204 exam 4
. The nurse is in a patient room ready to administer a new medication to the patient. Which action best demonstrates awareness of safe, skilled nursing practice? a. Identify the patient by comparing the patient's name and birth date to the medication administration record (MAR). b. Determine whether the medication and dose are appropriate for the patient. c. Make sure that the medication is in the medication cart. d. Check the accuracy of the dose with another nurse.
a
A patient has high blood pressure and takes an anticoagulant. The nurse explains that increased bleeding is a side effect of this herbal supplement. Which herb is the patient taking? a. Garlic b. Ginseng c. Feverfew d. Ginkgo biloba
a
The nurse is developing a plan of care for a patient. What is the most appropriate goal for a patient related to medications? a. The patient will administer all medications correctly by discharge. b. The patient will be taught common side effects of prescribed medications. c. The patient will have a good understanding of prescribed medications. d. The patient will have all medications administered by staff as prescribed.
a
Which action will the nurse take to administer a sustained-release capsule to a new patient who insists that he cannot swallow pills? a. Ask the health care provider to change the prescription. b. Crush the pill with a mortar and pestle. c. Hide the capsule in a piece of solid food. d. Open the capsule and sprinkle it over pudding.
a
Which action would the nurse take when caring for a patient with blood type A who is in need of packed red cells on an emergency basis, but none of the donors of this type are available? a. Arrange to provide red blood cells of group O. b. Arrange to provide red cells of group AB. c. Arrange for an autologous blood transfusion. d. Wait until the donor of blood type A becomes available.
a
Which information would the nurse provide to a patient with chronic diarrhea who asks why it's important to eat food items rich in potassium? a. Potassium improves smooth, skeletal, and cardiac muscle function. b. Potassium is necessary for production of adenosine triphosphate (ATP). c. Potassium decreases muscle wasting. d. Potassium acts as a cofactor for various enzymes.
a
Which intravenous fluid is administered to a patient who is dehydrated and needs an infusion of isotonic fluids to correct the condition? a. Dextrose 5% in water (D5W) b. Dextrose 10% in water (D10W) c. Dextrose 5% in lactated Ringer's (D5LR) d. Dextrose 5% in 0.9% sodium chloride (D5NS; D50.9% NaCl)
a
Which patient would a nurse expect to be at the highest risk for developing dehydration? a. A 78-year-old patient with dementia b. A 47-year-old patient with hyperthyroidism c. A 53-year-old patient with pulmonary embolism c. A 32-year-old patient with a respiratory infection
a
A nurse instructs the patient to use eardrops at room temperature. Which rationale supports the nurse's instructions? Select all that apply. One, some, or all responses may be correct. a. To reduce pain b. To prevent nausea c. To prevent loss of medication d. To prevent dizziness e. To ease removal of earwax
a b d
Which clinical finding would a nurse expect in a patient who has suffered burns on the chest and back and is suspected to have developed extracellular fluid volume deficit? Select all that apply. One, some, or all responses may be correct. a. Hypotension b. Cold, clammy skin c. Sudden weight gain d. Dry mucous membranes e. Crackles in dependent portion of lungs
a b d
Which treatment strategy would be included in the management of a patient who develops acute hemolytic transfusion reaction following transfusion with incompatible blood? Select all that apply. One, some, or all responses may be correct. a. Stop the transfusion immediately. b. Remove tubing and replace with new intravenous (IV) tubing and normal saline solution. c. Avoid keeping the IV line connected. d. Send blood and urine to the lab. e. Document the reaction, subsequent treatment, and patient response.
a b d e
The nurse is caring for a critically ill patient. What are the contraindications for administering medications by the oral route for this type of patient? (Select all that apply.) a. Vomiting b. Unconsciousness c. Diarrhea d. Penicillin allergy e. Intubation
a b e
Which action would the nurse take to promote comfort in a patient who reports pain in the extremity that had an infusing intravenous (IV) line after observing redness and warmth along the course of the vein starting at the access site? Select all that apply. One, some, or all responses may be correct. a. Stop the infusion. b. Apply cold compresses. c. Discontinue the IV line. d. Reuse the same line after some time. e. Set up a new line distal to the original.
a c
Which assessment finding indicates fluid volume excess in a patient with the syndrome of inappropriate antidiuretic hormone secretion (SIADH)? Select all that apply. One, some, or all responses may be correct. a. Total body weight gain of 8% b. Total body weight loss of 5% c. Urine specific gravity of 1.001 d. Blood urea nitrogen level of 22 mg/dL e. Serum sodium level of 130 mg/mL
a c e
The nurse accidentally gives a patient a medication at the wrong time. Which action is the nurse's first priority? a. Complete an occurrence report. b. Notify the health care provider. c. Inform the charge nurse of the error d. Assess the patient for adverse effects
d
The nurse is caring for a patient who is receiving intravenous (IV) therapy. After a few minutes, the nurse finds that the patient has confusion, an increased heart rate, and a decreased blood pressure. The nurse also observes a bluish coloring in the patient's skin. Which condition does the nurse infer from these findings? a. Phlebitis b. Infiltration c. Fluid overload, d. Catheter embolism
d
While administering medications to a hospitalized patient via the intravenous (IV) route, the nurse finds that the patient's pulse rate is 140 beats/min and blood pressure is 170/90 mm Hg. The nurse also finds that the patient is restless and has distended neck veins. Which condition does the nurse interpret from these findings? a. Phlebitis b. Infiltration c. Extravasation d. Pulmonary edema
d
. Which of the following now has bradycardia , muscle The patient has experienced an extensive burn and desirable for the nurse to obtain laboratory val weakness , and abdomi ues would nal cramping be most on the basis of the patient's assessment ? a . Serum potassium b . Serum magnesium c . Serum sodium d . Serum calcium
A
A patient experiences a loss of intracellular fluid . The nurse anticipates that the IV therapy that will be used to replace this type of loss is which of the following solutions ? a . 0.33 % normal saline b . 10 % dextrose c . 5 % dextrose in lactated Ringer d . dextrose 5 % in ½ normal saline ( NS )
A
A patient has a prescription for a medication that is administered via an inhaler . To determine if the patient requires a spacer for the inhaler , the nurse will determine which of the following ? a . Ability of the patient to control the rate of inhalation b . Dosage of medication required c . Schedule of administration d . Use of a dry - powder inhaler ( DPI )
A
A patient is admitted to the hospital with a diagno sis of adrenal insufficiency . In preparing to complete the admission history , the nurse anticipates that the patient will have experienced increased serum levels of a . magnesium . b . sodium . c . chloride . d potassium .
A
A patient is brought into the emergency department after having had severe diarrhea . Arterial blood gases are assessed , and the nurse anticipates that this patient will demonstrate which of the following results ? a . pH - 7.3 , PaCO - 38 mm Hg . HCO , -19 mEq / L b . pH - 7.5 , PaCO - 34 mm Hg . HCO , -20 mEq / L c . pH - 7.35 , PaCO - 35 mm Hg , HCO , -24 mEq / L d . pH - 7.52 , PaCO , -48 mm Hg . HCO , -28 mEq / L
A
A patient is currently taking Lasix and Digoxin . As a result of the medication regimen , the nurse is alert to the presence of a . cardiac dysrhythmias . b . severe diarrhea . c . hyperactive reflexes . d . peripheral cyanosis
A
A priority for the nurse in the administration of oral medications and prevention of aspiration is to do which of the following actions ? a . Checking for a gag reflex b . Assessing the ability to cough c. Allowing patient to self-administer d. using straws and extra water for administration
A
The nurse anticipates that the blood product that will be used for the patient with acute renal failure should be a . albumin . b . platelets c . whole blood . d . cryoprecipitate .
A
The nurse anticipates that which of the follow ing diagnostic tests will be done to determine the patient's renal function ? a . Creatinine b . Calcium level c . Hemoglobin d . Serum albumin
A
The nurse has been assigned to administer a rectal suppository to a patient . In which position would the nurse place the patient ? A. Lateral recumbent position b. Prone position c. Lateral position d. Dorsal recumbent
A
The nurse has begun an infusion of fresh frozen plasma ( FFP ) . Which symptom indicates an allergic reaction to the FFP ? A Respirations : 30 / min B Your an output : 50 mL / hr с Heart rate : 62 bpm D Temperature : 37.5 ° C
A
The nurse requires additional instruction if he / she selects which of the following IV catheter sizes for a patient who will be receiving a blood transfusion ? a . 26 gauge b . 22 gauge c . 20 gauge d . 18 gauge
A
The patient is to receive a medication via the buccal route . The nurse plans to implement which of the fol lowing actions ? a . Place the medication inside the cheek . b . Crush medication before administration . c . Use sterile technique to administer the medication d . Offer the patient a glass of orange juice after administration
A
The patient is to receive heparin by injection . The preferred site for this injection is in which location ? a . Abdomen b . Vastus lateralis c . Posterior gluteal d . Scapular region
A
The patient receiving an IV infusion of morphine sul fate begins to experience respiratory depression and decreased urine output . What is this effect ? a . Toxic b . Allergic c . Therapeutic d . Idiosyncratic
A
When a patient's serum sodium level is 120 mEq / L , the priority nursing assessment is to monitor the sta tus of which body system ? a . Neurological b . Gastrointestinal c . Pulmonary d . Hepatic
A
Which action by the client indicates the need for further instruction on insulin administration ? A. Aspirating before administering the dose b. Using a 27 - gauge needle to administer the insulin c. Administering rapid - acting insulin in the abdomen d. Holding the needle in place for several seconds after administering the insulin
A
Which activity is important to include in the plan of care for a client with a peripherally inserted central catheter ( PICC ) ? A Use sterile technique when changing B Change the IV tubing every 72 hours the PICC dressing с Take blood pressures in the arm D Never use a macro drip ( 10-15 where the PICC is inserted gtts / min ) tubing with IV infusions through the PICC line .
A
Which combination of foods would the nurse encourage a child with glomerulonephritis to choose for a meal ? A. Corn , roast chicken , peach b. Tuna salad , cheese melt , milk . C. Hamburger , baked potato , banana d. Bologna sandwich , salad , vanilla malted
A
Which is the most important nursing action involved in caring for client receiving medications ? A. Administering the medications b. Teaching about the medications . C. Ensuring adherence to the medication egimen d. Evaluating the client's ability to self - administer medications
A
Which prescribed action would the nurse question when caring for a client who has heart failure , with blood pressure 102/70 mm Hg , pulse 106 beats / minute , and bilateral lung crackles ? A. Infuse normal saline at 100 mL / h . B. Give furosemide 40 mg intravenous now . C. Administer potassium chloride 10 mEq orally now . D. Titrate oxygen by mask to keep oxygen saturation 93 % or higher .
A
Which principle explains how loop diuretics promote diuresis ? A. Osmosis b. Filtration c. Diffusion d. Active transport
A
You have a patient with very high blood sugar , and sugar in the urine . Select all that apply. A urine output would be increased B urine output would be decreased C blood volume would increase D blood volume would decrease
A d
Which nursing intervention is necessary before a blood transfusion is administered ? Select all that apply . A. Obtain the client's vital signs . B. Monitor hemoglobin and hematocrit levels . C. Allow the blood to reach room temperature . D. Determine typing and crossmatching of blood . E. Use a Y - type infusion set to initiate 0.9 % normal saline ..
A d e
2. A 75-year-old patient with chronic obstructive pulmonary disease (COPD) gets arterial blood gases ordered. What is the nurse's interpretation of the arterial blood gas results (pH 7.33, PCO2 58, PO2 83, HCO3− 33)? a. Partially compensated metabolic alkalosis b. Partially compensated respiratory acidosis c. Uncompensated metabolic acidosis d. Uncompensated respiratory alkalosis
b
A nurse is reviewing the different names for a drug. Which medication designation is assigned by the U.S. Adopted Names Council? a. Brand name b. Official name c. Trade name d. Chemical name
b
The nurse plans to administer a medication that can give immediate relief to a patient. Which parameter of the drug will the nurse check for to find if the drug can provide immediate relief to the patient? a. Peak concentration b. Onset of action c. Plateau concentration d. Duration of action
b
What action should be taken by the nurse first when preparing to administer medications to a patient? a. Check the medication expiration date. b. Check the medication administration record (MAR). c. Call the pharmacy for administration instructions. d. Check the patient's name band.
b
Which assessment finding would indicate phlebitis when a nurse is caring for a patient who is receiving intravenous (IV) therapy? a. Blanched skin b. Reddened area c. Increased heart rate d. Increased blood pressure
b
Which complication is likely in a patient with uncontrolled diabetes mellitus who has developed diabetic ketoacidosis? a. Hypokalemia b. Hyperkalemia. c. Hypocalcemia d. Reduced serum osmolality
b
Which patient will need teaching regarding dietary sodium restriction? a. An 88-year-old with a fractured femur scheduled for surgery b. A 65-year-old recently diagnosed with heart failure c. A 50-year-old recently diagnosed with asthma and diabetes d. A 20-year-old with vomiting and diarrhea from gastroenteritis
b
Which term would a nurse use to document when the arterial pH of a patient is 7.3? a. Alkalosis b. Acidosis c. Neutral pH d. Normal pH
b
A critical measure for patients with hypocalcemia and hypomagnesemia is b . implementing seizure precautions . a . encouraging increased fluid intake . d . administering analgesics . c . checking for digitalis toxicity .
B
A patient complains of a headache and nausea and vomiting during a blood transfusion . Which one of the following actions should the nurse take immediately ? a . Check the vital signs . b . Stop the blood transfusion . c . Slow down the rate of blood flow . d . Notify the physician and blood bank personnel .
B
Arterial blood gases are obtained for the patient . The patient's results : pH 7.48 , CO₂ - 42 , HCO , = 32 .. These are consistent with which one of the following acid - base imbalances ? a . Metabolic acidosis b . Metabolic alkalosis c . Respiratory acidosis d . Respiratory alkalosis
B
For a child who has ingested the remaining contents of an aspirin bottle , the nurse suspects signs and symptoms consistent with a . metabolic alkalosis . b . metabolic acidosis . c . respiratory alkalosis . d . respiratory acidosis
B
Mild hypoxemia is present with which of the follow ing PaO₂ concentrations ? a . 90 mm Hg b . 70 mm Hg c . 50 mm Hg d . 30 mm Hg
B
Of all of the following who is most at risk patients , the nurse for a fluid vol recognizes that the a . 6 - month - old ume deficit is individual a with severe vomiting . learning to drink from a cup . b . 42 - year - old who is moderately frequent headaches . active in 80 ° F d . 12 - year - old c . 90 - year - old with weather .
B
Since the client has a fluid volume deficit , the nurse anticipates a decrease in which vital sign when she changes position ? A. Respiratory rate . B. Blood pressure . C. Temperature . D. Pulse rate .
B
The nurse anticipates that the patient with insuffi cient fluid volume deficit will manifest a ( n ) a . decreased urine specific gravity . b . decreased body weight . c . increased blood pressure d . increased pulse strength
B
The nurse has been assigned to administer a rectal suppository to an adult patient . Which suppository placement is correct ? A. Along rectal wall , 1 to 2 inches into the rectum b. Along rectal wall , 3 to 4 inches into the rectum c. Inner aspect of the anal orifice d. Just before the internal anal sphincter
B
The nurse is working on the pediatric unit . In prepar ing to give medications to a appropriate interaction by the nurse is preschool - aged child , an a . " Do you want to take your medication now ? " b . " Would you like the medication with water or juice ? " c . " Let me explain about the shot that you will be getting . " d . " If you don't take the medication now you will not get better . "
B
The nurse plans to assess the client for orthostatic vital sign changes . Which action will the nurse take first ? A. Assist the client to a standing position . B. Position the client in a supine position . C. Elevate the head of the client's bed . D. Dangle the client's feet at the bedside .
B
The nurse receives a prescription to begin administering a loop diuretic to a patient with hypertension . Which factor would determine the route for administering the diuretic to the patient ? A. Hospital policy b. The prescriber's orders c. The type of medication prescribed d. The patient's size and muscle mass
B
The patient is taking an herbal remedy for mild anxi ety and difficulty sleeping . It also has the potential to interact with antidepressant medications . The nurse expects that this patient is taking a . chamomile . b . St. John's wort . c . echinacea . d . Ginkgo biloba .
B
The single best indicator of fluid status is the nurse's assessment of the patient's a . skin turgor . b . daily body weight . c . intake and output . d . serum electrolyte levels .
B
Which clinical finding would the nurse anticipate when admitting a client with an extracellular fluid volume excess ? A. Rapid , thready pulse b. Distended jugular veins c. Elevated hematocrit level d.Increased serum sodium level
B
Which condition is recognized by a nurse caring for a patient who has a partial pressure of carbon dioxide ( PaCO2 ) of 30 mmHg ? A. CO2 has accumulated in the blood . B. The PaCO2 is lower than normal .. c. The patient is hypoventilating . D. The patient has impaired renal function .
B
Which electrolyte disturbance would the nurse evaluate for when caring for a patient who is suffering from syndrome of inappropriate of antidiuretic hormone (SIADH) secretion? A. Hypernatremia B. Hyponatremia C. Hemoconcentration D. Increased serum osmolality
B
Which factor would the nurse recognize as the cause when a client's intravenous ( IV ) infusion infiltrates ? A. Excessive height of the IV bag b. Failure to secure the catheter adequately c. Contamination during the catheter insertion d. Infusion of a chemically irritating medication
B
Which food selection by the client indicates to the nurse that dietary teaching about thiazide diuretics is successful ? A. Apples b. Kidney beans c. Cherries d. Brussels sprouts
B
Which information would the nurse provide to a client with type 1 diabetes who requests information about the differences between penlike insulin delivery devices and syringes ? A. The penlike devices have a shorter injection time . " b. " Penlike devices provide a more accurate dose delivery . " c. " The penlike delivery system uses a smaller - gauge needle . D. " Penlike devices cost less by having reusable insulin cartridges . "
B
Which of the following is a correct technique for use of an insulin pen ? a . Clean the pen tip with household soap . b . Prime the pen with 2 units before use . c . Cover the needle until the next dose . d . Empty the pen and complete the dosage with a new pen , if necessary .
B
Which one of the following actions performed by the new staff nurse and observed by the nurse manager requires additional instruction ? a . Giving medications 20 minutes before the sched uled time . b . Applying a topical medicated cream without gloves c . Alternating the sides of the cheeks for buccal medications . d . Documenting on the MAR that the patient refused the medication
B
Which organ would the nurse identify as being responsible for the excretion of carbonic acid when teaching a group of nursing students about the acid - base regulation process ? A. Liver b. Lungs c. Kidneys d. Intestines
B
Which sign of hypokalemia will the nurse monitor for in a client receiving furosemide ? Chvostek sign Muscle weakness . Anxious behavior . Abdominal cramping
B
Which teaching does the nurse provide the patient with a sodium level of 120 mEq / L ? A. " Avoid eating canned vegetables . " b. " It is okay to eat cured meat and cheese . " c. " Refrain from eating potatoes and pickles . " d. " Increase your intake of green leafy vegetables . "
B
Which type of fluid would a nurse mention when teaching patients to replace sweat , vomiting , or diarrhea fluid losses ? A. Tap water or bottled water b. Fluid that has sodium ( salt ) in it c. Fluid that has K * and HCO3 in it d. Coffee or tea , whichever they prefer
B
The nurse has just begun an infusion of packed red blood cells (PRBCs). Which of the following cues should the nurse recognize as indicating a transfusion reaction that warrants stopping the infusion? (Select all that apply.) a. Patient complains of weakness and fatigue. b. Patient complains of feeling itchy. c. Patient is shivering and complains of chills. d. Temperature increased from 99.1° degrees to 101.3° F. e. Patient complains of nausea.
b c d
87. How should the patient be positioned after the admin istration of eardrops to the left car ? a . Prone b . Upright c . Right lateral d . Dorsal recumbent with hyperextension of the . neck
C
A medication is prescribed for the patient and is to be administered by IV bolus injection . A priority for the nurse before the administration of medication via this route is to a . set the rate of the IV infusion . b . check the patient's mental alertness . c . confirm placement of the IV line . d . determine the amount of IV fluid to be adminis tered .
C
An 8 - year - old is admitted to the pediatric unit with pneumonia . On assessment , the nurse notes that the child is warm and flushed , is lethargic , has difficulty breathing , and has crackles on auscultation . The nurse determines that the child is suffering from a metabolic acidosis . b . metabolic alkalosis . c . respiratory acidosis , d . respiratory alkalosis .
C
In reviewing the results of the patient's bloodwork , the nurse recognizes that the unexpected value that should be reported to the physician is a . calcium 9 mg / dL . b . sodium 140 mEq / L . c . potassium 3 mEq / L . d . magnesium 1.9 mEq / L .
C
One of the first indications of a fluid volume deficit is a . polyuria b . hypothermia c . tachycardia . d . increased blood pressure .
C
The Kefauver - Harris Drug Amendments were passed in 1962 to a classify habit - forming medications as narcotics . b . mandate accuracy in drug labeling . 76. c . require proof of drug safety and efficacy before marketing d . categorize drugs on their abuse and addiction potential .
C
The mucous membranes of a normally hydrated indi vidual are a . dry . b . red . c . moist . d . sticky .
C
The nurse has been assigned to administer a suppository to a patient . Which route of administration is suitable for administering a suppository ? A. Oral b. Skin c. Rectal d. Parenteral
C
The nurse is assessing the intravenous ( IV ) site in the right forearm and notices the area around it is cool , swollen , firm , and tender to touch . Which complication is most likely occurring ? A Infection B Septic shock C Infiltration D Phlebitis
C
The nurse is aware that the compensating mechanism most likely to occur in the presence of respiratory acidosis is a . hyperventilation to decrease the CO₂ levels b . hypoventilation to increase the CO₂ levels . c . retention of HCO , by the kidneys to increase the pH level . d . excretion of HCO , by the kidneys to decrease the pH level .
C
The nurse is documenting administration of a medi cation that is given at 10:00 a.m. , 2:00 p.m. , and 6:00 p.m. Which of the following medications is the nurse documenting ? a . Morphine sulfate 10 mg q4h pr b . Inderal 10 mg PO bid c . Diazepam 5 mg PO tid d . Keflex 500 mg PO q8h
C
The nurse observes that a patient has a rash , itchy skin , inflammation and swelling of the nasal passages , and raised skin eruptions after intravenous drug administration . Which type of drug effect is the patient experiencing ? A. Side effect b. Toxic effect c. Allergic effect d. Adverse effect
C
The nurse recognizes that an example of a Schedule II medication is a heroin . b . diazepam . C. morphine d. acetaminophen
C
The patient has a continuous For this infusion the tubing should be changed every IV infusion of 0.9 % NS . a . 24 hours . b . 48 hours . c . 72 hours . d . time the bag is changed .
C
The patient has heart failure and is on a restricted sodium diet . Which of the following foods in the patient's diet is the nurse most concerned about ? a . Celery b . Baked fish c . Canned soup d . Dried fruit
C
The physician orders 1000 mL of D , RL with 20 mEq KCI to run for 8 hours . Using an infusion set with a drop factor of 15 gtt / mL , the nurse calculates the flow rate to be which of the following ? a . 12 drops / minute . b . 22 drops / minute . c . 32 drops / minute . d . 42 drops / minute .
C
The registered nurse ( RN ) is caring for a client with renal calculi . To which health care . professional will the RN delegate the task of administering oral medications to this client ? A. Social worker b. Chief nursing officer c. Licensed practical nurse ( LPN ) d. Unlicensed assistive personnel
C
Which action will the nurse take first when a client's gravity flow intravenous ( IV ) rate is too slow ? A. Reposition the client's arm . B. Adjust the flow clamp to deliver the correct rate . C. Evaluate the appearance of the catheter insertion site . D. Determine the amount of fluid that should have been absorbed .
C
Which statement would the nurse use to respond to an older adult client who states , " I walk 2 miles [ 3.2 km ] a day for exercise , but now that the weather is hot , I am worried about becoming dehydrated " ? A. " Drink fruit juices if you start to feel dehydrated . B. " Thirst is a good guide to use to determine fluid intake . " c. " Fluids should be increased if the urine becomes darker . " d. " Water should be consumed when the skin becomes dry . "
C
Which type of interaction occurs when a patient consumes an alcoholic beverage with an antihistamine ? A. Side effect b. Toxic effect c. Synergistic effect d. Antagonistic effect
C
A patient has lost vascular volume Would the patient's skin be hot and dry , or cold and clammy ? in A hot B dry C cold D clammy E lack of skin tenting
C d
The nurse is caring for a patient who has an accumulation of fluids in the pleural cavity . The nurse understands that this fluid is transcellular fluid secreted by epithelial cells . Which bodily fluid is an example of a transcellular fluid ? Select all that apply . One , some , or all responses may be correct . A. Serum b. Plasma c. Peritoneal fluid d. Synovial fluid e. Cerebrospinal fluid
C d e
A nurse caring for a hospitalized patient is told in the shift change report that the patient's laboratory results are sodium = 140 mEq / L ; potassium = 4.1 mEq / L ; calcium = 9.5 mg / dL ; and magnesium = 3.8 mEq / L . Which abnormal level will the nurse report to the primary care provider ? ( Use your lab value sheet for reference ) A High sodium level B Low potassium level с Low calcium D High magnesium level
D
A patient has IV therapy for the administration of antibiotics and is stating that the " IV site hurts and is swollen . " Which of the following information . assessed on the patient indicates the presence of phlebitis , as opposed to infiltration ? a . Intensity of the pain b . Amount of subcutaneous edema . c . Skin discoloration of a bruised nature d . Warmth along the vein
D
A patient has reported a 2 - kg ( 4.4 - lb ) weight gain over the past 3 days . Which factor should the nurse question ? A Protein intake B Potassium intake с Calorie intake D Sodium intake
D
A patient has severe anemia and will be receiving blood transfusions . The nurse prepares and begins the infusion . Ten minutes after the infusion has begun , the patient develops tachycardia , chills , and low - back pain . After stopping the transfusion , the nurse should a . administer an antipyretic b . begin an infusion of epinephrine . c . run normal saline through the blood tubing . d . obtain and send urine and blood specimens to the laboratory
D
The majority of body fluid is located in which area ? a . Interstitial b . Extracellular c . Intravascular d . Intracellular
D
The nurse administers the IM medication of iron by the Z - track method . The medication was adminis tered by this method to a . provide faster absorption of the medication . b . reduce discomfort from the needle . c . provide more even absorption of the drug . d . prevent the drug from irritating sensitive tissue .
D
The nurse is evaluating the integrity of the ventroglu teal injection site . The nurse finds the site by locating the a . middle third of the lateral thigh . b . anterior aspect of the upper thigh . c . acromion process and axilla d . greater trochanter , anterior iliac spine , and iliac crest .
D
The patient has a PICC line in place . Which of the following actions indicates that additional instruc tion is necessary for the new staff nurse ? a . The PICC site is kept dry and protected . b . The lumen is flushed with 10 mL of preservative free saline . c . The catheter is measured from the site to the hub outside the body . d . The blood pressure is measured on the arm with the PICC line .
D
The patient tells the nurse that he is experiencing nausea , vomiting , clumsiness , and blurred vision . He says that he has been taking a lot of vitamins . On the basis of the patient's symptoms , which vitamin does the nurse suspect is creating the adverse effects ? a . Vitamin B3 b . Vitamin C c . Folic acid d . Vitamin A
D
The physician orders 100 mg of a hypnotic medica tion to help the patient sleep . The label on the medi cation bottle reads Seconal 50 mg . How many tablets should the nurse give the patient ? a . 1/2 tablet b . 1 tablet . c . 1 1/2 tablets d . 2 tablets
D
The student nurse reads the order to give a 4 - month old patient an intramuscular injection . The appropri ate and preferred muscle to select for a child is the a . deltoid . b . dorsogluteal . c . ventrogluteal . d . vastus lateralis
D
Which action woudl the be the nurse's priority before administration of packed red blood cells to a client ? A. Obtaining the client's current vital signs b. Assuring that there is a large - bore infusion cannula c. Monitoring the hemoglobin and hematocrit levels d. Determining proper typing and crossmatching of blood
D
Which mineral would the nurse caring for an elderly patient on digitalis therapy suggest consuming when test reports indicate that the patient's potassium level is 3.0 mEq / L ? A. Sodium b. Calcium c. Phosphate d. Potassium .
D
Which needle gauge would the nurse use when providing intravenous therapy for an elderly patient with dehydration ? A. 16 b. 18 c. 22 d. 24
D
Which nursing action has the highest priority when a client with a history of heart failure arrives for a scheduled clinic appointment and has gained 6 lb ( 2.7 kg ) ? A.Check for lower leg swelling . B. Notify the health care provider . C. Take the client's pulse rate . D. Listen to the client's breath sounds .
D
Which regulatory agency is responsible for ensuring that medications undergo vigorous testing before they are made available to the public ? A. Medicare program b. National Formulary United States c. Pharmacopeia d. Food and Drug Administration
D
Place the following steps for starting a peripheral intravenous infusion in the correct order. 1. Check health care provider's prescription and the patient care plan PO 2. Perform hand hygiene 3. Gather supplies and equipment. 4. Prepare the necessary supplies on the bedside table. 5. Use two identifiers to ensure correct patient. 6. Select an appropriate vein and insert the catheter.
1 3 2 5 4 6
A medication has a minimum effective concentration of 25 mg / dL , and the therapeutic range is 25-100 mg / dL . Which plasma concentration may cause toxic effects of the drug ? Record your answer using a whole number . _______ mg / dL
100
A nurse must give 1 g of cephalexin, PO, q 6 hr × 3 days. The supply on hand is 500 mg/capsule. How many capsules should the nurse administer for each dose?
2
A patient develops sudden onset of bronchiolar constriction, edema of pharynx and larynx, and shortness of breath following administration of a medication. Which type of allergic reaction is the patient experiencing? a. Rhinitis b. Medication allergy c. Anaphylactic reaction d. Idiosyncratic reaction
c
Which electrolyte disturbance is responsible for a patient who is positive for Chvostek sign and Trousseau sign and has tetany? a. Hypokalemia b. Hyponatremia c. Hypocalcemia d. Hypermagnesemia
c
Which site would the nurse select when preparing to insert the intravenous (IV) line for an older patient who is very weak and refuses to eat while considering the patient's age? a. Any prominent vein on the hand b. Any prominent vein on the foot c. Most distal appropriate site on the inner arm d. Most proximal appropriate site on the inner arm
c
Which transport mechanism is governed by oncotic and hydrostatic pressures? a. Osmosis b. Diffusion c. Filtration d. Active transport
c
A nurse is teaching a patient about examples of over-the-counter (OTC) medications. Which medication is classified as an OTC medication and will be included in the teaching session? Select all that apply. One, some, or all responses may be correct. a. Diuretics b. Vasodilators c. Mild analgesics d. Cold medications e. Nutritional supplements
c d e
A nurse who is responsible for dispensing medications understands that every patient requires a different dosage for a given drug and that various factors affect the absorption of drugs. Which factor influences absorption? Select all that apply. One, some, or all responses may be correct. a. Total body weight b. Body temperature c. Route or administration d. Solubility e. Blood flow to the site of administration
c d e
2. Which activity is important to include in the plan of care for a patient with a peripherally inserted central catheter (PICC)? (Select all that apply.) a. Change the PICC dressing only when it becomes soiled or loose. b. Change the IV tubing every 5 to 7 days. c. Take blood pressure in the arm without the PICC line. d. Use only macrodrip tubing with IV infusions through the PICC line. e. Use alcohol-impregnated disinfection caps on needleless ports when not in use.
c e
Which route of drug administration would require the nurse to instruct the patient to avoid chewing, swallowing, or drinking when taking the medication? Select all that apply. One, some, or all responses may be correct. a. Oral b. Nasal c. Buccal d. Topical e. Sublingual
c e
Fluid homeostasis in the body is maintained by fluid intake and absorption, fluid distribution, and fluid output. How much fluid does an average adult lose through feces? Record your answer using a whole number. _____ mL
200
Place the following steps in the correct sequence for starting a peripheral intravenous infusion. a. Insert needle until there is blood return. b. Cleanse the site using chlorhexidine and allow to air-dry. c. Apply tourniquet for maximum of 1 minute while palpating veins and then release. d. Release tourniquet. e. Stabilize, connect, and flush with normal saline. f. Gather all equipment and perform hand hygiene. g. Dispose of needle in sharps container and document. h. Use securement device or sterile dressing with label. i. Reapply tourniquet using a quick-release knot.
f, c, i, b, a, d, e, h, g
The nurse administers a 5-mg tablet of a medication to a patient who has osteoarthritis pain. The drug has a half-life of 4 hours. How much of the drug will remain in the blood after 12 hours? Record the answer to the third decimal place. _____ mg
0.625
Which action would the nurse take when managing a patient who has an intravenous (IV) line and reports purulent discharge, redness, localized warmth, and swelling at the catheter entry point? Select all that apply. One, some, or all responses may be correct. a. Apply cold compresses. b. Obtain drainage for culture. c. Replace old IV tubing and solution with new. d. Notify health care provider of findings. e. Administer steroids to reduce inflammation.
b c d
A patient develops skin rashes and hives after administration of penicillin. Which phenomenon is this known as? a. Aggravation b. Amelioration. c. Adverse reaction d. Therapeutic effect
c
Which electrolyte imbalance is likely present in a patient with gastroenteritis who has tachycardia, hypotension, oliguria, and dark-colored urine and whose reports reveal increased hematocrit, elevated blood urea nitrogen, and increased specific gravity of the urine? a. Low levels of sodium in the body b. Low levels of potassium in the body c. Decreased extracellular fluids with isotonicity d. Combined hypernatremia and extracellular volume depletion
c
89. An order is written for 80 mg of a medication in elixir form . The medication is available in 80 mg / tsp strength . The nurse prepares to administer how much ? a . 2 mL b . 5 mL c . 10 mL d . 15 mL
B
90. The nurse prepares to administer an intradermal injection for the administration of medication for a . pain . b . allergy sensitivity . c . anticoagulant therapy . d . low - dose insulin requirements .
B
The nurse recognizes that the patient , on the basis of the imbalance that is present , will require fluid replacement with isotonic solution . One of the iso tonic solutions that may be ordered by the physician is which of the following ? a . 0.45 % saline b . Lactated Ringer solution c . 5 % dextrose in normal saline d . 5 % dextrose in lactated Ringer solution
B
The nurse weighs the patient who is taking a diuretic and finds that he has lost 5 pounds over the last few days . What is the approximate fluid loss that the patient has experienced ? a . 1.5 L b . 2.3 L c . 4.6 L d . 5 L
B
The nursing student is preparing to administer an antibiotic to a patient . The the nursing student what the medication is and why he should take it . Which information patient asks would the nursing student include when replying to the patient ? A. Only the patient's health care provider can give this information . B. The student provides the name of the medication and a description of its desired effect . C. Information about medications is confidential and cannot be shared . D. The patient has to speak with his assigned nurse about this .
B
The nurse takes the first blood pressure measurement . After recording the first pressure measurement , what action will the nurse take ? A. Count the client's radial pulse b. Remove the blood pressure cuff . C. Help the client change positions . D. Assess for an auscultatory gap .
A
The nurse will be starting a new IV infusion and needs to select the site for the insertion . In selection of a site , the nurse should a . use sites on an extremity away from a dialysis graft . b . start with the most proximal site . c . look for hard , cordlike veins . d . use the patient's dominant arm .
A
The patient asks the nurse about different herbal ther apies that may promote physical stamina and mental concentration . On the basis of the patient's request , the nurse provides information on a . ginseng . b . ginger . c . echinacea . d . chamomile .
A
The patient has experienced an extensive burn and now has bradycardia , muscle weakness , and abdomi nal cramping . Which of the following laboratory val ues would be most desirable for the nurse to obtain on the basis of the patient's assessment ? a . Serum potassium b . Serum magnesium c . Serum sodium d . Serum calcium
A
Which of the following is a medication order that is to be administered immediately ? a . Diazepam 10 mg IV stat b . Lanoxin 0.125 mg PO daily c . Ibuprofen 300 mg q4h prn d . Ativan 1 mg IV on call for surgery
A
Which problem often occurs in older clients and may have contributed to the fluid volume deficit the client is experiencing ? A. Decreased hepatic blood flow . B. Decreased drug absorption . C. Decreased drug half - life . D. Decreased Gl acidity .
A
Which process is responsible for the shift of body fluids associated with the intravenous administration of albumin ? A. Osmosis b. Diffusion c. Active transport d. Hydrostatic pressure
A
Which product would the nurse instruct intravenous drug users ( IDUS ) to use for cleaning of needles and syringes between uses ? A. Bleach b. Hot water c. Ammonia d. Rubbing alcohol
A
e . refuse to give the medication and notify the nurse d . manager administer the medication and watch the patient carefully . An order is written by the prescriber for morphine 40 mg IM q2h pm for pain . The nurse recognizes that this is significantly more than the usual therapeutic dose . The nurse should a . call the prescriber to clarify the order . b . give 4 mg IM as it was probably intended to be written .
A
loss is which of the following therapy that will be used a loss of intracellular fluid . The to replace this type of nurse anticipates A patient experiences that the IV solutions ? d . dextrose 5 % in ½ normal saline ( NS ) c . 5 % dextrose in lactated b . 10 % dextrose a . 0.33 % normal saline Ringer .
A
Which patient is considered to be at an increased risk for fluid and electrolyte imbalance ? Select all that apply . A. Older adult patients b. Overweight patients c. Healthy adult patients d. Infants e. Patients who take herbals
A d e
The nurse is preparing to administer a medication to a patient who is receiving continuous enteral feedings . Which action by the nurse is important before administering the medication ? Select all that apply a. Use 15 to 45 mL ( or facility policy ) of water to flush the tubing . B. Keep the patient flat during administration . C. Perform gastric suction after administration . D. Count the water intake as output on the intake and output record . E. Flush the tubing with at least 15 mL of water before and after feeding .
A e
A nurse is explaining to a patient about the side effects of a prescribed drug . Which statement related to side effects is applicable ? Select all that apply a. Predictable b. Often unavoidable c. Occur after prolonged intake d. Occur at usual therapeutic dose e. Caused by defective drug excretion
A b d
Which patient condition would cause the nurse to monitor for development of hypokalemia ? Select all that apply . A. Diarrhea b. Vomiting c. Adrenal insufficiency d. End - stage renal disease e. Potassium - wasting diuretics usage
A b e
The nurse is responsible for the storage and safe usage of drugs . Which guideline would the nurse follow for the safe use of narcotics ? Select all thatapply. A. Store narcotics in locked containers b. Preserve unused portion of the drug . C. Frequently count narcotics , especially during shift change d. Discrepancies in narcotic count should not be reported . E. Patient details should be documented and recorded .
A c e
When a client is admitted with dehydration , which clinical manifestations would the nurse expect to find ? Select all that apply a. Oliguria b. Dyspnea c. Hypotension d. Pulmonary crackles e. Tenting skin turgor
A c e
Which assessment would the nurse perform on a patient with gastroenteritis ? Select all that apply a. Examine oral mucosa . b. Measure chest expansion .. c. Measure urine output . D. Assess hemoglobin levels .. e. Measure blood pressure and pulse .
A c e
Which common cause of hypokalemia would the nurse educate the patients about when teaching a group of patients about the importance of fluid and electrolyte balance in a health awareness program ? Select all that apply . A. Diarrhea b. Acute oliguria c. Repeated vomiting d. Calcium - deficient diet e. Hyperaldosteronism
A c e
A patient is receiving an intravenous push ( IVP ) medication . As the nurse is administering the medication , the patient's intravenous ( IV ) site becomes swollen . Which action would the nurse take first ? A. Continue to let the IV run b. Apply a warm compress to the infiltrated site c. Stop the administration of the medication and follow agency policy d. Do not worry about this because vesicant filtration is not a problem
C
An IV of 50 mL is to be infused over 30 microdrip infusion set will be used . The nurse minutes calcu . A lates the infusion rate as a . 30 gtt / min . b . 50 gtt / min . c . 100 gtt / min . d . 200 gtt / min .
C
For a patient with a nursing diagnosis / hypothesis of Increased fluid volume / fluid retention , the nurse is alert to which one of the following signs ? a . Dry mucous membranes b . Weak , thready pulse c . Increased blood pressure d . Flushed skin
C
For the patient taking calcium supplements , the nurse is assessing the average daily intake and recognizes that it should be a total for fluids of a . 1500 mL . b . 2000 mL . c . 2500 mL . . 3000 mL .
C
For the patient who needs fluid replacement , which of the following should be avoided ? a . Juice b . Water c . Coffee d . Lemon - lime soda
C
For the patient with a vitamin D deficiency and inad equate calcium intake , the nurse observes for which of the following ? a . Anxiety b . Diaphoresis c . Chvostek sign d . Nausea and vomiting
C
The patient is ordered to have eye drops administered daily to both eyes . Eye drops should be instilled on the a cornea b . outer canthus . c . lower conjunctival sac . d . opening of the lacrimal duct .
C
The patient is to be given the medication that is enclosed in a cylindrical gelatin coating . The nurse knows that this medication comes in the form of a a . tablet . b . powder . c . capsule . d . suppository .
C
The physician has ordered 6 mg morphine sulfate every 3 to 4 hours prn for a patient's postoperative pain . The unit dose in the medication dispenser has 15 mg in I ml .. How much solution should the nurse give ? a . 0.2 ml b . 0.3 mL c . 0.4 mL d . 0.75 ml .
C
When a client who is taking a diuretic has been instructed to eat foods high in potassium , which fruit would the nurse suggest ? A. Apples b. Grapes c. Cantaloupe d. Cranberries
C
Which action would the nurse take with the client experiencing rising blood osmolality and orthostatic hypotension ? A. Restrict fluid intake . B. Auscultate the abdomen . C. Review the intake and output . D. Order an ultrasound of the kidneys .
C
Which assessment finding is consistent with hypovolemia ? A. A1 lb ( 0.5 kg ) weight loss in 1 week , pale - yellow urine b. Engorged neck veins when upright , bradycardial c. Dry mucous membranes , thready pulse , tachycardia d. Bounding radial pulse , flat neck veins when supine
C
Which blood types can potentially be used for transfusion when a client has type A negative blood ? A. Type O positive b. Type AB positive c. Type A or O negative d. Type A or AB negative
C
Which patient is at highest risk for the development of hypocalcemia ? A. 56 - year - old with acute renal failure b. 40 - year - old with appendicitis c. 28 - year - old who has acute pancreatitis d. 65 - year - old with hypertension and asthma
C
Which statement would the nurse make when explaining how to choose a donor for platelet transfusion for a patient with blood type O who needs platelets ? A. Rh compatibility is excluded . B. " The donor can be of any blood group . " c. " The donor should be of blood group d." The donor can be exempted from screening for infections . "
C
Two medications are to be given , one from an ampule and one from a vial . Identify the correct order of the procedure for putting the medications into the same syringe . The ampule and vial have both been prepared . a . Draw an amount of air into the syringe equal to the vial's medication dose . b . Draw up the amount of medication ordered from the ampule .. c . Verify the total dose in the syringe d . Attach a filter needle to the syringe . e . Insert the needle into the vial and instill the air into the space above the medication . f . Draw the medication from the vial
D a e f b c
Which clinical finding would the nurse observe in a patient diagnosed with chronic heart failure who is at risk for developing extracellular fluid volume excess? Select all that apply. One, some, or all responses may be correct. a. Ankle edema b. Postural hypotension c. Overnight weight loss d. Overnight weight gain e. Neck veins full when upright
a d e
A nurse caring for a hospitalized patient with dehydration is told in the shift report that the patient's laboratory results have just come in. The nurse recognizes which abnormal lab values that can reflect a fluid volume deficit? (Select all that apply.) a. Sodium (Na) level 150 mEq/L b. Potassium (K) level 3.5 mEq/L c. Calcium (Ca) level 9.5 mg/dL d.Blood urea nitrogen (BUN) 27 mg/dL
a d
A patient has been using herbal medication as part of her daily routine. Which actions should the nurse take? (Select all that apply.) a. Document the herbs as part of the medication history. b. Recommend a reputable company from which to buy herbs. c. Allow the patient to self-administer the herbs with her morning medications. d. Inform the primary care provider of the findings. e. Identify possible adverse effects of the herbal medications.
a d e
Which disease would the nurse screen for in blood donors ? Select all that apply a. Human immunodeficiency virus ( HIV ) b. Influenza c. Hepatitis d. Gonorrhea e. Cytomegalovirus
A c
89. The nurse is assessing a patient's peripheral edema An obvious indentation that lasts several seconds is classified as a . 1+ . b . 2+ . c . 3+ . d . 4+ .
C
Which concern when caring for a client prescribed furosemide 40 mg every day in conjunction with digoxin would prompt the nurse to ask the health care provider about potassium supplements ? A. Digoxin causes significant potassium depletion . B. The liver destroys potassium as digoxin is detoxified . C. Lasix requires adequate serum potassium to promote diuresis . D. Digoxin toxicity occurs rapidly in the presence of hypokalemia .
D
2. The nurse is caring for a patient with hypocalcemia who does not like milk. Which food should the nurse encourage the patient to consume? a. Cod b. Eggs c. Spinach d. Tomatoes
c
A patient is prescribed a sublingual nitroglycerin drug . Which instruction would the nurse provide to the patient ? Select all that apply a. Do not swallow the medication . B. Place the medication under the tongue . C. Spit out the drug in case of irritation . D. Take the medication with water . E. Place the drug between your tongue and cheek .
A b
How much fluid is lost daily through the skin (including perspiration) in a healthy adult? Record your answer using a whole number. _____ mL
500
Arrange the steps of vaginal administration of a suppository in the correct sequence. 1. Instruct the patient to remain on her back, in a side-lying position or with hips elevated on a pillow, for 5 to 10 minutes 2. Fully insert the applicator or suppository; use a rolling motion, inserting downward and backward 3. Lubricate the applicator or suppository using a water-soluble gel. 4. Expose, the vaginal orifice with nondominant hand.
3 4 2 1
Arrange the steps in the correct order for performing a venipuncture. 1. Advance catheter into the vein until the hub is near insertion. 2. Puncture the vein with a catheter at a 10-to 30-degree angle. 3. Palpate the vein for resilience. 4. Stabilize the vein below insertion site. 5. Look for blood return; if blood returns, stop inserting the needle. 6. Clean the site with chlorhexidine.
3 6 4 2 5 1
A nurse is reviewing the different routes of medication administration. Arrange the routes of medication administration in descending order (quickest to slowest) of drug absorption. 1. Subcutaneous 2. Intramuscular 3. Oral 4. Intravenous
4 2 1 3
Which grade on the edema scale does the nurse document in the medical record when the nurse applies pressure on a patient's skin and finds that the indentation remains for several minutes and is about 8 mm deep ?
4+
When receiving hemodialysis , the client may develop hyponatremia . Which clinical findings related to the potential development of hyponatremia would the nurse monitor ? Select all that apply a. Diarrhea b. Seizures c. Chvostek sign d. Cardiac dysrhythmias e. Increased temperature
A b
A patient with gastroenteritis experiences lightheadedness on sitting upright . On assessment , the blood pressure is 90/50 mm Hg in the supine position , pulse rate is 110 beats / min , and the oral mucous membranes are dry . Which action would the nurse take to promote fluid and electrolyte balance in the patient ? Select all that apply . One , some , or all responses may be correct . A. Provide oral fluids . B. Administer 0.9 % NaCl . C. Promote excess fluid intake . D. Administer antidiarrheal agents . E. Provide a comfortable environment .
A b
Which statement describes the partial pressure of carbon dioxide ( PaCO2 ) ? A. A measure of how well the lungs are excreting CO2 b. A measure of how well the kidneys are excreting metabolic acids c. A measure of how well gas exchange is occurring in the lungs d. The ability of hemoglobin to carry as much O2 as possible .
A. The partial pressure of carbon dioxide or PaCO2 measures how well the lungs are excreting CO2 produced by the cells during metabolism . Bicarbonate ( HCO3 ) measures how well the kidneys are excreting metabolic acids . Partial pressure of oxygen ( PaO2 ) measures how well gas exchange occurs in the lungs . Oxygen saturation ( SaO2 ) is the percentage of hemoglobin that carries as much 02 as possible .
A nurse works on a geriatric unit . Which physiologic change affecting the metabolism medication would the nurse be aware of in these patients ? Select all that apply a. Reduced liver function b. Reduced absorptive capacity c. Reduced functioning of brain receptors d. Shortening of half - life of drugs excreted through the kidney e. Reduced function of the immune system
Ab
Which finding would the nurse expect when assessing a client hospitalized for dehydration ? Select all that apply a. Protruding eyeballs b. Postural hypotension c. Client reports eating an average of two meals daily . D. Skin on forehead remains tented after being pinched . E. Weight loss of 4 ounces ( 0.11 kg ) over 4 days .
B d
A patient has lost vascular volume . What would you expect to find on assessment that reflects physiological compensatory mechanisms ? A increased urinary output B decreased urinary output C increased heart rate D decreased heart rate E increased blood pressure
B c
For a patient with a nursing diagnosis of Fluid Volume Deficit , the nurse is alert to which signs and symptoms ? ( Select all that apply . ) A Hypertension B Flushed skin C Dry mucous membranes D Weak , thready pulse E Pale , Yellow urine .
B c d
A diabetic patient has been switched from oral antidiabetic drugs to insulin . The patient has been prescribed regular insulin and NPH ( intermediate ) insulin . When teaching the patient about self - administration of insulin , which instruction would the nurse give the patient regarding preparation of the insulin ? Select all that apply a. Shake the insulin vial before preparing . B. Roll the cloudy insulin vial between the palms of the hands . C. Prepare the regular insulin first and then draw up the NPH insulin . D. Presence of bubbles in syringe does not alter the insulin dose . E. Administer both insulins before a meal .
B c e
Which clinical finding would the nurse evaluate for in a patient with hypomagnesemia ? Select all that apply . A. Lethargy b.mSeizures c. Irritable nerves and muscles d. Hypoactive deep tendon reflexes e. Hyperactive deep tendon reflexes
B c e
Identify the correct sequence for this stage of inser tion of a peripheral IV . a . Cleanse the site with 2 % chlorhexidine and allow the site to air dry . b . Apply clean gloves . c . Select an appropriate vein . d . Insert the IV catheter at a 10- to 30 - degree angle . e . Apply the tourniquet with a quick - release knot . f . Advance the catheter .
B c e a d f
A client is admitted with dehydration . Which findings should the nurse expect the client to exhibit ? Select all that apply a. Supple skin turgor b. Rapid , thready pulse c. Decreased hematocrit d. Elevated specific gravity e. Adventitious breath sounds
B d
A client with Crohn disease is admitted to the hospital with abdominal pain , fever , poor skin turgor , and having experienced 10 liquid bowel movements in the past 24 hours . The nurse suspects that the client is dehydrated based on which assessment findings ? Select all that apply . A. Moist skin b. Sunken eyes c. Decreased apical pulse d. Dry mucous membranes e. Increased blood pressure
B d
Which inquiry would help the nurse obtain a relevant history when examining a patient who is suspected of having fluid , electrolyte and acid - base imbalances ? Select all that apply . A. Obtain details of the patient's sleep patterns . B. Inquire about the patient's sexual behavior . C. Obtain a history of medication or herbal remedies used . D. Inquire whether the patient is on any weight - loss diet plan . E. Inquire about the type of fluids the patient drinks daily .
C d e
Patient is nauseated, has been vomiting for several hours and needs to receive an antiemetic medication. The nurse recognizes that administration of the medication , considering the patient's status and the medication , is best via which route ( s ) ? Select all that apply . a . Oral b . Enteral c . Parenteral d . Inhalation e . Topical - rectal suppository f . Topical - nasal application
C e
The nurse is preparing to insert an intravenous ( IV ) catheter in a thin , emaciated client who is scheduled to begin intravenous fluid therapy . Which interventions would the nurse follow to provide high - quality care ? Select all that apply a. Insert an 18 - gauge IV catheter b. Change the IV line every 7 days c. Flush the IV line with normal saline d. Insert the IV catheter in the client's femur e. Stop the insertion procedure when there is a break in technique
C e
The nurse is to apply a transdermal patch to a patient . Select the three correct techniques . a . Use the same location for the new transdermal patch . b . Place transdermal patches over bony areas c . Write initials , date , and time on patches before applied . d . Massage the patch when it is in place . e. Remove patches if the patient required defibrillation. f. Clean the skin site where the patch will be placed.
C e f
An elderly obese patient who has undergone total hip replacement surgery has been prescribed low - molecular - weight heparin ( LMWH ) enoxaparin . Which information would the nurse inform the patient about subcutaneous administration ? Select all that apply . A. It produces no discomfort or pain to patient . B. The medication is absorbed faster due to a rich blood supply . C. The abdomen is not an appropriate site for subcutaneous injections . D. The injection site should not be near any bony prominence or large nerves . E. The medication is injected into the connective tissue below the dermis .
D e
The patient is to use a traditional metered - dose inhaler ( MDI ) . Place the steps of the procedure in the correct order . a . Patient places the mouthpiece of the inhaler in the mouth . b . Patient removes inhaler and exhales through pursed lips . c . Patient takes a deep breath and blows out com pletely . d . Patient inhales slowly and pushes the canister . e . Patient shakes the MDI . f . Patient continues to inhale for 3 to 5 seconds and hold the breath to 5 to 10 seconds ..
E c a d f b
2. A patient has reported a 2-kg (4.4-lb) weight gain over the past 3 days. Which assessment cues should the nurse recognize as additional evidence for a nursing diagnosis of Fluid Volume Overload (Hypervolemia)? (Select all that apply.) a. Third spacing/edema b. Potassium intake c. Bounding, rapid pulse d. Crackles in lungs e. Dry mucous membranes
a c d
Which dietary instruction would the nurse give to a patient who presents with muscle twitching and cramping when the health care provider diagnoses the patient with calcium deficiency? Select all that apply. One, some, or all responses may be correct. A. Supplement with vitamin D. B. Avoid rhubarb and spinach. C. Increase the intake of dairy products. D. Increase the intake of tofu. E. Increase consumption of tomatoes and bananas.
a c d
2. A nurse in the emergency department is caring for an adult patient with traumatic abdominal injuries. The patient's pulse rate has increased from 90 to 120 beats/min over the past hour and the patient is experiencing orthostatic hypotension. For which imbalance should the nurse assess? a. Respiratory acidosis b. Extracellular fluid volume deficit c. Metabolic alkalosis d. Intracellular fluid volume excess
b
Which solution would the health care provider hang with the transfusion when planning to transfuse a patient with a unit of packed red blood cells? a. 5% dextrose in water b. 0.9% sodium chloride c. 5% dextrose in 0.9% sodium chloride d. 5% dextrose in lactated Ringer's solution
b
Which type of fluid would a nurse mention when teaching patients to replace sweat, vomiting, or diarrhea fluid losses? a. Tap water or bottled water b. Fluid that has sodium (salt) in it c. Fluid that has K+ and HCO3 in it d. Coffee or tea, whichever they prefer
b
2. For a patient with a nursing diagnosis of Dehydration, the nurse recognizes which cues as signs and symptoms of dehydration? (Select all that apply). a. Hypertension b. Elevated urine specific gravity c. Dry mucous membranes d. Weak, thready pulse Pale yellow urine
b c d
The nurse is evaluating whether a patient is taking prescribed medications correctly. Which patient practice indicates the need for additional instruction? Select all that apply. One, some, or all responses may be correct. a. "I always check my medication before I take it." b. "I use multiple medication cups to prepare a single dose." c. "I use a plastic spoon as a measuring device to take syrups." d. "I use a scored tablet if the dose must be divided." e. "I notice that a part of my medication is often left in the crusher."
b c e
A patient is prescribed lozenges for a cough. Which instruction would the nurse give to this patient regarding the use of lozenges? Select all that apply. One, some, or all responses may be correct a. "The lozenge should be crushed before swallowing. b. "Allow the medication to dissolve in your mouth." c. "Dissolve the lozenge in water before swallowing." d. "The medication should not be ingested e. "Dissolve the medication in juice before swallowing.
b d
The nurse administers a bronchodilator for a hypertensive patient with shortness of breath. Which finding does the nurse assess to determine the effectiveness of the medication? Select all that apply. One, some, or all responses may be correct. a. Temperature b. Respiratory rate c. Blood pressure d. Oxygen saturation e. Auscultation of lungs
b d e
Which precaution would the nurse follow to prevent speed shock during the intravenous (IV) administration of medications? Select all that apply. One, some, or all responses may be correct. a. Refrain from inserting IV catheters over the joints. b. Stop the infusion immediately if sudden onset of dizziness occurs. c. Do not use electronic pumps for the infusion. d. Monitor the gravity flow set closely during administration. e. Follow the recommended infusion rate of medication.
b d e
Which type of intravenous solution would the nurse expect the health care provider to prescribe for a patient with an isotonic fluid volume deficit? Select all that apply. One, some, or all responses may be correct. a. 3% normal saline solution b. 0.9% normal saline solution c. 0.45% normal saline solution d. D5 0.2% normal saline solution e. D5 0.45% normal saline solution
b e
2. The nurse is assessing the intravenous (IV) site in the right antecubital and notices that the area about 1 inch around it is cool, swollen, firm, and tender to touch. Which action should the nurse take first? a. Take patient's temperature. b. Apply an ice pack to site. c. Stop infusion and remove IV catheter. d. Call the primary care provider immediately.
c
A nurse is teaching self-administration of insulin to a patient. Which instruction would the nurse include in the teaching? a. Shake the vial before drawing insulin. b. Administer regular insulin intramuscularly. c. Roll the insulin between your palms if the preparation is cloudy. d. Administer insulin after having meals.
c
A patient is transitioning from the hospital to the home environment, and a home care referral is obtained. Which action will the discharge nurse take in relation to safe medication administration? a. Set up the follow-up appointments with the health care provider for the patient. b. Ensure that someone will provide housekeeping for the patient at home. c. Ensure that the home care agency is aware of medication and health teaching needs. d. Make sure that the patient's family knows how to safely bathe him or her and provide mouth care.
c
The health care provider prescribes a transdermal medication. The nurse understands what feature of the transdermal route? a. It is inhaled into the respiratory tract. b. It is dissolved inside the cheek. c. It is absorbed through the skin. d. It is inserted into the vaginal cavity.
c
The nurse is administering medications to a 4-year-old patient. After the nurse explains which medications are being given, the mother states, "I don't remember my child having that medication before." Which action would the nurse take next? a. Give the medications. b. Identify the patient using two patient identifiers. c. Withhold the medications and verify the medication prescriptions. d. Provide education to the mother to help her better understand her child's medications.
c
The nurse is caring for a patient who is unable to hold a cup or spoon. How should the nurse administer oral medications to the patient? a. Crush the pills and mix them in pudding before administering. b. Ask the pharmacist to change all of the medications to a liquid form. c. Use a small paper cup to place the pills into the patient's mouth. d. Place the pills on the table and have the patient take the pills by hand.
c
The nurse is teaching a patient about how to take a sublingual nitroglycerin tablet. Which statement by the patient best demonstrates understanding of the teaching? a. "I will take the tablet with plenty of water." b. "I will place the tablet inside my cheek." c. "I will put the tablet under my tongue." d. "I will take the tablet while I am eating."
c
The nurse reviews a primary care provider's order and finds that the medication amount is greater than the standard dose. What action should the nurse take? a. Give the standard dose rather than the one that is ordered. b. Consult with the nursing supervisor to get a second opinion. c. Call the primary care provider to discuss the order in question. d. Administer the medication as ordered by the primary care provider.
c
Which assessment finding is consistent with hypovolemia? a. A 1 Ib (g,5 kg) weight loss in I week, pale-yellow urine b. Engorged neck veins when upright, bradycardia c. Dry mucous membranes, thready pulse, tachycardia d. Bounding radial pulse, flat neck veins when supine
c
Which condition would the nurse suspect in a patient who has a malignancy in which the malignant cells secrete chemicals similar to parathyroid hormone? a. Hyperkalemia b. Hypernatremia c. Hypercalcemia d. Hypermagnesemia
c
Which implication would be made by a nurse assessing a patient whose recent blood gas determination indicated a pH of 7.32 and respirations at 32 breaths/min? a. The rapid breathing is causing the low pH. b. The nurse should sedate the patient to slow down respirations. c.The rapid breathing is an attempt to compensate for the low pH. d. The nurse should give the patient a paper bag to breathe into to correct the low pH.
c
Which laboratory value would the nurse assess specifically in a patient with a cardiac history who is taking the diuretic furosemide and is seen in the emergency department for muscle weakness? a. Serum albumin b. Serum sodium c. Hematocrit d. Serum potassium
d
