 4. Increased fluid intake is necessary following the procedure. 5. Metallic objects such as jewelry or belt buckles may interfere with the test and need to be removed.
Correct answer: 1, 5 Rationale: The most commonly used screening and diagnostic tool for measuring bone mineral density is the dual x-ray absorptiometry (DEXA) test. It is a painless test that emits less radiation than a chest x-ray. A height is taken before the start of the test. The client stays dressed but is asked to remove any metallic objects such as belt buckles, coins, keys, or jewelry because they may interfere with testing. No special follow-up care for the test is necessary.
68. The nurse is providing instructions to a client who is scheduled for a gallium scan. Which statement made by the client indicates an understanding of the instructions? 1. "The procedure will take all day." 2. "I need to have an injection 2 to 3 hours before the procedure." 3. "I will need to avoid food and fluids and remain on bed rest for 2 days after the procedure." 4. "I need to get a good night's rest because I will have to stand for several hours for this test."
Correct answer: 2 Rationale: A gallium scan is similar to a bone scan but with injection of gallium isotope instead of radioisotope. Gallium is injected 2 to 3 hours before the procedure. The procedure takes 30 to 60 minutes to perform. The client needs to lie still during the procedure. There is no special aftercare.
46. Tobramycin sulfate is prescribed. The nurse is administering the medication by intermittent intravenous infusion every 8 hours. The nurse monitors the client for signs of an adverse effect related to this medication and determines that which, if noted on assessment, would indicate its presence? 1. Client complaint of diarrhea 2. Client complaint of ringing in the ears 3. A white blood cell count of 6000 mm3 (6 × 109/L) 4. A blood urea nitrogen (BUN) of 10 mg/dL (3.6 mmol/L)
Correct answer: 2 Rationale: Adverse effects of tobramycin sulfate[an aminoglycoside] include nephrotoxicity as evidenced by an increased BUN and serum creatinine; irreversible ototoxicity as evidenced by tinnitus, dizziness, ringing or roaring in the ears, and reduced hearing; and neurotoxicity as evidenced by headaches, dizziness, lethargy, tremors, and visual disturbances. The normal BUN is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). A normal white blood cell count is 5000 to 10,000 mm3 (5 to 10 × 109/L). The correct option is the only one that indicates an adverse effect of the medication.
42. A client is receiving amoxicillin orally every 8 hours. Which finding would indicate to the nurse that the client is experiencing a frequent minor side effect related to the medication. 1. Fever 2. Vaginal drainage 3. Severe watery diarrhea 4. Severe abdominal cramps
Correct answer: 2 Rationale: Amoxicillin is a type of penicillin. Frequent minor side effects include gastrointestinal disturbances, headache, and oral or vaginal candidiasis (perineal itching). A less common but more harmful effect that can occur include superinfection, such as potentially fatal antibiotic-associated colitis, which results from altered bacterial balance. Symptoms and signs include abdominal cramps, severe watery diarrhea, and fever.
44. A client is receiving amphotericin B by the intravenous (IV) route. During ongoing therapy with this medication, the nurse should most closely assess the client for which finding that indicates a complication? 1. Decreased pulse 2. Decreased urine output 3. Decreased body temperature 4. Decreased blood urea nitrogen level
Correct answer: 2 Rationale: Amphotericin B is an antifungal medication and can cause side and adverse effects such as chills, fever, headache, vomiting, and impaired renal function. A decreased urine output is an indication of impaired renal function. Changes in the pulse and temperature are not related to impaired renal function. The blood urea nitrogen level would be elevated if renal function was impaired. The nurse monitors for these side and adverse effects and also carefully assesses the IV site because of the irritating effects of the medication.
38. A client is receiving amphotericin B by the intravenous (IV) route. The nurse determines that the client is having an adverse effect to the medication if which laboratory study result is noted? 1. Elevated platelet count 2. Elevated serum creatinine 3. Low white blood cell count 4. Lowered hemoglobin and hematocrit
Correct answer: 2 Rationale: Amphotericin B is an antifungal medication. It exerts direct toxicity on cells of the kidneys and causes renal impairment in most clients. To evaluate renal injury, tests of kidney function should be performed weekly, and intake and output should be monitored. If the serum creatinine level rises above 3.5 mg/dL (309 mcmol/L), the dose of amphotericin B should be reduced. The laboratory abnormalities in the remaining options are unrelated to the use of this medication.
104. A health care provider is about to perform a paracentesis for a client with abdominal ascites. The nurse assisting with the procedure should help the client into which position? 1. Supine 2. Upright 3. Right side-lying 4. Left side-lying
Correct answer: 2 Rationale: An upright position allows the intestine to float posteriorly and helps prevent intestinal laceration during catheter insertion. The client ideally sits upright in a chair, with the feet flat on the floor and with the bladder emptied before the procedure. Therefore, the remaining positions are incorrect.
40. Azithromycin has been prescribed for a client. The nurse should instruct the client to take the medication in which way? 1. With meals 2. 1 hour before meals 3. With an aluminum-containing antacid 4. With a magnesium-containing antacid
Correct answer: 2 Rationale: Azithromycin is a macrolide antibiotic. It should be taken 1 hour before or 2 hours after meals. It is not administered with meals, and it should not be taken with either aluminum- or magnesium-containing antacids.
29. The clinic nurse reads the results of a tuberculin skin test performed on a 5-year-old child who is at low risk for contracting tuberculosis. The results indicate an area of induration measuring 10 mm. How would the nurse interpret these results? 1. Positive 2. Negative 3. Inconclusive 4. Requiring a repeat test
Correct answer: 2 Rationale: Induration measuring 15 mm or greater is considered a positive result in a child 4 years of age or older who has no associated risk factors. {Please note that induration of 10 mm or greater is considered positive for TB with the exception of immunocompromised pt such as HIV/AIDS, then induration of 5 mm or greater is considered positive for TB} Options 1, 3, and 4 are incorrect interpretations.
97. The nurse is preparing to administer piperacillin/tazobactam. An abnormal elevation in which laboratory value should prompt the nurse to withhold the medication and notify the health care provider (HCP) before administering the medication? 1. Hematocrit and hemoglobin 2. Blood urea nitrogen and creatinine 3. Prothrombin time and partial thromboplastin time 4. Aspartate aminotransferase and alanine transaminase
Correct answer: 2 Rationale: Piperacillin/tazobactam is a penicillin-type antibiotic normally eliminated rapidly by the kidney but that can accumulate to harmful levels if renal function is severely impaired. Dosages must be reduced in clients with renal impairment. Therefore, an elevation in blood urea nitrogen and creatinine should be reported to the HCP for dosage adjustment.
49. The nurse is caring for a client after pulmonary angiography with catheter insertion via the left groin. Which assessment finding is related to an allergic reaction to the contrast medium? 1. Hypothermia 2. Decreased blood pressure 3. Hematoma in the left groin 4. Discomfort in the left groin
Correct answer: 2 Rationale: Signs of allergic reaction to the contrast dye include early signs such as localized itching and edema, which are followed by more severe symptoms such as respiratory distress, stridor, and decreased blood pressure. Hypothermia, discomfort in the left groin, and hematoma in the left groin are abnormal assessment findings but are not related to allergic reaction to the contrast medium.
86. The ambulatory care nurse is providing instructions to a client who is scheduled for a colonoscopy to remove a polyp. Which instructions are appropriate for client preparation for this procedure? 1. Clear liquids may be consumed starting 24 hours after the procedure. 2. A bowel preparation will be needed in preparation for the procedure. 3. Clear liquids only are allowed on the day of the scheduled procedure. 4. If blood-tinged stools are noted after the procedure, the health care provider should be notified.
Correct answer: 2 Rationale: The client should be instructed that bowel preparation with a laxative is prescribed before the procedure to cleanse the bowel. Oral intake is allowed after the procedure once the client is stable. A clear liquid diet is permitted on the day before the procedure (per health care provider preference), and then oral intake is avoided for 8 hours immediately before the procedure. If a polyp has been removed, the client is instructed that the stool may be tinged with blood. However, any signs of tenderness, abdominal pain, or bloody stools should be reported to the health care provider.
111. The health care provider (HCP) tells a client that a blood transfusion is needed and that a blood sample must be drawn first for blood typing and crossmatching. The nurse explains to the client what a typing and crossmatch test is for and why it is done. What response by the client about blood typing implies to the nurse that further teaching is needed? 1. "It is an antigen found on the surface of the red blood cell." 2. "It is an antibody found on the surface of the red blood cell." 3. "An acute transfusion reaction can happen if I get blood incompatible with mine." 4. "If I have group AB blood, I'm a universal recipient because I have no antibodies to react to the transfused blood."
Correct answer: 2 Rationale: The major blood types are A, B, AB, and O. The blood type indicates an antigen, not an antibody, found on the surface of the red blood cell. The other responses are accurate statements.
23. The nurse is preparing to obtain a sputum specimen from a client. Which nursing action will facilitate obtaining the specimen? 1. Limiting fluids 2. Having the client take 3 to 4 deep breaths 3. Asking the client to spit into the collection container 4. Asking the client to obtain the specimen after eating
Correct answer: 2 Rationale: To obtain a sputum specimen, the client should rinse the mouth to reduce contamination, breathe deeply, and then cough into a sputum specimen container. The client should be encouraged to cough and not spit so as to obtain sputum. Sputum can be thinned by fluids or by a respiratory treatment such as inhalation of nebulized saline or water. The optimal time to obtain a specimen is on arising in the morning.
2. The nurse caring for a client who is taking an aminoglycoside should monitor the client for which adverse effects of the medication? Select all that apply. 1. Seizures 2. Ototoxicity 3. Renal toxicity 4. Dysrhythmias 5. Hepatotoxicity
Correct answer: 2, 3, 4 Rationale: Aminoglycosides are administered to inhibit the growth of bacteria. Adverse effects of this medication include confusion, ototoxicity, renal toxicity, gastrointestinal irritation, palpitations or dysrhythmias, blood pressure changes, and hypersensitivity reactions. Therefore, the remaining options are incorrect.
100. The nurse is caring for a client who is scheduled to have a lumbar puncture (LP). What are some contraindications for a client to have an LP? Select all that apply. 1. Clients with an allergy to sulfa 2. Clients with infection near the LP site 3. Clients with increased intracranial pressure 4. Clients receiving anticoagulation medications 5. Clients with a history of migraine headaches 6. Clients who have severe degenerative vertebral joint disease
Correct answer: 2, 3, 4, 6 Rationale: Contraindications for clients having an LP performed include the following: those receiving anticoagulation medications, those with infection near the LP site, those with increased intracranial pressure, and those who have severe degenerative vertebral joint disease. Clients with an allergy to sulfa or with a history of migraine headaches are not contraindicated for having an LP performed.
46. The nurse is caring for a client who had intracranial surgery and is now suspected of having developed diabetes insipidus (DI). What initial prescription should the nurse expect from the health care provider (HCP)? 1. Serum electrolytes 2. Urine specific gravity 3. 24-hour fluid intake and output without restricting food or fluid intake 4. Postoperative magnetic resonance imaging to detect any damage to the hypothalamus or pituitary gland
Correct answer: 3 Rationale: The first step in diagnosing DI is to measure a 24-hour fluid intake and output without restricting food or fluid intake. All of the other options may be done but would not be as definitive as a 24-hour fluid intake and output test.
3. Ketoconazole is prescribed for a client with a diagnosis of candidiasis. Which interventions should the nurse include when administering this medication? Select all that apply. 1. Restrict fluid intake. 2. Monitor liver function studies. 3. Instruct the client to avoid alcohol. 4. Administer the medication with an antacid. 5. Instruct the client to avoid exposure to the sun. 6. Administer the medication on an empty stomach.
Correct answer: 2, 3, 5 Rationale: Ketoconazole is an antifungal medication. There is no reason for the client to restrict fluid intake; in fact, this could be harmful to the client. The medication is hepatotoxic, and the nurse monitors liver function. It is administered with food (not on an empty stomach) and antacids are avoided for 2 hours after taking the medication to ensure absorption. The client is also instructed to avoid alcohol. In addition, the client is instructed to avoid exposure to the sun because the medication increases photosensitivity.
98. The nurse is teaching a client about what to expect during a gallium scan. The nurse should include which item as part of the instructions? 1. The procedure is noninvasive. 2. The client must stand erect during the filming. 3. The procedure takes about 30 to 60 minutes to perform. 4. The client should remain on bed rest for the remainder of the day after the scan.
Correct answer: 3 Rationale: A gallium scan requires the injection of gallium isotope 2 to 3 hours before the procedure; therefore, the procedure is invasive. The procedure takes 30 to 60 minutes to perform. The client will lie down during the procedure and must lie still. There is no special aftercare.
7. Amikacin is prescribed for a client with a bacterial infection. The nurse instructs the client to contact the health care provider (HCP) immediately if which occurs? 1. Nausea 2. Lethargy 3. Hearing loss 4. Muscle aches
Correct answer: 3 Rationale: Amikacin is an aminoglycoside. Adverse effects of aminoglycosides include ototoxicity (hearing problems), confusion, disorientation, gastrointestinal irritation, palpitations, blood pressure changes, nephrotoxicity, and hypersensitivity. The nurse instructs the client to report hearing loss to the HCP immediately. Lethargy and muscle aches are not associated with the use of this medication. It is not necessary to contact the HCP immediately if nausea occurs. If nausea persists or results in vomiting, the HCP should be notified.
26. The nurse collects a 24-hour urine specimen for catecholamine testing from a client with suspected pheochromocytoma. The results of the catecholamine test are reported as epinephrine 20 mcg (109 nmol) and norepinephrine 100 mcg (590 nmol). The nurse should make which interpretation about this result? 1. Insignificant and unrelated to pheochromocytoma 2. Lower than normal, ruling out pheochromocytoma 3. Higher than normal, indicating pheochromocytoma 4. Normal results for a client with pheochromocytoma
Correct answer: 3 Rationale: Assays of catecholamines are performed on single-void urine specimens, 2- to 4-hour specimens, and 24-hour urine specimens. The normal range of urinary catecholamines is epinephrine <20 mcg/day (<109 nmol/day) and norepinephrine <100 mcg/day (<590 nmol/day), with higher levels occurring in pheochromocytoma. {Note: You do NOT have to know the normal values of catecholamines; yet, you must know that pheochromocytoma is a benign tumor of the adrenal MEDULLA that excessively secretes the catecholamines Epinephrine and Norepinephrine.}
99. The nurse asks the student nurse, "What does it mean when an antibiotic is classified as a bactericidal agent?" The nurse determines that the student nurse has a correct understanding when which statement is made? 1. "It has low efficacy." 2. "It has a very low potency." 3. "It kills the infectious agent." 4. "It slows the growth of the infectious agent."
Correct answer: 3 Rationale: Bactericidal agents cause bacterial cell death and lysis and thus kill the infectious agent. Potency refers to the strength of an antibiotic, and efficacy is related to antibiotic effectiveness. An antibiotic is classified as bacteriostatic if the agent slows bacterial growth, allowing the body to complete the cycle of destruction.
39. A client who has been diagnosed with pneumonia has been given a prescription for erythromycin. Client teaching about this medication should include which best instruction? 1. Take the medication with juice. 2. Take the medication with a meal. 3. Take the medication on an empty stomach. 4. Take the medication at bedtime with a snack.
Correct answer: 3 Rationale: Erythromycin is a macrolide antibiotic. Oral erythromycin should best be administered on an empty stomach with a full glass of water (1 hour before or 2 hours following ingestion of food). Some preparations may be administered with food if gastrointestinal upset occurs, but it is best to administer on an empty stomach.
108. The nurse is providing information to a client about a computed tomography (CT) scan of the head. Which statement should the nurse include when reviewing preparation for the CT with the client? 1. "You will need to stand up straight for the entire procedure." 2. "All scans require the injection of dye before the procedure." 3. "Each set of head scans takes less than 5 minutes to perform." 4. "You will need to remain on bed rest for 12 hours after the scan."
Correct answer: 3 Rationale: For a CT scan of the head, the client lies on a movable table in a head-holding device. Each set of head scans takes less than 5 minutes to perform. An iodinated contrast medium may or may not be used. No special aftercare is indicated, so the client may resume the usual diet and activity afterward.
20. The nurse is caring for a client who has undergone renal angiography using the left femoral artery for access. The nurse determines that the client is experiencing a complication of the procedure if which finding is observed? 1. Urine output, 50 mL/hr 2. Blood pressure, 110/74 mm Hg 3. Pallor and coolness of the left leg 4. Absence of hematoma in the left groin
Correct answer: 3 Rationale: Potential complications after renal angiography include allergic reaction to the dye; renal damage from the dye; and vascular complications, which include hemorrhage, thrombosis, or embolism. The nurse detects these complications by noting signs and symptoms of allergic reaction, decreased urine output, hematoma or hemorrhage at the insertion site, or signs of decreased circulation to the affected leg.
5. The nurse working in the outpatient radiology department is giving discharge instructions to a client who has had a bone scan. Which instruction should the nurse include in the client's teaching plan? 1. Report any feelings of nausea or flushing. 2. Avoid eating very much for the rest of the day. 3. Drink extra water for a day or so after the procedure. 4. Try to go up and down stairs at least twice before the end of the day.
Correct answer: 3 Rationale: The client should drink large amounts of water for 24 to 48 hours to excrete the radioisotope through the kidneys. No special diet or activity prescriptions or restrictions are required after a bone scan. Nausea or flushing would accompany allergic reaction to a dye, which is not used in this procedure.
70. The nurse notes that the health care provider has documented a suspected diagnosis of herpes zoster in the client's chart. The nurse should prepare the client for which diagnostic test to confirm this diagnosis? 1. Patch test 2. Skin biopsy 3. Culture of the lesion 4. Wood's lamp examination
Correct answer: 3 Rationale: With the classic presentation of herpes zoster, the clinical examination is diagnostic. A viral culture of the lesion provides the definitive diagnosis. Herpes zoster is caused by a reactivation of the varicella-zoster virus, the cause of chickenpox. A patch test is a skin test that involves the administration of an allergen to the skin's surface to identify specific allergies. A biopsy identifies tissue type. In a Wood's lamp examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin.
43. The nurse is creating a plan of care for a client who is receiving amphotericin B intravenously. A main component of the plan of care is monitoring for adverse effects related to the administration of this medication. Which should the nurse include in a list of manifestations to watch for? 1. Fatigue 2. Confusion 3. Visual difficulties 4. Increased urinary output
Correct answer: 3 Rationale: Amphotericin B is an antifungal. Vision and hearing alterations, seizures, hepatic failure, paresthesias (tingling, numbness, or pain in the hands and feet), and coagulation defects also occur. Other adverse effects include nephrotoxicity, which occurs commonly and is evidenced by decreased urine output. Cardiovascular toxicity (as evidenced by hypotension and ventricular fibrillation) and anaphylactic reaction occur rarely.
4. The nurse is caring for a client who has been taking a sulfonamide and should monitor for signs and symptoms of which adverse effects of the medication? Select all that apply. 1. Ototoxicity 2. Palpitations 3. Nephrotoxicity 4. Bone marrow suppression 5. Gastrointestinal (GI) effects 6. Increased white blood cell (WBC) count
Correct answer: 3, 4, 5 Rationale: Adverse effects of sulfonamides include nephrotoxicity, bone marrow suppression, GI effects, hepatotoxicity, dermatological effects, and some neurological symptoms, including headache, dizziness, vertigo, ataxia, depression, and seizures. Options 1, 2, and 6 are unrelated to these medications.
93. The nurse is developing a plan of care for a client who will be returning to the nursing unit after a percutaneous transhepatic cholangiogram. The nurse should include which intervention in the postprocedure plan of care? 1. Encourage fluid and food intake. 2. Allow the client bathroom privileges only. 3. Allow the client to sit in a chair for meals. 4. Place a sandbag or other approved device over the insertion site.
Correct answer: 4 Rationale: A percutaneous transhepatic cholangiogram is an x-ray of the biliary duct system that is taken with the use of an iodinated dye instilled via a percutaneous needle inserted through the liver into the intrahepatic ducts. This procedure may be done when a client has jaundice or persistent upper abdominal pain, although ultrasound scans and endoscopic retrograde cholangiopancreatography are usually the preferred tests. After this procedure, the nurse monitors the client's vital signs closely for indications of hemorrhage and observes the needle insertion site for bleeding and bile leakage. A sandbag or other pressure device is placed over the insertion site to prevent bleeding. Oral intake is avoided in the immediate postprocedure period in case surgery is necessary to control hemorrhage or bile extravasation, and the client is maintained on bed rest.
25. A client has just returned to a nursing unit following bronchoscopy. Which nursing intervention should the nurse implement? 1. Administering atropine intravenously 2. Administering small doses of a sedative 3. Encouraging additional fluids for the next 24 hours 4. Ensuring the return of the gag reflex before offering food or fluids
Correct answer: 4 Rationale: After bronchoscopy, the nurse keeps the client on NPO (nothing by mouth) status until the gag reflex returns because the preoperative sedation and local anesthesia impair swallowing and the protective laryngeal reflexes for a number of hours. Additional fluids are unnecessary because no contrast dye is used that would need flushing from the system. Atropine and a sedative would be administered before the procedure, not after.
94. A clinic nurse is providing instructions to a client who is scheduled for a glucose tolerance test. Which instruction should the nurse provide to the client in preparation for the test? 1. Eat a normal breakfast on the day of the test. 2. Take insulin as scheduled on the day of the test. 3. Eat a low-carbohydrate diet for at least 3 days before the test. 4. Avoid alcohol, coffee, and tea for 36 hours before and during the test.
Correct answer: 4 Rationale: Alcohol, coffee, and tea should be avoided for 36 hours before testing. Fasting is required from midnight before the test until the test is completed, although water is permitted. The client is told to discontinue insulin or oral hypoglycemic agents on the day of the test. The nurse instructs the client to consume a high-carbohydrate diet (at least 200 to 300 g of carbohydrate per day) for at least 3 days before the test and to discontinue oral contraceptives, corticosteroids, salicylates, and thiazide derivatives 3 days before the test.
74. Azithromycin is prescribed for a client. The nurse provides instructions to the client about the medication and emphasizes that it is best to take the medication with which item? 1. Milk 2. Antacid 3. The evening meal 4. Water on an empty stomach
Correct answer: 4 Rationale: Azithromycin is a macrolide antibiotic that has excellent tissue penetration properties and can reach high concentrations in infected tissues. It has a long duration of action, which allows it to be dosed once daily. Taking the medication with milk, an antacid, or food decreases both the rate and the extent of gastrointestinal absorption. Therefore, it is best to take the medication with water on an empty stomach.
17. A client suspected of having an abdominal tumor is scheduled for a computed tomography (CT) scan with dye injection. How should the nurse describe this test to the client? 1. The test may be painful. 2. The test will take approximately 2 hours. 3. Fluids will be restricted following the test. 4. The dye injected may cause a warm, flushing sensation.
Correct answer: 4 Rationale: CT scanning causes no pain and can take 15 to 60 minutes to perform. The dye may cause a warm, flushing sensation when injected. Fluids are encouraged following the procedure. If an iodine dye is used, the client should be asked about allergies to seafood or iodine.
54. The nurse is caring for a client with a urinary tract infection (UTI). The culture report reveals the presence of Pseudomonas aeruginosa. The nurse anticipates that which medication will be prescribed to treat the infection? 1. Isoniazid 2. Rifampin 3. Ethambutol 4. Ciprofloxacin
Correct answer: 4 Rationale: Ciprofloxacin is an antimicrobial agent that is used to treat UTIs caused by P. aeruginosa. The medications identified in the other options are antituberculosis medications.
63. A client is scheduled for a digital subtraction angiography study. After being provided information and instructions regarding the test, which statement by the client indicates that the teaching has been effective? 1. "The purpose of the test is to detect lesions in the brain." 2. "The purpose of the test is to inject medication into the bone." 3. "The purpose of the test is to examine the cerebrospinal column." 4. "The purpose of the test is to provide information about the blood vessels."
Correct answer: 4 Rationale: Digital subtraction angiography is a radiographic method to study the blood vessels. The nurse should explain to the client that the test provides information about the blood vessels. {Angiography indicates visualization of blood vessels and with ANGIOGRAPHY, a contrast is usually needed, so assess for allergy to seafood or iodine}. Options 1, 2, and 3 are incorrect.
39. A client has just returned from the cardiac catheterization laboratory. The left-sided femoral vessel was used as the access site. How should the nurse position the client? 1. Knee chest, with the foot of the bed elevated 2. Supine, with the head of the bed elevated 45 to 90 degrees 3. Semi Fowler's, with the knees placed on top of 1 pillow 4. Supine, with the head of the bed elevated about 15 degrees
Correct answer: 4 Rationale: Following cardiac catheterization, the extremity used for catheter insertion is kept straight for 4 to 6 hours. If the femoral artery was used, strict bed rest is necessary for 6 to 12 hours. The client may turn from side to side. The head of the bed is not elevated more than 15 degrees (unless otherwise prescribed) to prevent kinking of the blood vessel at the groin and possible arterial occlusion.
28. A client is scheduled to have a needle liver biopsy. During the procedure, the nurse should instruct the client to take which action? 1. Lie on the right side. 2. Assume a lithotomy position. 3. Breathe deeply as the needle is inserted. 4. Lie supine with the right arm over the head.
Correct answer: 4 Rationale: For the health care provider to have optimal access to the liver during a liver biopsy, the client should be instructed to lie in a supine position with the right arm over the head. {After liver biopsy, the pt should be kept on the affected (RIGHT) side.} Options 1 and 2 are not positions that would provide access to the liver. During a liver biopsy, the client needs to remain still and expire fully, not breathe deeply, while the needle is inserted.
27. A client who is receiving nitrofurantoin calls the clinic complaining of troublesome effects related to the medication. Which side or adverse effect(s) indicates the need to stop treatment with this medication? 1. Nausea 2. Anorexia 3. Diarrhea 4. Cough and chest pain
Correct answer: 4 Rationale: Gastrointestinal (GI) effects are the most frequent adverse reactions to this medication and can be minimized by administering the medication with milk or meals. Pulmonary reactions, manifested as dyspnea, chest pain, chills, fever, cough, and the presence of alveolar infiltrates on the x-ray should indicate the need to stop the treatment. These symptoms resolve in 2 to 4 days following discontinuation of this medication.
22. Itraconazole is prescribed for a client to treat a fungal infection. The nurse monitors the client closely for which manifestation that is indicative of an adverse effect? 1. Diarrhea 2. Headache 3. Increased urine output 4. Anorexia and abdominal pain
Correct answer: 4 Rationale: Itraconazole is an antifungal medication. Hepatitis is an adverse effect associated with the medication, and if anorexia of any degree, abdominal pain, unusual tiredness or weakness, dark urine, or jaundice develops, the health care provider should be notified.
28. Itraconazole is prescribed for a client with a fungal infection of the hands. The nurse provides instructions to the client about the medication. Which statement by the client indicates an understanding of the instructions? 1. "I should take the medication on an empty stomach." 2. "I should decrease my fluid intake while taking the medication." 3. "I may become unusually fatigued while taking this medication." 4. "If my urine becomes very dark in color, I should contact my health care provider (HCP)."
Correct answer: 4 Rationale: Itraconazole is an antifungal medication. The client should be instructed to take the medication with food because it increases the absorption of the medication. Fluid should be increased to prevent constipation, which can occur as a side effect. Hepatitis is an adverse reaction associated with the medication, and if anorexia of any degree, abdominal pain, unusual tiredness or weakness, dark urine, or jaundice develops, the HCP should be notified.
69. A client with acquired immunodeficiency syndrome is suspected of having cutaneous Kaposi's sarcoma. The nurse should prepare the client for which test to confirm the presence of this type of sarcoma? 1. Liver biopsy 2. Sputum culture 3. White blood cell count 4. Punch biopsy of the cutaneous lesions
Correct answer: 4 Rationale: Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis to the upper body and then to the face and oral mucosa. The lymphatic system, lungs, and gastrointestinal (GI) tract can become involved as well. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is by punch biopsy of cutaneous lesions and biopsy of pulmonary and GI lesions. The remaining options are incorrect and would not confirm the presence of Kaposi's sarcoma.
92. The school nurse is providing instructions to the parents of the children attending the school regarding the application of permethrin. Which action should the nurse tell the parents to take? 1. Apply permethrin before washing the hair. 2. Apply permethrin at bedtime and rinse it off in the morning. 3. Avoid saturating the hair and scalp when applying permethrin. 4. Allow permethrin to remain on the hair for 10 minutes and then rinse with water.
Correct answer: 4 Rationale: Permethrin is a medication that may be prescribed to treat scabies. The instructions for the use of permethrin include wash, rinse, and towel-dry the hair; apply sufficient volume to saturate the hair and scalp; allow the medication to remain on the hair for 10 minutes; and then rinse with water. The remaining options are incorrect instructions.
84. The clinic nurse is providing instructions to a client who is scheduled for a barium enema. What should the nurse instruct the client to do in preparation for this procedure? 1. Liquids are restricted for 24 hours after the test. 2. A clear liquid diet is required for 4 days before the test. 3. Laxatives should not be taken for at least 1 week before the test. 4. A low-fiber diet needs to be maintained for 1 to 3 days before the test.
Correct answer: 4 Rationale: Preparation for a barium enema includes maintaining a low-fiber diet for 1 to 3 days before the test. Clear liquids or water may be allowed 12 to 24 hours before the test. Laxatives and enemas may be prescribed before the test to cleanse the bowel. The client is encouraged to drink liquids after the procedure to facilitate the passage of barium.
113. A client with type 2 diabetes mellitus presents to the health care provider's office with a glycosylated hemoglobin (HgbA1C) level of 10.5%. Which statement by the client indicates an understanding of this test and its results? 1. "The results of the test are probably high because I ate a donut for breakfast this morning." 2. "The results of the test are probably low because I had not eaten anything for 12 hours before my blood was drawn." 3. "I know that I need to check my glycosylated hemoglobin before each meal and at bedtime, but I don't always do it. I will do it more regularly." 4. "Well, I have 3 months to really work on watching my diet and lowering my blood sugar. My next glycosylated hemoglobin test should be better then."
Correct answer: 4 Rationale: The HgbA1C test provides a measurement of glycemic control over the previous 2 to 3 months, with increases in the HgbA1C reflecting elevated blood glucose levels. An HgbA1C of less than 6% is recommended by most health care providers. Thus, option 4 is the correct one. Options 1 and 2 are incorrect, as HgbA1C measures glycemic control over a few months, and thus having fasted for a long time or having just eaten something does not affect HgbA1C. Option 3 is incorrect because clients check their blood glucose levels, not their HgbA1C, before meals and at bedtime.
85. A client recovering from cardiac surgery has a left pleural effusion and is about to undergo a thoracentesis. What position should the nurse place the client in for the procedure? 1. Dorsal recumbent 2. Left lateral, with the right arm supported by a pillow 3. Right side-lying, with the legs curled up into a fetal position 4. Upright and leaning forward with the arms on an over-the-bed table
Correct answer: 4 Rationale: The client undergoing thoracentesis usually sits in an upright position with the anterior thorax supported by pillows or leaning over an over-the-bed table. The client must be placed in a position that will enlist the aid of gravity in accessing and draining the effusion. The dorsal recumbent position is an inaccessible position. Any side-lying position will cause fluid to accumulate under that side, which is inaccessible to the health care provider. However, if the client cannot sit upright, the client will be placed in a side-lying position on the unaffected side, with the side to be tapped uppermost.
109. The nurse is caring for a client admitted with a diagnosis of systemic lupus erythematosus (SLE). A highly sensitive C-reactive protein (hsCRP) blood test is prescribed. What other blood test is often used along with the hsCRP? 1. Cardiac enzymes 2. Serum electrolytes 3. Complete blood count (CBC) 4. Erythrocyte sedimentation rate (ESR)
Correct answer: 4 Rationale: The hsCRP is a test to measure inflammation in clients with an autoimmune disease such as SLE and is often done with or instead of the ESR. Both tests are very useful for detecting inflammation anywhere in the body. Cardiac enzymes, serum electrolytes, and a CBC are incorrect.
76. A nursing student is assigned to an adult client who is scheduled for bone marrow aspiration. The coassigned nurse asks the nursing student about the possible sites that could be used for obtaining the bone marrow. The student demonstrates understanding of the procedure by identifying what as the correct aspiration site? 1. Ribs 2. Femur 3. Scapula 4. Iliac crest
Correct answer: 4 Rationale: The most common sites for bone marrow aspiration in the adult are the iliac crest and the sternum. These areas are rich in bone marrow and are easily accessible for testing. The ribs, femur, and scapula are incorrect options.
57. The nurse is scheduling diagnostic tests for a client. Which of the diagnostic tests prescribed should be performed last? 1. Barium enema 2. Barium swallow 3. Gallbladder series 4. Oral cholecystogram
Rationale: A barium swallow should be done after a barium enema or gallbladder series to prevent the contrast used in the barium swallow from obstructing the view of other organs. It takes several days for swallowed barium to pass completely out of the gastrointestinal tract.
How to prepare for MRI?
Remove all metal containting objects