Test Five Prep
A patient, who weighs 143 pounds, has a prescription for Garamycin at two mg/kg, IV, every eight hours. There is 100 mg in 50 ml solution on hand. The nurse should administer __________ milliliters to the patient with each dose. a. 45 b. 55 c. 65 d. 75
The correct answer is c. First convert 143 lbs to 65 kg.Multiple 65 kg x 2 mg/kg to get 130 mg q 8 hours.Multiple 130 mg x 50ml/100mg to get 65 ml q 8 hrs.
Patients with an ileostomy are at greater risk for dehydration and an electrolyte imbalance. True False
True
A cardiologist prescribes digoxin (Lanoxin) 125 mcg by mouth every morning for a client diagnosed with heart failure. The pharmacy dispenses tablets that contain 0.25 mg each. How many tablets should the nurse administer in each dose? Record your answer using one decimal place. ______ tablets
0.5. The nurse should begin by converting 125 mcg to milligrams. 125 mcg = 0.125 mg 1,000 The following formula is used to calculate drug dosages: Dose on hand = Dose desired Quantity on hand X The nurse should use the following equations: 0.25 mg = 0.125 mg 1 tablet X 0.25(X) = 0.125 X = 0.5 tablet
A patient's blood pressure continues to be elevated despite being prescribed an ACE inhibitor for several weeks. What should the nurse do at this time? 1. Ask if the patient is taking the prescribed medication. 2. Suggest to the physician that another medication be added. 3. Schedule the patient to have the blood pressure checked again in a week. 4. Realize the patient is anxious because of the diagnosis.
1. Ask if the patient is taking the prescribed medication.
The nurse is instructing a patient with hypertension about lifestyle modifications. What would be appropriate to include in the teaching for this patient? Select all that apply. 1. Review the DASH diet. 2. Begin a walking program, and progress to 30 minutes 5 to 6 days each week. 3. Plan a weight lifting regimen. 4. Eliminate dairy products from the diet. 5. Restrict fluid intake.
1. Review the DASH diet. 2. Begin a walking program, and progress to 30 minutes 5 to 6 days each week.
A patient with hypertension is prescribed the alpha-adrenergic blocker doxazosin (Cardura). What should the nurse instruct the patient about this medication? Select all that apply. 1. Take the medication at bedtime. 2. Change positions slowly and sit down if dizziness occurs. 3. Notify the primary healthcare provider if nasal congestion develops. 4. Restrict the intake of all alcoholic beverages and items containing caffeine. 5. Avoid engaging in hazardous activity for 12 to 24 hours after the first dose.
1. Take the medication at bedtime. 2. Change positions slowly and sit down if dizziness occurs. 3. Notify the primary healthcare provider if nasal congestion develops. 5. Avoid engaging in hazardous activity for 12 to 24 hours after the first dose.
The client is scheduled to have an upper gastrointestinal tract series of x-rays. Following the x-rays, the nurse should instruct the client to: 1. Take a laxative. 2. Follow a clear liquid diet. 3. Administer an enema. 4. Take an antiemetic.
1. The client should take a laxative after an upper gastrointestinal series to stimulate a bowel movement. This examination involves the administration of barium, which must be promptly eliminated from the body because it may harden and cause an obstruction. A clear liquid diet would have no effect on stimulating removal of the barium. The client should not have nausea and an antiemetic would not be necessary; additionally, the antiemetic will decrease peristalsis and increase the likelihood of eliminating the barium. An enema would be ineffective because the barium is too high in the gastrointestinal tract.
While conducting an assessment, the nurse suspects that a patient is experiencing a hypertensive crisis. What did the nurse assess to make this clinical decision? Select all that apply. 1. acute onset of confusion 2. onset of projectile vomiting 3. complaints of a severe headache 4. systolic blood pressure 198 mmHg 5. diastolic blood pressure 148 mmHg
1. acute onset of confusion 3. complaints of a severe headache 4. systolic blood pressure 198 mmHg 5. diastolic blood pressure 148 mmHg Rationale: Manifestations of hypertensive crisis include confusion, headache, diastolic blood pressure greater than 120 mmHg, and systolic blood pressure greater than 180 mmHg. Projectile vomiting is not a manifestation of hypertensive crisis.
The nurse suspects that a patient's hypertension is being influenced by sympathetic nervous system stimulation. Which substances should the nurse identify as contributing to this patient's elevated blood pressure? Select all that apply. 1. epinephrine 2. angiotensin II 3. norepinephrine 4. adrenomedullin 5. antidiuretic hormone
1. epinephrine 2. angiotensin II 3. norepinephrine 5. antidiuretic hormone Rationale: Epinephrine and norepinephrine, and the hormones angiotensin II and antidiuretic hormone are vasoconstrictors that increase the blood pressure. Adrenomedullin is a hormone that decreases blood pressure.
The nurse suspects a patient receiving a blood transfusion is experiencing a hypersensitivity reaction. What action should the nurse perform first? 1. Discard the product immediately 2. Replace all tubing and attach a new line with normal saline. 3. Flush the line and run normal saline attached at the Y connection. 4. Remove the intravenous catheter and establish access distal to the site.
2 Rationale: When a hypersensitivity reaction is suspected, it is important to avoid any further exposure to the potential cause. The best way to do this is by replacing all tubing and attaching a new intravenous line primed with normal saline. The blood product is usually returned to the blood bank in the event of a hypersensitivity reaction. flushing the line and running normal saline attached at the Y connection does not reduce exposure to the blood product. The intravenous catheter does not need to be removed; instead, the blood transfusion needs to be stopped.
A client is prescribed diltiazem (Car dizem) to manage his hypertension. The nurse should tell the client the diltiazem will: 1. lower his blood pressure only. 2. lower his heart rate and blood pressure. 3. lower his blood pressure and increase his urine output. 4. lower his heart rate and blood pressure and increase his urine output
2. Diltiazem, a calcium channel blocker, will reduce both the heart rate and blood pressure. It doesn't directly affect urine output.
A client with major abdominal trauma needs an emergency blood transfusion. The client's blood type is AB negative. Of the blood types available, the safest type for the nurse to administer is: 1. AB positive. 2. A positive. 3. B negative. 4. O positive.
3. Individuals with AB negative blood (AB type, Rh negative) can receive A negative, B negative, and AB negative blood. It's unsafe to give Rh-positive blood to an Rh-negative person.
The nurse is teaching a community education class on hypertension and risk factors for this disorder. What is the primary risk factor leading to the higher incidence of hypertension in older adults? 1. being a black adult 2. being a white male 3. having a family history of hypertension 4. age-related increase in the systolic blood pressure
4. age-related increase in the systolic blood pressure
A patient, who has a colostomy, asks what type of foods they should avoid to decrease odorous gas. You would tell the patient to avoid:* A. Onions, alcoholic beverages, eggs, and cabbage B. Beef, fried foods, lettuce, and rice C. Apple, pears, nuts, and wheat D. Potatoes, peas, carrots, and chicken
A
A patient is demonstrating signs of ineffective peripheral tissue perfusion. What intervention would be appropriate for this patient? 1. Encourage patient to reduce level of exercise. 2. Discuss smoking cessation techniques. 3. Keep extremities cool. 4. Assist with pillow placement under knees.
2. Discuss smoking cessation techniques.
The nurse is making initial rounds at the beginning of the shift and notes that the TPN bag of an assigned patient is empty. Which solution should the nurse hang until another bag of TPN is mixed and delivered to the nursing unit? A. 5% Dextrose in water B. 10% Dextrose in water C. 5% Dextrose in Ringer's lactate D. 5% Dextrose in in 0.9% NS
B. 10% dextrose in water
After administering a dose of promethazine (Phenergan) to a patient with nausea and vomiting, what common temporary adverse effect of the medication does the nurse explain may be experienced? A. Tinnitus B. Drowsiness C. Reduced hearing D. Sensation of falling
B. Drowsiness Although being given to this patient as an antiemetic, promethazine also has sedative and amnesic properties. For this reason, the patient is likely to experience drowsiness as an adverse effect of the medication. Tinnitus, reduced hearing, and loss of balance are not side effects of promethazine.
A nurse is preparing to hang the first bag of TPN solution via a central line in the patient. The nurse should obtain which most essential piece of equipment before hanging the solution? A. Urine test strips B. Blood glucose meter C. Electronic infusion pump D. Noninvasive BP monitor
C. Electric infusion pump
A patient with a history of peptic ulcer disease has presented to the emergency department reporting severe abdominal pain and has a rigid, boardlike abdomen that prompts the health care team to suspect a perforated ulcer. What intervention should the nurse anticipate? A. Providing IV fluids and inserting a nasogastric (NG) tube B. Administering oral bicarbonate and testing the patient's gastric pH level C. Performing a fecal occult blood test and administering IV calcium gluconate D. Starting parenteral nutrition and placing the patient in a high-Fowler's position
A. Providing IV fluids and inserting a nasogastric (NG) tube A perforated peptic ulcer requires IV replacement of fluid losses and continued gastric aspiration by NG tube. Nothing is given by mouth, and gastric pH testing is not a priority. Calcium gluconate is not a medication directly relevant to the patient's suspected diagnosis, and parenteral nutrition is not a priority in the short term.
A client receiving total parenteral nutrition (TPN) exhibits symptoms of congestive heart failure (CHF) and pulmonary edema. Which complication of TPN is the client most likely experiencing? A. Calcium imbalance B. Fluid volume deficit C. Fluid volume overload D. Potassium imbalance
Answer C. Rationales: Incorrect: This client's symptoms are not indicative of calcium imbalance. Incorrect: This client's symptoms are not indicative of fluid deficit. Correct: Congestive heart failure and pulmonary edema are symptoms of fluid overload Incorrect: This client's symptoms are not indicative of potassium imbalance.
An RN receives the change-of-shift report about these clients. Which client does the nurse assess first? A. 30-year-old admitted 2 hours ago with malnutrition that is associated with malabsorption syndrome B. 45-year-old who had gastric bypass surgery and is reporting severe incisional pain C. 50-year-old receiving total parenteral nutrition (TPN) with a blood glucose (BG) level of 300 mg/dL D. 75-year-old with dementia who is receiving nasogastric feedings and has a respiratory rate of 38 breaths/min
Answer D. Rationales: Incorrect: The client admitted 2 hours ago with malnutrition needs assessments and/or interventions by the RN, but maintaining respiratory function in the client with tachypnea is the highest priority. Incorrect: The client who had gastric bypass surgery and is reporting severe incisional pain needs assessments and/or interventions by the RN, but maintaining respiratory function in the client with tachypnea is the highest priority. Incorrect: The client receiving TPN with a BG level of 300 mg/dL needs assessments and/or interventions by the RN, but maintaining respiratory function in the client with tachypnea is the highest priority. Correct: Aspiration is a major complication in clients receiving tube feedings, especially in clients with an altered level of consciousness. This client needs respiratory assessment and interventions immediately.
A client is discharged home with an enteral feeding tube. What does the home health nurse do to determine the patency of the client's enteral tube? A. Arranges for the client to have an x-ray performed . Auscultates the client's abdomen for bowel sounds before each feeding C. Instills air into the tube to check for placement and patency before each feeding D. Tests aspirated tube contents for pH level before each feeding
Answer D. Rationales: Incorrect: The client should have an x-ray performed when the enteral tube is initially inserted. Incorrect: The presence of bowel sounds does not indicate that the enteral tube is in place. Incorrect: This traditional auscultatory method for checking enteral tube placement is not reliable, especially for the client with a small-bore tube. Correct: This is considered to be the most accurate method for confirming enteral tube placement.
A client is brought to the emergency department having experienced blood loss due to a deep puncture wound. A 3 unit Fresh-frozen plasma (FFP) is ordered. The nurse determines that the reason behind this order is to:
Answer: A. Provide clotting factors and volume expansion. Fresh-frozen plasma may be used to provide clotting factors or volume expansion. It is rich in clotting factors and can be thawed quickly and transfused right away. Option B is incorrect since it will not specifically increase the hemoglobin, hematocrit, and neutrophil level. Options C and D are incorrect since FFP does not contain any platelet.
Nurse Paulo has received a blood unit from the blood bank and has rechecked the blood bag properly with nurse Edward. Prior the facilitation of the blood transfusion, nurse Paulo priority check which of the following? A. Intake and output. B. NPO standing order. C. Vital signs. D. Skin turgor.
Answer: C. Vital signs. The nurse must assess the vital signs before and 15 minutes after the procedure so that any changes during the transfusion may indicate a transfusion reaction is happening.
Nurse Daniel is caring for a client receiving a transfusion of packed red blood cells (PRBCs). The client started to vomit and to be nauseous. Client's blood pressure is 95/40 mm Hg from a baseline of 110/70 mm Hg. The client's temperature is 100.5°F orally from a baseline of 99.5°F orally. The nurse understand that the client may be experiencing which of the following? A. Circulatory overload. B. Delayed transfusion reaction .C. Hypocalcemia. D. Septicemia.
Answer: D. Septicemia. Septicemia happens with the transfusion of blood that is contaminated with microorganisms. Assessment includes rapid onset of high fever and chills, hypotension, nausea, diarrhea, vomiting, and shock. Option A: Circulatory overload causes hypertension, cough, dyspnea, chest pain, tachycardia, and wheezing upon auscultation. Option B: Delayed reaction can occur days to years after a transfusion. It causes, fever, rashes, mild jaundice, and oliguria or anuria. Option C: Hypocalcemia causes paresthesias, tetany, muscle cramps, hyperactive reflexes, positive Trousseau's sign, and positive Chovstek's sign.
Nurse Jay is caring for a client with an ongoing transfusion of packed RBC's when suddenly the client is having difficulty of breathing, skin is flushed and having chills. Which action should nurse Jay take first? A. Administer oxygen.B. Place the client on droplight.C. Check the client's temperature.D. Stop the transfusion.
Answer: D. Stop the transfusion. The client in this situation is experiencing transfusion reaction so the priority action of the nurse is to first stop the transfusion.
The nurse explains to the patient with gastroesophageal reflux disease that this disorder: A. results in acid erosion and ulceration of the esophagus caused by frequent vomiting B. will require surgical wrapping or repair of the pyloric sphincter to control the symptoms C. is the protrusion of a portion of the stomach into to esophagus through an opening in the diaphragm D. often involves relaxation of the lower esophageal sphincter, allowing stomach contents to back up into the espophagus
Answer: D. The acidic contents of the stomach touching the inside of the esophagus are responsible for the physical sensation known as "heart-burn" that is a cardinal symptom of GERD
After a healthcare provider prescribed propranolol for a pt with frequent premature ventricular contractions, the nurse should include with of the following in the care plan? A. inform pt that excessive respiratory response to activity should gradually decrease B. measure heart rate daily before taking dose C. Pt will have increased resistance to infection D. current skin eruptions will improve within 30 days
B
Mira is managing her hypertension with an ACE inhibitor. Which of the following statements stated by her indicates a need for further teaching? A. I should not take my pills with food B. I need to increase my intake of orange juice, bananas, and green veggies C. I will avoid coffee, tea, and cola D. I will avoid salt substitutes
B
You're providing diet teaching to a patient with an ileostomy. Which foods should the patient consume in very small amounts or completely avoid? A. Peanut butter, bananas, rice B. Corn, popcorn, nut and seeds C. Grape juice, bread, and pasta D. Vinegar, soft drinks, and cured meats
B
A 61-year-old patient with suspected bowel obstruction had a nasogastric tube inserted at 4:00 AM. The nurse shares in the morning report that the day shift staff should check the tube for patency at what times? A. 7:00 AM, 10:00 AM, and 1:00 PM B. 8:00 AM, 12:00 PM, and 4:00 PM C. 9:00 AM and 3:00 PM D. 9:00 AM, 12:00 PM, and 3:00 PM
B. 8:00 AM, 12:00 PM, and 4:00 PM A nasogastric tube should be checked for patency routinely at 4-hour intervals. Thus if the tube were inserted at 4:00 AM, it would be due to be checked at 8:00 AM, 12:00 PM, and 4:00 PM.
The patient who is admitted with a diagnosis of diverticulitis and a history of irritable bowel disease and gastroesophageal reflux disease (GERD) has received a dose of Mylanta 30 mL PO. The nurse should evaluate its effectiveness by questioning the patient as to whether which symptom has been resolved? A. Diarrhea B. Heartburn C. Constipation D. Lower abdominal pain
B. Heartburn Mylanta is an antacid that contains both aluminum and magnesium. It is indicated for the relief of GI discomfort, such as heartburn associated with GERD. Mylanta can cause both diarrhea and constipation as a side effect. Mylanta does not affect lower abdominal pain.
The nurse is planning care for a 68-year-old patient with an abdominal mass and suspected bowel obstruction. Which factor in the patient's history increases the patient's risk for colorectal cancer?A. Osteoarthritis B. History of colorectal polyps C. History of lactose intolerance D. Use of herbs as dietary supplements
B. History of colorectal polyps A history of colorectal polyps places this patient at risk for colorectal cancer. This tissue can degenerate over time and become malignant. Osteoarthritis, lactose intolerance, and the use of herbs do not pose additional risk to the patient.
The nurse should administer an as-needed dose of magnesium hydroxide (MOM) after noting what information while reviewing a patient's medical record? A. Abdominal pain and bloating B. No bowel movement for 3 days C. A decrease in appetite by 50% over 24 hours D. Muscle tremors and other signs of hypomagnesemia
B. No bowel movement for 3 days MOM is an osmotic laxative that produces a soft, semisolid stool usually within 15 minutes to 3 hours. This medication would benefit the patient who has not had a bowel movement for 3 days. MOM would not be given for abdominal pain and bloating, decreased appetite, or signs of hypomagnesemia.
A pt is taking digoxin and furosemide (Lasix) to manage congestive heart failure. The nurse determiens that the pt understands diet therapy when the pt makes which meal choice? A. veggie beef soup, mac and cheese, and a roll B. beef ravioli w/ bread C. baked white fish, mashed potatoes, and carrot salad D. roasted chicken, brown rice, and stewed tomatoes
C
You're providing teaching to a patient with an ileostomy on how to change their pouch drainage system. Which statement is INCORRECT about how to change a pouching system for an ostomy?* A. Empty the pouch when it is 1/3 to 1/2 full. B. Change the pouching system every 3-5 days. C. When measuring the stoma for skin barrier placement, be sure the opening of the skin barrier is a 2/3 inch larger than the stoma. D. Keep the skin around the stoma clean and dry at all times.
C
A nurse prepares a client for a colonoscopy scheduled for tomorrow. The client states, "My doctor told me that the fecal occult blood test was negative for colon cancer. I don't think I need the colonoscopy and would like to cancel it." How should the nurse respond? a. Your doctor should not have given you that information prior to the colonoscopy. b. The colonoscopy is required due to the high percentage of false negatives with the blood test. c. A negative fecal occult blood test does not rule out the possibility of colon cancer. d. I will contact your doctor so that you can discuss your concerns about the procedure.
C ~ A negative result from a fecal occult blood test does not completely rule out the possibility of colon cancer. To determine whether the client has colon cancer, a colonoscopy should be performed so the entire colon can be visualized and a tissue sample taken for biopsy. The client may want to speak with the provider, but the nurse should address the clients concerns prior to contacting the provider.
A nurse cares for a client with colon cancer who has a new colostomy. The client states, "I think it would be helpful to talk with someone who has had a similar experience." How should the nurse respond? a. I have a good friend with a colostomy who would be willing to talk with you. b. The enterostomal therapist will be able to answer all of your questions. c. I will make a referral to the United Ostomy Associations of America. d. You'll find that most people with colostomies don't want to talk about them.
C ~ Nurses need to become familiar with community-based resources to better assist clients. The local chapter of the United Ostomy Associations of America has resources for clients and their families, including Ostomates (specially trained visitors who also have ostomies). The nurse should not suggest that the client speak with a personal contact of the nurse. Although the enterostomal therapist is an expert in ostomy care, talking with him or her is not the same as talking with someone who actually has had a colostomy. The nurse should not brush aside the client's request by saying that most people with colostomies do not want to talk about them. Many people are willing to share their ostomy experience in the hope of helping others.
Which clinical manifestations of inflammatory bowel disease are common to both patients with ulcerative colitis (UC) and Crohn's disease (select all that apply)? A. Restricted to rectum B. Strictures are common. C. Bloody, diarrhea stools D. Cramping abdominal pain E. Lesions penetrate intestine.
C, D. Clinical manifestations of UC and Crohn's disease include bloody diarrhea, cramping abdominal pain, and nutritional disorders. Intestinal lesions associated with UC are usually restricted to the rectum before moving into the colon. Lesions that penetrate the intestine or cause strictures are characteristic of Crohn's disease.
A patient who weighs 200 pounds, has a prescription for a Dopamine Drip at 5 mcg/kg/min. There is 400 mg per 500 ml D5W on hand. The nurse should administer __________ milliliters to the patient each hour. a. 17 b. 24 c. 34 d. 44
C- 34. First, 200 lb is 90.7 kg.Multiply the 5 mcg/min by 90.7 kg to get 453.5 mcg/min.Multiply the 453.5 mcg/min x 60 min to get 27210 mcg/hr.Multiply 27210 mcg/hr x 1 mg/1000 mcg to get 27.21 mg/hr.Multiply 27.21 mg/hr x 500 ml/400 mg to get the answer of 34 ml/hr.
The patient receiving chemotherapy rings the call bell and reports the onset of nausea. The nurse should prepare an as-needed dose of which medication? A. Morphine sulfate B. Zolpidem (Ambien) C. Ondansetron (Zofran) D. Dexamethasone (Decadron)
C- Ondansetron is a 5-HT3 receptor antagonist antiemetic that is especially effective in reducing cancer chemotherapy-induced nausea and vomiting. Morphine sulfate may cause nausea and vomiting. Zolpidem does not relieve nausea and vomiting. Dexamethasone is usually used in combination with ondansetron for acute and chemotherapy-induced emesis.
The patient with chronic gastritis is being put on a combination of medications to eradicate H. pylori. Which drugs does the nurse know will probably be used for this patient? A. Antibiotic(s), antacid, and corticosteroid B. Antibiotic(s), aspirin, and antiulcer/protectant C. Antibiotic(s), proton pump inhibitor, and bismuth D. Antibiotic(s) and nonsteroidal antiinflammatory drugs (NSAIDs)
C. Antibiotic(s), proton pump inhibitor, and bismuth To eradicate H. pylori, a combination of antibiotics, a proton pump inhibitor, and possibly bismuth (for quadruple therapy) will be used. Corticosteroids, aspirin, and NSAIDs are drugs that can cause gastritis and do not affect H. pylori.
The nurse determines that a patient has experienced the beneficial effects of therapy with famotidine (Pepcid) when which symptom is relieved? A. Nausea B. Belching C. Epigastric pain D. Difficulty swallowing
C. Epigastric pain Famotidine is an H2-receptor antagonist that inhibits parietal cell output of HCl acid and minimizes damage to gastric mucosa related to hyperacidity, thus relieving epigastric pain. Famotidine is not indicated for nausea, belching, and dysphagia.
A female patient has a sliding hiatal hernia. What nursing interventions will prevent the symptoms of heartburn and dyspepsia that she is experiencing? A. Keep the patient NPO. B. Put the bed in the Trendelenberg position. C. Have the patient eat 4 to 6 smaller meals each day. D. Give various antacids to determine which one works for the patient.
C. Have the patient eat 4 to 6 smaller meals each day. Eating smaller meals during the day will decrease the gastric pressure and the symptoms of hiatal hernia. Keeping the patient NPO or in a Trendelenberg position are not safe or realistic for a long period of time for any patient. Varying antacids will only be done with the care provider's prescription, so this is not a nursing intervention.
Following administration of a dose of metoclopramide (Reglan) to the patient, the nurse determines that the medication has been effective when what is noted? A. Decreased blood pressure B. Absence of muscle tremors C. Relief of nausea and vomiting D. No further episodes of diarrhea
C. Relief of nausea and vomiting Metoclopramide is classified as a prokinetic and antiemetic medication. If it is effective, the patient's nausea and vomiting should resolve. Metoclopramide does not affect blood pressure, muscle tremors, or diarrhea.
Describe, in order, how food travels from the stomach to the rectum: A. It exits the stomach into: the cecum to the jejunum to the ileum, then into the duodenum, descending colon, transverse colon, ascending colon, sigmoid colon, and rectum. B. It exits the stomach into: the duodenum to the ileum to the jejunum, then into the cecum, ascending colon, sigmoid colon, descending colon, transverse colon, and rectum. C. It exits the stomach into: the ileum to the jejunum to the duodenum, then into the cecum, sigmoid colon, transverse colon, descending colon, ascending colon, and rectum. D. It exits the stomach into: the duodenum to the jejunum to the ileum, then into the cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum.
D
Nurse Margie just administered an ACE inhibitor to her pt. Before ambulating the pt for the first time after administration, the nurse should monitor for: A. hypokalemia B. irregular heartbeat C. edema D. hypotension
D
The action of an ACE inhibitor interrupts the renin-angiotensin-aldosterone mechanism, thereby producing which of the following?A. reduced renal blood flow B. reduced sodium and water retention C. increased peripheral vascular resistance D. increased sodium excretion and potassium reabsorption
D
The nurse is scheduled to administer a dose of digoxin to and adult pt with atrial fibrillation. The pt has a potassium level of 4.3 mEq/L. The nurse should perform which of the following activities next? A. withhold dose only for that day B. obtain order for dose of potassium before giving digoxin C. withhold dose and notify prescriber D. administer dose as ordered
D
The nurse is caring for a 68-year-old patient admitted with abdominal pain, nausea, and vomiting. The patient has an abdominal mass, and a bowel obstruction is suspected. The nurse auscultating the abdomen listens for which type of bowel sounds that are consistent with the patient's clinical picture? A. Low-pitched and rumbling above the area of obstruction B. High-pitched and hypoactive below the area of obstruction C. Low-pitched and hyperactive below the area of obstruction D. High-pitched and hyperactive above the area of obstruction
D. High-pitched and hyperactive above the area of obstruction Early in intestinal obstruction, the patient's bowel sounds are hyperactive and high-pitched, sometimes referred to as "tinkling" above the level of the obstruction. This occurs because peristaltic action increases to "push past" the area of obstruction. As the obstruction becomes complete, bowel sounds decrease and finally become absent.
The nurse is preparing to administer a dose of bisacodyl (Dulcolax). In explaining the medication to the patient, the nurse would explain that it acts in what way? A. Increases bulk in the stool B. Lubricates the intestinal tract to soften feces C. Increases fluid retention in the intestinal tract D. Increases peristalsis by stimulating nerves in the colon wall
D. Increases peristalsis by stimulating nerves in the colon wall Bisacodyl is a stimulant laxative that aids in producing a bowel movement by irritating the colon wall and stimulating enteric nerves. It is available in oral and suppository forms. Fiber and bulk forming drugs increase bulk in the stool; water and stool softeners soften feces, and saline and osmotic solutions cause fluid retention in the intestinal tract.
Which nursing intervention takes highest priority when caring for a newly admitted client who's receiving a blood transfusion? A. Warming the blood prior transfusion. B. Informing the client that the transfusion usually takes 4 to 6 hours. C. Documenting blood administration in the client chart. D. Instructing the client to report any itching, chest pain, or dyspnea.
D. Instructing the client to report any itching, headache, or dyspnea. This will help the nurse take immediate action incase a reaction happens during a transfusion.
A nurse is preparing to change the TPN solution bag and tubing. The patient's central line is located in the right subclavian vein. The nurse asks the patient to take which essential action during the tubing change? A. Breathe normally B. Turn the head to the right C. Exhale slowly and evenly D. Take a deep breath, hold it, and bear down
D. Take a deep breath, hold it, and bear down
What should the nurse instruct the patient to do to best enhance the effectiveness of a daily dose of docusate sodium (Colace)? A. Take a dose of mineral oil at the same time. B. Add extra salt to food on at least one meal tray. C. Ensure dietary intake of 10 g of fiber each day. D. Take each dose with a full glass of water or other liquid.
D. Take each dose with a full glass of water or other liquid. Docusate lowers the surface tension of stool, permitting water and fats to penetrate and soften the stool for easier passage. The patient should take the dose with a full glass of water and should increase overall fluid intake, if able, to enhance effectiveness of the medication. Dietary fiber intake should be a minimum of 20 g daily to prevent constipation. Mineral oil and extra salt are not recommended.
A nurse monitors a patient receiving TPN for complications of the therapy and should assess the patient for which manifestation of hyperglycemia? A. Fever, weak pulse, and thirst B. Nausea, vomiting, and oliguria C. Sweating, chills, and abdominal pain D. Weakness, thirst, and increased urine output
D. Weakness, thirst, increased urine output
The nurse is monitoring a blood transfusion being administered to a trauma patient experiencing shock. Which assessment finding indicates a dangerous transfusion reaction? 1. increasing dyspnea 2. increasing blood pressure 3. multiple urticaric, pruritic skin lesions 4. an increase in body temperature by 0.3 degree
I Rationale: A hemolytic reaction is the most dangerous type of transfusion reaction and usually results from an ABO incompatibility. Manifestations of a hemolytic reaction include dyspnea. manifestation appears the blood transfusion must be discontinued immediately. The patient is receiving blood for shock. An increase blood pressure would be a desired outcome. Skin lesions are seem in a hypersensitivity reaction to the blood transfusion. An increase in body temperature 0.3 degree is not significant when receiving a blood transfusion
A patient has a prescription for Tylenol at 650mg every 6 hours. A nurse only has 325mg pills of Tylenol available. How many pills would be administered every 6 hours? a. 2 b. 3 c. 4 d. 5
a- 325 mg x 2 pills is equal to a total of 650 mg. Therefore, the patient should receive a maximum of 2 pills every 6 hours. It is important to verify the dosage of certain medications, such as Tylenol, to prevent overdosing a patient within a 24-hour period.
A patient is suffering from heart failure. Which of the following would be recommended by a nurse as part of the patient's health care plan? a. Discouraging a diet of fruit and vegetables b. Checking for swelling of the lower limbs c. Encourage the daily intake of fluids d. Encouraging vigorous exercise
b- Swelling of the lower limbs, known as edema, is due to a buildup of fluid from an impaired circulatory system and is a common side effect of Congestive Heart Failure. It would not be appropriate to discourage fruits and vegetables, as they are part of a heart healthy diet and should be encouraged. Patients with heart failure are usually put on a water regimen of around 1-2 L of fluid total per day. This is due to the increased pressure on the heart to process fluids and may cause worsening edema. Patients with heart failure need to be careful with the amount of vigorous exercise activities they undertake. Heart rate should be monitored closely to prevent overexertion.
A nurse just started a blood transfusion for a patient with a Hemoglobin of 6. The patient says, "I feel hot, my stomach hurts, and I am having difficulty breathing." What should be the nurses first action? a. Notify the physician immediately b. Stop the infusion c. Take vital signs d. Call a code
b- The first action should be to stop the transfusion immediately once the patient complains of any unusual symptoms. The patient is reporting symptoms of a transfusion reaction therefore the transfusion should be stopped to prevent the patient from worsening. The provider should be notified immediately after stopping the transfusion. Vital signs should be taken as quickly as possible or as instructed by the provider after the transfusion has been stopped and the physician has been notified.A code should be called if the patient becomes unresponsive. A rapid response could be called if the patient is at risk of destabilizing.
A patient is being discharged with a new diagnosis of Congestive Heart Failure. Which of the following statements made by the patient indicate understanding of the diagnosis? a. "I can drink as much fluid as I want." b. "I should notify my doctor if my feet start to swell." c. "Weight gain of 3-5 lbs in one day is to be expected." d. "It is normally to have difficulty breathing at night."
b- The patient should notify the physician if edema starts developing in the lower extremities. This indicates more pressure on the heart and can cause complications.Patients with Congestive Heart Failure need to have a limited fluid intake, typically around 2 L per day to prevent fluid overloading. The patient should be aware this includes all types of fluids, not just water. Weight gain of 3-5 lbs in one day should be reported to the physician as this is a significant weight increase and may indicate fluid retention. The patient's medications may need to be adjusted. The patient complaining of difficulty breathing at night is experiencing pulmonary edema, a condition in which fluid builds up into the lungs. This symptom should be reported to the physician immediately.
