Med Surg Exam 1 All Together

A patient is scheduled to undergo a bronchoscopy for the investigation of a bronchial mass. What benzodiazepine should the clinic nurse anticipate administering for conscious sedation? A) Triazolam (Halcion) B) Midazolam (Versed) C) Oxazepam (Serax) D) Chlordiazepoxide (Librium)

Ans: B Feedback: Midazolam (Versed) is frequently used for conscious sedation during invasive procedures. Halcion, Serax, and Librium are not typically used for this purpose.

The client has required 2 sublingual nitroglycerine tablets that are gr 1/150 per tablet. How many mg of nitroglycerine did the client receive?

Correct Answer: 0.8 mg or 800 mcg Rationale: The client received gr 2/150 of NTG. There are 60 mg in 1 grain. To convert, multiply 2/150 x 60 = 120/150 = 0.8 mg or 800 mcg.

You are creating a nursing care plan for a patient who is hospitalized following right total hip replacement. What nursing action should you specify to prevent inward rotation of the patients hip when the patient is in a partial lateral position? A) Use of an abduction pillow between the patients legs B) Alignment of the head with the spine using a pillow C) Support of the lower back with a small pillow D) Placement of trochanter rolls under the greater trochanter

Ans: A Feedback: Abduction pillows can be used to keep the hip in correct alignment if precautions are warranted following hip replacement. Trochanter rolls and back pillows do not achieve this goal.

The anesthetist is coming to the surgical admissions unit to see a patient prior to surgery scheduled for tomorrow morning. Which of the following is the priority information that the nurse should provide to the anesthetist during the visit? A) Last bowel movement B) Latex allergy C) Number of pregnancies D) Difficulty falling asleep

Ans: B Feedback: Due to the increased number of patients with latex allergies, it is essential to identify this allergy early on so precautions can be taken in the OR. The anesthetist should be informed of any allergies. This is a priority over pregnancy history, insomnia, or recent bowel function, though some of these may be relevant.

A patient is admitted with thrombophlebitis and sent home on enoxaparin (Lovenox). Which statement indicates a good understanding of why enoxaparin is being administered? A) Enoxaparin inhibits the formation of additional clots. B) Enoxaparin eliminates certain clotting factors. C) Enoxaparin decreases the viscosity of blood. D) Enoxaparin will dissolve the existing clots.

Ans: A Feedback: Low molecular weight heparins prevent the development of additional clots. They do not eliminate clotting factors. LMWHs do not dissolve the clot or decrease the viscosity of blood.

A patient is administered a benzodiazepine for anxiety. Which of the following will place the patient at risk for benzodiazepine toxicity? A) Decreased albumin B) Increased calcium C) Decreased potassium D) Low bicarbonate

Ans: A Feedback: Patients with liver disease are at risk for adverse effects with drugs that are highly bound to plasma proteins. Increased calcium will not contribute to benzodiazepine toxicity. Decreased potassium will not have a direct impact on benzodiazepine toxicity. The normal bicarbonate will not contribute to benzodiazepine toxicity.

What is a nonpharmacological measure that is effective in treating nausea and vomiting in pregnant women? A) Ginkgo biloba B) Ginger C) Garlic D) Ginseng

Ans: B Feedback: Clinical trials indicate that ginger can effectively reduce nausea and vomiting associated with motion sickness, pregnancy, and surgery.

A patient is being discharged from the hospital with warfarin (Coumadin) to be taken at home. Which of the following foods should the patient be instructed to avoid in his diet? A) Eggs B) Dairy products C) Apples D) Spinach

Ans: D Feedback: Spinach is a green leafy vegetable that is high in vitamin K and will interact to prevent adequate levels of anticoagulant therapy. Eggs, dairy products, and apples are not contraindicated with warfarin.

During the process of administering medications, the nurse checks the name band for the clients name. What should be this nurses next action? 1. Administer the medication as ordered. 2. Initial the MAR that the medication will be given. 3. Double check the clients identification using a second method. 4. Educate the client regarding the medication to be given.

Correct Answer: 3 Rationale 1: This nurse should employ a second method to verify the clients identification. Rationale 2: The MAR will be initialed after the medication has been given. Rationale 3: The Joint Commissions National Safety Goals require a two-step check of client identification prior to the administration of medications. This nurse should employ a second method to verify the clients identification. Rationale 4: Once the nurse has verified client identification, the nurse should educate the client regarding the medication to be given.

The nurse is to administer 75 mL of an antibiotic solution by IV over the next 30 minutes. The tubing has a drop factor of 20. How many drops per minute should the nurse set the controller to deliver? Standard Text: Record your answer, rounding to the nearest whole number.

Correct Answer: 50 drops per minute Rationale: 75 mL/1 hour 20 drops/30 minutes = 50 drops per minute.

A school nurse is teaching a group of high school students about risk factors for diabetes. Which of the following actions has the greatest potential to reduce an individuals risk for developing diabetes? A) Have blood glucose levels checked annually. B) Stop using tobacco in any form. C) Undergo eye examinations regularly. D) Lose weight, if obese.

A school nurse is teaching a group of high school students about risk factors for diabetes. Which of the following actions has the greatest potential to reduce an individuals risk for developing diabetes? A) Have blood glucose levels checked annually. B) Stop using tobacco in any form. C) Undergo eye examinations regularly. D) Lose weight, if obese.

The nurse is caring for an older adult patient who is receiving rehabilitation following an ischemic stroke. A review of the patients electronic health record reveals that the patient usually defers her selfcare to family members or members of the care team. What should the nurse include as an initial goal when planning this patients subsequent care? A) The patient will demonstrate independent self-care. B) The patients family will collaboratively manage the patients care. C) The nurse will delegate the patients care to a nursing assistant. D) The patient will participate in a life skills program.

Ans: A Feedback: An appropriate patient goal will focus on the patient demonstrating independent self-care. The rehabilitation process helps patients achieve an acceptable quality of life with dignity, self-respect, and independence. The other options are incorrect because an appropriate goal would not be for the family to manage the patients care, the patients care would not be delegated to a nursing assistant, and participating in a social program is not an appropriate initial goal.

A school nurse is providing health promotion teaching to a group of high school seniors. The nurse should highlight what salient risk factor for traumatic brain injury? A) Substance abuse B) Sports participation C) Anger mismanagement D) Lack of community resources

Ans: A Feedback: Of spinal cord injuries, 50% are related to substance abuse, and approximately 50% of all patients with traumatic brain injury were intoxicated at the time of injury. This association exceeds the significance of sports participation, anger mismanagement, or lack of community resources.

A patient who is receiving rehabilitation following a spinal cord injury has been diagnosed with reflex incontinence. The nurse caring for the patient should include which intervention in this patients plan of care? A) Regular perineal care to prevent skin breakdown B) Kegel exercises to strengthen the pelvic floor C) Administration of hypotonic IV fluid D) Limited fluid intake to prevent incontinence

Ans: A Feedback: Reflex incontinence is associated with a spinal cord lesion that interrupts cerebral control, resulting in no sensory awareness of the need to void. Total incontinence occurs in patients with a psychological impairment when they cannot control excreta. A patient who is paralyzed cannot perform Kegel exercises. Intravenous fluids would make no difference in reflex incontinence. Limited fluid intake would make no impact on a patients inability to sense the need to void.

You are the nurse creating the care plan for a patient newly admitted to your rehabilitation unit. The patient is an 82-year-old patient who has had a stroke but who lived independently until this event. What is a goal that you should include in this patients nursing care plan? A) Maintain joint mobility. B) Refer to social services. C) Ambulate three times every day. D) Perform passive range of motion twice daily.

Ans: A Feedback: The major goals may include absence of contracture and deformity, maintenance of muscle strength and joint mobility, independent mobility, increased activity tolerance, and prevention of further disability. The other listed actions are interventions, not goals.

An adult patients current goals of rehabilitation focus primarily on self-care. What is a priority when teaching a patient who has self-care deficits in ADLs? A) To provide an optimal learning environment with minimal distractions B) To describe the evidence base for any chosen interventions C) To help the patient become aware of the requirements of assisted-living centers D) To ensure that the patient is able to perform self-care without any aid from caregivers

Ans: A Feedback: The nurses role is to provide an optimal learning environment that minimizes distractions. Describing the evidence base is not a priority, though nursing actions should indeed be evidence-based. Assisted living facilities are not relevant to most patients. Absolute independence in ADLs is not an appropriate goal for every patient.

You are the nurse caring for an elderly patient who has been on a bowel training program due to the neurologic effects of a stroke. In the past several days, the patient has begun exhibiting normal bowel patterns. Once a bowel routine has been well established, you should avoid which of the following? A) Use of a bedpan B) Use of a padded or raised commode C) Massage of the patients abdomen D) Use of a bedside toilet

Ans: A Feedback: Use of bedpans should be avoided once a bowel routine has been established. An acceptable alternative to a private bathroom is a padded commode or bedside toilet. Massaging the abdomen from right to left facilitates movement of feces in the lower tract.

A pediatric patient is receiving chemotherapy. What is the recommended treatment of nausea and vomiting with pediatric chemotherapy agents? A) Corticosteroids and 5-HT3 receptor antagonists B) Phenothiazines and benzodiazepines C) Proton pump inhibitors and antacids D) Prokinetic agents and antihistamines

Ans: A Feedback: 5-HT3 receptor antagonists and corticosteroids are used to treat nausea and vomiting in pediatric oncology patients

A 1-year-old postoperative patient has been experiencing repeated vomiting. What antiemetic drug has a black box warning against use in a patient of this age? A) Promethazine (Phenergan) B) Benzquinamide (Emete-Con) C) Buclizine (Bucladin-S) D) Cyclizine (Marezine)

Ans: A Feedback: A black box warning alerts nurses that promethazine is contraindicated in children younger than 2 years of age because of the risk of potentially fatal respiratory depression. Benzquinamide, buclizine, and cyclizine do not have such warnings.

Which of the following is the antidote for acetaminophen (Tylenol) poisoning? A) Acetylcysteine (Mucomyst) B) Allopurinol (Zyloprim) C) Diclofenac sodium (Voltaren) D) Ketorolac (Toradol)

Ans: A Feedback: A specific antidote, acetylcysteine (Mucomyst), is a mucolytic agent given for acetaminophen poisoning.

The perioperative nurse is preparing to discharge a female patient home from day surgery performed under general anesthetic. What instruction should the nurse give the patient prior to the patient leaving the hospital? A) The patient should not drive herself home. B) The patient should take an OTC sleeping pill for 2 nights. C) The patient should attempt to eat a large meal at home to aid wound healing. D) The patient should remain in bed for the first 48 hours postoperative.

Ans: A Feedback: Although recovery time varies, depending on the type and extent of surgery and the patients overall condition, instructions usually advise limited activity for 24 to 48 hours. Complete bedrest is contraindicated in most cases, however. During this time, the patient should not drive a vehicle and should eat only as tolerated. The nurse does not normally make OTC recommendations for hypnotics.

A patient is administered acetylsalicylic acid (aspirin) for fever and headache. What is the action of acetylsalicylic acid (aspirin)? A) Inhibiting prostaglandin synthesis in the central and peripheral nervous system B) Providing selective action by inhibiting prostaglandin synthesis in the CNS C) Inhibiting the release of norepinephrine to increase blood pressure D) Suppressing the function of the hypothalamus to decrease inflammation

Ans: A Feedback: Aspirin inhibits prostaglandin synthesis in the central nervous system and the peripheral nervous system. Acetylsalicylic acid does not provide selective action by inhibiting prostaglandin synthesis in the CNS. Aspirin does not inhibit the release of norepinephrine to increase blood pressure. Aspirin does not suppress the function of the hypothalamus to decrease inflammation.

The perioperative nurse is providing care for a patient who is recovering on the postsurgical unit following a transurethral prostate resection (TUPR). The patient is reluctant to ambulate, citing the need to recover in bed. For what complication is the patient most at risk? A) Atelectasis B) Anemia C) Dehydration D) Peripheral edema

Ans: A Feedback: Atelectasis occurs when the postoperative patient fails to move, cough, and breathe deeply. With good nursing care, this is an avoidable complication, but reduced mobility greatly increases the risk. Anemia occurs rarely and usually in situations where the patient loses a significant amount of blood or continues bleeding postoperatively. Fluid shifts postoperatively may result in dehydration and peripheral edema, but the patient is most at risk for atelectasis.

A patient with multiple sclerosis is admitted to the medical division for treatment of severe spasticity. What medication is used to treat spasticity and is administered intrathecally? A) Baclofen (Lioresal) B) Carisoprodol (Soma) C) Diazepam (Valium) D) Dantrolene (Dantrium)

Ans: A Feedback: Baclofen is used to treat spasticity in MS and spinal cord injuries. It can be administered intrathecally. Carisoprodol is used to relieve discomfort from acute, painful musculoskeletal disorders. Diazepam is used to relieve muscle spasms but not used intrathecally. Dantrolene is used to treat malignant hyperthermia but not multiple sclerosis.

An OR nurse is participating in an interdisciplinary audit of infection control practices in the surgical department. The nurse should know that a basic guideline for maintaining surgical asepsis is what? A) Sterile surfaces or articles may touch other sterile surfaces. B) Sterile supplies can be used on another patient if the packages are intact. C) The outer lip of a sterile solution is considered sterile. D) The scrub nurse may pour a sterile solution from a nonsterile bottle.

Ans: A Feedback: Basic guidelines for maintaining sterile technique include that sterile surfaces or articles may touch other sterile surfaces only. The other options each constitute a break in sterile technique.

A patient will soon begin treatment for diabetes using glyburide. Which of the following conditions must be met in order for treatment to be effective? A) The patient must have functioning pancreatic beta cells. B) The patient must have hemoglobin A1C of 7%. C) The patient must not have hyperglycemia. D) The patient must be able to self-administer the medication.

Ans: A Feedback: Because glyburide stimulates pancreatic beta cells to produce more insulin, it is effective only when functioning pancreatic beta cells are present. The presence of normal blood glucose levels would render the medication unnecessary. Selfadministration is common but not absolutely necessary.

You are providing preoperative teaching to a patient scheduled for hip replacement surgery in 1 month. During the preoperative teaching, the patient gives you a list of medications she takes, the dosage, and frequency. Which of the following interventions provides the patient with the most accurate information? A) Instruct the patient to stop taking St. Johns wort at least 2 weeks prior to surgery due to its interaction with anesthetic agents. B) Instruct the patient to continue taking ephedrine prior to surgery due to its beneficial effect on blood pressure. C) Instruct the patient to discontinue Synthroid due to its effect on blood coagulation and the potential for heart dysrhythmias. D) Instruct the patient to continue any herbal supplements unless otherwise instructed, and inform the patient that these supplements have minimal effect on the surgical procedure.

Ans: A Feedback: Because of the potential effects of herbal medications on coagulation and potential lethal interactions with other medications, the nurse must ask surgical patients specifically about the use of these agents, document their use, and inform the surgical team and anesthesiologist, anesthetist, or nurse anesthetist. Currently, it is recommended that the use of herbal products be discontinued at least 2 weeks before surgery. Patients with uncontrolled thyroid disorders are at risk for thyrotoxicosis and respiratory failure. The administration of Synthroid is imperative in the preoperative period. The use of ephedrine in the preoperative phase can cause hypertension and should be avoided.

Vecuronium will be administered to a surgical patient to facilitate intubation and achieve balanced anesthesia. This medication induces paralysis by A) antagonizing acetylcholine receptors at neuromuscular junctions. B) potentiating the effects of acetylcholinesterase in synapses. C) crossing the blood-brain barrier and agonizing cerebellar function. D) binding with serotonin and inhibiting its neuromuscular effects.

Ans: A Feedback: Because vecuronium is structurally similar to ACh, it binds to the receptors on the muscle and prevents normal function of ACh, producing skeletal muscle paralysis. The drug does not influence the physiology of serotonin, the cerebellum, or acetylcholinesterase.

A 15-year-old child is brought to the emergency department with symptoms of hyperglycemia and is subsequently diagnosed with diabetes. Based on the fact that the childs pancreatic beta cells are being destroyed, the patient would be diagnosed with what type of diabetes? A) Type 1 diabetes B) Type 2 diabetes C) Noninsulin-dependent diabetes D) Prediabetes

Ans: A Feedback: Beta cell destruction is the hallmark of type 1 diabetes. Noninsulin-dependent diabetes is synonymous with type 2 diabetes, which involves insulin resistance and impaired insulin secretion, but not beta cell destruction. Prediabetes is characterized by normal glucose metabolism, but a previous history of hyperglycemia, often during illness or pregnancy.

The most recent blood work of a patient with a longstanding diagnosis of type 1 diabetes has shown the presence of microalbuminuria. What is the nurses most appropriate action? A) Teach the patient about actions to slow the progression of nephropathy. B) Ensure that the patient receives a comprehensive assessment of liver function. C) Determine whether the patient has been using expired insulin. D) Administer a fluid challenge and have the test repeated.

Ans: A Feedback: Clinical nephropathy eventually develops in more than 85% of people with microalbuminuria. As such, educational interventions addressing this microvascular complication are warranted. Expired insulin does not cause nephropathy, and the patients liver function is not likely affected. There is no indication for the use of a fluid challenge.

A patient presents to the clinic complaining of symptoms that suggest diabetes. What criteria would support checking blood levels for the diagnosis of diabetes? A) Fasting plasma glucose greater than or equal to 126 mg/dL B) Random plasma glucose greater than 150 mg/dL C) Fasting plasma glucose greater than 116 mg/dL on 2 separate occasions D) Random plasma glucose greater than 126 mg/dL

Ans: A Feedback: Criteria for the diagnosis of diabetes include symptoms of diabetes plus random plasma glucose greater than or equal to 200 mg/dL, or a fasting plasma glucose greater than or equal to 126 mg/dL.

A patient is recovering from a stroke and has developed severe muscle contractions. Which of the following medications will inhibit the release of calcium in skeletal muscle cells? A) Dantrolene sodium (Dantrium) B) Baclofen (Lioresal) C) Carisoprodol (Soma) D) Cyclobenzaprine (Flexeril)

Ans: A Feedback: Dantrium relieves spasticity by inhibiting the release of calcium in skeletal muscle cells. Lioresal, Soma, and Flexeril act centrally.

A patient with a longstanding diagnosis of type 1 diabetes has a history of poor glycemic control. The nurse recognizes the need to assess the patient for signs and symptoms of peripheral neuropathy. Peripheral neuropathy constitutes a risk for what nursing diagnosis? A) Infection B) Acute pain C) Acute confusion D) Impaired urinary elimination

Ans: A Feedback: Decreased sensations of pain and temperature place patients with neuropathy at increased risk for injury and undetected foot infections. The neurologic changes associated with peripheral neuropathy do not normally result in pain, confusion, or impairments in urinary function.

A 39-year-old patient has been diagnosed with thyroid cancer and will have a thyroidectomy performed. During surgery in this nerve-rich and highly vascular region of the body, the patient may require vecuronium. What will be the primary purpose of this medication? A) To ensure that the patient does not move during surgery B) To prevent intraoperative vomiting C) To protect the patient's airway during surgery D) To induce hypnosis and amnesia

Ans: A Feedback: Delicate repairs, such as neck surgery and neurosurgery, may require the use of neuromuscular agents to prevent movement and subsequent damage. Vecuronium is not used to prevent nausea and vomiting, to protect the patient's airway, or to induce hypnosis and amnesia.

A patient has been ordered a fentanyl patch known as Duragesic for chronic pain. What patient teaching should be provided to the patient and family? A) Remove the patch every 3 days. B) Apply it to the chest only. C) Apply it for breakthrough pain. D) Remove it daily and clean skin.

Ans: A Feedback: Duragesic has a slow onset of action, but lasts about 72 hours. Duragesic can be iapplied to other areas of the skin, not solely on the chest. Duragesic is not applied for breakthrough pain. Duragesic is not removed daily.

An OR nurse will be participating in the intraoperative phase of a patients kidney transplant. What action will the nurse prioritize in this aspect of nursing care? A) Monitoring the patients physiologic status B) Providing emotional support to family C) Maintaining the patients cognitive status D) Maintaining a clean environment

Ans: A Feedback: During the intraoperative phase, the nurse is responsible for physiologic monitoring. The intraoperative nurse cannot support the family at this time and the nurse is not responsible for maintaining the patients cognitive status. The intraoperative nurse maintains an aseptic, not clean, environment.

A circulating nurse provides care in a surgical department that has multiple surgeries scheduled for the day. The nurse should know to monitor which patient most closely during the intraoperative period because of the increased risk for hypothermia? A) A 74-year-old woman with a low body mass index B) A 17-year-old boy with traumatic injuries C) A 45-year-old woman having an abdominal hysterectomy D) A 13-year-old girl undergoing craniofacial surgery

Ans: A Feedback: Elderly patients are at greatest risk during surgical procedures because they have an impaired ability to increase their metabolic rate and impaired thermoregulatory mechanisms, which increase susceptibility to hypothermia. The other patients are likely at a lower risk.

A pregnant woman suffers from morning sickness. Which of the following should be considered a first-line treatment? A) Vitamin B6 B) Promethazine (Phenergan) C) Vitamin E D) Diphenhydramine (Benadryl)

Ans: A Feedback: For pregnant women, taking pyridoxine (vitamin B6) 30 to 75 mg daily in three divided doses with or without the antihistamine doxylamine 12.5 mg every 8 hours as needed is considered a first-line treatment option that is safe and effective. Phenergan is not a first-line treatment for morning sickness. Benadryl and vitamin E are not used to treat nausea.

A patient of Italian descent has been prescribed antidiabetic medications. Heavy intake of which of the following herbs should be avoided by this patient? A) Garlic B) Anise C) Basil D) Oregano

Ans: A Feedback: Garlic has been known to cause hypoglycemia when taken with antidiabetic medications. Anise, basil, and oregano are not noted to carry this risk.

A patient has been administered heparin to prevent thromboembolism development status postmyocardial infarction. The patient develops heparin-induced thrombocytopenia. Which of the following medications will be administered? A) Argatroban (Acova) B) Vitamin K C) Calcium gluconate D) Aminocaproic acid (Amicar)

Ans: A Feedback: Heparin-induced thrombocytopenia may occur in 1% to 3% of those receiving heparin and is a very serious side effect of heparin. In this patient, all heparin administration must be discontinued and anticoagulation managed with a direct thrombin inhibitor, such as argatroban. The patient is not administered vitamin K, calcium gluconate, or aminocaproic acid.

An outpatient has been prescribed hydrocodone for back pain related to a compression fracture. Which of the following interventions should the patient be taught regarding the medication administration? A) Consume a diet high in fiber. B) Decrease activity due to pain. C) Elevate the lower extremities. D) Take aspirin with the medication.

Ans: A Feedback: Hydrocodone is an opioid, which, in the gastrointestinal tract, slows motility. To prevent constipation, the patient should consume a diet high in fiber. A decrease in activity due to pain will increase constipation. Elevating the lower extremities will not increase or decrease pain. Hydrocodone should not be routinely combined with aspirin unless prescribed by the physician.

A patient is taking tizanidine (Zanaflex) to treat spasticity from multiple sclerosis. Which of the following adverse effects of muscle relaxants is most pronounced with this medication? A) Hypotension B) Dark black urine C) Excessive salivation D) Eczema

Ans: A Feedback: Hypotension is the most significant adverse effect of tizanidine. Dark black urine, excessive salivation, and eczema are not adverse effects of tizanidine.

A patient is admitted to the emergency room in status epilepticus. What medication may be administered intravenously to assist in reducing seizure activity? A) Diazepam (Valium) B) Hydromorphone (Dilaudid) C) Insulin D) Meperidine (Demerol)

Ans: A Feedback: IV diazepam is an adjunctive skeletal muscle relaxant administered for the treatment of severe recurrent convulsive seizures and status epilepticus. Ethosuximide (Zarontin) is not administered for status epilepticus. Meperidine (Demerol) and insulin are not administered for status epilepticus.

A nurse is conducting a class on how to self-manage insulin regimens. A patient asks how long a vial of insulin can be stored at room temperature before it goes bad. What would be the nurses best answer? A) If you are going to use up the vial within 1 month it can be kept at room temperature. B) If a vial of insulin will be used up within 21 days, it may be kept at room temperature. C) If a vial of insulin will be used up within 2 weeks, it may be kept at room temperature. D) If a vial of insulin will be used up within 1 week, it may be kept at room temperature.

Ans: A Feedback: If a vial of insulin will be used up within 1 month, it may be kept at room temperature.

A patient has been brought to the emergency department by paramedics after being found unconscious. The patients Medic Alert bracelet indicates that the patient has type 1 diabetes and the patients blood glucose is 22 mg/dL (1.2 mmol/L). The nurse should anticipate what intervention? A) IV administration of 50% dextrose in water B) Subcutaneous administration of 10 units of Humalog C) Subcutaneous administration of 12 to 15 units of regular insulin D) IV bolus of 5% dextrose in 0.45% NaCl

Ans: A Feedback: In hospitals and emergency departments, for patients who are unconscious or cannot swallow, 25 to 50 mL of 50% dextrose in water (D50W) may be administered IV for the treatment of hypoglycemia. Five percent dextrose would be inadequate and insulin would exacerbate the patients condition.

The nurse is preparing an elderly patient for a scheduled removal of orthopedic hardware, a procedure to be performed under general anesthetic. For which adverse effect should the nurse most closely monitor the patient? A) Hypothermia B) Pulmonary edema C) Cerebral ischemia D) Arthritis

Ans: A Feedback: Inadvertent hypothermia may occur as a result of a low temperature in the OR, infusion of cold fluids, inhalation of cold gases, open body wounds or cavities, decreased muscle activity, advanced age, or the pharmaceutical agents used (e.g., vasodilators, phenothiazines, general anesthetics). The anesthetist monitors for pulmonary edema and cerebral ischemia. Arthritis is not an adverse effect of surgical anesthesia.

A patient is having seizure activity, and the physician has ordered diazepam (Valium) to be given parenterally. If this medication is administered intravenously, when will its onset of action be observed? A) 1 to 5 minutes B) 7 to 10 minutes C) More than 10 minutes D) Less than 1 minute

Ans: A Feedback: Intravenous diazepam (Valium) is administered intravenously to decrease seizure activity and has a 1- to 5-minute onset of action. Diazepam (Valium) decreases seizure activity in less than 7 to 10 minutes. Diazepam (Valium) should decrease seizure activity in less than 10 minutes. Diazepam (Valium) will take more than 1 minute to begin working.

A clinic nurse is conducting a preoperative interview with an adult patient who will soon be scheduled to undergo cardiac surgery. What interview question most directly addresses the patients safety? A) What prescription and nonprescription medications do you currently take? B) Have you previously been admitted to the hospital, either for surgery or for medical treatment? C) How long do you expect to be at home recovering after your surgery? D) Would you say that you tend to eat a fairly healthy diet?

Ans: A Feedback: It is imperative to know a preoperative patients current medication regimen, including OTC medications and supplements. None of the other listed questions directly addresses an issue with major safety implications.

When administering benzodiazepines, which of the following medications should be considered the drug of first choice? A) Lorazepam (Ativan) B) Estazolam (Prosom) C) Temazepam (Restoril) D) Triazolam (Halcion)

Ans: A Feedback: Lorazepam (Ativan) is probably the benzodiazepine of first choice. The drug provides rapid tranquilization of patients experiencing agitation. Administered intravenously, it reduces nausea and vomiting as well as anxiety and induces procedural amnesia. Lorazepam has a slow onset of action (5 to 20 minutes) because of delayed brain penetration but an intermediate to prolonged duration.

A patient is receiving low molecular weight heparin to prevent thromboembolic complications. The nursing student asks the nursing instructor the reason why this treatment is given instead of heparin. What is the instructor's best explanation of the rationale for LMWH over heparin? A) "LMWH is associated with less thrombocytopenia than standard heparin." B) "LMWH is associated with stronger anticoagulant effects than standard heparin." C) "LMWH is given to patients who have a history of blood dyscrasia." D) "LMWH is more effective than standard heparin for patients with hypertension."

Ans: A Feedback: Low molecular weight heparins are associated with less thrombocytopenia than standard heparin. Low molecular weight heparin is not stronger than standard heparin. Low molecular weight heparin is administered cautiously in patients with blood dyscrasia and hypertension.

The OR nurse acts in the circulating role during a patients scheduled cesarean section. For what task is this nurse solely responsible? A) Performing documentation B) Estimating the patients blood loss C) Setting up the sterile tables D) Keeping track of drains and sponges

Ans: A Feedback: Main responsibilities of the circulating nurse include verifying consent; coordinating the team; and ensuring cleanliness, proper temperature and humidity, lighting, safe function of equipment, and the availability of supplies and materials. The circulating nurse monitors aseptic practices to avoid breaks in technique while coordinating the movement of related personnel as well as implementing fire safety precautions. The circulating nurse also monitors the patient and documents specific activities throughout the operation to ensure the patients safety and well-being. Estimating the patients blood loss is the surgeons responsibility; setting up the sterile tables is the responsibility of the first scrub; and keeping track of the drains and sponges is the joint responsibility of the circulating nurse and the scrub nurse.

A patient who regularly takes metformin has developed a severe infection. How will the infection change his diabetic regimen? A) Metformin is contraindicated in the presence of an infection. B) Metformin will be given more frequently to decrease blood sugar. C) Metformin will result in better regulation of blood sugar. D) Metformin will allow the patient to decrease the absorption of glucose.

Ans: A Feedback: Metformin is contraindicated in patients with diabetes complicated by fever, severe infections, severe trauma, major surgery, acidosis, and pregnancy. Metformin will not be given more frequently to decrease blood sugar. Metformin should be discontinued and is not administered for better regulation of blood sugar. Metformin will not decrease the absorption of glucose in this patient.

A patient has been given MS Contin. You enter the room and the patient is unresponsive. His respirations are 6 breaths per minute. What medication will be ordered for the patient? A) Naloxone (Narcan) B) Capsaicin (Zostrix) C) Butorphanol (Stadol) D) Nalbuphine (Nubain)

Ans: A Feedback: Naloxone (Narcan) has long been the drug of choice to treat respiratory depression caused by an opioid. Capsaicin is made from cayenne pepper and applied topically for for pain relief. Butorphanol (Stadol) is a synthetic, Schedule IV agonist similar to morphine in analgesic effects and ability to cause respiratory depression. Nalbuphine (Nubain) is a synthetic analgesic used for moderate to severe pain.

In which of the following patients should the nurse question the physician's order for IV morphine? A) An 88-year-old female with failure to thrive B) A 45-year-old female, 1-day postoperative mastectomy C) An 8-year-old male with a fractured femur D) A 17-year-old female, 1-day postoperative appendectomy

Ans: A Feedback: Opioid analgesics should be used cautiously in older adults, especially if they are debilitated. Treatment with morphine 1 day after mastectomy is appropriate for pain management. The treatment of pain with morphine is appropriate for a patient with a fractured femur. The treatment of pain with morphine is appropriate for a patient who is 1-day postoperative for an appendectomy.

A patient asks the nurse why a quick-acting sugar given by mouth is better in the regulation of insulin than the use of intravenous glucose for a low blood sugar. Which of the following statements by the nurse represents the most appropriate response to this question? A) "The ingestion of food allows the digestive tract to stimulate vagal activity and the release of incretins." B) "The combination of insulin and food will yield a higher blood sugar than intravenous glucose." C) "Both food and intravenous glucose will produce changes similarly in the gastrointestinal tract to increase blood sugar." D) "You are mistaken. The intravenous glucose yields a higher blood glucose through the release of incretins."

Ans: A Feedback: Oral glucose is more effective than intravenous glucose because glucose or food in the digestive tract stimulates vagal activity and induces the release of gastrointestinal hormones called incretins. The combination of insulin and food does not yield a higher blood glucose than intravenous insulin. Food stimulates the vagal nerve activity, but intravenous glucose does not. A statement that indicates that the patient is mistaken will belittle the patient and should be rephrased.

A patient has been living with type 2 diabetes for several years, and the nurse realizes that the patient is likely to have minimal contact with the health care system. In order to ensure that the patient maintains adequate blood sugar control over the long term, the nurse should recommend which of the following? A) Participation in a support group for persons with diabetes B) Regular consultation of websites that address diabetes management C) Weekly telephone check-ins with an endocrinologist D) Participation in clinical trials relating to antihyperglycemics

Ans: A Feedback: Participation in support groups is encouraged for patients who have had diabetes for many years as well as for those who are newly diagnosed. This is more interactive and instructive than simply consulting websites. Weekly telephone contact with an endocrinologist is not realistic in most cases. Participation in research trials may or may not be beneficial and appropriate, depending on patients circumstances.

A patient is admitted to the hospital with severe dehydration and also has decreased albumin levels. What effect will the patient's current status have if a prescribed dose of phenytoin (Dilantin) is administered? A) Potentially toxic serum level B) Reduced serum level C) Increased seizure activity D) Thromboembolism

Ans: A Feedback: Phenytoin is highly bound to plasma proteins and only a fraction is not bound to albumin; hypoalbuminemia will result in toxic serum levels of phenytoin. A reduced serum level of phenytoin will not be seen with hypoalbuminemia. The patient will not suffer from increased seizure activity. The patient will not suffer from thromboembolism.

The nurse is caring for an 88-year-old patient who is recovering from an ileac-femoral bypass graft. The patient is day 2 postoperative and has been mentally intact, as per baseline. When the nurse assesses the patient, it is clear that he is confused and has been experiencing disturbed sleep patterns and impaired psychomotor skills. What should the nurse suspect is the problem with the patient? A) Postoperative delirium B) Postoperative dementia C) Senile dementia D) Senile confusion

Ans: A Feedback: Postoperative delirium, characterized by confusion, perceptual and cognitive deficits, altered attention levels, disturbed sleep patterns, and impaired psychomotor skills, is a significant problem for older adults. Dementia does not have a sudden onset. Senile confusion is not a recognized health problem.

A patient with a diagnosis of diabetes is prescribed pramlintide (Symlin). How will this drug assist in controlling the patient's blood sugar? A) It slows gastric emptying. B) It blocks the absorption of food. C) It is absorbed by insulin. D) It increases the release of insulin.

Ans: A Feedback: Pramlintide slows gastric emptying, helping to regulate the postprandial rise in blood sugar. Pramlintide does not block the absorption of food. Pramlintide is not absorbed by insulin. Pramlintide does not increase the release of insulin.

17. A patient suffers from gouty arthritis. Why is probenecid (Benemid) administered? A) To increase urinary excretion of uric acid B) To decrease the level of liver enzymes C) To diminish the temperature D) To increase protein metabolism

Ans: A Feedback: Probenecid (Benemid) increases the urinary excretion of uric acid. Probenecid (Benemid) will not decrease the level of liver enzymes, diminish temperature, or increase protein metabolism.

A patient is experiencing nausea and vomiting as a response to radiation therapy. Which of the following antiemetic agents is a phenothiazine administered to control nausea and vomiting? A) Prochlorperazine (Compazine) B) Metoclopramide (Reglan) C) Mesna (Mesnex) D) Dexamethasone

Ans: A Feedback: Prochlorperazine (Compazine) is a commonly used phenothiazine administered for nausea and vomiting related to radiation therapy. Metoclopramide is a prokinetic agent that increases GI motility and the rate of gastric emptying by increasing the release of acetylcholine from nerve endings in the GI tract. Mesna is used for thrombocytopenia. Dexamethasone is a corticosteroid.

The nurse is performing a preadmission assessment of a patient scheduled for a bilateral mastectomy. Of what purpose of the preadmission assessment should the nurse be aware? A) Verifies completion of preoperative diagnostic testing B) Discusses and reviews patients health insurance coverage C) Determines the patients suitability as a surgical candidate D) Informs the patient of need for postoperative transportation

Ans: A Feedback: Purposes of preadmission testing (PAT) include verifying completion of preoperative diagnostic testing. The nurses role in PAT does not normally involve financial considerations or addressing transportation. The physician determines the patients suitability for surgery.

A patient who underwent a bowel resection to correct diverticula suffered irreparable nerve damage. During the case review, the team is determining if incorrect positioning may have contributed to the patients nerve damage. What surgical position places the patient at highest risk for nerve damage? A) Trendelenburg B) Prone C) Dorsal recumbent D) Lithotomy

Ans: A Feedback: Shoulder braces must be well padded to prevent irreparable nerve injury, especially when the Trendelenburg position is necessary. The other listed positions are less likely to cause nerve injury.

A 16-year-old has been brought to the emergency department by his football coach after twisting his ankle during a practice drill. Diagnostic testing reveals a fracture. This patient is experiencing what type of pain? A) Acute somatic pain B) Acute cutaneous pain C) Visceral pain D) Neuropathic pain

Ans: A Feedback: Sprains and other traumatic injuries are examples of acute somatic pain. Somatic pain results from stimulation of nociceptors in skin, bone, muscle, and soft tissue. Visceral pain, which is diffuse and not well localized, results when nociceptors are stimulated in abdominal or thoracic organs and their surrounding tissues. Neuropathic pain is caused by lesions or physiologic changes that injure peripheral pain receptors, nerves, or the central nervous system. Cutaneous pain is not a recognized category.

Following the administration of pentazocine (Talwin) to a patient with moderate pain, the nurse should assess for what change in the patient's vital signs? A) Increased blood pressure B) Decreased oxygen saturation C) Increased temperature D) Increased respiratory rate

Ans: A Feedback: Talwin may cause increased blood pressure. It does not typically cause deoxygenation, fever, or tachypnea.

A patient has been admitted to the postsurgical unit from postanesthetic recovery following a transurethral prostatic resection. The patient is experiencing nausea subsequent to anesthesia. What antiemetic is the most common first-line drug for the treatment of postoperative nausea and vomiting? A) Ondansetron (Zofran) B) Dronabinol (Marinol) C) Dimenhydrinate (Dramamine) D) Hydroxyzine (Vistaril, Atarax)

Ans: A Feedback: The 5-HT3 receptor antagonists are usually considered drugs of first choice for postoperative nausea and vomiting. Ondansetron (Zofran) is the prototype of the 5-HT3 receptor antagonists.

A perinatal nurse is preparing a dose of IV indomethacin for administration to a neonate. What is the most plausible indication for this treatment? A) Patent ductus arteriosus B) Tetralogy of Fallot C) Patent foramen ovale D) Cardiomyopathy

Ans: A Feedback: The FDA has approved IV indomethacin for treatment of patent ductus arteriosus in premature infants.

A patient is receiving acetaminophen (Tylenol) for fever. The patient also has inflammation in the knees and elbows with pain. Why will acetaminophen (Tylenol) assist in reducing fever but not in decreasing the inflammatory process? A) Prostaglandin inhibition is limited to the central nervous system. B) Acetaminophen inhibits cyclooxygenase (COX-1 and COX-2) only. C) Acetaminophen has an antiplatelet effect to decrease edema. D) Prostaglandins decrease the gastric acid secretion.

Ans: A Feedback: The action of acetaminophen on prostaglandin inhibition is limited to the central nervous system. Aspirin and other nonselective NSAIDs inhibit COX-1 and COX-2. Acetaminophen does not produce an antiplatelet effect. Prostaglandins do not affect gastric secretions.

The perioperative nurse has completed the presurgical assessment of an 82-year-old female patient who is scheduled for a left total knee replacement. When planning this patients care, the nurse should address the consequences of the patients aging cardiovascular system. These include an increased risk of which of the following? A) Hypervolemia B) Hyponatremia C) Hyperkalemia D) Hyperphosphatemia

Ans: A Feedback: The aging heart and blood vessels have decreased ability to respond to stress. Reduced cardiac output and limited cardiac reserve make the elderly patient vulnerable to changes in circulating volume and blood oxygen levels. There is not an increased risk for hypopnea, hyperkalemia, or hyperphosphatemia because of an aging cardiovascular system.

A patient waiting in the presurgical holding area asks the nurse, Why exactly do they have to put a breathing tube into me? My surgery is on my knee. What is the best rationale for intubation during a surgical procedure that the nurse should describe? A) The tube provides an airway for ventilation. B) The tube protects the patients esophagus from trauma. C) The patient may receive an antiemetic through the tube. D) The patients vital signs can be monitored with the tube.

Ans: A Feedback: The anesthetic is administered and the patients airway is maintained through an intranasal intubation, oral intubation, or a laryngeal mask airway. The tube also helps protect aspiration of stomach contents. The tube does not protect the esophagus. Because the tube goes into the lungs, no medications are given through the tube. The patients vital signs are not monitored through the tube.

A patient began taking acetylsalicylic acid (aspirin) several years ago to prevent platelet aggregation following a myocardial infarction. Which dose of aspirin is most likely appropriate for this patient? A) 80 mg B) 180 mg C) 325 mg D) 650 mg

Ans: A Feedback: The dose of aspirin given depends mainly on the condition being treated. Low doses (325 mg initially and 80 mg daily) are used for the drug's antiplatelet effects in preventing arterial thrombotic disorders such as myocardial infarction and stroke.

A diabetic nurse is working for the summer at a camp for adolescents with diabetes. When providing information on the prevention and management of hypoglycemia, what action should the nurse promote? A) Always carry a form of fast-acting sugar. B) Perform exercise prior to eating whenever possible. C) Eat a meal or snack every 8 hours. D) Check blood sugar at least every 24 hours.

Ans: A Feedback: The following teaching points should be included in information provided to the patient on how to prevent hypoglycemia: Always carry a form of fast-acting sugar, increase food prior to exercise, eat a meal or snack every 4 to 5 hours, and check blood sugar regularly.

One of the things a nurse has taught to a patient during preoperative teaching is to have nothing by mouth for the specified time before surgery. The patient asks the nurse why this is important. What is the most appropriate response for the patient? A) You will need to have food and fluid restricted before surgery so you are not at risk for choking. B) The restriction of food or fluid will prevent the development of pneumonia related to decreased lung capacity. C) The presence of food in the stomach interferes with the absorption of anesthetic agents. D) By withholding food for 8 hours before surgery, you will not develop constipation in the postoperative period.

Ans: A Feedback: The major purpose of withholding food and fluid before surgery is to prevent aspiration. There is no scientific basis for withholding food and the development of pneumonia or interference with absorption of anesthetic agents. Constipation in patients in the postoperative period is related to the anesthesia, not from withholding food or fluid in the hours before surgery.

A diabetes nurse educator is teaching a group of patients with type 1 diabetes about sick day rules. What guideline applies to periods of illness in a diabetic patient? A) Do not eliminate insulin when nauseated and vomiting. B) Report elevated glucose levels greater than 150 mg/dL. C) Eat three substantial meals a day, if possible. D) Reduce food intake and insulin doses in times of illness.

Ans: A Feedback: The most important issue to teach patients with diabetes who become ill is not to eliminate insulin doses when nausea and vomiting occur. Rather, they should take their usual insulin or oral hypoglycemic agent dose, then attempt to consume frequent, small portions of carbohydrates. In general, blood sugar levels will rise but should be reported if they are greater than 300 mg/dL.

The nurse is performing the shift assessment of a postsurgical patient. The nurse finds his mental status, level of consciousness, speech, and orientation are intact and at baseline, but the patient tells you he is very anxious. What should the nurse do next? A) Assess the patients oxygen levels. B) Administer antianxiety medications. C) Page the patients the physician. D) Initiate a social work referral.

Ans: A Feedback: The nurse assesses the patients mental status and level of consciousness, speech, and orientation and compares them with the preoperative baseline. Although a change in mental status or postoperative restlessness may be related to anxiety, pain, or medications, it may also be a symptom of oxygen deficit or hemorrhage. Antianxiety medications are not given until the cause of the anxiety is known. The physician is notified only if the reason for the anxiety is serious or if an order for medication is needed. A social work consult is inappropriate at this time.

A hospital patient has a standing order for aprepitant on an as-needed basis. The patient should be encouraged to request a dose of the drug A) when she anticipates that she will become nauseous. B) at the same time each day. C) as soon as she senses the onset of nausea. D) when her nausea results in vomiting.

Ans: A Feedback: The nurse instructs patients to take aprepitant as prescribed before the onset of nausea and vomiting. It does not need to be taken on a regular schedule and should not be withheld until the onset or peak of symptoms.

A diabetic educator is discussing sick day rules with a newly diagnosed type 1 diabetic. The educator is aware that the patient will require further teaching when the patient states what? A) I will not take my insulin on the days when I am sick, but I will certainly check my blood sugar every 2 hours. B) If I cannot eat a meal, I will eat a soft food such as soup, gelatin, or pudding six to eight times a day. C) I will call the doctor if I am not able to keep liquids in my body due to vomiting or diarrhea. D) I will call the doctor if my blood sugar is over 300 mg/dL or if I have ketones in my urine.

Ans: A Feedback: The nurse must explanation the sick day rules again to the patient who plans to stop taking insulin when sick. The nurse should emphasize that the patient should take insulin agents as usual and test ones blood sugar and urine ketones every 3 to 4 hours. In fact, insulin-requiring patients may need supplemental doses of regular insulin every 3 to 4 hours. The patient should report elevated glucose levels (greater than 300 mg/dL or as otherwise instructed) or urine ketones to the physician. If the patient is not able to eat normally, the patient should be instructed to substitute soft foods such a gelatin, soup, and pudding. If vomiting, diarrhea, or fever persists, the patient should have an intake of liquids every 30 to 60 minutes to prevent dehydration.

The admitting nurse in a short-stay surgical unit is responsible for numerous aspects of care. What must the nurse verify before the patient is taken to the preoperative holding area? A) That preoperative teaching was performed B) That the family is aware of the length of the surgery C) That follow-up home care is not necessary D) That the family understands the patient will be discharged immediately after surgery.

Ans: A Feedback: The nurse needs to be sure that the patient and family understand that the patient will first go to the preoperative holding area before going to the OR for the surgical procedure and then will spend some time in the PACU before being discharged home with the family later that day. Other preoperative teaching content should also be verified and reinforced, as needed. The nurse should ensure that any plans for follow-up home care are in place.

The circulating nurse in an outpatient surgery center is assessing a patient who is scheduled to receive moderate sedation. What principle should guide the care of a patient receiving this form of anesthesia? A) The patient must never be left unattended by the nurse. B) The patient should begin a course of antiemetics the day before surgery. C) The patient should be informed that he or she will remember most of the procedure. D) The patient must be able to maintain his or her own airway.

Ans: A Feedback: The patient receiving moderate sedation should never be left unattended. The patients ability to maintain his or her airway depends on the level of sedation. The administration of moderate sedation is not a counter indication for giving an antiemetic. The patient receiving moderate sedation does not remember most of the procedure.

A 30-year-old male patient has been ordered Demerol 75 mg IM every 4 hours after a fractured femur. What action should the nurse take? A) Give the medication as ordered. B) Administer half the dose. C) Call the physician for a smaller dose. D) Give the dose by mouth.

Ans: A Feedback: The patient should be administered the full dose of medication, which is within dosing recommendations. A male patient with a fractured femur who has adequate hepatic and renal function should not receive a lower dose of Demerol and should not receive the medication by mouth.

An adult patient has just been admitted to the PACU following abdominal surgery. As the patient begins to awaken, he is uncharacteristically restless. The nurse checks his skin and it is cold, moist, and pale. The nurse concerned the patient may be at risk for what? A) Hemorrhage and shock B) Aspiration C) Postoperative infection D) Hypertension and dysrhythmias

Ans: A Feedback: The patient with a hemorrhage presents with hypotension; rapid, thready pulse; disorientation; restlessness; oliguria; and cold, pale skin. Aspiration would manifest in airway disturbance. Hypertension or dysrhythmias would be less likely to cause pallor and cool skin. An infection would not be present at this early postoperative stage.

A surgical patient has just been admitted to the unit from PACU with patient-controlled analgesia (PCA). The nurse should know that the requirements for safe and effective use of PCA include what? A) A clear understanding of the need to self-dose B) An understanding of how to adjust the medication dosage C) A caregiver who can administer the medication as ordered D) An expectation of infrequent need for analgesia

Ans: A Feedback: The two requirements for PCA are an understanding of the need to self-dose and the physical ability to self-dose. The patient does not adjust the dose and only the patient himself or herself should administer a dose. PCAs are normally used for patients who are expected to have moderate to severe pain with a regular need for analgesia.

In the 18 months following the death of his wife, a middle-aged man has been taking benzodiazepines on a daily basis. He has expressed to the nurse his desire to stop taking these medications. In order to minimize the chances of withdrawal symptoms, the nurse knows that the patient will likely be advised to A) taper down his dose of benzodiazepines over a prolonged period of time. B) replace the benzodiazepine with a herbal supplement in anticipation of stopping the medication. C) replace the immediate-acting form of the drug with a long-acting form. D) replace the benzodiazepine with an anticonvulsant.

Ans: A Feedback: To avoid withdrawal symptoms, it is necessary to taper benzodiazepines gradually before discontinuing them completely. Long-acting benzodiazepines, anticonvulsants, and herbal remedies are not recommended in the effort to prevent withdrawal.

A nurse is caring for a patient newly diagnosed with type 1 diabetes. The nurse is educating the patient about self-administration of insulin in the home setting. The nurse should teach the patient to do which of the following? A) Avoid using the same injection site more than once in 2 to 3 weeks. B) Avoid mixing more than one type of insulin in a syringe. C) Cleanse the injection site thoroughly with alcohol prior to injecting. D) Inject at a 45 angle.

Ans: A Feedback: To prevent lipodystrophy, the patient should try not to use the same site more than once in 2 to 3 weeks. Mixing different types of insulin in a syringe is acceptable, within specific guidelines, and the needle is usually inserted at a 90 angle. Cleansing the injection site with alcohol is optional.

A nurse is teaching a patient about her prescription for Tylenol #3 that she will take at home. This medication consists of acetaminophen and what other drug? A) Codeine B) Acetylsalicylic acid (aspirin) C) Methadone (Dolophine) D) Tramadol (Ultram)

Ans: A Feedback: Tylenol #3 is acetaminophen (Tylenol) and codeine. Acetylsalicylic acid (aspirin) is not combined with acetaminophen (Tylenol). Methadone (Dolophine) is not combined with Tylenol. Tramadol (Ultram) is not combined with Tylenol.

A patient who has been treated with warfarin (Coumadin) after cardiac surgery is found to have an INR of 9.0. Which medication will be administered to assist in the development of clotting factors? A) Vitamin K B) Vitamin E C) Protamine sulfate D) Acetylsalicylic acid (Aspirin)

Ans: A Feedback: Vitamin K is the antidote for warfarin overdosage. In this case, the patient may be at the therapeutic level to control thrombus formation, but, due to the injury, it is important to control bleeding. Vitamin E is not used as an antidote for warfarin overdosage. Protamine sulfate is used as an antidote to heparin or low molecular-weight heparin. Acetylsalicylic acid (Aspirin) is used to decrease coagulation as a preventive measure for myocardial infarction.

The OR nurse is participating in the appendectomy of a 20 year-old female patient who has a dangerously low body mass index. The nurse recognizes the patients consequent risk for hypothermia. What action should the nurse implement to prevent the development of hypothermia? A) Ensure that IV fluids are warmed to the patients body temperature. B) Transfuse packed red blood cells to increase oxygen carrying capacity. C) Place warmed bags of normal saline at strategic points around the patients body. D) Monitor the patients blood pressure and heart rate vigilantly.

Ans: A Feedback: Warmed IV fluids can prevent the development of hypothermia. Applying warmed bags of saline around the patient is not common practice. The patient is not transfused to prevent hypothermia. Blood pressure and heart rate monitoring are important, but do not relate directly to the risk for hypothermia.

A patient who is recovering in hospital from a bilateral mastectomy has developed minor bleeding at one of her incision sites. During the process of clot formation, plasminogen will become part of a clot by which of the following means? A) By binding with fibrin B) By binding with platelets C) By activating plasmin D) By activating factor VII

Ans: A Feedback: When a blood clot is being formed, plasminogen, an inactive protein present in many body tissues and fluids, is bound to fibrin and becomes a component of the clot. Plasminogen does not bind to platelets, activate plasmin, or active factor VII.

The nurse is discharging a patient home from an outpatient surgery center. The nurse has reviewed all of the discharge instructions with the patient and her caregiver. What else should the nurse do before discharging the patient from the facility? Select all that apply. A) Provide all discharge instructions in writing. B) Provide the nurses or surgeons contact information. C) Give prescriptions to the patient. D) Irrigate the patients incision and perform a sterile dressing change. E) Administer a bolus dose of an opioid analgesic.

Ans: A, B, C Feedback: Before discharging the patient, the nurse provides written instructions, prescriptions and the nurses or surgeons telephone number. Administration of an opioid would necessitate further monitoring to ensure safety. A dressing change would not normally be ordered on the day of surgery.

A nurse in the preoperative holding area is admitting a woman prior to reduction mammoplasty. What should the nurse include in the care given to this patient? Select all that apply. A) Establishing an IV line B) Verifying the surgical site with the patient C) Taking measures to ensure the patients comfort D) Applying a grounding device to the patient E) Preparing the medications to be administered in the OR

Ans: A, B, C Feedback: In the holding area, the nurse reviews charts, identifies patients, verifies surgical site and marks site per institutional policy, establishes IV lines, administers medications, if prescribed, and takes measures to ensure each patients comfort. A nurse in the preoperative holding area does not prepare medications to be administered by anyone else. A grounding device is applied in the OR.

An intraoperative nurse is applying interventions that will address surgical patients risks for perioperative positioning injury. Which of the following factors contribute to this increased risk for injury in the intraoperative phase of the surgical experience? Select all that apply. A) Absence of reflexes B) Diminished ability to communicate C) Loss of pain sensation D) Nausea resulting from anesthetic E) Reduced blood pressure

Ans: A, B, C Feedback: Loss of pain sense, reflexes, and ability to communicate subjects the intraoperative patient to possible injury. Nausea and low blood pressure are not central factors that contribute to this risk, though they are adverse outcomes.

The nurse is preparing to send a patient to the OR for a scheduled surgery. What should the nurse ensure is on the chart when it accompanies the patient to surgery? Select all that apply. A) Laboratory reports B) Nurses notes C) Verification form D) Social work assessment E) Dieticians assessment

Ans: A, B, C Feedback: The completed chart (with the preoperative checklist and verification form) accompanies the patient to the OR with the surgical consent form attached, along with all laboratory reports and nurses records. Any unusual last-minute observations that may have a bearing on anesthesia or surgery are noted prominently at the front of the chart. The social work and dieticians assessments are not normally necessary when the patient goes to surgery.

The rehabilitation nurse is working closely with a patient who has a new orthosis following a knee injury. What are the nurses responsibilities to this patient? Select all that apply. A) Help the patient learn to apply and remove the orthosis. B) Teach the patient how to care for the skin that comes in contact with the orthosis. C) Assist in the initial fitting of the orthosis. D) Assist the patient in learning how to move the affected body part correctly. E) Collaborate with the physical therapist to set goals for care.

Ans: A, B, D, E Feedback: In addition to learning how to apply and remove the orthosis and maneuver the affected body part correctly, patients must learn how to properly care for the skin that comes in contact with the appliance. Skin problems or pressure ulcers may develop if the device is applied too tightly or too loosely or if it is adjusted improperly. Nurses do not perform the initial fitting of orthoses.

The nurse is planning the care of a patient who has type 1 diabetes and who will be undergoing knee replacement surgery. This patients care plan should reflect an increased risk of what postsurgical complications? Select all that apply. A) Hypoglycemia B) Delirium C) Acidosis D) Glucosuria E) Fluid overload

Ans: A, C, D Feedback: Hypoglycemia may develop during anesthesia or postoperatively from inadequate carbohydrates or excessive administration of insulin. Hyperglycemia, which can increase the risk for surgical wound infection, may result from the stress of surgery, which can trigger increased levels of catecholamine. Other risks are acidosis and glucosuria. Risks of fluid overload and delirium are not normally increased.

When creating plans of nursing care for patients who are undergoing surgery using general anesthetic, what nursing diagnoses should the nurse identify? Select all that apply. A) Disturbed sensory perception related to anesthetic B) Risk for impaired nutrition: less than body requirements related to anesthesia C) Risk of latex allergy response related to surgical exposure D) Disturbed body image related to anesthesia E) Anxiety related to surgical concerns

Ans: A, C, E Feedback: Based on the assessment data, some major nursing diagnoses may include the following: anxiety related to surgical or environmental concerns, risk of latex allergy response due to possible exposure to latex in the OR environment, risk for perioperative positioning injury related to positioning in the OR, risk for injury related to anesthesia and surgical procedure, or disturbed sensory perception (global) related to general anesthesia or sedation. Malnutrition and disturbed body image are much less likely.

The PACU nurse is caring for a 45-year-old male patient who had a left lobectomy. The nurse is assessing the patient frequently for airway patency and cardiovascular status. The nurse should know that the most common cardiovascular complications seen in the PACU include what? Select all that apply. A) Hypotension B) Hypervolemia C) Heart murmurs D) Dysrhythmias E) Hypertension

Ans: A, D, E Feedback: The primary cardiovascular complications seen in the PACU include hypotension and shock, hemorrhage, hypertension, and dysrhythmias. Heart murmurs are not adverse reactions to surgery. Hypervolemia is not a common cardiovascular complication seen in the PACU, though fluid balance must be vigilantly monitored.

The surgical nurse is preparing to send a patient from the presurgical area to the OR and is reviewing the patients informed consent form. What are the criteria for legally valid informed consent? Select all that apply. A) Consent must be freely given. B) Consent must be notarized. C) Consent must be signed on the day of surgery. D) Consent must be obtained by a physician. E) Signature must be witnessed by a professional staff member.

Ans: A, D, E Feedback: Valid consent must be freely given, without coercion. Consent must be obtained by a physician and the patients signature must be witnessed by a professional staff member.

A patient is being transferred from a rehabilitation setting to a long-term care facility. During this process, the nurse has utilized the referral system? Using this system achieves what goal of the patients care? A) Minimizing costs of the patients care B) Maintaining continuity of the patients care C) Maintain the nursing care plan between diverse sites D) Keeping the primary care provider informed

Ans: B Feedback: A referral system maintains continuity of care when the patient is transferred to the home or to a long term care facility. The interests of cost and of keeping the primary care provider informed are not primary. The nursing plan is likely to differ between sites.

You are the rehabilitation nurse caring for a 25-year-old patient who suffered extensive injuries in a motorcycle accident. During each patient contact, what action should you perform most frequently? A) Complete a physical assessment. B) Evaluate the patients positioning. C) Plan nursing interventions. D) Assist the patient to ambulate.

Ans: B Feedback: During each patient contact, the nurse evaluates the patients position and assists the patient to achieve and maintain proper positioning and alignment. The nurse does not complete a physical assessment during each patient contact. Similarly, the nurse does not plan nursing interventions or assist the patient to ambulate each time the nurse has contact with the patient.

While assessing a newly admitted patient you note the following: impaired coordination, decreased muscle strength, limited range of motion, and reluctance to move. What nursing diagnosis do these signs and symptoms most clearly suggest? A) Ineffective health maintenance B) Impaired physical mobility C) Disturbed sensory perception: Kinesthetic D) Ineffective role performance

Ans: B Feedback: Impaired physical mobility is a limitation of physical movement that is identified by the characteristics found in this patient. The other listed diagnoses are not directly suggested by the noted assessment findings.

The nurse is providing care for an older adult man whose diagnosis of dementia has recently led to urinary incontinence. When planning this patients care, what intervention should the nurse avoid? A) Scheduled toileting B) Indwelling catheter C) External condom catheter D) Incontinence pads

Ans: B Feedback: Indwelling catheters are avoided if at all possible because of the high incidence of urinary tract infections with their use. Intermittent self-catheterization is an appropriate alternative for managing reflex incontinence, urinary retention, and overflow incontinence related to an overdistended bladder. External catheters (condom catheters) and leg bags to collect spontaneous voiding are useful for male patients with reflex or total incontinence. Incontinence pads should be used as a last resort because they only manage, rather than solve, the incontinence.

A 74-year-old woman experienced a cerebrovascular accident 6 weeks ago and is currently receiving inpatient rehabilitation. You are coaching the patient to contract and relax her muscles while keeping her extremity in a fixed position. Which type of exercise is the patient performing? A) Passive B) Isometric C) Resistive D) Abduction

Ans: B Feedback: Isometric exercises are those in which there is alternating contraction and relaxation of a muscle while keeping the part in a fixed position. This exercise is performed by the patient. Passive exercises are carried out by the therapist or the nurse without assistance from the patient. Resistive exercises are carried out by the patient working against resistance produced by either manual or mechanical means. Abduction is movement of a part away from the midline of the body.

As a member of the rehabilitation team, the nurse is conscious of the need to perform the nursing role in collaboration with the other members of the team. Which of the following variables has the greatest bearing on the nurses choice of actions and interventions during rehabilitative care? A) The skills of the other members of the team B) The circumstances of the patient C) The desires of the patients family D) The nurses education and experience level

Ans: B Feedback: Nurses assume an equal or, depending on the circumstances of the patient, a more critical role than other members of the health care team in the rehabilitation process. The nurses role on the rehabilitation team does not depend primarily on other members of the team, the family's desires, or the nurses education level.

You are admitting a patient into your rehabilitation unit after an industrial accident. The patients nursing diagnoses include disturbed sensory perception and you assess that he has decreased strength and dexterity. You know that this patient may need what to accomplish self-care? A) Advice from his family B) Appropriate assistive devices C) A personal health care aide D) An assisted-living environment

Ans: B Feedback: Patients with impaired mobility, sensation, strength, or dexterity may need to use assistive devices to accomplish self-care. An assisted-living environment is less common than the use of assistive devices. Family involvement is imperative, but this may or may not take the form of advice. A healthcare aide is not needed by most patients.

The policies and procedures on a preoperative unit are being amended to bring them closer into alignment with the focus of the Surgical Care Improvement Project (SCIP). What intervention most directly addresses the priorities of the SCIP? A) Actions aimed at increasing participation of families in planning care B) Actions aimed at preventing surgical site infections C) Actions aimed at increasing interdisciplinary collaboration D) Actions aimed at promoting the use of complementary and alternative medicine (CAM)

Ans: B Feedback: SCIP identifies performance measures aimed at preventing surgical complications, including venous thromboembolism (VTE) and surgical site infections (SSI). It does not explicitly address family participation, interdisciplinary collaboration, or CAM.

A patient has completed the acute treatment phase of care following a stroke and the patient will now begin rehabilitation. What should the nurse identify as the major goal of the rehabilitative process? A) To provide 24-hour, collaborative care for the patient B) To restore the patients ability to function independently C) To minimize the patients time spent in acute care settings D) To promote rapport between caregivers and the patient

Ans: B Feedback: The goal of rehabilitation is to restore the patients ability to function independently or at a preillness or preinjury level of functioning as quickly as possible. Twenty-four hour care, rapport, and minimizing time in acute care are not central goals of rehabilitation.

A nurse has been asked to become involved in the care of an adult patient in his fifties who has experienced a new onset of urinary incontinence. During what aspect of the assessment should the nurse explore physiologic risk factors for elimination problems? A) Physical assessment B) Health history C) Genetic history D) Initial assessment

Ans: B Feedback: The health history is used to explore bladder and bowel function, symptoms associated with dysfunction, physiologic risk factors for elimination problems, perception of micturition (urination or voiding) and defecation cues, and functional toileting abilities. Elimination problems are not explored in the other listed aspects of assessment.

You are the nurse caring for a female patient who developed a pressure ulcer as a result of decreased mobility. The nurse on the shift before you has provided patient teaching about pressure ulcers and healing promotion. You assess that the patient has understood the teaching by observing what? A) Patient performs range-of-motion exercises. B) Patient avoids placing her body weight on the healing site. C) Patient elevates her body parts that are susceptible to edema. D) Patient demonstrates the technique for massaging the wound site.

Ans: B Feedback: The major goals of pressure ulcer treatment may include relief of pressure, improved mobility, improved sensory perception, improved tissue perfusion, improved nutritional status, minimized friction and shear forces, dry surfaces in contact with skin, and healing of pressure ulcer, if present. The other options do not demonstrate the achievement of the goal of the patient teaching.

An interdisciplinary team has been working collaboratively to improve the health outcomes of a young adult who suffered a spinal cord injury in a workplace accident. Which member of the rehabilitation team is the one who determines the final outcome of the process? A) Most-responsible nurse B) Patient C) Patients family D) Primary care physician

Ans: B Feedback: The patient is the key member of the rehabilitation team. He or she is the focus of the team effort and the one who determines the final outcomes of the process. The nurse, family, and doctor are part of the rehabilitation team but do not determine the final outcome.

A nurse is giving a talk to a local community group whose members advocate for disabled members of the community. The group is interested in emerging trends that are impacting the care of people who are disabled in the community. The nurse should describe an increasing focus on what aspect of care? A) Extended rehabilitation care B) Independent living C) Acute-care center treatment D) State institutions that provide care for life

Ans: B Feedback: There is a growing trend toward independent living for patients who are severely disabled, either alone or in groups. The goal is integration into the community. The nurse would be sure to mention this fact when talking to a local community group. The nurse would not describe extended rehabilitation care, acute-care center treatment, or state institutions because these are not increasing in importance.

A patient is on call to the OR for an aortobifemoral bypass and the nurse administers the ordered preoperative medication. After administering a preoperative medication to the patient, what should the nurse do? A) Encourage light ambulation. B) Place the bed in a low position with the side rails up. C) Tell the patient that he will be asleep before he leaves for surgery. D) Take the patients vital signs every 15 minutes.

Ans: B Feedback: When the preoperative medication is given, the bed should be placed in low position with the side rails raised. The patient should not get up without assistance. The patient may not be asleep, but he may be drowsy. Vital signs should be taken before the preoperative medication is given; vital signs are not normally required every 15 minutes after administration.

A patient has been administered an opioid. For which of the following effects should the patient be assessed? A) Oliguria B) Decreased level of consciousness C) Edema D) Tachycardia

Ans: B E) Feedback: Opioids will produce decreased LOC. Oliguria is not a result of the administration of an opioid. Edema is not a result of the administration of an opioid. Tachycardia is not a result of the administration of an opioid.

A hospice patient has been ordered morphine (Roxanol) 5 mg sub-Q every 2 hours. Roxanol contains 10 mg/mL. How many milliliters will be administered? A) 0.25 mL B) 0.5 mL C) 1 mL D) 2 mL

Ans: B Feedback: 5 mg/X = 10 mg/mL. The calculation results in 0.5 mL. The administration of 0.25, 1, or 2 mL is incorrect

A patient is administered promethazine. The patient has an elevated creatinine level. Which of the following is important when administering promethazine to this patient? A) Administer the routine dose. B) Administer a lower dose. C) Administer a higher dose. D) Hold the medication.

Ans: B Feedback: A dose reduction may be necessary in patients with renal impairment to avoid the possibility of adverse effects, toxicity, or increased sensitivity to phenothiazines.

A patient asks the nurse what dose of acetylsalicylic acid (Aspirin) is needed each day for antiplatelet effects to prevent heart attacks. What dose is most appropriate to reduce platelet aggregation? A) 10 mg B) 30 mg C) 625 mg D) 1000 mg

Ans: B Feedback: A single dose of 300 to 600 mg or multiple doses of 30 mg inhibit cyclooxygenase in circulating platelets almost completely. The dose of 10 mg is too small. The doses of 625 mg and 1000 mg are too large.

The OR will be caring for a patient who will receive a transsacral block. For what patient would the use of a transsacral block be appropriate for pain control? A) A middle-aged man who is scheduled for a thoracotomy B) An older adult man who will undergo an inguinal hernia repair C) A 50-year-old woman who will be having a reduction mammoplasty D) A child who requires closed reduction of a right humerus fracture

Ans: B Feedback: A transsacral block produces anesthesia for the perineum and lower abdomen. Both a thoracotomy and breast reduction are in the chest region, and a transsacral block would not provide pain control for these procedures. A closed reduction of a right humerus is a procedure on the right arm, and a transsacral block would not provide pain control.

An older adult patient suffers from generalized anxiety disorder. The use of benzodiazepines in this patient population creates a risk for what adverse effect? A) Seizures B) Falls C) Dysrhythmias D) Sexual dysfunction

Ans: B Feedback: Adverse effects of benzodiazepines may contribute to falls and other injuries unless patients are carefully monitored and safeguarded. Seizures, dysrhythmias, and sexual dysfunction are not characteristic adverse effects.

The nurse is performing a preoperative assessment on a patient going to surgery. The patient informs the nurse that he drinks approximately two bottles of wine each day and has for the last several years. What postoperative difficulties can the nurse anticipate for this patient? A) Alcohol withdrawal syndrome immediately following surgery B) Alcohol withdrawal syndrome 2 to 4 days after his last alcohol drink C) Alcohol withdrawal syndrome upon administration of general anesthesia D) Alcohol withdrawal syndrome 1 week after his last alcohol drink

Ans: B Feedback: Alcohol withdrawal syndrome may be anticipated between 48 and 96 hours after alcohol withdrawal and is associated with a significant mortality rate when it occurs postoperatively.

A patient in his mid-30s has received a diagnosis of type 2 diabetes. Following his diagnosis, he has been meeting with a nurse regularly as well as performing extensive online research. Which of the patient's statements should prompt the nurse to perform further teaching? A) "I don't like getting this diagnosis, but I know that treatment now can prevent future health consequences." B) "I'm disappointed, but I take some solace in the fact that I won't ever have to have insulin injections." C) "People always tried to encourage me to lose weight, and I suppose they might have been right." D) "From what I've learned, I know that the basic problem is that my pancreas can't keep up with my insulin needs."

Ans: B Feedback: Among people with type 2 diabetes, 20% to 30% require exogenous insulin at some point in their lives. Obesity is a major cause, and vigilant treatment can prevent future sequelae. The essence of type 2 diabetes is the pancreas' inability to meet insulin needs.

A patient is admitted to the intensive care unit with a diagnosis of septicemia. In addition to relieving agitation and anxiety, what is a rationale for using benzodiazepines in the treatment of a critically ill patient? A) Increased diffusion and perfusion B) Decreased cardiac workload C) Increased level of consciousness D) Decreased blood pH

Ans: B Feedback: Antianxiety and sedative-hypnotic drugs are often useful in critically ill patients to relieve stress, anxiety, and agitation. Their calming effects decrease cardiac workload (e.g., heart rate, blood pressure, force of myocardial contraction, myocardial oxygen consumption) and respiratory effort. They do not decrease blood pH, increase diffusion and perfusion, or increase LOC.

A 55-year-old man has been diagnosed with coronary artery disease and begun antiplatelet therapy. The man has asked the nurse why he is not taking a "blood thinner like warfarin." What is the most likely rationale for the clinician's use of an antiplatelet agent rather than an anticoagulant? A) Antiplatelet agents do not require the man to undergo frequent blood work; anticoagulants require constant blood work to ensure safety. B) Antiplatelet agents are more effective against arterial thrombosis; anticoagulants are more effective against venous thrombosis. C) Antiplatelet agents are most effective in large vessels; anticoagulants are most effective in the small vessels of the peripheral circulation. D) Antiplatelet agents have fewer adverse effects than anticoagulants.

Ans: B Feedback: Anticoagulants are more effective in preventing venous thrombosis than arterial thrombosis. Antiplatelet drugs are used to prevent arterial thrombosis. CAD has an arterial rather than venous etiology. The rationale for the use of antiplatelet agents in CAD is not likely related to the need for blood work or the presence of adverse effects.

Nonopioid analgesics may sometimes be added to a narcotic analgesic. What action will result? A) Antagonism B) Additive effect C) Interference D) Increased excretion

Ans: B Feedback: Aspirin and Tylenol are added to narcotic analgesics for additive effects of pain relief without the addition of narcotic adverse effects. Aspirin and Tylenol do not provide an antagonistic effect. Aspirin and Tylenol do not cause an interference of action. Aspirin and Tylenol will not increase excretion

A patient suffers from insomnia and is prescribed flurazepam. This medication has a longer half-life than 24 hours. Which of the following contributes to the long half-life of this medication and other benzodiazepines? A) Metabolism by cytochrome P450 B) Presence of active metabolites C) Excretion by the renal system D) Movement of calcium in the cell

Ans: B Feedback: Benzodiazepines differ mainly in their plasma half-lives, production of active metabolites, and clinical uses. Drugs with half-lives longer than 24 hours form active metabolites that also have long half-lives and tend to accumulate, especially in older adults and people with impaired liver function. Flurazepam is not metabolized by cytochrome P450. Flurazepam is excreted in the renal system but does not contribute to the effect on the half-life. Flurazepam does not contribute to movement of calcium in the cell.

A patient suffers from trigeminal neuralgia. What antiepileptic agent may be used to treat this disorder? A) Phenytoin (Dilantin) B) Carbamazepine (Tegretol) C) Fosphenytoin (Cerebyx) D) Ethosuximide (Zarontin)

Ans: B Feedback: Carbamazepine (Tegretol) is prescribed to treat trigeminal neuralgia. Phenytoin is not administered for trigeminal neuralgia. Fosphenytoin is not administered for trigeminal neuralgia. Ethosuximide is not administered for trigeminal neuralgia.

A patient is admitted with acute, painful muscle spasms and suffers from intermittent porphyria, an inherited enzyme deficiency. Which of the following muscle relaxants is contraindicated due to the patient's history of porphyria? A) Baclofen (Lioresal) B) Carisoprodol (Soma) C) Diazepam (Valium) D) Dantrolene (Dantrium)

Ans: B Feedback: Carisoprodol is used to relieve discomfort from acute, painful musculoskeletal disorders. It is contraindicated in patients with intermittent porphyria. Baclofen is not known to be contraindicated with porphyria. Diazepam is not known to be contraindicated with porphyria. Dantrolene is not known to be contraindicated with porphyria.

An occupational health nurse is screening a group of workers for diabetes. What statement should the nurse interpret as suggestive of diabetes? A) Ive always been a fan of sweet foods, but lately Im turned off by them. B) Lately, I drink and drink and cant seem to quench my thirst. C) No matter how much sleep I get, it seems to take me hours to wake up. D) When I went to the washroom the last few days, my urine smelled odd.

Ans: B Feedback: Classic clinical manifestations of diabetes include the three Ps: polyuria, polydipsia, and polyphagia. Lack of interest in sweet foods, fatigue, and foul-smelling urine are not suggestive of diabetes.

A nurse is conducting a medication reconciliation for a 79-year-old man who has just relocated to the long-term care facility. The nurse notes that the man has been taking colchicine (Colcrys) on a regular basis. This aspect of the man's medication regimen should signal the nurse to the possibility that he has a diagnosis of A) osteoarthritis. B) gout. C) inflammatory bowel disease. D) bursitis or tendonitis.

Ans: B Feedback: Colchicine (Colcrys), the prototype agent for the treatment and prevention of gout, is the most commonly administered antigout medication. Colchicine is not indicated in the treatment of osteoarthritis, IBD, tendonitis, or bursitis. Page

A patient is being observed for acute benzodiazepine withdrawal symptoms. Which of the following symptoms is characteristic of this problem? A) Bradycardia B) Agitation C) Lethargy D) Diaphoresis

Ans: B Feedback: Common signs and symptoms of withdrawal include increased anxiety, psychomotor agitation, insomnia, irritability, headache, tremor, and palpitations. Bradycardia, lethargy, and diaphoresis are uncharacteristic.

A nurse is instructing a patient on the administration of an opioid medication. What medication effect will most likely develop? A) Lower extremity paresthesia B) Drowsiness C) Occipital headache D) Polyuria

Ans: B Feedback: Drowsiness and sedation are results of central nervous system depression. The patient will not develop lower extremity paresthesia, occipital headache, or polyuria. If these effects develop, they are not related to the opioid medication.

A patient with type 2 diabetes achieves adequate glycemic control through diet and exercise. Upon being admitted to the hospital for a cholecystectomy, however, the patient has required insulin injections on two occasions. The nurse would identify what likely cause for this short-term change in treatment? A) Alterations in bile metabolism and release have likely caused hyperglycemia. B) Stress has likely caused an increase in the patients blood sugar levels. C) The patient has likely overestimated her ability to control her diabetes using nonpharmacologic measures. D) The patients volatile fluid balance surrounding surgery has likely caused unstable blood sugars.

Ans: B Feedback: During periods of physiologic stress, such as surgery, blood glucose levels tend to increase, because levels of stress hormones (epinephrine, norepinephrine, glucagon, cortisol, and growth hormone) increase. The patients need for insulin is unrelated to the action of bile, the patients overestimation of previous blood sugar control, or fluid imbalance.

A patient's severe family tragedy 1 year ago resulted in depression and insomnia. Which of the following hypnotics may be safely taken for longer-term treatment of insomnia? A) Lorazepam (Ativan) B) Eszopiclone (Lunesta) C) Chloral hydrate D) Oxazepam (Serax)

Ans: B Feedback: Eszopiclone (Lunesta) is the first oral nonbenzodiazepine hypnotic to receive FDA approval for long-term use (12 months).

A nurse is providing preoperative teaching to a patient who will soon undergo a cardiac bypass. The nurses teaching plan includes exercises of the extremities. What is the purpose of teaching a patient leg exercises prior to surgery? A) Leg exercises increase the patients muscle mass postoperatively. B) Leg exercises improve circulation and prevent venous thrombosis. C) Leg exercises help to prevent pressure sores to the sacrum and heels. D) Leg exercise help increase the patients level of consciousness after surgery.

Ans: B Feedback: Exercise of the extremities includes extension and flexion of the knee and hip joints (similar to bicycle riding while lying on the side) unless contraindicated by type of surgical procedure (e.g., hip replacement). When the patient does leg exercises postoperatively, circulation is increased, which helps to prevent blood clots from forming. Leg exercises do not prevent pressure sores to the sacrum, or increase the patients level of consciousness. Leg exercises have the potential to increase strength and mobility, but are unlikely to make a change to muscle mass in the short term.

The nurse knows that elderly patients are at higher risk for complications and adverse outcomes during the intraoperative period. What is the best rationale for this phenomenon? A) The elderly patient has a more angular bone structure than a younger person. B) The elderly patient has reduced ability to adjust rapidly to emotional and physical stress. C) The elderly patient has impaired thermoregulatory mechanisms, which increase susceptibility to hyperthermia. D) The elderly patient has an impaired ability to decrease his or her metabolic rate.

Ans: B Feedback: Factors that affect the elderly surgical patient in the intraoperative period include the following: impaired ability to increase metabolic rate and impaired thermoregulatory mechanisms increase susceptibility to hypothermia. Bone loss (25% in women, 12% in men) necessitates careful manipulation and positioning during surgery. Reduced ability to adjust rapidly to emotional and physical stress influences surgical outcomes and requires meticulous observation of vital functions. Older adults do not have more angular bones than younger people.

The patients surgery is nearly finished and the surgeon has opted to use tissue adhesives to close the surgical wound. This requires the nurse to prioritize assessments related to what complication? A) Hypothermia B) Anaphylaxis C) Infection D) Malignant hyperthermia

Ans: B Feedback: Fibrin sealants are used in a variety of surgical procedures, and cyanoacrylate tissue adhesives are used to close wounds without the use of sutures. These sealants have been implicated in allergic reactions and anaphylaxis. There is not an increased risk of malignant hyperthermia, hypothermia, or infection because of the use of tissue adhesives.

A patient will undergo an endoscopy with conscious sedation using midazolam (Versed). The nurse who is participating in this procedure should monitor the patient closely for signs of A) increased intracranial pressure. B) respiratory depression. C) hemorrhage. D) rhabdomyolysis.

Ans: B Feedback: Following administration of midazolam, continuous monitoring for respiratory depression is required, and if necessary, age-specific resuscitative measures should be implemented. Increased ICP, rhabdomyolysis, and hemorrhage are less likely than respiratory depression.

A patient with traumatic injuries describes his current pain as being "unbearable." The pathophysiology of pain begins with a signal from A) myelin sheaths. B) nociceptors. C) baroceptors. D) synapses.

Ans: B Feedback: For a person to feel pain, the signal from nociceptors in peripheral tissues must be transmitted to the spinal cord, then to the hypothalamus and cerebral cortex in the brain. Myelin sheaths, synapses, and baroceptors are not directly involved in pain transmission.

A diabetic patient calls the clinic complaining of having a flu bug. The nurse tells him to take his regular dose of insulin. What else should the nurse tell the patient? A) Make sure to stick to your normal diet. B) Try to eat small amounts of carbs, if possible. C) Ensure that you check your blood glucose every hour. D) For now, check your urine for ketones every 8 hours.

Ans: B Feedback: For prevention of DKA related to illness, the patient should attempt to consume frequent small portions of carbohydrates (including foods usually avoided, such as juices, regular sodas, and gelatin). Drinking fluids every hour is important to prevent dehydration. Blood glucose and urine ketones must be assessed every 3 to 4 hours.

A 50-year-old man has undergone a bunionectomy and has been admitted to the postsurgical unit. What aspect of the man's medical history would contraindicate the use of heparin for DVT prophylaxis? A) The man is morbidly obese. B) The man has a diagnosis of ulcerative colitis. C) The man had a myocardial infarction 18 months ago. D) The man has a diagnosis of type 2 diabetes mellitus.

Ans: B Feedback: GI ulcerations contraindicate the use of heparin. Obesity, diabetes, and previous MI do not rule out the safe use of heparin. Page

Prior to her elective hip replacement surgery, the nurse is explaining the basic characteristics of general anesthesia to the patient. The nurse should perform this education in the understanding that general anesthesia is best understood as A) a nonreversible, temporary state of unresponsiveness. B) a state of reversible unconsciousness. C) stage N2 non-rapid eye movement sleep. D) stage N3 non-rapid eye movement sleep.

Ans: B Feedback: General anesthesia is defined as a medication-induced reversible unconsciousness with loss of protective reflexes. There is the misconception that general anesthesia is a deep sleep.

A patient has been administered hydroxyzine for the treatment of nausea. Which of the following statements indicates that she has understood the teaching provided by the nurse? A) "I will take repeated doses of this medication until my nausea resolves." B) "I may experience drowsiness with this medication." C) "I should eat before I take this medication." D) "I will need to take potassium with this medication."

Ans: B Feedback: Hydroxyzine will produce drowsiness in the patient. Repeated doses are unsafe. The patient should not eat with nausea. The patient does not need to take potassium with hydroxyzine.

During the care of a preoperative patient, the nurse has given the patient a preoperative benzodiazepine. The patient is now requesting to void. What action should the nurse take? A) Assist the patient to the bathroom. B) Offer the patient a bedpan or urinal. C) Wait until the patient gets to the operating room and is catheterized. D) Have the patient go to the bathroom.

Ans: B Feedback: If a preanesthetic medication is administered, the patient is kept in bed with the side rails raised because the medication can cause lightheadedness or drowsiness. If a patient needs to void following administration of a sedative, the nurse should offer the patient a urinal. The patient should not get out of bed because of the potential for lightheadedness.

The intraoperative nurse is implementing a care plan that addresses the surgical patients risk for vomiting. Interventions that address the potential for vomiting reduce the risk of what subsequent surgical complication? A) Impaired skin integrity B) Hypoxia C) Malignant hyperthermia D) Hypothermia

Ans: B Feedback: If the patient aspirates vomitus, an asthma-like attack with severe bronchial spasms and wheezing is triggered. Pneumonitis and pulmonary edema can subsequently develop, leading to extreme hypoxia. Vomiting can cause choking, but the question asks about aspirated vomitus. Malignant hyperthermia is an adverse reaction to anesthesia. Aspirated vomitus does not cause hypothermia. Vomiting does not result in impaired skin integrity.

A patient is 2 hours postoperative with a Foley catheter in situ. The last hourly urine output recorded for this patient was 10 mL. The tubing of the Foley is patent. What should the nurse do? A) Irrigate the Foley with 30 mL normal saline. B) Notify the physician and continue to monitor the hourly urine output closely. C) Decrease the IV fluid rate and massage the patients abdomen. D) Have the patient sit in high-Fowlers position.

Ans: B Feedback: If the patient has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 30 mL/hr are reported. The urine output should continue to be monitored hourly by the nurse. Irrigation would not be warranted.

A patient is admitted to the emergency department with a suspected overdose of acetaminophen (Tylenol). What adverse effect is most common in acute or chronic overdose of acetaminophen (Tylenol)? A) Nephrotoxicity B) Hepatotoxicity C) Pulmonary insufficiency D) Pancreatitis

Ans: B Feedback: In acute or chronic overdose of acetaminophen (Tylenol), the patient can develop hepatotoxicity. Nephrotoxicity is not an adverse effect associated with Tylenol overdose. Pulmonary insufficiency is not an adverse effect associated with Tylenol overdose. Pancreatitis is not an adverse effect associated with Tylenol overdose.

A patient with a history of type 1 diabetes has just been admitted to the critical care unit (CCU) for diabetic ketoacidosis. The CCU nurse should prioritize what assessment during the patients initial phase of treatment? A) Monitoring the patient for dysrhythmias B) Maintaining and monitoring the patients fluid balance C) Assessing the patients level of consciousness D) Assessing the patient for signs and symptoms of venous thromboembolism

Ans: B Feedback: In addition to treating hyperglycemia, management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the hyperglycemia with insulin. The nurse should monitor the patient for dysrhythmias, decreased LOC and VTE, but restoration and maintenance of fluid balance is the highest priority.

A child has symptoms of influenza, including a fever. Which of the following medications should not be administered to the child because of the risk of Reye's syndrome? A) Acetaminophen (Tylenol) B) Acetylsalicylic acid (aspirin) C) Ibuprofen (Motrin) D) Ascorbic Acid (vitamin C)

Ans: B Feedback: In children and adolescents, aspirin is contraindicated in the presence of viral infections, such as influenza or chickenpox, because of its association with Reye's syndrome. Acetaminophen (Tylenol) and ibuprofen (Motrin) are safe to administer for fever reduction and pain relief in children and adolescents. Ascorbic acid (vitamin C) is safe to administer to children but is not used to reduce fever or pain.

A patient is allergic to acetylsalicylic acid (aspirin). Which of the following medications is contraindicated due to cross-hypersensitivity reactions? A) Acetaminophen (Tylenol) B) Naproxen sodium (Naprosyn) C) Morphine sulfate (MS Contin) D) Naloxone (Narcan)

Ans: B Feedback: In people who have demonstrated hypersensitivity to aspirin, all nonaspirin NSAIDs are contraindicated because cross-hypersensitivity reactions may occur with any drugs that inhibit prostaglandin synthesis. Acetaminophen (Tylenol) does not have cross-sensitivity with acetylsalicylic acid (aspirin) because it is not an NSAID. Morphine sulfate (MS Contin) does not have a cross-sensitivity to aspirin because it is an opioid, not an NSAID. Naloxone (Narcan) is an opioid antagonist and does not have cross-sensitivity with aspirin.

The surgical patient is a 35-year-old woman who has been administered general anesthesia. The nurse recognizes that the patient is in stage II (the excitement stage) of anesthesia. Which intervention would be most appropriate for the nurse to implement during this stage? A) Rub the patients back. B) Restrain the patient. C) Encourage the patient to express feelings. D) Stroke the patients hand.

Ans: B Feedback: In stage II, the patient may struggle, shout, or laugh. The movements of the patient may be uncontrolled, so it is essential the nurse help to restrain the patient for safety. None of the other listed actions protects the patients safety.

A patient has been started on cyclobenzaprine (Flexeril). For the duration of treatment, the nurse should teach the patient to avoid A) OTC vitamin supplements. B) alcohol. C) stool softeners. D) fatty foods.

Ans: B Feedback: Increased CNS depression occurs when cyclobenzaprine is combined with alcohol or other CNS depressants. There is no particular need for the patient to avoid fatty foods, stool softeners, or vitamin supplements.

A patient is diagnosed with salicylate overdose. Which of the following medications will be administered for the treatment of salicylate overdose? A) Intravenous meperidine (Demerol) B) Intravenous sodium bicarbonate C) Intravenous furosemide (Lasix) D) Inhaled acetylcysteine (Mucomyst)

Ans: B Feedback: Intravenous sodium bicarbonate produces alkaline urine in which salicylates are more rapidly excreted in patients with salicylism.

A 69-year-old woman has been taking metformin for the treatment of type 2 diabetes for several years. Which of the following changes in the woman's laboratory values may demonstrate a need to discontinue the medication? A) A decrease in hemoglobin and hematocrit B) A decrease in glomerular filtration rate C) A decrease in potassium accompanied by an increase in sodium D) An increase in white blood cells

Ans: B Feedback: It is essential to discontinue metformin if renal impairment occurs. The other listed changes in laboratory values do not necessarily indicate that metformin should be discontinued.

Verification that all required documentation is completed is an important function of the intraoperative nurse. The intraoperative nurse should confirm that the patients accompanying documentation includes which of the following? A) Discharge planning B) Informed consent C) Analgesia prescription D) Educational resources

Ans: B Feedback: It is important to review the patients record for the following: correct informed surgical consent, with patients signature; completed records for health history and physical examination; results of diagnostic studies; and allergies (including latex). Discharge planning records and prescriptions are not normally necessary. Educational resources would not be included at this stage of the surgical process.

The nurse is creating the plan of care for a patient who is status postsurgery for reduction of a femur fracture. What is the most important short-term goal for this patient? A) Relief of pain B) Adequate respiratory function C) Resumption of activities of daily living (ADLs) D) Unimpaired wound healing

Ans: B Feedback: Maintenance of the patients airway and breathing are imperative. Respiratory status is important because pulmonary complications are among the most frequent and serious problems encountered by the surgical patient. Wound healing and eventual resumption of ADLs would be later concerns. Pain management is a high priority, but respiratory function is a more acute physiological need.

The OR nurse is taking the patient into the OR when the patient informs the operating nurse that his grandmother spiked a 104F temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the patient? A) The patient may be experiencing presurgical anxiety. B) The patient may be at risk for malignant hyperthermia. C) The grandmothers surgery has minimal relevance to the patients surgery. D) The patient may be at risk for a sudden onset of postsurgical infection.

Ans: B Feedback: Malignant hyperthermia is an inherited muscle disorder chemically induced by anesthetic agents. Identifying patients at risk is imperative because the mortality rate is 50%. The patients anxiety is not relevant, the grandmothers surgery is very relevant, and all patients are at risk for hypothermia.

An OR nurse is teaching a nursing student about the principles of surgical asepsis as a requirement in the restricted zone of the operating suite. What personal protective equipment should the nurse wear at all times in the restricted zone of the OR? A) Reusable shoe covers B) Mask covering the nose and mouth C) Goggles D) Gloves

Ans: B Feedback: Masks are worn at all times in the restricted zone of the OR. Shoe covers are worn one time only; goggles and gloves are worn as required, but not necessarily at all times.

A patient is given midazolam (Versed) in combination with an opioid in the preoperative phase before a laparoscopic cholecystectomy. What does the administration of midazolam (Versed) assist in minimizing? A) Oral secretions B) Anxiety C) Hypotension D) Muscle tone

Ans: B Feedback: Midazolam (Versed) provides preoperative sedation and mechanical ventilation. It does not reduce secretions, increase blood pressure, or reduce muscle tone.

A surgical patient has highly elevated AST and ALT levels. Standard orders specify that she is to receive morphine sulfate 10 mg postoperatively. What action should the nurse take prior to administering the medication? A) Draw up half of the medication for administration. B) Notify the physician for a reduced dosage. C) Assess the patient's respiratory status. D) Assess the patient's pain tolerance.

Ans: B Feedback: Morphine and meperidine form pharmacologically active metabolites. Thus, liver impairment can interfere with metabolism, and kidney impairment can interfere with excretion. Drug accumulation and increased adverse effects may occur if dosage is not reduced. The nurse cannot administer half of the medication without a physician's order. It is important to assess the patient's respiratory status before administration, but this action is not the primary intervention in this case. Narcotics prior to surgery are administered to increase pain tolerance during the surgical procedure, not during the preoperative phase.

A patient is discharged from the hospital with a prescription of warfarin (Coumadin). Which of the following statements indicates successful patient teaching? A) "If I miss a dose, I will take two doses." B) "I will avoid herbal remedies." C) "I will eat spinach or broccoli daily." D) "I will discontinue my other medications."

Ans: B Feedback: Most commonly used herbs and supplements have a profound effect on drugs for anticoagulation. The patient should never double up on dosing related to a missed dose. The patient should avoid green leafy vegetables due to vitamin K. The patient should not discontinue his or her medications.

The nurse is discussing macrovascular complications of diabetes with a patient. The nurse would address what topic during this dialogue? A) The need for frequent eye examinations for patients with diabetes B) The fact that patients with diabetes have an elevated risk of myocardial infarction C) The relationship between kidney function and blood glucose levels D) The need to monitor urine for the presence of albumin

Ans: B Feedback: Myocardial infarction and stroke are considered macrovascular complications of diabetes, while the effects on vision and renal function are considered to be microvascular.

A patient is taking ibuprofen (Motrin) for knee pain. The patient is admitted to the hospital with abdominal pain. Which of the following assessments should the nurse prioritize? A) Assessment for diarrhea B) Assessment for occult blood in the patient's stool C) Assessment of the patient's urine for hematuria D) Assessment for hemoptysis

Ans: B Feedback: Nonsteroidal anti-inflammatory agents that block COX-1 and COX-2 place the patient at risk for gastrointestinal bleed. Patients who have symptoms of abdominal pain and are taking NSAIDs should be assessed for signs and symptoms of gastrointestinal bleed. Assessing the patient for diarrhea is not related to ibuprofen (Motrin) administration. Assessing the patient for hematuria or hemoptysis is not a priority.

A nurse is caring for a patient with type 1 diabetes who is being discharged home tomorrow. What is the best way to assess the patients ability to prepare and self-administer insulin? A) Ask the patient to describe the process in detail. B) Observe the patient drawing up and administering the insulin. C) Provide a health education session reviewing the main points of insulin delivery. D) Review the patients first hemoglobin A1C result after discharge.

Ans: B Feedback: Nurses should assess the patients ability to perform diabetes related self-care as soon as possible during the hospitalization or office visit to determine whether the patient requires further diabetes teaching. While consulting a home care nurse is beneficial, an initial assessment should be performed during the hospitalization or office visit. Nurses should directly observe the patient performing the skills such as insulin preparation and infection, blood glucose monitoring, and foot care. Simply questioning the patient about these skills without actually observing performance of the skill is not sufficient. Further education does not guarantee learning.

You are caring for an 88-year-old woman who is scheduled for a right mastectomy. You know that elderly patients are frequently more anxious prior to surgery than younger patients. What would you increase with this patient to decrease her anxiety? A) Analgesia B) Therapeutic touch C) Preoperative medication D) Sleeping medication the night before surgery

Ans: B Feedback: Older patients report higher levels of preoperative anxiety; therefore, the nurse should be prepared to spend additional time, increase the amount of therapeutic touch utilized, and encourage family members to be present to decrease anxiety. For most patients, nonpharmacologic interventions should be attempted before administering medications.

The nurse is providing preoperative teaching to a patient scheduled for surgery. The nurse is instructing the patient on the use of deep breathing, coughing, and the use of incentive spirometry when the patient states, I dont know why youre focusing on my breathing. My surgery is on my hip, not my chest. What rationale for these instructions should the nurse provide? A) To prevent chronic obstructive pulmonary disease (COPD) B) To promote optimal lung expansion C) To enhance peripheral circulation D) To prevent pneumothorax

Ans: B Feedback: One goal of preoperative nursing care is to teach the patient how to promote optimal lung expansion and consequent blood oxygenation after anesthesia. COPD is not a realistic risk and pneumothorax is also unlikely. Breathing exercises do not primarily affect peripheral circulation. 18. One of the things a nurse has taught to a patient during preoperative teaching is

A 58-year-old patient who has been living with diabetes since age 14 states he has pain in his feet and hands. What is this pain most likely a result of? A) A diabetes-related infectious process B) Peripheral neuropathy C) An autoimmune disorder D) Hypertension resulting from diabetes

Ans: B Feedback: Pain in the feet and hands is related to changes in small blood vessels resulting in neuropathy. The long-term effect of diabetes can result in an infectious process, but the pain described is not indicative of an infection. Latent autoimmune diabetes of the adult has an onset in adulthood and thus is not a long-term disorder. Hypertension is a longterm chronic effect of diabetes but is not what has been described with pain in the feet and hands.

The nursing instructor is discussing the difference between ambulatory surgical centers and hospitalbased surgical units. A student asks why some patients have surgery in the hospital and others are sent to ambulatory surgery centers. What is the instructors best response? A) Patients who go to ambulatory surgery centers are more independent than patients admitted to the hospital. B) Patients admitted to the hospital for surgery usually have multiple health needs. C) In most cases, only emergency and trauma patients are admitted to the hospital. D) Patients who have surgery in the hospital are those who need to have anesthesia administered.

Ans: B Feedback: Patients admitted to the clinical unit for postoperative care have multiple needs and stay for a short period of time. Patients who have surgery in ambulatory centers do not necessarily have greater independence. It is not true that only trauma and emergency surgeries are done in the hospital. Ambulatory centers can administer anesthesia.

While the surgical patient is anesthetized, the scrub nurse hears a member of the surgical team make an inappropriate remark about the patients weight. How should the nurse best respond? A) Ignore the comment because the patient is unconscious. B) Discourage the colleague from making such comments. C) Report the comment immediately to a supervisor. D) Realize that humor is needed in the workplace.

Ans: B Feedback: Patients, whether conscious or unconscious, should not be subjected to excess noise, inappropriate conversation, or, most of all, derogatory comments. The nurse must act as an advocate on behalf of the patient and discourage any such remarks. Reporting to a supervisor, however, is not likely necessary.

A patient is administered a phenothiazine for nausea and vomiting. What is the action of phenothiazine? A) Increases gastric motility B) Antagonizes dopamine receptors C) Blocks histamine receptors D) Antagonizes serotonin receptors

Ans: B Feedback: Phenothiazines act on the CTZ and vomiting center by blocking dopamine. They do not increase gastric motility. Phenothiazines do not block histamine receptors. Phenothiazines do not antagonize serotonin receptors.

A patient is being treated for a seizure disorder with phenytoin (Dilantin). He is admitted to the emergency room with sinus bradycardia. What action will occur regarding his antiepileptic agent? A) Phenytoin (Dilantin) dose will be reduced. B) Phenytoin (Dilantin) will be discontinued. C) Phenytoin (Dilantin) will be given every other day. D) Phenytoin (Dilantin) dose will be increased.

Ans: B Feedback: Phenytoin should be discontinued immediately because it is contraindicated in patients with sinus bradycardia. Reducing the frequency of administration would likely be insufficient.

A 54-year-old woman is being admitted to the postsurgical unit following a transverse rectus abdominis myocutaneous (TRAM) flap. The patient's care plan specifies the use of preemptive analgesia. This approach to pain control will involve A) frequent administration of high-dose opioids. B) simultaneous use of analgesics from different drug classes. C) alternating administration of opioid antagonists with opioid agonists. D) patient-controlled analgesia.

Ans: B Feedback: Preemptive analgesia is used to reduce postsurgical pain by simultaneously administering medications from different drug classes to suppress pain by blocking multiple pain pathways. It is not synonymous with PCA and does not require alternation between opioid agonists and antagonists.

When reviewing a newly admitted patient's previous medication record, the nurse notes that the patient has previously been treated with aprepitant (Emend). The nurse is justified is suspecting that this patient's medical history includes which of the following? A) Placement of a nasogastric tube B) Chemotherapy C) Endoscopy D) Radiation therapy

Ans: B Feedback: Prescribers often order aprepitant as part of combination therapy along with a 5-HT3 receptor antagonist and corticosteroids to treat both acute and delayed nausea and vomiting associated with chemotherapy. NG tube insertion, radiation therapy, and endoscopy are not typical indications for the use of aprepitant.

A patient has a history of clot formation. She is scheduled for bowel resection due to colorectal cancer. What anticoagulant agent will be administered prophylactically? A) Acetylsalicylic acid (Aspirin) B) Heparin C) Warfarin (Coumadin) D) Streptokinase (Streptase)

Ans: B Feedback: Prophylactically, low doses of heparin are given to prevent thrombus formation in patients having major abdominal surgery. Acetylsalicylic acid is not used to prevent thrombus in patients having major abdominal surgery. Warfarin takes several days for therapeutic effects to occur; thus it is not used prophylactically to prevent thrombus in a patient with abdominal surgery. Streptokinase promotes thrombolysis and is not used to prevent thrombus.

A patient suffers from pain in the elbow related to inflammation. What are the chemical mediators of inflammation? A) Insulin, thyroid hormone, and calcitonin B) Bradykinin, histamine, and leukotrienes C) Phospholipids, arachidonic acid, and platelets D) Red blood cells, lymph, and serosa

Ans: B Feedback: Prostaglandins sensitize pain receptors and increase the pain associated with other chemical mediators of inflammation and immunity, such as bradykinin, histamine, and leukotrienes. Insulin, thyroid hormone, and calcitonin are not chemical mediators of inflammation. Phospholipids, arachidonic acid, and platelets are not chemical mediators of inflammation. Red blood cells, lymph, and serosa are not chemical mediators of inflammation.

A nurse has noted that a newly admitted patient has been taking ramelteon (Rozerem) for the past several weeks. The nurse is justified in suspecting that this patient was experiencing what problem prior to starting this drug? A) Somnambulism (sleepwalking) B) Difficulty falling asleep at night C) Early morning waking D) Frequent nighttime awakenings

Ans: B Feedback: Ramelteon (Rozerem), the newest oral nonbenzodiazepine hypnotic, has received FDA approval for the long-term treatment of insomnia characterized by difficulty with sleep onset.

A medical nurse is caring for a patient with type 1 diabetes. The patients medication administration record includes the administration of regular insulin three times daily. Knowing that the patients lunch tray will arrive at 11:45, when should the nurse administer the patients insulin? A) 10:45 B) 11:15 C) 11:45 D) 11:50

Ans: B Feedback: Regular insulin is usually administered 2030 min before a meal. Earlier administration creates a risk for hypoglycemia; later administration creates a risk for hyperglycemia.

A diabetes nurse is assessing a patients knowledge of self-care skills. What would be the most appropriate way for the educator to assess the patients knowledge of nutritional therapy in diabetes? A) Ask the patient to describe an optimally healthy meal. B) Ask the patient to keep a food diary and review it with the nurse. C) Ask the patients family what he typically eats. D) Ask the patient to describe a typical days food intake.

Ans: B Feedback: Reviewing the patients actual food intake is the most accurate method of gauging the patients diet.

A patient enters the emergency room with complaints of visual changes, drowsiness, and tinnitus. The patient is confused and hyperventilating. These symptoms may be attributable to which of the following? A) Acute acetaminophen toxicity B) Salicylism C) Ibuprofen overdose D) Caffeine overdose

Ans: B Feedback: Salicylism, toxicity due to salicylates that may be associated with chronic use, is characterized by dizziness, tinnitus, difficulty hearing, and mental confusion. Ibuprofen overdose will cause gastric mucosal damage. Caffeine overdose will produce tachycardia.

Sitagliptin (Januvia) is prescribed for a patient who has been diagnosed with type 2 diabetes. What is the action of sitagliptin (Januvia)? A) It blocks the S phase of the cell cycle. B) It slows the rate of inactivation of the incretin hormones. C) It is a synthetically prepared monosodium salt. D) It inhibits hydrogen, potassium, and ATPase.

Ans: B Feedback: Sitagliptin (Januvia) minimizes the rate of inactivation of the incretin hormones to increase hormone levels and prolong their activity. Sitagliptin does not block the S phase of the cell cycle. Sitagliptin is not a synthetically prepared monosodium salt. Sitagliptin does not inhibit hydrogen, potassium, and ATPase.

A patient has just been diagnosed with type 2 diabetes. The physician has prescribed an oral antidiabetic agent that will inhibit the production of glucose by the liver and thereby aid in the control of blood glucose. What type of oral antidiabetic agent did the physician prescribe for this patient? A) A sulfonylurea B) A biguanide C) A thiazolidinedione D) An alpha glucosidase inhibitor

Ans: B Feedback: Sulfonylureas exert their primary action by directly stimulating the pancreas to secrete insulin and therefore require a functioning pancreas to be effective. Biguanides inhibit the production of glucose by the liver and are in used in type 2 diabetes to control blood glucose levels. Thiazolidinediones enhance insulin action at the receptor site without increasing insulin secretion from the beta cells of the pancreas. Alpha glucosidase inhibitors work by delaying the absorption of glucose in the intestinal system, resulting in a lower postprandial blood glucose level.

The nursing instructor is discussing postoperative care with a group of nursing students. A student nurse asks, Why does the patient go to the PACU instead of just going straight up to the postsurgical unit? What is the nursing instructors best response? A) The PACU allows the patient to recover from anesthesia in a stimulating environment to facilitate awakening and reorientation. B) The PACU allows the patient to recover from the effects of anesthesia, and the patient stays in the PACU until he or she is oriented, has stable vital signs, and is without complications. C) Frequently, patients are placed in the medicalsurgical unit to recover, but hospitals are usually short of beds, and the PACU is an excellent place to triage patients. D) Patients remain in the PACU for a predetermined time because the surgeon will often need to reinforce or alter the patients incision in the hours following surgery.

Ans: B Feedback: The PACU provides care for the patient while he or she recovers from the effects of anesthesia. The patient must be oriented, have stable vital signs, and show no evidence of hemorrhage or other complications. Patients will sometimes recover in the ICU, but this is considered an extension of the PACU. The PACU does allow the patient to recover from anesthesia, but the environment is calm and quiet as patients are initially disoriented and confused as they begin to awaken and reorient. Patients are not usually placed in the medicalsurgical unit for recovery and, although hospitals are occasionally short of beds, the PACU is not used for patient triage. Incisions are very rarely modified in the immediate postoperative period.

A patient who suffers from cancer pain is receiving morphine every 2 hours. For iwhich of the following should the family be taught to assess while the patient is on morphine? A) Diarrhea B) Respiratory depression C) Lung sounds D) Urinary incontinence

Ans: B Feedback: The administration of morphine can result in respiratory depression. The family should be taught to assess the patient for respiratory depression. Morphine sulfate can be administered to treat severe diarrhea. The patient's lung sounds are important to assess, but only after the nurse assesses for respiratory depression. Morphine does not cause urinary incontinence

The surgeons preoperative assessment of a patient has identified that the patient is at a high risk for venous thromboembolism. Once the patient is admitted to the postsurgical unit, what intervention should the nurse prioritize to reduce the patients risk of developing this complication? A) Maintain the head of the bed at 45 degrees or higher. B) Encourage early ambulation. C) Encourage oral fluid intake. D) Perform passive range-of-motion exercises every 8 hours.

Ans: B Feedback: The benefits of early ambulation and leg exercises in preventing DVT cannot be overemphasized, and these activities are recommended for all patients, regardless of their risk. Increasing the head of the bed is not effective. Ambulation is superior to passive range-of-motion exercises. Fluid intake is important, but is less protective than early ambulation.

A patient with a history of alcoholism is being treated in the intensive care unit for multiple trauma following a motor vehicle accident. The patient is currently being treated with lorazepam (Ativan) to treat signs of alcohol withdrawal as well as hydromorphone (Dilaudid) for the pain of injuries. The intensive care nurse should prioritize what assessments? A) Arterial blood gases B) Respiratory rate and oxygen saturation C) Deep tendon reflexes and pupillary response D) Cardiac rate and rhythm

Ans: B Feedback: The combination of opioids and benzodiazepines creates a significant risk for CNS depression; respiratory function is consequently an important focus of assessment. It would likely supersede other assessments, even though each may be warranted.

A patient has experienced the formation of clots and has bruising. It is determined that there is a depletion of the patient's coagulation factors and widespread bleeding. Which of the following medications will be administered? A) Aminocaproic acid (Amicar) B) Heparin C) Warfarin (Coumadin) D) Protamine sulfate

Ans: B Feedback: The development of clots and widespread bleeding is indicative of disseminated intravascular coagulation. The patient should be administered heparin to slow the formation of clots. The goal of heparin therapy in DIC is to prevent blood coagulation long enough for clotting factors to replenish and control hemorrhage. Aminocaproic acid is used to control excessive bleeding from systemic hyperfibrinolysis. Warfarin is administered orally to decrease clot formation. Protamine sulfate would not be administered.

A surgical patient's balanced anesthesia includes the use of vecuronium. What nursing action should the operating room nurses prioritize? A) Monitoring the patient for signs of increased level of consciousness B) Assessing and protecting the patient's airway C) Protecting the patient's skin integrity D) Monitoring the patient's deep tendon reflexes

Ans: B Feedback: The maintenance of the patient's airway and respiratory function following the administration of neuromuscular blocking agents such as vecuronium is the most important nursing implication. The importance of airway protection supersedes that of DTR assessment, assessing LOC, and maintaining skin integrity, though each of these is a valid consideration

An elderly patient comes to the clinic with her daughter. The patient is a diabetic and is concerned about foot care. The nurse goes over foot care with the patient and her daughter as the nurse realizes that foot care is extremely important. Why would the nurse feel that foot care is so important to this patient? A) An elderly patient with foot ulcers experiences severe foot pain due to the diabetic polyneuropathy. B) Avoiding foot ulcers may mean the difference between institutionalization and continued independent living. C) Hypoglycemia is linked with a risk for falls; this risk is elevated in older adults with diabetes. D) Oral antihyperglycemics have the possible adverse effect of decreased circulation to the lower extremities.

Ans: B Feedback: The nurse recognizes that providing information on the long-term complicationsespecially foot and eye problemsassociated with diabetes is important. Avoiding amputation through early detection of foot ulcers may mean the difference between institutionalization and continued independent living for the elderly person with diabetes. While the nurse recognizes that hypoglycemia is a dangerous situation and may lead to falls, hypoglycemia is not directly connected to the importance of foot care. Decrease in circulation is related to vascular changes and is not associated with drugs administered for diabetes.

The nurse is caring for a patient who is postoperative day 2 following a colon resection. While turning him, wound dehiscence with evisceration occurs. What should be the nurses first response? A) Return the patient to his previous position and call the physician. B) Place saline-soaked sterile dressings on the wound. C) Assess the patients blood pressure and pulse. D) Pull the dehiscence closed using gloved hands.

Ans: B Feedback: The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. Then the nurse should call the physician and take the patients vital signs. The dehiscence needs to be surgically closed, so the nurse should never try to close it.

The nurse admits a patient to the PACU with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the patients blood pressure is 94/47 mm Hg, and the pulse is 110. The nurse documents that the patients skin is cold, moist, and pale. Of what is the patient showing signs? A) Hypothermia B) Hypovolemic shock C) Neurogenic shock D) Malignant hyperthermia

Ans: B Feedback: The patient is exhibiting symptoms of hypovolemic shock; therefore, the nurse should notify the patients physician and anticipate orders for fluid and/or blood product replacement. Neurogenic shock does not normally result in tachycardia and malignant hyperthermia would not present at this stage in the operative experience. Hypothermia does not cause hypotension and tachycardia.

You are the nurse caring for an unconscious trauma victim who needs emergency surgery. The patient is a 55-year-old man with an adult son. He is legally divorced and is planning to be remarried in a few weeks. His parents are at the hospital with the other family members. The physician has explained the need for surgery, the procedure to be done, and the risks to the children, the parents, and the fianc. Who should be asked to sign the surgery consent form? A) The fianc B) The son C) The physician, acting as a surrogate D) The patients father

Ans: B Feedback: The patient personally signs the consent if of legal age and mentally capable. Permission is otherwise obtained from a surrogate, who most often is a responsible family member (preferably next of kin) or legal guardian. In this instance, the child would be the appropriate person to ask to sign the consent form as he is the closest relative at the hospital. The fianc is not legally related to him as the marriage has not yet taken place. The father would only be asked to sign the consent if no children were present to sign. The physician would not sign if family members were available.

A 77-year-old mans coronary artery bypass graft has been successful and discharge planning is underway. When planning the patients subsequent care, the nurse should know that the postoperative phase of perioperative nursing ends at what time? A) When the patient is returned to his room after surgery B) When a follow-up evaluation in the clinical or home setting is done C) When the patient is fully recovered from all effects of the surgery D) When the family becomes partly responsible for the patients care

Ans: B Feedback: The postoperative phase begins with the admission of the patient to the PACU and ends with a follow-up evaluation in the clinical setting or home.

The nurse is caring for a patient who has just been transferred to the PACU from the OR. What is the highest nursing priority? A) Assessing for hemorrhage B) Maintaining a patent airway C) Managing the patients pain D) Assessing vital signs every 30 minutes

Ans: B Feedback: The primary objective in the immediate postoperative period is to maintain ventilation and, thus, prevent hypoxemia (reduced oxygen in the blood) and hypercapnia (excess carbon dioxide in the blood). Assessing for hemorrhage and assessing vital sign are also important, but constitute second and third priorities. Pain management is important but only after the patient has been stabilized.

A patient has a left temporal brain tumor. He smells an odor of ammonia prior to experiencing rapid rhythmic jerking movements. What is the odor of ammonia classified as? A) Chemical agent evoked by the tumor B) An aura prior to the seizure activity C) The metastatic process of tumor growth D) The inhibition of serotonin and acetylcholine

Ans: B Feedback: The smell of ammonia is an aura, which is a warning prior to seizure activity. The tumor will not evoke a chemical agent prior to the seizure. The metastatic process will not evoke a chemical smell. The chemical smell is not related to the inhibition of serotonin and acetylcholine.

An older adult's physician has recommended the occasional use of hydroxyzine for relief of nausea. Following administration, the nurse should assess the patient for A) pruritus. B) drowsiness. C) urinary frequency. D) bradycardia.

Ans: B Feedback: The use of hydroxyzine is associated with drowsiness. Antihistamines do not typically cause pruritus, frequency, or bradycardia.

A postoperative patient rapidly presents with hypotension; rapid, thready pulse; oliguria; and cold, pale skin. The nurse suspects that the patient is experiencing a hemorrhage. What should be the nurses first action? A) Leave and promptly notify the physician. B) Quickly attempt to determine the cause of hemorrhage. C) Begin resuscitation. D) Put the patient in the Trendelenberg position.

Ans: B Feedback: Transfusing blood or blood products and determining the cause of hemorrhage are the initial therapeutic measures. Resuscitation is not necessarily required and the nurse must not leave the patient. The Trendelenberg position would be contraindicated.

A patient is diagnosed with type 1 diabetes. What distinguishing characteristic is associated with type 1 diabetes? A) Blood glucose levels can be controlled by diet. B) Exogenous insulin is required for life. C) Oral agents can control blood sugar. D) The disease always starts in childhood.

Ans: B Feedback: Type 1 diabetes will result in eventual destruction of beta cells, and no insulin is produced. The blood glucose level can only be controlled by diet in type 2 diabetes. In type 2 diabetes, oral agents can be administered. Type 1 diabetes is diagnosed at many ages, not only in childhood.

A patient underwent an open bowel resection 2 days ago and the nurses most recent assessment of the patients abdominal incision reveals that it is dehiscing. What factor should the nurse suspect may have caused the dehiscence? A) The patients surgical dressing was changed yesterday and today. B) The patient has vomited three times in the past 12 hours. C) The patient has begun voiding on the commode instead of a bedpan. D) The patient used PCA until this morning.

Ans: B Feedback: Vomiting can produce tension on wounds, particularly of the torso. Dressing changes and light mobilization are unlikely to cause dehiscence. The use of a PCA is not associated with wound dehiscence.

The PACU nurse is caring for a patient who has arrived from the OR. During the initial assessment, the nurse observes that the patients skin has become blue and dusky. The nurse looks, listens, and feels for breathing, and determines the patient is not breathing. What is the priority intervention? A) Check the patients oxygen saturation level, continue to monitor for apnea, and perform a focused assessment. B) Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw. C) Assess the arterial pulses, and place the patient in the Trendelenburg position. D) Reintubate the patient.

Ans: B Feedback: When a nurse finds a patient who is not breathing, the priority intervention is to open the airway and treat a possible hypopharyngeal obstruction. To treat the possible airway obstruction, the nurse tilts the head back and then pushes forward on the angle of the lower jaw or performs the jaw thrust method to open the airway. This is an emergency and requires the basic life support intervention of airway, breathing, and circulation assessment. Arterial pulses should be checked only after airway and breathing have been established. Reintubation and resuscitation would begin after rapidly ruling out a hypopharyngeal obstruction.

The nurse is preparing to change a patients abdominal dressing. The nurse recognizes the first step is to provide the patient with information regarding the procedure. Which of the following explanations should the nurse provide to the patient? A) The dressing change is often painful, and we will be giving you pain medication prior to the procedure so you do not have to worry. B) During the dressing change, I will provide privacy at a time of your choosing, it should not be painful, and you can look at the incision and help with the procedure if you want to. C) The dressing change should not be painful, but you can never be sure, and infection is always a concern. D) The best time for doing a dressing change is during lunch so we are not interrupted. I will provide privacy, and it should not be painful.

Ans: B Feedback: When having dressings changed, the patient needs to be informed that the dressing change is a simple procedure with little discomfort; privacy will be provided; and the patient is free to look at the incision or even assist in the dressing change itself. If the patient decides to look at the incision, assurance is given that the incision will shrink as it heals and that the redness will likely fade. Dressing changes should not be painful, but giving pain medication prior to the procedure is always a good preventive measure. Telling the patient that the dressing change should not be painful, but you can never be sure, and infection is always a concern does not offer the patient any real information or options and serves only to create fear. The best time for dressing changes is when it is most convenient for the patient; nutrition is important so interrupting lunch is probably a poor choice.

A nurse educator is explaining the pathophysiology of diabetes to a newly diagnosed patient. The patient does not understand why she had a "constant, insatiable thirst" in the months preceding her diagnosis. What phenomenon should the nurse describe? A) "The excess glucose in your blood accumulates in your blood vessels and neurons, including the neurons that control thirst." B) "Excess glucose pulled more water through your kidneys and the increased urination caused thirst." C) "Increased thirst is your body's attempt to dilute your blood because it contains too much glucose." D) "When your body cells are starved for useful glucose, they signal your body to increase food and fluid intake."

Ans: B Feedback: When large amounts of glucose are present, water is pulled into the renal tubule. This results in a greatly increased urine output (polyuria). The excessive loss of fluid in urine leads to increased thirst (polydipsia). Glucose does not directly affect the thirst center.

The nurse is preparing a patient for surgery. The patient states that she is very nervous and really does not understand what the surgical procedure is for or how it will be performed. What is the most appropriate nursing action for the nurse to take? A) Have the patient sign the informed consent and place it in the chart. B) Call the physician to review the procedure with the patient. C) Explain the procedure clearly to the patient and her family. D) Provide the patient with a pamphlet explaining the procedure.

Ans: B Feedback: While the nurse may ask the patient to sign the consent form and witness the signature, it is the surgeons responsibility to provide a clear and simple explanation of what the surgery will entail prior to the patient giving consent. The surgeon must also inform the patient of the benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts as well as what to expect in the early and late postoperative periods. The nurse clarifies the information provided, and, if the patient requests additional information, the nurse notifies the physician. The consent formed should not be signed until the patient understands the procedure that has been explained by the surgeon. The provision of a pamphlet will benefit teaching the patient about the surgical procedure, but will not substitute for the information provided by the physician.

A certified registered nurse anesthetist is describing the minimum alveolar concentration (MAC) of isoflurane. How will the addition of nitrous oxide or IV anesthetics affect the MAC of isoflurane? A) The MAC will remain the same. B) The MAC will decrease. C) The MAC of isoflurane will not be relevant. D) The MAC will be more difficult to calculate

Ans: B Feedback: With the addition of other medications such as opioids, intravenous anesthetics, or nitrous oxide, the MAC values decrease.

A patient is brought to the emergency department by the paramedics. The patient is a type 2 diabetic and is experiencing HHS. The nurse should identify what components of HHS? Select all that apply. A) Leukocytosis B) Glycosuria C) Dehydration D) Hypernatremia E) Hyperglycemia

Ans: B, C, D, E Feedback: In HHS, persistent hyperglycemia causes osmotic diuresis, which results in losses of water and electrolytes. To maintain osmotic equilibrium, water shifts from the intracellular fluid space to the extracellular fluid space. With glycosuria and dehydration, hypernatremia and increased osmolarity occur. Leukocytosis does not take place.

The nurse is caring for a postoperative patient who needs daily dressing changes. The patient is 3 days postoperative and is scheduled for discharge the next day. Until now, the patient has refused to learn how to change her dressing. What would indicate to the nurse the patients possible readiness to learn how to change her dressing? Select all that apply. A) The patient wants you to teach a family member to do dressing changes. B) The patient expresses interest in the dressing change. C) The patient is willing to look at the incision during a dressing change. D) The patient expresses dislike of the surgical wound. E) The patient assists in opening the packages of dressing material for the nurse.

Ans: B, C, E Feedback: While changing the dressing, the nurse has an opportunity to teach the patient how to care for the incision and change the dressings at home. The nurse observes for indicators of the patients readiness to learn, such as looking at the incision, expressing interest, or assisting in the dressing change. Expressing dislike and wanting to delegate to a family member do not suggest readiness to learn.

A surgical patient has been in the PACU for the past 3 hours. What are the determining factors for the patient to be discharged from the PACU? Select all that apply. A) Absence of pain B) Stable blood pressure C) Ability to tolerate oral fluids D) Sufficient oxygen saturation E) Adequate respiratory function

Ans: B, D, E Feedback: A patient remains in the PACU until fully recovered from the anesthetic agent. Indicators of recovery include stable blood pressure, adequate respiratory function, and adequate oxygen saturation level compared with baseline. Patients can be released from PACU before resuming oral intake. Pain is often present at discharge from the PACU and can be addressed in other inpatient settings.

You are the nurse caring for an elderly adult who is bedridden. What intervention would you include in the care plan that would most effectively prevent pressure ulcers? A) Turn and reposition the patient a minimum of every 8 hours. B) Vigorously massage lotion into bony prominences. C) Post a turning schedule at the patients bedside and ensure staff adherence. D) Slide, rather than lift, the patient when turning.

Ans: C Feedback: A turning schedule with a signing sheet will help ensure that the patient gets turned and, thus, help prevent pressure ulcers. Turning should occur every 1 to 2 hours, not every 8 hours, for patients who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist, but should avoid vigorous massage, which could damage capillaries. When moving the patient, the nurse should lift, rather than slide, the patient to avoid shearing.

A patient has been transferred to a rehabilitative setting from an acute care unit. What is the most important reason for the nurse to begin a program for activities of daily living (ADLs) as soon as the patient is admitted to a rehabilitation facility? A) The ability to perform ADLs may be the key to dependence. B) The ability to perform ADLs is essential to living in a group home. C) The ability to perform ADLs may be the key to reentry into the community. D) The ability to perform ADLs is necessary to function in an assisted-living situation.

Ans: C Feedback: An ADL program is started as soon as the rehabilitation process begins because the ability to perform ADLs is frequently the key to independence, return to the home, and reentry into the community. ADLs are frequently the key to independence, not dependence. The ability to perform ADLs is not always a criterion for admission to a group home or assisted-living facility.

An elderly woman diagnosed with osteoarthritis has been referred for care. The patient has difficulty ambulating because of chronic pain. When creating a nursing care plan, what intervention may the nurse use to best promote the patients mobility? A) Motivate the patient to walk in the afternoon rather than the morning. B) Encourage the patient to push through the pain in order to gain further mobility. C) Administer an analgesic as ordered to facilitate the patients mobility. D) Have another person with osteoarthritis visit the patient.

Ans: C Feedback: At times, mobility is restricted because of pain, paralysis, loss of muscle strength, systemic disease, an immobilizing device (e.g., cast, brace), or prescribed limits to promote healing. If mobility is restricted because of pain, providing pain management through the administration of an analgesic will increase the patients level of comfort during ambulation and allow the patient to ambulate. Motivating the patent or having another person with the same diagnosis visit is not an intervention that will help with mobility. The patient should not be encouraged to push through the pain.

A female patient, 47 years old, visits the clinic because she has been experiencing stress incontinence when she sneezes or exercises vigorously. What is the best instruction the nurse can give the patient? A) Keep a record of when the incontinence occurs. B) Perform clean intermittent self-catheterization. C) Perform Kegel exercises four to six times per day. D) Wear a protective undergarment to address this age-related change.

Ans: C Feedback: For cognitively intact women who experience stress incontinence, the nurse should instruct the patient to perform Kegel exercises four to six times per day to strengthen the pubococcygeus muscle. Keeping a record of when the incontinence occurs or accepting incontinence as part of aging are incorrect answers because they are of no value in treating stress incontinence. Women with stress incontinence do not need clean intermittent catheterization. Protective undergarments hide the effects of urinary incontinence but they do not resolve the problem.

The nurse is providing care for a 90-year-old patient whose severe cognitive and mobility deficits result in the nursing diagnosis of risk for impaired skin integrity due to lack of mobility. When planning relevant assessments, the nurse should prioritize inspection of what area? A) The patients elbows B) The soles of the patients feet C) The patients heels D) The patients knees

Ans: C Feedback: Full inspection of the patients skin is necessary, but the coccyx and the heels are the most susceptible areas for skin breakdown due to shear and friction.

A 52-year-old married man with two adolescent children is beginning rehabilitation following a motor vehicle accident. You are the nurse planning the patients care. Who will the patients condition affect? A) Himself B) His wife and any children that still live at home C) Him and his entire family D) No one, provided he has a complete recovery

Ans: C Feedback: Patients and families who suddenly experience a physically disabling event or the onset of a chronic illness are the ones who face several psychosocial adjustments, even if the patient recovers completely.

The nurse is working with a rehabilitation patient who has a deficit in mobility following a skiing accident. The nurse knows that preparation for ambulation is extremely important. What nursing action will best provide the foundation of preparation for ambulation? A) Stimulating the patients desire to ambulate B) Assessing the patients understanding of ambulation C) Helping the patient perform frequent exercise D) Setting realistic expectations

Ans: C Feedback: Regaining the ability to walk is a prime morale builder. However, to be prepared for ambulation whether with brace, walker, cane, or crutches the patient must strengthen the muscles required. Therefore, exercise is the foundation of preparation.

An elderly patient is brought to the emergency department with a fractured tibia. The patient appears malnourished, and the nurse is concerned about the patients healing process related to insufficient protein levels. What laboratory finding would the floor nurse prioritize when assessing for protein deficiency? A) Hemoglobin B) Bilirubin C) Albumin D) Cortisol

Ans: C Feedback: Serum albumin is a sensitive indicator of protein deficiency. Albumin levels of less than 3 g/mL are indicative of hypoalbuminemia. Altered hemoglobin levels, cortisol levels, and bilirubin levels are not indicators of protein deficiency.

You are the nurse caring for a patient who has paraplegia following a hunting accident. You know to assess regularly for the development of pressure ulcers on this patient. What rationale would you cite for this nursing action? A) You know that this patient will have a decreased level of consciousness. B) You know that this patient may not be motivated to prevent pressure ulcers. C) You know that the risk for pressure ulcers is directly related to the duration of immobility. D) You know that the risk for pressure ulcers is related to what caused the immobility.

Ans: C Feedback: The development of pressure ulcers is directly related to the duration of immobility: If pressure continues long enough, small vessel thrombosis and tissue necrosis occur, and a pressure ulcer results. The cause of the immobility is not what is important in the development of a pressure ulcer; the duration of the immobility is what matters. Paraplegia does not result in a decreased level of consciousness and there is no reason to believe that the patient does not want to prevent pressure ulcers.

A physician has explained to a patient that he has developed diabetic neuropathy in his right foot. Later that day, the patient asks the nurse what causes diabetic neuropathy. What would be the nurses best response? A) Research has shown that diabetic neuropathy is caused by fluctuations in blood sugar that have gone on for years. B) The cause is not known for sure but it is thought to have something to do with ketoacidosis. C) The cause is not known for sure but it is thought to involve elevated blood glucose levels over a period of years. D) Research has shown that diabetic neuropathy is caused by a combination of elevated glucose levels and elevated ketone levels.

Ans: C Feedback: The etiology of neuropathy may involve elevated blood glucose levels over a period of years. High blood sugars (rather than fluctuations or variations in blood sugars) are thought to be responsible. Ketones and ketoacidosis are not direct causes of neuropathies.

A nurse is caring for a patient undergoing rehabilitation following a snowboarding accident. Within the interdisciplinary team, the nurse has been given the responsibility for coordinating the patients total rehabilitative plan of care. What nursing role is this nurse performing? A) Patient educator B) Caregiver C) Case manager D) Patient advocate

Ans: C Feedback: When the nurse coordinates the patients total rehabilitative plan of care, the nurse is functioning as a case manager. The nurse must coordinate services provided by all of the team members. The other answers are incorrect.

A home care nurse performs the initial visit to a patient who is soon being discharged from a rehabilitation facility. This initial visit is to assess what the patient can do and to see what he will need when discharged home. What does this help ensure for the patient? A) Social relationships B) Family assistance C) Continuity of care D) Realistic expectations

Ans: C Feedback: A home care nurse may visit the patient in the hospital, interview the patient and the family, and review the ADL sheet to learn which activities the patient can perform. This helps ensure that continuity of care is provided and that the patient does not regress, but instead maintains the independence gained while in the hospital or rehabilitation setting. This initial visit does not ensure social relationships, family assistance, or realistic expectations.

The rehabilitation team has reaffirmed the need to maximize the independence of a patient in rehabilitation. When working toward this goal, what action should the nurse prioritize? A) Encourage families to become paraprofessionals in rehabilitation. B) Delegate care planning to the patient and family. C) Recognize the importance of informal caregivers. D) Make patients and families to work together.

Ans: C Feedback: In working toward maximizing independence, nurses affirm the patient as an active participant and recognize the importance of informal caregivers in the rehabilitation process. Nurses do not encourage families to become paraprofessionals in rehabilitation. The patient and family are central, but care planning is not their responsibility. Nurses do not make patients and families work together.

An adult hospital patient has been experiencing intractable nausea and vomiting for several hours, so the nurse has obtained an order for an antiemetic from the primary care provider. The order reads: "Promethazine 25 mg sub-Q every 6 hours PRN." The nurse should contact the care provider to question what aspect of this order? A) The drug B) The dose C) The route D) The frequency

Ans: C Feedback: A black box warning alerts nurses that promethazine is contraindicated for subcutaneous administration. The other parameters of the order are within recommendations.

A patient with muscle spasms is administered cyclobenzaprine (Flexeril). Which adverse effect should the nurse assess for with this medication? A) Muscle spasms B) Insomnia C) Drowsiness D) Urinary incontinence

Ans: C Feedback: A common adverse effect with cyclobenzaprine (Flexeril) is drowsiness. The patient will not experience muscle spasms, insomnia, or urinary incontinence.

A 55-year-old woman will have a partial mastectomy performed as treatment for breast cancer. The anesthesiologist has informed the operating room nurse that opioids will be used to supplement anesthesia. What opioid is most likely to be utilized? A) Codeine B) Oxycodone C) Fentanyl D) Meperidine

Ans: C Feedback: A synthetic opioid that is about 100 times more potent than morphine sulfate, fentanyl can be used to supplement sedation, regional techniques, and general anesthesia. Codeine, meperidine, and oxycodone do not have intraoperative applications.

A patient has been prescribed acarbose (Precose). What is the advantage of acarbose over alternative drugs? A) It can replace the use of insulin. B) The patient does not have to limit food intake. C) It delays the digestion of complex carbohydrates. D) It prevents alkalosis.

Ans: C Feedback: Acarbose delays the digestion of complex carbohydrates into glucose and other simple sugars. Acarbose may be combined with insulin or an oral agent, usually a sulfonylurea. The patient will still need to remain on a diabetic dietary regime. The drug does not directly prevent acid-base imbalances.

A patient is administered an antihistamine for nausea. Which of the following is an adverse effect of this classification of medication? A) Diarrhea B) Prolonged QRS complex C) Urinary retention D) Inverted T wave

Ans: C Feedback: Adverse anticholinergic effects of antihistamines are dizziness, confusion, dry mouth, and urinary retention. Diarrhea, prolonged QRS complex, and inverted T wave are not adverse effects of antihistamines.

A patient's medication regimen for treatment of anxiety has been changed from a benzodiazepine. The patient asks the nurse what likely prompted his care provider to change his medication. What is the nurse's best response? A) "Your doctor may have been concerned about causing depression." B) "Your doctor may have been worried about the possibility of convulsions." C) "Long-term use of benzodiazepines can result in dependency." D) "Long-term use of benzodiazepines can cause insomnia."

Ans: C Feedback: Although benzodiazepines are effective anxiolytics, long-term use is associated with concerns over tolerance, dependency, withdrawal, lack of efficacy for treating the depression that often accompanies anxiety disorders, and the need for multiple daily dosing with some agents. They do not cause insomnia, convulsions, or depression.

The nurse is checking the informed consent for a 17-year-old who has just been married and expecting her first child. She is scheduled for a cesarean section. She is still living with her parents and is on her parents health insurance. When obtaining informed consent for the cesarean section, who is legally responsible for signing? A) Her parents B) Her husband C) The patient D) The obstetrician

Ans: C Feedback: An emancipated minor (married or independently earning his or her own living) may sign his or her own consent form. In this case, the patient is the only person who can provide consent unless she would be neurologically incapacitated or incompetent, in which case her husband would need to provide consent.

The nurse is caring for a patient after abdominal surgery in the PACU. The patients blood pressure has increased and the patient is restless. The patients oxygen saturation is 97%. What cause for this change in status should the nurse first suspect? A) The patient is hypothermic. B) The patient is in shock. C) The patient is in pain. D) The patient is hypoxic.

Ans: C Feedback: An increase in blood pressure and restlessness are symptoms of pain. The patients oxygen saturation is 97%, so hypothermia, hypoxia, and shock are not likely causes of the patients restlessness.

A patient is scheduled for surgery the next day and the different phases of the patients surgical experience will require input from members of numerous health disciplines. How should the patients care best be coordinated? A) By planning care using a surgical approach B) By identifying the professional with the most knowledge of the patient C) By implementing an interdisciplinary approach to care D) By using the nursing process to guide all aspects of care and treatment

Ans: C Feedback: An interdisciplinary approach involving the surgeon, anesthesiologist or anesthetist, and nurse is best. This is superior to each of the other listed options.

A patient is being administered heparin IV and has been started on warfarin (Coumadin). The patient asks the nurse why she is taking both medications. What is the nurse's most accurate response? A) "After a certain period of time, you must start warfarin and heparin together." B) "You will need both warfarin and heparin for several days." C) "Warfarin takes 3 to 5 days to develop anticoagulant effects, and you still need heparin." D) "Warfarin cannot be given without heparin due to the amount of clotting you need."

Ans: C Feedback: Anticoagulant effects do not occur for 3 to 5 days after warfarin is started because clotting factors already in the blood follow their normal pathway of elimination. The statement "After a certain period of time, you must start warfarin and heparin together" does not explain clearly the reason for the two medications concurrently. The statement "You will need both warfarin and heparin for several days" does not explain clearly the reason for the two medications. The statement "Warfarin cannot be given without heparin due to the amount of clotting you need" is not accurate.

What is the most effective way to evaluate the patient's pain response after administering an opioid analgesic? A) Observe the patient when he/she is not aware you are assessing him/her. B) Ask another nurse to assess the patient's response to the medication. C) Using a pain scale, ask the patient to describe the pain. D) Ask the family to determine the patient's response to the pain.

Ans: C Feedback: Asking the patient to describe the pain using a pain scale is the most effective assessment of pain response. Observing the patient when he/she is unaware is an objective assessment and does not represent a true pain experience. Asking another nurse to assess the patient's response will not provide accurate data. Asking the family to determine the patient's response will not provide accurate data.

A patient is suffering from bursitis in the right elbow. Which of the following orally administered medications is most likely to diminish inflammation and assist in relieving pain? A) Acetaminophen (Tylenol) B) Morphine sulfate C) Acetylsalicylic acid (aspirin) D) Codeine

Ans: C Feedback: Aspirin is widely used to prevent and treat mild to moderate pain and inflammation associated with musculoskeletal disorders. Aspirin is administered orally. Acetaminophen (Tylenol) will only relieve pain and not affect inflammation. Morphine sulfate will relieve pain but not affect inflammation. Codeine will relieve pain but not affect inflammation.

The clinic nurse is doing a preoperative assessment of a patient who will be undergoing outpatient cataract surgery with lens implantation in 1 week. While taking the patients medical history, the nurse notes that this patient had a kidney transplant 8 years ago and that the patient is taking immunosuppressive drugs. For what is this patient at increased risk when having surgery? A) Rejection of the kidney B) Rejection of the implanted lens C) Infection D) Adrenal storm

Ans: C Feedback: Because patients who are immunosuppressed are highly susceptible to infection, great care is taken to ensure strict asepsis. The patient is unlikely to experience rejection or adrenal storm.

As an intraoperative nurse, you know that the patients emotional state can influence the outcome of his or her surgical procedure. How would you best reinforce the patients ability to influence outcome? A) Teach the patient strategies for distraction. B) Pair the patient with another patient who has better coping strategies. C) Incorporate cultural and religious considerations, as appropriate. D) Give the patient antianxiety medication.

Ans: C Feedback: Because the patients emotional state remains a concern, the care initiated by preoperative nurses is continued by the intraoperative nursing staff that provides the patient with information and reassurance. The nurse supports coping strategies and reinforces the patients ability to influence outcomes by encouraging active participation in the plan of care incorporating cultural, ethnic, and religious considerations, as appropriate. Buddying a patient is normally inappropriate and distraction may or may not be effective. Nonpharmacologic measures should be prioritized.

A patient is diagnosed with familial adenomatous polyposis. Which of the following nonsteroidal anti-inflammatory agents has the potential to reduce the number of polyps and decrease the risk of colon cancer? A) Ibuprofen (Motrin) B) Nabumetone (Relafen) C) Celecoxib (Celebrex) D) Probenecid (Benemid)

Ans: C Feedback: Celecoxib (Celebrex), a COX-2 inhibitor, is used to treat familial adenomatous polyposis, in which the drug reduces the number of polyps and may decrease risk of colon cancer. Ibuprofen (Motrin) and nabumetone (Relafen) are not recommended for use in preventing familial adenomatous polyposis. Probenecid (Benemid) is used to treat gouty arthritis, not for the prevention of adenomatous polyposis.

A child with night terrors is administered a benzodiazepine agent. Why must the nurse follow the child's health status closely? A) The child is more likely to develop insomnia. B) The child is more likely to develop dependence. C) The child is more vulnerable to adverse effects. D) The child is more vulnerable to hepatotoxicity.

Ans: C Feedback: Children may be more sensitive to its effects of this drug, namely mood and/or mental changes. Hepatotoxicity, insomnia, and dependence are not among the most common adverse effect.

A patient's current medical status includes multiple comorbidities. In recent months, the patient has been complaining of insomnia that has begun to have a significant impact on his quality of life. What aspect of this patient's health is most likely to cause insomnia? A) The patient has hypothyroidism. B) The patient is morbidly obese. C) The patient has chronic pain. D) The patient has type 2 diabetes.

Ans: C Feedback: Chronic pain is commonly associated with insomnia. Diabetes, obesity, and hypothyroidism are not normally associated with insomnia.

A middle-aged woman has become increasingly debilitated by anxiety, to the extent that she has sought medical help. After a thorough assessment, her care provider has diagnosed her with an anxiety disorder. The etiology of anxiety involves which of the following physiological processes? A) Stimulation of the parasympathetic nervous system B) Stimulating effects of somatotropin C) Increased activation of the autonomic nervous system D) Adrenocortical suppression

Ans: C Feedback: Clinical manifestations of anxiety include overactivity of the autonomic nervous system, such as dyspnea, palpitations, tachycardia, sweating, dry mouth, dizziness, nausea, and diarrhea. Somatotropin is not directly involved, and the adrenal cortex is not suppressed during times of anxiety. The parasympathetic nervous system is not stimulated during times of anxiety.

A patient newly diagnosed with type 2 diabetes is attending a nutrition class. What general guideline would be important to teach the patients at this class? A) Low fat generally indicates low sugar. B) Protein should constitute 30% to 40% of caloric intake. C) Most calories should be derived from carbohydrates. D) Animal fats should be eliminated from the diet.

Ans: C Feedback: Currently, the ADA and the Academy of Nutrition and Dietetics (formerly the American Dietetic Association) recommend that for all levels of caloric intake, 50% to 60% of calories should be derived from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein.Low fat does not automatically mean low sugar. Dietary animal fat does not need to be eliminated from the diet.

A patient is admitted to the ED complaining of severe abdominal pain, stating that he has been vomiting coffee-ground like emesis. The patient is diagnosed with a perforated gastric ulcer and is informed that he needs surgery. When can the patient most likely anticipate that the surgery will be scheduled? A) Within 24 hours B) Within the next week C) Without delay because the bleed is emergent D) As soon as all the days elective surgeries have been completed

Ans: C Feedback: Emergency surgeries are unplanned and occur with little time for preparation for the patient or the perioperative team. An active bleed is considered an emergency, and the patient requires immediate attention because the disorder may be life threatening. The surgery would not likely be deferred until after elective surgeries have been completed.

A nurse is providing health education to an adolescent newly diagnosed with type 1 diabetes mellitus and her family. The nurse teaches the patient and family that which of the following nonpharmacologic measures will decrease the bodys need for insulin? A) Adequate sleep B) Low stimulation C) Exercise D) Low-fat diet

Ans: C Feedback: Exercise lowers blood glucose, increases levels of HDLs, and decreases total cholesterol and triglyceride levels. Low fat intake and low levels of stimulation do not reduce a patients need for insulin. Adequate sleep is beneficial in reducing stress, but does not have an effect that is pronounced as that of exercise.

A patient will be undergoing a total hip arthroplasty later in the day and it is anticipated that the patient may require blood transfusion during surgery. How can the nurse best ensure the patients safety if a blood transfusion is required? A) Prime IV tubing with a unit of blood and keep it on hold. B) Check that the patients electrolyte levels have been assessed preoperatively. C) Ensure that the patient has had a current cross-match. D) Keep the blood on standby and warmed to body temperature.

Ans: C Feedback: Few patients undergoing an elective procedure require blood transfusion, but those undergoing high-risk procedures may require an intraoperative transfusion. The circulating nurse anticipates this need, checks that blood has been cross-matched and held in reserve, and is prepared to administer blood. Storing the blood at body temperature or in IV tubing would result in spoilage and potential infection.

A patient with type 1 diabetes mellitus is seeing the nurse to review foot care. What would be a priority instruction for the nurse to give the patient? A) Examine feet weekly for redness, blisters, and abrasions. B) Avoid the use of moisturizing lotions. C) Avoid hot-water bottles and heating pads. D) Dry feet vigorously after each bath.

Ans: C Feedback: High-risk behaviors, such as walking barefoot, using heating pads on the feet, wearing open-toed shoes, soaking the feet, and shaving calluses, should be avoided. Socks should be worn for warmth. Feet should be examined each day for cuts, blisters, swelling, redness, tenderness, and abrasions. Lotion should be applied to dry feet but never between the toes. After a bath, the patient should gently, not vigorously, pat feet dry to avoid injury

A hospital patient with a diagnosis of type 1 diabetes is ordered Humulin R on a sliding scale. Based on the patient's blood glucose reading, the nurse administered 8 units of insulin at 07:45. The nurse recognizes the need to follow up this intervention and will reassess the patient's blood glucose level when the insulin reaches peak efficacy. The nurse should consequently check the patient's blood glucose level at what time? A) 08:15 B) Between 08:45 and 09:45 C) Between 09:45 and 10:45 D) Between 11:15 and 11:45

Ans: C Feedback: Humulin R peaks between 2 and 3 hours after administration.

A 28-year-old pregnant woman is spilling sugar in her urine. The physician orders a glucose tolerance test, which reveals gestational diabetes. The patient is shocked by the diagnosis, stating that she is conscientious about her health, and asks the nurse what causes gestational diabetes. The nurse should explain that gestational diabetes is a result of what etiologic factor? A) Increased caloric intake during the first trimester B) Changes in osmolality and fluid balance C) The effects of hormonal changes during pregnancy D) Overconsumption of carbohydrates during the first two trimesters

Ans: C Feedback: Hyperglycemia and eventual gestational diabetes develops during pregnancy because of the secretion of placental hormones, which causes insulin resistance. The disease is not the result of food intake or changes in osmolality.

You are caring for a 71-year-old patient who is 4 days postoperative for bilateral inguinal hernias. The patient has a history of congestive heart failure and peptic ulcer disease. The patient is highly reluctant to ambulate and will not drink fluids except for hot tea with her meals. The nurses aide reports to you that this patients vital signs are slightly elevated and that she has a nonproductive cough. When you assess the patient, you auscultate crackles at the base of the lungs. What would you suspect is wrong with your patient? A) Pulmonary embolism B) Hypervolemia C) Hypostatic pulmonary congestion D) Malignant hyperthermia

Ans: C Feedback: Hypostatic pulmonary congestion, caused by a weakened cardiovascular system that permits stagnation of secretions at lung bases, may develop; this condition occurs most frequently in elderly patients who are not mobilized effectively. The symptoms are often vague, with perhaps a slight elevation of temperature, pulse, and respiratory rate, as well as a cough. Physical examination reveals dullness and crackles at the base of the lungs. If the condition progresses, then the outcome may be fatal. A pulmonary embolism does not have this presentation and hypervolemia is unlikely due to the patients low fluid intake. Malignant hyperthermia occurs concurrent with the administration of anesthetic.

A patient has been taking phenytoin (Dilantin) for a seizure disorder. He has recently run out of his medication and has not obtained a refill. What is the patient at risk for developing? A) Hypotension B) Migraine headaches C) Status epilepticus D) Depression

Ans: C Feedback: In a person taking medications for a diagnosed seizure disorder, the most common cause of status epilepticus is abruptly stopping AEDs. Abruptly stopping phenytoin will not cause hypotension. Abruptly stopping phenytoin will not cause migraine headaches. Abruptly stopping phenytoin will not cause depression.

The ED nurse is caring for an 11-year-old brought in by ambulance after having been hit by a car. The childs parents are thought to be en route to the hospital but have not yet arrived. No other family members are present and attempts to contact the parents have been unsuccessful. The child needs emergency surgery to save her life. How should the need for informed consent be addressed? A) A social worker should temporarily sign the informed consent. B) Consent should be obtained from the hospitals ethics committee. C) Surgery should be done without informed consent. D) Surgery should be delayed until the parents arrive.

Ans: C Feedback: In an emergency, it may be necessary for the surgeon to operate as a lifesaving measure without the patients informed consent. However, every effort must be made to contact the patients family. In such a situation, contact can be made by electronic means. In this scenario, the surgery is considered lifesaving, and the parents are on their way to the hospital and not available. A delay would be unacceptable. Neither a social worker nor a member of the ethics committee may sign.

The operating room nurse is reading the anesthesiologist's consult of a 30-year-old female patient who will undergo surgical repair of a meniscus tear later that day. The nurse reads that total intravenous anesthesia (TIVA) is indicated. What is the most likely rationale for this intervention? A) The patient has a diagnosis of chronic obstructive pulmonary disease (COPD). B) The patient's insurer does not reimburse for inhaled anesthesia. C) The patient has previously experienced severe postoperative nausea and vomiting. D) The patient is in the first trimester of pregnancy.

Ans: C Feedback: In patients who have history of severe postoperative nausea and vomiting, the anesthetist may substitute the inhalation anesthetic with a technique called total intravenous anesthesia (TIVA). TIVA is not necessarily indicated in patients who are pregnant or who have COPD. Insurance considerations would not normally be an absolute indication for the use of TIVA.

The nurse just received a postoperative patient from the PACU to the medicalsurgical unit. The patient is an 84-year-old woman who had surgery for a left hip replacement. Which of the following concerns should the nurse prioritize for this patient in the first few hours on the unit? A) Beginning early ambulation B) Maintaining clean dressings on the surgical site C) Close monitoring of neurologic status D) Resumption of normal oral intake

Ans: C Feedback: In the initial hours after admission to the clinical unit, adequate ventilation, hemodynamic stability, incisional pain, surgical site integrity, nausea and vomiting, neurologic status, and spontaneous voiding are primary concerns. A patient who has had total hip replacement does not ambulate during the first few hours on the unit. Dressings are assessed, but may have some drainage on them. Oral intake will take more time to resume.

A student with diabetes tells the school nurse that he is feeling nervous and hungry. The nurse assesses the child and finds he has tachycardia and is diaphoretic with a blood glucose level of 50 mg/dL (2.8 mmol/L). What should the school nurse administer? A) A combination of protein and carbohydrates, such as a small cup of yogurt B) Two teaspoons of sugar dissolved in a cup of apple juice C) Half of a cup of juice, followed by cheese and crackers D) Half a sandwich with a protein-based filling

Ans: C Feedback: Initial treatment for hypoglycemia is 15 g concentrated carbohydrate, such as two or three glucose tablets, 1 tube glucose gel, or 0.5 cup juice. After initial treatment, the nurse should follow with a snack including starch and protein, such as cheese and crackers, milk and crackers, or half of a sandwich. It is unnecessary to add sugar to juice, even it if is labeled as unsweetened juice, because the fruit sugar in juice contains enough simple carbohydrate to raise the blood glucose level and additional sugar may result in a sharp rise in blood sugar that will last for several hours.

A diabetes educator is teaching a patient about type 2 diabetes. The educator recognizes that the patient understands the primary treatment for type 2 diabetes when the patient states what? A) I read that a pancreas transplant will provide a cure for my diabetes. B) I will take my oral antidiabetic agents when my morning blood sugar is high. C) I will make sure to follow the weight loss plan designed by the dietitian. D) I will make sure I call the diabetes educator when I have questions about my insulin.

Ans: C Feedback: Insulin resistance is associated with obesity; thus the primary treatment of type 2 diabetes is weight loss. Oral antidiabetic agents may be added if diet and exercise are not successful in controlling blood glucose levels. If maximum doses of a single category of oral agents fail to reduce glucose levels to satisfactory levels, additional oral agents may be used. Some patients may require insulin on an ongoing basis or on a temporary basis during times of acute psychological stress, but it is not the central component of type 2 treatment. Pancreas transplantation is associated with type 1 diabetes.

A patient with type 1 diabetes has told the nurse that his most recent urine test for ketones was positive. What is the nurses most plausible conclusion based on this assessment finding? A) The patient should withhold his next scheduled dose of insulin. B) The patient should promptly eat some protein and carbohydrates. C) The patients insulin levels are inadequate. D) The patient would benefit from a dose of metformin (Glucophage).

Ans: C Feedback: Ketones in the urine signal that there is a deficiency of insulin and that control of type 1 diabetes is deteriorating. Withholding insulin or eating food would exacerbate the patients ketonuria. Metformin will not cause short-term resolution of hyperglycemia.

You are caring for a male patient who has had spinal anesthesia. The patient is under a physicians order to lie flat postoperatively. When the patient asks to go to the bathroom, you encourage him to adhere to the physicians order. What rationale for complying with this order should the nurse explain to the patient? A) Preventing the risk of hypotension B) Preventing respiratory depression C) Preventing the onset of a headache D) Preventing pain at the lumbar injection site

Ans: C Feedback: Lying flat reduces the risk of headache after spinal anesthesia. Hypotension and respiratory depression may be adverse effects of spinal anesthesia associated with the spread of the anesthetic, but lying flat does not help reduce these effects. Pain at the lumbar injection site typically is not a problem.

A patient with osteoarthritis has been prescribed meloxicam (Mobic). Which of the following instructions should the patient be given? A) Take the medication with orange juice. B) Crush enteric-coated tablets to aid swallowing. C) Take the medication with food. D) Take the medication at bedtime.

Ans: C Feedback: Meloxicam should be taken with food. Enteric-coated tablets are never crushed, and it is not always necessary to take this medication at bedtime. Orange juice is not of particular benefit.

An elderly patient has taken ibuprofen (Motrin) 800 mg two times per day for the past 3 years. Which of the following laboratory tests is the priority assessment? A) Renin and aldosterone levels B) 24-hour urine for microalbumin C) Blood urea nitrogen and serum creatinine D) Complete blood count

Ans: C Feedback: Nonsteroidal anti-inflammatory agents in long-term use can cause renal impairment. The patient should be assessed for renal impairment with the elevation of the serum BUN and creatinine. NSAIDs do not affect renin and aldosterone levels. A 24-hour urine for microalbumin is not recommended when administering ibuprofen. A complete blood count may not be necessary.

The nurse is caring for a 78-year-old man who has had an outpatient cholecystectomy. The nurse is getting him up for his first walk postoperatively. To decrease the potential for orthostatic hypotension and consequent falls, what should the nurse have the patient do? A) Sit in a chair for 10 minutes prior to ambulating. B) Drink plenty of fluids to increase circulating blood volume. C) Stand upright for 2 to 3 minutes prior to ambulating. D) Perform range-of-motion exercises for each joint.

Ans: C Feedback: Older adults are at an increased risk for orthostatic hypotension secondary to age-related changes in vascular tone. The patient should sit up and then stand for 2 to 3 minutes before ambulating to alleviate orthostatic hypotension. The nurse should assess the patients ability to mobilize safely, but full assessment of range of motion in all joints is not normally necessary. Sitting in a chair and increasing fluid intake are insufficient to prevent orthostatic hypotension and consequent falls.

A patient is admitted to the surgical division after a mastectomy. The patient has a PCA pump and states to you that she is fearful she will overdose on morphine. Which of the following interventions is most appropriate to teach the patient? A) "The pump will administer all of the doses, so you don't have to worry." B) "If you follow the instructions, that won't happen to you." C) "The device is preset, so you cannot receive more than you need." D) "The device will give you a placebo when you press it often."

Ans: C Feedback: PCA pumps deliver a basic amount of analgesic by continuous infusion, with the patient injecting additional doses when needed. The amount of the drug is preset and limited. The pump will administer a basal rate, but the patient can administer the medication at preset intervals. Telling the patient not to worry is not effective teaching or use of therapeutic communication. Telling the patient to follow the instructions is not effective teaching or use of therapeutic communication. Instructing the patient on a placebo is not effective teaching or use of therapeutic communication.

As an intraoperative nurse, you are the advocate for each of the patients who receives care in the surgical setting. How can you best exemplify the principles of patient advocacy? A) By encouraging the patient to perform deep breathing preoperatively B) By limiting the patients contact with family members preoperatively C) By maintaining each of your patients privacy D) By eliciting informed consent from patients

Ans: C Feedback: Patient advocacy in the OR entails maintaining the patients physical and emotional comfort, privacy, rights, and dignity. Deep breathing is not necessary before surgery and obtaining informed consent is the purview of the physician. Family contact should not be limited.

The nurse is caring for a 79-year-old man who has returned to the postsurgical unit following abdominal surgery. The patient is unable to ambulate and is now refusing to wear an external pneumatic compression stocking. The nurse should explain that refusing to wear external pneumatic compression stockings increases his risk of what postsurgical complication? A) Sepsis B) Infection C) Pulmonary embolism D) Hematoma

Ans: C Feedback: Patients who have surgery that limits mobility are at an increased risk for pulmonary embolism secondary to deep vein thrombosis. The use of an external pneumatic compression stocking significantly reduces the risk by increasing venous return to the heart and limiting blood stasis. The risk of infection or sepsis would not be affected by an external pneumatic compression stocking. A hematoma or bruise would not be affected by the external pneumatic compression stocking unless the stockings were placed directly over the hematoma.

The nurse has been educating the patient on the self-administration of phenytoin (Dilantin). Which of the following statements by the patient demonstrates an understanding of the medication? A) "I'll only take the drug when I feel an impending seizure." B) "I'll reduce my dose if I remain seizure free." C) "I'll make sure to take the drug with food." D) "I'll stop taking the drug if I don't have a seizure for 8 weeks."

Ans: C Feedback: Phenytoin should be taken with food to reduce the chance of stomach upset. It should be taken on a regular basis, and not only when a seizure occurs. The patient should not arbitrarily reduce his or her dose of phenytoin. Abrupt cessation can cause seizures

The nurse is caring for an 82-year-old female patient in the PACU. The woman begins to awaken and responds to her name, but is confused, restless, and agitated. What principle should guide the nurses subsequent assessment? A) Postoperative confusion in older adults is an indication of impaired oxygenation or possibly a stroke during surgery. B) Confusion, restlessness, and agitation are expected postoperative findings in older adults and they will diminish in time. C) Postoperative confusion is common in the older adult patent, but it could also indicate a significant blood loss. D) Confusion, restlessness, and agitation indicate an underlying cognitive deficit such as dementia.

Ans: C Feedback: Postoperative confusion is common in the older adult patient, but it could also indicate blood loss and the potential for hypovolemic shock; it is a critical symptom for the nurse to identify. Despite being common, it is not considered to be an expected finding. Postoperative confusion is an indication of an oxygen problem or possibly a stroke during surgery, but blood loss is more likely. A new onset of confusion, restlessness, and agitation does not necessarily suggest an underlying cognitive disorder.

A patient with Parkinson's disease develops nausea and vomiting. Promethazine may be contraindicated because it depletes levels of what neurotransmitter? A) Acetylcholine B) Serotonin C) Dopamine D) Adenosine

Ans: C Feedback: Promethazine and other phenothiazines have widespread effects on the body. The therapeutic effects in nausea and vomiting are attributed to their ability to block dopamine from receptor sites in the brain and CTZ. This blockage of dopamine has the potential to exacerbate parkinsonian effects.

A patient is scheduled to undergo craniofacial surgery, a procedure that will necessitate the use of propofol. The operating use nurse should be aware that alternative medications will be absolutely necessary in order to produce what effect in the patient? A) Amnesia B) Euphoria C) Analgesia D) Hypnosis

Ans: C Feedback: Propofol produces amnesia, euphoria, and hypnosis. It therefore blocks the perception of pain. It does not, however, provide analgesia.

The nurse is caring for a patient on the medicalsurgical unit postoperative day 5. During each patient assessment, the nurse evaluates the patient for infection. Which of the following would be most indicative of infection? A) Presence of an indwelling urinary catheter B) Rectal temperature of 99.5F (37.5C) C) Red, warm, tender incision D) White blood cell (WBC) count of 8,000/mL

Ans: C Feedback: Redness, warmth, and tenderness in the incision area should lead the nurse to suspect a postoperative infection. The presence of any invasive device predisposes a patient to infection, but by itself does not indicate infection. An oral temperature of 99.5F may not signal infection in a postoperative patient because of the inflammatory process. A normal WBC count ranges from 4,000 to 10,000/mL.

The dressing surrounding a mastectomy patients Jackson-Pratt drain has scant drainage on it. The nurse believes that the amount of drainage on the dressing may be increasing. How can the nurse best confirm this suspicion? A) Describe the appearance of the dressing in the electronic health record. B) Photograph the patients abdomen for later comparison using a smartphone. C) Trace the outline of the drainage on the dressing for future comparison. D) Remove and weigh the dressing, reapply it, and then repeat in 8 hours.

Ans: C Feedback: Spots of drainage on a dressing are outlined with a pen, and the date and time of the outline are recorded on the dressing so that increased drainage can be easily seen. A dressing is never removed and then reapplied. Photographs normally require informed consent, so they would not be used for this purpose. Documentation is necessary, but does not confirm or rule out an increase in drainage.

Maintaining an aseptic environment in the OR is essential to patient safety and infection control. When moving around surgical areas, what distance must the nurse maintain from the sterile field? A) 2 feet B) 18 inches C) 1 foot D) 6 inches

Ans: C Feedback: Sterile areas must be kept in view during movement around the area. At least a 1-foot distance from the sterile field must be maintained to prevent inadvertent contamination.

A patient is to be administered glipizide (Glucotrol). Which of the following factors would contraindicate the administration of glipizide (Glucotrol) to this patient? A) A diagnosis of hypertension B) The ingestion of carbohydrates C) Allergy to sulfonamides D) Increase in alkaline phosphatase

Ans: C Feedback: Sulfonylureas are contraindicated in patients with hypersensitivity to them, with severe renal or hepatic impairment, and who are pregnant. A diagnosis of hypertension does not cause contraindication of sulfonylureas. The patient should consume carbohydrates in association with the oral hypoglycemic agent. An increase in alkaline phosphatase does not result in the contraindication of glipizide (Glucotrol).

A patient who is scheduled to begin chemotherapy for the treatment of breast cancer is anxious about the possibility of experiencing nausea and has asked the nurse multiple questions about the physiology of the phenomenon. When explaining the physiology of nausea and vomiting, the nurse should include which of the following statements? A) The vomiting center is a cluster of cells in the cerebellum. B) The vomiting center sends afferent signals to the chemoreceptor trigger zone (CTZ). C) The chemoreceptor trigger zone CTZ is composed of neurons in the fourth ventricle. D) The CTZ is located partly within the central nervous system and partly in the peripheral nervous system.

Ans: C Feedback: The CTZ is composed of neurons in the fourth ventricle. The vomiting center is a nucleus of cells in the medulla oblongata. Stimuli are relayed to the vomiting center by afferent signals from the chemoreceptor trigger zone (CTZ).

The OR nurse is providing care for a 25-year-old major trauma patient who has been involved in a motorcycle accident. The nurse should know that the patient is at increased risk for what complication of surgery? A) Respiratory depression B) Hypothermia C) Anesthesia awareness D) Moderate sedation

Ans: C Feedback: The Joint Commission has issued an alert regarding the phenomenon of patients being partially awake while under general anesthesia (referred to as anesthesia awareness). Patients at greatest risk of anesthesia awareness are cardiac, obstetric, and major trauma patients. This patient does not likely face a heightened risk of respiratory depression or hypothermia. Moderate sedation is not a complication.

A patient is scheduled for a bowel resection in the morning and the patients orders include a cleansing enema tonight. The patient wants to know why this is necessary. The nurse should explain that the cleansing enema will have what therapeutic effect? A) Preventing aspiration of gastric contents B) Preventing the accumulation of abdominal gas postoperatively C) Preventing potential contamination of the peritoneum D) Facilitating better absorption of medications

Ans: C Feedback: The administration of a cleansing enema will allow for satisfactory visualization of the surgical site and to prevent trauma to the intestine or contamination of the peritoneum by feces. It will have no effect on aspiration of gastric contents or the absorption of medications. The patient should expect to develop gas in the postoperative period.

The perioperative nurse is constantly assessing the surgical patient for signs and symptoms of complications of surgery. Which symptom should first signal to the nurse the possibility that the patient is developing malignant hyperthermia? A) Increased temperature B) Oliguria C) Tachycardia D) Hypotension

Ans: C Feedback: The initial symptoms of malignant hyperthermia are related to cardiovascular and musculoskeletal activity. Tachycardia (heart rate greater than 150 beats per minute) is often the earliest sign. Oliguria, hypotension, and increased temperature are later signs of malignant hyperthermia.

A 68-year-old patient is scheduled for a bilateral mastectomy. The OR nurse has come out to the holding area to meet the patient and quickly realizes that the patient is profoundly anxious. What is the most appropriate intervention for the nurse to apply? A) Reassure the patient that modern surgery is free of significant risks. B) Describe the surgery to the patient in as much detail as possible. C) Clearly explain any information that the patient seeks. D) Remind the patient that the anesthetic will render her unconscious.

Ans: C Feedback: The nurse can alleviate anxiety by supplying information as the patient requests it. The nurse should not assume that every patient wants as much detail as possible and false reassurance must be avoided. Reminding the patient that she will be unconscious is unlikely to reduce anxiety.

A patient is undergoing a course of radiotherapy for the treatment of leukemia. Treatments in the past have caused the patient severe nausea and vomiting. The oncology nurse should normally administer antiemetics on what schedule? A) Simultaneous with radiation treatment B) The night before a scheduled radiation treatment C) 30 to 60 minutes before the treatment D) 10 to 15 minutes before the treatment

Ans: C Feedback: The nurse should normally administer antiemetic drugs 30 to 60 minutes before a nausea-producing event, when possible.

The nurse is caring for a trauma victim in the ED who will require emergency surgery due to injuries. Before the patient leaves the ED for the OR, the patient goes into cardiac arrest. The nurse assists in the successful resuscitation and proceeds to release the patient to the OR staff. When can the ED nurse perform the preoperative assessment? A) When he or she has the opportunity to review the patients electronic health record B) When the patient arrives in the OR C) When assisting with the resuscitation D) Preoperative assessment is not necessary in this case

Ans: C Feedback: The only opportunity for preoperative assessment may take place at the same time as resuscitation in the ED. Preoperative assessment is necessary, but the nurse could not normally enter the OR to perform this assessment. The health record is an inadequate data source.

In anticipation of a patients scheduled surgery, the nurse is teaching her to perform deep breathing and coughing to use postoperatively. What action should the nurse teach the patient? A) The patient should take three deep breaths and cough hard three times, at least every 15 minutes for the immediately postoperative period. B) The patient should take three deep breaths and exhale forcefully and then take a quick short breath and cough from deep in the lungs. C) The patient should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs. D) The patient should rapidly inhale, hold for 30 seconds or as long as possible, and exhale slowly.

Ans: C Feedback: The patient assumes a sitting position to enhance lung expansion. The nurse then demonstrates how to take a deep, slow breath and how to exhale slowly. After practicing deep breathing several times, the patient is instructed to breathe deeply, exhale through the mouth, take a short breath, and cough from deep in the lungs.

The nurse is preparing a patient for surgery prior to her hysterectomy without oophorectomy. The nurse is witnessing the patients signature on a consent form. Which comment by the patient would best indicate informed consent? A) I know Ill be fine because the physician said he has done this procedure hundreds of times. B) I know Ill have pain after the surgery but theyll do their best to keep it to a minimum. C) The physician is going to remove my uterus and told me about the risk of bleeding. D) Because the physician isnt taking my ovaries, Ill still be able to have children.

Ans: C Feedback: The surgeon must inform the patient of the benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts as well as what to expect in the early and late postoperative periods. The nurse clarifies the information provided, and, if the patient requests additional information, the nurse notifies the physician. In the correct response, the patient is able to tell the nurse what will occur during the procedure and the associated risks. This indicates the patient has a sufficient understanding of the procedure to provide informed consent. Clarification of information given may be necessary, but no additional information should be given. The other listed statements do not reflect an understanding of the surgery to be performed.

The nurse is caring for a patient who is admitted to the ER with the diagnosis of acute appendicitis. The nurse notes during the assessment that the patients ribs and xiphoid process are prominent. The patient states she exercises two to three times daily and her mother indicates that she is being treated for anorexia nervosa. How should the nurse best follow up these assessment data? A) Inform the postoperative team about the patients risk for wound dehiscence. B) Evaluate the patients ability to manage her pain level. C) Facilitate a detailed analysis of the patients electrolyte levels. D) Instruct the patient on the need for a high-sodium diet to promote healing.

Ans: C Feedback: The surgical team should be informed about the patients medical history regarding anorexia nervosa. Any nutritional deficiency, such as malnutrition, should be corrected before surgery to provide adequate protein for tissue repair. The electrolyte levels should be evaluated and corrected to prevent metabolic abnormalities in the operative and postoperative phase. The risk of wound dehiscence is more likely associated with obesity. Instruction on proper nutrition should take place in the postoperative period, and a consultation should be made with her psychiatric specialist. Evaluation of pain management is always important, but not particularly significant in this scenario.

Which of the following patients with type 1 diabetes is most likely to experience adequate glucose control? A) A patient who skips breakfast when his glucose reading is greater than 220 mg/dL B) A patient who never deviates from her prescribed dose of insulin C) A patient who adheres closely to a meal plan and meal schedule D) A patient who eliminates carbohydrates from his daily intake

Ans: C Feedback: The therapeutic goal for diabetes management is to achieve normal blood glucose levels without hypoglycemia. Therefore, diabetes management involves constant assessment and modification of the treatment plan by health professionals and daily adjustments in therapy (possibly including insulin) by patients. For patients who require insulin to help control blood glucose levels, maintaining consistency in the amount of calories and carbohydrates ingested at meals is essential. In addition, consistency in the approximate time intervals between meals, and the snacks, help maintain overall glucose control. Skipping meals is never advisable for person with type 1 diabetes.

The nurse is doing a preoperative assessment of an 87-year-old man who is slated to have a right lung lobe resection to treat lung cancer. What underlying principle should guide the nurses preoperative assessment of an elderly patient? A) Elderly patients have a smaller lung capacity than younger patients. B) Elderly patients require higher medication doses than younger patients. C) Elderly patients have less physiologic reserve than younger patients. D) Elderly patients have more sophisticated coping skills than younger patients.

Ans: C Feedback: The underlying principle that guides the preoperative assessment, surgical care, and postoperative care is that elderly patients have less physiologic reserve (the ability of an organ to return to normal after a disturbance in its equilibrium) than do younger patients. Elderly patients do not have larger lung capacities than younger patients. Elderly patients cannot necessarily cope better than younger patients and they often require lower doses of medications.

The nurse is caring for a patient who is experiencing pain and anxiety following his prostatectomy. Which intervention will likely best assist in decreasing the patients pain and anxiety? A) Administration of NSAIDs rather than opioids B) Allowing the patient to increase activity C) Use of guided imagery along with pain medication D) Use of deep breathing and coughing exercises

Ans: C Feedback: The use of guided imagery will enhance pain relief and assist in reduction of anxiety. It may be combined with analgesics. Deep breathing and the increase in activity may produce increased pain. Replacing opioids with NSAIDs may cause an increase in pain.

The circulating nurse will be participating in a 78-year-old patients total hip replacement. Which of the following considerations should the nurse prioritize during the preparation of the patient in the OR? A) The patient should be placed in Trendelenburg position. B) The patient must be firmly restrained at all times. C) Pressure points should be assessed and well padded. D) The preoperative shave should be done by the circulating nurse.

Ans: C Feedback: The vascular supply should not be obstructed by an awkward position or undue pressure on a body part. During surgical procedures, the patient is at risk for impairment of skin integrity due to a stationary position and immobility. An elderly patient is at an increased risk of injury and impaired skin integrity. A Trendelenburg position is not indicated for this patient. Once anesthetized for a total hip replacement, the patient cannot move; restraints are not necessary. A preoperative shave is not performed; excess hair is removed by means of a clipper.

A patient is taking warfarin (Coumadin) to prevent clot formation related to atrial fibrillation. How are the effects of the warfarin (Coumadin) monitored? A) RBC B) aPTT C) PT and INR D) Platelet count

Ans: C Feedback: The warfarin dose is regulated according to the INR. The INR is based on the prothrombin time. The red blood cell count is not indicative of warfarin dosage. The aPTT is utilized to determine heparin dose. The platelet count is required to determine warfarin dose.

The nurse in the ED is caring for a man who has returned to the ED 4 days after receiving stitches for a knife wound on his hand. The wound is now infected, so the stitches were removed, and the wound is cleaned and packed with gauze. The ED doctor plans to have the man return tomorrow to remove the packing and resuture the wound. You are aware that the wound will now heal by what means? A) Late intention B) Second intention C) Third intention D) First intention

Ans: C Feedback: Third-intention healing or secondary suture is used for deep wounds that either had not been sutured early or that had the suture break down and are resutured later, which is what has happened in this case. Secondary suture brings the two opposing granulation surfaces back together; however, this usually results in a deeper and wider scar. These wounds are also packed postoperatively with moist gauze and covered with a dry, sterile dressing. Late intention is a term that sounds plausible, but is not used in practice. Second intention is when the wound is left open and the wound is filled with granular tissue. First intention wounds are wounds made aseptically with a minimum of tissue destruction.

During a teaching session on the care of the diabetic patient, a family member asks why her daughter has a different insulin than her best friend. The nurse should make which of the following statements to explain the differences in insulin? A) "Insulin is prescribed based on the insurer's criteria for reimbursement." B) "Insulin is prescribed based on the patient's age." C) "Insulins have different onsets and durations of action." D) "Insulin type is matched with the appropriate oral hypoglycemic agent."

Ans: C Feedback: When insulin therapy is indicated, the physician may choose from several preparations that vary in composition, onset, duration of action, and other characteristics. Insulin is not prescribed based solely on cost. Insulin is not prescribed based solely on the patient's age. Insulin is not usually matched with oral hypoglycemic agents.

The nurse is performing wound care on a 68-year-old postsurgical patient. Which of the following practices violates the principles of surgical asepsis? A) Holding sterile objects above the level of the nurses waist B) Considering a 1 inch (2.5 cm) edge around the sterile field as being contaminated C) Pouring solution onto a sterile field cloth D) Opening the outermost flap of a sterile package away from the body

Ans: C Feedback: Whenever a sterile barrier is breached, the area must be considered contaminated. Pouring solution onto a sterile field cloth violates surgical asepsis because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. The other options are practices that help ensure surgical asepsis.

A hospital patient is to receive 4 units of regular insulin prior to lunch. The nurse knows that the lunch trays are usually distributed at approximately 12:15. The nurse should plan to administer the patient's insulin at what time? A) 12:15 B) 12:10 C) 11:45 D) 11:15

Ans: C Feedback: With regular insulin before meals, it is very important that the medication be injected 30 to 45 minutes before meals so that the insulin is available when blood sugar increases after meals.

The home health nurse is caring for a postoperative patient who was discharged home on day 2 after surgery. The nurse is performing the initial visit on the patients postoperatative day 2. During the visit, the nurse will assess for wound infection. For most patients, what is the earliest postoperative day that a wound infection becomes evident? A) Day 9 B) Day 7 C) Day 5 D) Day 3

Ans: C Feedback: Wound infection may not be evident until at least postoperative day 5. This makes the other options incorrect.

The intraoperative nurse is transferring a patient from the OR to the PACU after replacement of the right knee. The patient is a 73-year-old woman. The nurse should prioritize which of the following actions? A) Keeping the patient sterile B) Keeping the patient restrained C) Keeping the patient warm D) Keeping the patient hydrated

Ans: C Feedback: Special attention is given to keeping the patient warm because elderly patients are more susceptible to hypothermia. It is all important for the nurse to pay attention to hydration, but hypovolemia does not occur as quickly as hypothermia. The patient is never sterile and restraints are very rarely necessary.

The PACU nurse is caring for a patient who has been deemed ready to go to the postsurgical floor after her surgery. What would the PACU nurse be responsible for reporting to the nurse on the floor? Select all that apply. A) The names of the anesthetics that were used B) The identities of the staff in the OR C) The patients preoperative level of consciousness D) The presence of family and/or significant others E) The patients full name

Ans: C, D, E Feedback: The PACU nurse is responsible for informing the floor nurse of the patients intraoperative factors (e.g., insertion of drains or catheters, administration of blood or medications during surgery, or occurrence of unexpected events), preoperative level of consciousness, presence of family and/or significant others, and identification of the patient by name. The PACU nurse does not tell which anesthetic was used, only the type and amount used. The PACU nurse does not identify the staff that was in the OR with the patient.

A patient is undergoing rehabilitation following a stroke that left him with severe motor and sensory deficits. The patient has been unable to ambulate since his accident, but has recently achieved the goals of sitting and standing balance. What is the patient now able to use? A) A cane B) Crutches C) A two-wheeled walker D) Parallel bars

Ans: D Feedback: After sitting and standing balance is achieved, the patient is able to use parallel bars. The patient must be able to use the parallel bars before he can safely use devices like a cane, crutches, or a walker.

You are the nurse providing care for a patient who has limited mobility after a stroke. What would you do to assess the patient for contractures? A) Assess the patients deep tendon reflexes (DTRs). B) Assess the patients muscle size. C) Assess the patient for joint pain. D) Assess the patients range of motion.

Ans: D Feedback: Each joint of the body has a normal range of motion. To assess a patient for contractures, the nurse should assess whether the patient can complete the full range of motion. Assessing DTRs, muscle size, or joint pain do not reveal the presence or absence of contractures.

A 93-year-old male patient with failure to thrive has begun exhibiting urinary incontinence. When choosing appropriate interventions, you know that various age-related factors can alter urinary elimination patterns in elderly patients. What is an example of these factors? A) Decreased residual volume B) Urethral stenosis C) Increased bladder capacity D) Decreased muscle tone

Ans: D Feedback: Factors that alter elimination patterns in the older adult include decreased bladder capacity, decreased muscle tone, increased residual volumes, and delayed perception of elimination cues. The other noted phenomena are atypical.

You are planning rehabilitation activities for a patient who is working toward discharge back into the community. During a care conference, the team has identified a need to focus on the patients instrumental activities of daily living (IADLs). When planning the patients subsequent care, you should focus particularly on which of the following? A) Dressing B) Bathing C) Feeding D) Meal preparation

Ans: D Feedback: Instrumental activities of daily living (IADLs) include grocery shopping, meal preparation, housekeeping, transportation, and managing finances. Activities of daily living (ADLs) include bathing dressing, feeding, and toileting.

You are caring for a 35-year-old man whose severe workplace injuries necessitate bilateral below-the knee amputations. How can you anticipate that the patient will respond to this news? A) The patient will go through the stages of grief over the next week to 10 days. B) The patient will progress sequentially through five stages of the grief process. C) The patient will require psychotherapy to process his grief. D) The patient will experience grief in an individualized manner.

Ans: D Feedback: Loss of limb is a profoundly emotional experience, which the patient will experience in a subjective manner, and largely unpredictable, manner. Psychotherapy may or may not be necessary. It is not possible to accurately predict the sequence or timing of the patients grief. The patient may or may not benefit from psychotherapy.

An elderly female patient who is bedridden is admitted to the unit because of a pressure ulcer that can no longer be treated in a community setting. During your assessment of the patient, you find that the ulcer extends into the muscle and bone. At what stage would document this ulcer? A) I B) II C) III D) IV

Ans: D Feedback: Stage III and IV pressure ulcers are characterized by extensive tissue damage. In addition to the interventions listed for stage I, these advanced draining, necrotic pressure ulcers must be cleaned (dbrided) to create an area that will heal. Stage IV is an ulcer that extends to underlying muscle and bone. Stage III is an ulcer that extends into the subcutaneous tissue. With this type of ulcer, necrosis of tissue and infection may develop. Stage I is an area of erythema that does not blanch with pressure. Stage II involves a break in the skin that may drain.

The nurse is caring for a hospice patient who is scheduled for a surgical procedure to reduce the size of his spinal tumor in an effort to relieve his pain. The nurse should plan this patient care with the knowledge that his surgical procedure is classified as which of the following? A) Diagnostic B) Laparoscopic C) Curative D) Palliative

Ans: D Feedback: A patient on hospice will undergo a surgical procedure only for palliative care to reduce pain, but it is not curative. The reduction of tumor size to relieve pain is considered a palliative procedure. A laparoscopic procedure is a type of surgery that is utilized for diagnostic purposes or for repair. The excision of a tumor is classified as curative. This patient is not having the tumor removed, only the size reduced.

A patient has suffered from hypoglycemia twice in the past week. She states she eats one meal per day and snacks the rest of the day. What patient education will you provide for this patient? A) She should limit her alcohol with meals. B) She should increase her caloric intake. C) She should increase her protein intake during snacks. D) She should not eat at sporadic times.

Ans: D Feedback: A regular dietary intake associated with the administration of insulin or oral hypoglycemic will prevent episodes of hypoglycemia. The patient should limit her alcohol consumption, but alcohol consumption does not contribute to hypoglycemia. The patient should not necessarily increase her caloric or protein intake. The patient should coordinate her exercise with her dietary intake, but dietary intake is not the cause of her hypoglycemia.

A 79-year-old woman has been brought to the emergency department by ambulance with signs and symptoms of ischemic stroke. The care team would consider the STAT administration of what drug? A) Low molecular weight heparin B) Vitamin K C) Clopidogrel (Plavix) D) Alteplase (Activase)

Ans: D Feedback: Alteplase (Activase) is used as first-line therapy for the treatment of acute ischemic stroke in selected people. Vitamin K would exacerbate the woman's symptoms, and LMWH and Plavix would be ineffective.

A nurse is assessing a patient who has diabetes for the presence of peripheral neuropathy. The nurse should question the patient about what sign or symptom that would suggest the possible development of peripheral neuropathy? A) Persistently cold feet B) Pain that does not respond to analgesia C) Acute pain, unrelieved by rest D) The presence of a tingling sensation

Ans: D Feedback: Although approximately half of patients with diabetic neuropathy do not have symptoms, initial symptoms may include paresthesias (prickling, tingling, or heightened sensation) and burning sensations (especially at night). Cold and intense pain are atypical early signs of this complication.

An 8-month-old infant is admitted to the pediatric floor of the community hospital with a new diagnosis of diabetes. The patient is to receive 1 unit of regular insulin subcutaneously. How will that 1 unit be administered? A) It is administered orally. B) It is administered as U-5. C) It is administered with a TB syringe. D) It is administered as U-10.

Ans: D Feedback: An infant should receive the dosage in a dilution strength of U-10. It is not administered orally, as U-5, or in a TB syringe.

An adult patient is administered hydroxyzine for nausea. What adverse effect is most likely with this medication? A) Thrombocytopenia B) Palpitations C) Hypertonic muscle tone D) Dry mouth

Ans: D Feedback: Anticholinergic effects, including dry mouth, can result from the use of hydroxyzine. This drug is not associated with thrombocytopenia, palpitations, or hypertonicity.

A patient who has been taking valproic acid (sodium valproate) for a seizure disorder is asking the nurse about getting pregnant. Why is pregnancy discouraged in women who are being treated for seizure disorders? A) Seizure disorders are genetic. B) Seizure disorders are familial. C) Antiepilepsy drugs decrease fertility. D) Antiepilepsy drugs are teratogenic.

Ans: D Feedback: Antiepileptic drugs such as valproic acid must be used cautiously during pregnancy because they are teratogenic. Seizure disorders are not normally genetic or familial. Antiepilepsy medications do not decrease fertility.

When acetylsalicylic acid (aspirin) is administered in low doses, it blocks the synthesis of thromboxane A2. What physiological effect results from this action? A) Inflammation is relieved. B) Core body temperature is reduced. C) Pain is relieved. D) Platelet aggregation is inhibited.

Ans: D Feedback: At low doses, aspirin blocks the synthesis of thromboxane A2 to inhibit platelet aggregation; this lasts for the life of the platelet.

A patient's medication administration record specifies that the patient is to receive 20 units of NPH insulin at 08:00. Before administering this medication, the nurse must do which of the following? A) Massage the chosen injection site. B) Assess the patient's understanding of diabetes. C) Assess the patient's urine for the presence of glucose. D) Have a colleague confirm the dosage.

Ans: D Feedback: Before administering insulin, patient safety requires that two nurses always check the dosage. Assessing the patient's understanding of the disease may or may not be appropriate or necessary at this time. Injection sites are not massaged before administration. It is not necessary to assess urine for the presence of glucose.

A patient has received a diagnosis of type 2 diabetes. The diabetes nurse has made contact with the patient and will implement a program of health education. What is the nurses priority action? A) Ensure that the patient understands the basic pathophysiology of diabetes. B) Identify the patients body mass index. C) Teach the patient survival skills for diabetes. D) Assess the patients readiness to learn.

Ans: D Feedback: Before initiating diabetes education, the nurse assesses the patients (and familys) readiness to learn. This must precede other physiologic assessments (such as BMI) and providing health education.

A 77-year-old woman who experiences significant anxiety has been taking diazepam for several months. She was brought to the clinical earlier this week by her daughter, who stated that her mother had been behaving in an uncharacteristically confused manner. The clinician discontinued the patient's diazepam. Three days later, the daughter states that her mother has still been having problems with impaired memory and confusion. The nurse should consider what possible explanation for the patient's current status? A) Benzodiazepines can occasionally cause permanent alterations in personality and level of consciousness. B) The patient may have decreased liver function. C) The patient may have been experiencing a hypersensitivity to the drug, rather than an adverse effect. D) The adverse effects of benzodiazepines can persist for several days after stopping the drug.

Ans: D Feedback: Both therapeutic effects and adverse effects of diazepam are more likely to occur after 2 or 3 days of therapy than initially. Such effects accumulate with chronic usage and persist for several days after the drug is discontinued. Hypersensitivity and decreased liver function are unlikely. Benzodiazepines do not cause permanent changes in cognition.

A diabetes nurse educator is presenting the American Diabetes Association (ADA) recommendations for levels of caloric intake. What do the ADAs recommendations include? A) 10% of calories from carbohydrates, 50% from fat, and the remaining 40% from protein B) 10% to 20% of calories from carbohydrates, 20% to 30% from fat, and the remaining 50% to 60% from protein C) 20% to 30% of calories from carbohydrates, 50% to 60% from fat, and the remaining 10% to 20% from protein D) 50% to 60% of calories from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein

Ans: D Feedback: Currently, the ADA and the Academy of Nutrition and Dietetics (formerly the American Dietetic Association) recommend that for all levels of caloric intake, 50% to 60% of calories come from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein.

A patient is admitted to the hospital for severe back spasms and pain. Which of the following skeletal muscle relaxants will act peripherally on the muscle itself? A) Cyclobenzaprine (Flexeril) B) Carisoprodol (Soma) C) Methocarbamol (Robaxin) D) Dantrolene sodium (Dantrium)

Ans: D Feedback: Dantrolene is the only skeletal muscle relaxant that acts peripherally on the muscle itself; it inhibits the release of calcium in skeletal muscle cells, thereby decreasing the strength of muscle contraction. The other listed drugs act centrally.

12. An 85-year-old patient is administered dimenhydrinate (Dramamine). Which of the following is the priority nursing intervention? A) Encourage fluids with this patient. B) Have the patient void after administration. C) Maintain IV access. D) Protect from injury.

Ans: D Feedback: Dimenhydrinate (Dramamine) causes drowsiness, especially in older adults, and therefore should be used cautiously. The nurse should protect the patient from injury. The nurse should not force fluids. The patient will not require IV access unless fluid replacement is ordered.

A patient is prescribed eptifibatide (Integrilin), which inhibits platelet aggregation by preventing activation of GP IIb/IIIa receptors on the platelet surface and the subsequent binding of fibrinogen and von Willebrand factor to platelets. Which of the following syndromes are treated with eptifibatide? A) Blocked carotid arteries B) Intermittent claudication C) Hypertension D) Unstable angina

Ans: D Feedback: Eptifibatide (Integrilin) inhibits platelet aggregation by preventing activation of GP IIb/IIIa receptors on the platelet surface and the subsequent binding of fibrinogen and von Willebrand factor to platelets. Eptifibatide is used for acute coronary syndromes, including unstable angina, myocardial infarction, and non-Q wave MI. Blocked carotid arteries, intermittent claudication, and hypertension are not treated with eptifibatide.

The nurse is caring for a patient who is scheduled to have a needle biopsy of the pleura. The patient has had a consultation with the anesthesiologist and a conduction block will be used. Which local conduction block can be used to block the nerves leading to the chest? A) Transsacral block B) Brachial plexus block C) Peudental block D) Paravertebral block

Ans: D Feedback: Examples of common local conduction blocks include paravertebral anesthesia, which produces anesthesia of the nerves supplying the chest, abdominal wall, and extremities; brachial plexus block, which produces anesthesia of the arm; and transsacral (caudal) block, which produces anesthesia of the perineum and, occasionally, the lower abdomen. A peudental block was used in obstetrics before the almost-routine use of epidural anesthesia.

A patient is administered promethazine (Phenergan) for nausea and vomiting. Which of the following is an adverse effect of promethazine (Phenergan)? A) Urinary incontinence B) Tachycardia C) Taste alteration D) Extrapyramidal symptoms

Ans: D Feedback: Extrapyramidal symptoms are adverse effects of promethazine. Urinary retention is an adverse effect, not urinary incontinence. Tachycardia is not an adverse effect of promethazine. Taste alteration is not an adverse effect of promethazine.

The nurses aide notifies the nurse that a patient has decreased oxygen saturation levels. The nurse assesses the patient and finds that he is tachypnic, has crackles on auscultation, and his sputum is frothy and pink. The nurse should suspect what complication? A) Pulmonary embolism B) Atelectasis C) Laryngospasm D) Flash pulmonary edema

Ans: D Feedback: Flash pulmonary edema occurs when protein and fluid accumulate in the alveoli unrelated to elevated pulmonary artery occlusive pressure. Signs and symptoms include agitation; tachypnea; tachycardia; decreased pulse oximetry readings; frothy, pink sputum; and crackles on auscultation. Laryngospasm does not cause crackles or frothy, pink sputum. The patient with atelectasis has decreased breath sounds over the affected area; the scenario does not indicate this. A pulmonary embolism does not cause this symptomatology.

An 80-year-old patient has severe pain after a case of shingles. The pain is noted along the shoulder and back. He states the pain is so severe he cannot sleep. What is the primary medication that will relieve this pain? A) Meperidine (Demerol) B) Morphine sulfate (MS Contin) C) Naproxen sodium (Naprosyn) D) Gabapentin (Neurontin)

Ans: D Feedback: Gabapentin is the first oral medication approved by the FDA for the management of postherpetic neuralgia. Meperidine will provide pain relief but is not effective in postherpetic neuralgia. Morphine sulfate will provide pain relief but is not effective in postherpetic neuralgia. Naproxen sodium will decrease inflammation but is not effective for postherpetic neuralgia.

A medical nurse is aware of the need to screen specific patients for their risk of hyperglycemic hyperosmolar syndrome (HHS). In what patient population does hyperosmolar nonketotic syndrome most often occur? A) Patients who are obese and who have no known history of diabetes B) Patients with type 1 diabetes and poor dietary control C) Adolescents with type 2 diabetes and sporadic use of antihyperglycemics D) Middle-aged or older people with either type 2 diabetes or no known history of diabetes

Ans: D Feedback: HHS occurs most often in older people (50 to 70 years of age) who have no known history of diabetes or who have type 2 diabetes.

The PACU nurse is caring for a male patient who had a hernia repair. The patients blood pressure is now 164/92 mm Hg; he has no history of hypertension prior to surgery and his preoperative blood pressure was 112/68 mm Hg. The nurse should assess for what potential causes of hypertension following surgery? A) Dysrhythmias, blood loss, and hyperthermia B) Electrolyte imbalances and neurologic changes C) A parasympathetic reaction and low blood volumes D) Pain, hypoxia, or bladder distention

Ans: D Feedback: Hypertension is common in the immediate postoperative period secondary to sympathetic nervous system stimulation from pain, hypoxia, or bladder distention. Dysrhythmias, blood loss, hyperthermia, electrolyte imbalances, and neurologic changes are not common postoperative reasons for hypertension. A parasympathetic reaction and low blood volumes would cause hypotension.

A nurse at a long-term care facility is conducting a medication reconciliation for a man who has just moved into the facility. The man is currently taking clopidogrel (Plavix). The nurse is most justified is suspecting that this man has a history of A) hemorrhagic cerebrovascular accident. B) hemophilia A. C) idiopathic thrombocytopenic purpura (ITP). D) myocardial infarction.

Ans: D Feedback: Indications for use of Plavix include reduction of myocardial infarction, stroke, and vascular death in patients with atherosclerosis and in those after placement of coronary stents. It is not indicated in the treatment of ITP, CVA, or hemophilia.

A nurse is teaching basic survival skills to a patient newly diagnosed with type 1 diabetes. What topic should the nurse address? A) Signs and symptoms of diabetic nephropathy B) Management of diabetic ketoacidosis C) Effects of surgery and pregnancy on blood sugar levels D) Recognition of hypoglycemia and hyperglycemia

Ans: D Feedback: It is imperative that newly diagnosed patients know the signs and symptoms and management of hypoand hyperglycemia. The other listed topics are valid points for education, but are not components of the patients immediate survival skills following a new diagnosis.

The anesthesiologist has specified that ketamine will be included in a surgical patient's balanced anesthesia. When in postanesthetic recovery, the nurse should assess for what adverse effect of this medication? A) Labile blood pressure B) Increased intracranial pressure C) Hyperventilation and respiratory alkalosis D) Delirium and agitation

Ans: D Feedback: Ketamine can produce emergence delirium, hallucinations, and unpleasant dreams. Symptoms of this effect may include confusion, agitation, and nystagmus. The drug preserves blood pressure and does not cause hyperventilation or increased ICP.

A patient is admitted to a neurological unit with a confirmed cerebrovascular bleed. Which of the following medications used to treat inflammation is contraindicated in this patient? A) Furosemide (Lasix) B) Hydrochlorothiazide with triamterene C) Digoxin (Lanoxin) D) Ketorolac (Toradol)

Ans: D Feedback: Ketorolac (Toradol) should not be administered to a patient with a suspected or confirmed cerebrovascular bleed. Furosemide (Lasix) is administered to reduce fluid volume and is not administered to treat inflammation. Hydrochlorothiazide with triamterene is administered to reduce fluid volume and is not administered to treat inflammation. Digoxin (Lanoxin) is administered to increase cardiac output, not to treat inflammation.

A patient has been receiving morphine sulfate 5 mg IV every 4 hours for the past several days. She states that the pain is not being relieved as well as it was in the past. What is the reason for this development? A) She has developed a dependency on the morphine. B) She has metastatic cancer and is dying. C) She has greater pain with inactivity. D) She has developed tolerance to morphine.

Ans: D Feedback: Larger-than-usual doses of morphine are required to treat pain in opiate-tolerant people. The patient has not developed a dependence on morphine. A patient with metastatic cancer will require increasing pain management, but this feature is not the rationale for the patient's statement. The increased pain is not related to inactivity.

A patient with impaired liver function is suffering from a seizure disorder that most often results in partial seizures. Which of the following AEDs may be administered to a patient with impaired liver function? A) Oxcarbazepine (Trileptal) B) Fosphenytoin (Cerebyx) C) Carbamazepine (Tegretol) D) Levetiracetam (Keppra)

Ans: D Feedback: Levetiracetam (Keppra) is not primarily metabolized in the liver. Oxcarbazepine (Trileptal) is metabolized in the liver. Fosphenytoin (Cerebyx) is metabolized in the liver. Carbamazepine (Tegretol) is metabolized in the liver.

The nurse is creating the care plan for a 70-year-old obese patient who has been admitted to the postsurgical unit following a colon resection. This patients age and increased body mass index mean that she is at increased risk for what complication in the postoperative period? A) Hyperglycemia B) Azotemia C) Falls D) Infection

Ans: D Feedback: Like age, obesity increases the risk and severity of complications associated with surgery. During surgery, fatty tissues are especially susceptible to infection. In addition, obesity increases technical and mechanical problems related to surgery. Therefore, dehiscence (wound separation) and wound infections are more common. A postoperative patient who is obese will not likely be at greater risk for hyperglycemia, azotemia, or falls.

A nurse is caring for a patient following knee surgery that was performed under a spinal anesthetic. What intervention should the nurse implement to prevent a spinal headache? A) Have the patient sit in a chair and perform deep breathing exercises. B) Ambulate the patient as early as possible. C) Limit the patients fluid intake for the first 24 hours postoperatively. D) Keep the patient positioned supine.

Ans: D Feedback: Measures that increase cerebrospinal pressure are helpful in relieving headache. These include maintaining a quiet environment, keeping the patient lying flat, and keeping the patient well hydrated. Having the patient sit or stand up decreases cerebrospinal pressure and would not relieve a spinal headache. Limiting fluids is incorrect because it also decreases cerebrospinal pressure and would not relieve a spinal headache.

A patient with type 2 diabetes has been managing his blood glucose levels using diet and metformin (Glucophage). Following an ordered increase in the patients daily dose of metformin, the nurse should prioritize which of the following assessments? A) Monitoring the patients neutrophil levels B) Assessing the patient for signs of impaired liver function C) Monitoring the patients level of consciousness and behavior D) Reviewing the patients creatinine and BUN levels

Ans: D Feedback: Metformin has the potential to be nephrotoxic; consequently, the nurse should monitor the patients renal function. This drug does not typically affect patients neutrophils, liver function, or cognition.

A patient is near the end of life and has developed increased respiratory secretions and labored breathing. The physician is likely to order which of the following medications to decrease these symptoms? A) Meclizine (Antivert) B) Ampicillin C) Naloxone (Narcan) D) Morphine sulfate

Ans: D Feedback: Morphine is used for the treatment of acute pulmonary edema. Meclizine (Antivert) is given for dizziness. Ampicillin is used to treat infection. Naloxone (Narcan) is the opioid antidote.

The nurse is providing teaching about tissue repair and wound healing to a patient who has a leg ulcer. Which of the following statements by the patient indicates that teaching has been effective? A) Ill make sure to limit my intake of protein. B) Ill make sure that the bandage is wrapped tightly. C) My foot should feel cool or cold while my legs healing. D) Ill eat plenty of fruits and vegetables.

Ans: D Feedback: Optimal nutritional status is important for wound healing; the patient should eat plenty of fruits and vegetables and not reduce protein intake. To avoid impeding circulation to the area, the bandage should be secure but not tight. If the patients foot feels cold, circulation is impaired, which inhibits wound healing.

The nurse is caring for a patient in the postoperative period following an abdominal hysterectomy. The patient states, I dont want to use my pain meds because theyll make me dependent and I wont get better as fast. Which response is most important when explaining the use of pain medication? A) You will need the pain medication for at least 1 week to help in your recovery. What do you mean you feel you wont get better faster? B) Pain medication will help to decrease your pain and increase your ability to breath. Dependency is a risk with pain medication, but you are young and wont have any problems. C) Pain medication can be given by mouth to prevent the risk of dependency that you are worried about. The pain medication has not been shown to affect your risk of a slowed recovery. D) You will move more easily and heal more quickly with decreased pain. Dependence only occurs when it is administered for an extended period of time.

Ans: D Feedback: Postoperatively, medications are administered to relieve pain and maintain comfort without increasing the risk of inadequate air exchange. In the responses by the nurse, (response D) addresses the patients concerns about drug dependency and the nurses need to increase the patients ability to move and recover from surgery. The other responses offer incorrect information, such as increasing the patients ability to breathe or specifying the time needed to take the medication. Opioids will cause respiratory depression.

A patient is in diabetic ketoacidosis. The patient blood glucose level is over 600 mg/dL. The physician has ordered the patient to receive an initial dose of 25 units of insulin intravenously. What type of insulin will most likely be administered? A) NPH insulin B) Lente insulin C) Ultralente insulin D) Regular insulin

Ans: D Feedback: Regular insulin has rapid onset of action and can be given via IV. It is the drug of choice for acute situations, such as diabetic ketoacidosis. Isophane insulin (NPH) is used for long-term insulin therapy. Lente insulin is an intermediate-acting insulin. Ultralente insulin is a long-acting insulin.

The nurse is packing a patients abdominal wound with sterile, half-inch Iodoform gauze. During the procedure, the nurse drops some of the gauze onto the patients abdomen 2 inches (5 cm) away from the wound. What should the nurse do? A) Apply povidone-iodine (Betadine) to that section of the gauze and continue packing the wound. B) Pick up the gauze and continue packing the wound after irrigating the abdominal wound with Betadine solution. C) Continue packing the wound and inform the physician that an antibiotic is needed. D) Discard the gauze packing and repack the wound with new Iodoform gauze.

Ans: D Feedback: Sterile surfaces or articles may touch other sterile surfaces or articles and remain sterile; contact with unsterile objects at any point renders a sterile area contaminated. The sterile gauze became contaminated when it was dropped on the patients abdomen. It should be discarded and new Iodoform gauze should be used to pack the wound. Betadine should not be used in the wound unless ordered.

The nurse is planning patient teaching for a patient who is scheduled for an open hemicolectomy. The nurse intends to address the topics of incision splinting and leg exercises during this teaching session. When is the best time for the nurse to provide teaching? A) Upon the patients admission to the postanesthesia care unit (PACU) B) When the patient returns from the PACU C) During the intraoperative period D) As soon as possible before the surgical procedure

Ans: D Feedback: Teaching is most effective when provided before surgery. Preoperative teaching is initiated as soon as possible, beginning in the physicians office, clinic, or at the time of preadmission testing when diagnostic tests are performed. Upon admission to the PACU, the patient is usually drowsy, making this an inopportune time for teaching. Upon the patients return from the PACU, the patient may remain drowsy. During the intraoperative period, anesthesia alters the patients mental status, rendering teaching ineffective.

A 77-year-old patient is suffering from insomnia. Which of the following medications can be most safely administered to this patient to induce sleep? A) Alprazolam (Xanax) B) Clonazepam (Klonopin) C) Diazepam (Valium) D) Temazepam (Restoril)

Ans: D Feedback: Temazepam (Restoril) is eliminated by conjugation with glucuronide. Thus, temazepam (Restoril) is the drug of choice for patients who are elderly, have liver disease, or are taking drugs that interfere with hepatic drug-metabolizing enzymes. Alprazolam (Xanax) is not administered for insomnia. Clonazepam (Klonopin) is not administered for insomnia. Diazepam (Valium) is not administered for insomnia.

As a perioperative nurse, you know that the National Patient Safety Goals have the potential to improve patient outcomes in a wide variety of health care settings. Which of these Goals has the most direct relevance to the OR? A) Improve safety related to medication use B) Reduce the risk of patient harm resulting from falls C) Reduce the incidence of health care-associated infections D) Reduce the risk of fires

Ans: D Feedback: The National Patient Safety Goals all pertain to the perioperative areas, but the one with the most direct relevance to the OR is the reduction of the risk of surgical fires.

A perioperative nurse is explaining the process of general anesthesia in anticipation of the adult patient's imminent bowel resection. When describing the phase of induction, the nurse should explain that this is usually achieved by what means? A) Intramuscular injection of anesthetics and benzodiazepines B) Intravenous administration of opioid analgesics C) Subcutaneous injection of a rapid-acting anesthetic D) Intravenous administration of anesthetics

Ans: D Feedback: The administration of a general anesthetic can be divided into three phases. The first phase is induction, which is rendering the patient unconscious by using inhalation anesthetics, intravenous anesthetics, or both. Adult patients usually receive a rapidacting intravenous anesthetic medication. IM medications, sub-Q medications, and opioids are not used.

A 90-year-old female patient is scheduled to undergo a partial mastectomy for the treatment of breast cancer. What nursing diagnosis should the nurse prioritize when planning this patients postoperative care? A) Risk for Delayed Growth and Development related to prolonged hospitalization B) Risk for Decisional Conflict related to discharge planning C) Risk for Impaired Memory related to old age D) Risk for Infection related to reduced immune function

Ans: D Feedback: The lessened physiological reserve of older adults results in an increased risk for infection postoperatively. This physiological consideration is a priority over psychosocial considerations, which may or may not be applicable. Impaired memory is always attributed to a pathophysiological etiology, not advanced age.

A 59-year-old male patient is scheduled for a hemorrhoidectomy. The OR nurse should anticipate assisting the other team members with positioning the patient in what manner? A) Dorsal recumbent position B) Trendelenburg position C) Sims position D) Lithotomy position

Ans: D Feedback: The lithotomy position is used for nearly all perineal, rectal, and vaginal surgical procedures. The Sims or lateral position is used for renal surgery and the Trendelenburg position usually is used for surgery on the lower abdomen and pelvis. The usual position for surgery, called the dorsal recumbent position, is flat on the back, but this would be impracticable for rectal surgery.

A patient is taking warfarin (Coumadin) after open heart surgery. The patient tells the home care nurse she has pain in both knees that began this week. The nurse notes bruises on both knees. Based on the effects of her medications and the complaint of pain, what does the nurse suspect is the cause of the pain? A) Joint thrombosis B) Torn medial meniscus C) Degenerative joint disease caused by her medication D) Bleeding

Ans: D Feedback: The main adverse effect of warfarin (Coumadin) is bleeding. The sudden onset of pain in the knees alerts the nurse to assess the patient for bleeding. Arthritis, torn medical meniscus, and degenerative joint disease could all be symptoms of knee pain, but the onset and combination of anticoagulant therapy is not an etiology of these types of injuries and disease.

A patient has been diagnosed with a brain tumor, which has caused partial seizure activity. The patient is being treated with gabapentin (Neurontin). After administering the medication, the nurse should assess the patient because of the potential for what adverse effect? A) Tetany B) Hypersensitivity C) Paradoxical seizures D) CNS depression

Ans: D Feedback: The most common adverse effects of gabapentin are associated with CNS depression and include dizziness, somnolence, insomnia, and ataxia. The drug has not been noted to cause tetany, hypersensitivity reactions, or paradoxical seizures.

A patient has been started on dantrolene (Dantrium). What is the most serious adverse effect about which the patient should be instructed? A) Metabolic acidosis B) Hypercarbia C) Renal calculi D) Hepatitis

Ans: D Feedback: The most serious adverse effect of oral dantrolene is fatal hepatitis. Metabolic acidosis, hypercarbia, and renal calculi are not adverse effects of oral dantrolene.

A patient is receiving IV heparin every 6 hours. An activated partial thromboplastin time (aPTT) is drawn 1 hour before the 08:00 dose. The PTT is 92 seconds. What is the most appropriate action by the nurse? A) Give the next two doses at the same time. B) Give the dose and chart the patient response. C) Check the patient's vital signs and give the dose. D) Hold the dose and call the aPTT result to the physician's attention.

Ans: D Feedback: The normal control value is 25 to 35 seconds; therefore, therapeutic values are 45 to 70 seconds, approximately. A result of 92 seconds is a risk for bleeding, and the dose should be held until approval to administer is provided by the physician. The nurse should not give the next two doses at the same time. The nurse should not give the dose and document the patient's response. The nurse should not check the patient's vital signs and give the dose.

The nurse is caring for a 78-year-old female patient who is scheduled for surgery to remove her brain tumor. The patient is very apprehensive and keeps asking when she will get her preoperative medicine. The medicine is ordered to be given on call to OR. When would be the best time to give this medication? A) As soon as possible, in order to alleviate the patients anxiety B) As the patient is transferred to the OR bed C) When the porter arrives on the floor to take the patient to surgery D) After being notified by the OR and before other preoperative preparations

Ans: D Feedback: The nurse can have the medication ready to administer as soon as a call is received from the OR staff. It usually takes 15 to 20 minutes to prepare the patient for the OR. If the nurse gives the medication before attending to the other details of preoperative preparation, the patient will have at least partial benefit from the preoperative medication and will have a smoother anesthetic and operative course.

A female patient has been achieving significant improvements in her ADLs since beginning rehabilitation from the effects of a brain hemorrhage. The nurse must observe and assess the patients ability to perform ADLs to determine the patients level of independence in self-care and her need for nursing intervention. Which of the following additional considerations should the nurse prioritize? A) Liaising with the patients insurer to describe the patients successes. B) Teaching the patient about the pathophysiology of her functional deficits. C) Eliciting ways to get the patient to express a positive attitude. D) Appraising the family's involvement in the patients ADLs.

Ans: D Feedback: The nurse should also be aware of the patients medical conditions or other health problems, the effect that they have on the ability to perform ADLs, and the family's involvement in the patients ADLs. It is not normally necessary to teach the patient about the pathophysiology of her functional deficits. A positive attitude is beneficial, but creating this is not normally within the purview of the nurse. The nurse does not liaise with the insurance company.

An older adult patient with type 2 diabetes is brought to the emergency department by his daughter. The patient is found to have a blood glucose level of 623 mg/dL. The patients daughter reports that the patient recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority? A) Administration of antihypertensive medications B) Administering sodium bicarbonate intravenously C) Reversing acidosis by administering insulin D) Fluid and electrolyte replacement

Ans: D Feedback: The overall approach to HHS includes fluid replacement, correction of electrolyte imbalances, and insulin administration. Antihypertensive medications are not indicated, as hypotension generally accompanies HHS due to dehydration. Sodium bicarbonate is not administered to patients with HHS, as their plasma bicarbonate level is usually normal. Insulin administration plays a less important role in the treatment of HHS because it is not needed for reversal of acidosis, as in diabetic ketoacidosis (DKA).

The nurse admitting a patient who is insulin dependent to the same-day surgical suite for carpal tunnel surgery. How should this patients diagnosis of type 1 diabetes affect the care that the nurse plans? A) The nurse should administer a bolus of dextrose IV solution preoperatively. B) The nurse should keep the patient NPO for at least 8 hours preoperatively. C) The nurse should initiate a subcutaneous infusion of long-acting insulin. D) The nurse should assess the patients blood glucose levels vigilantly.

Ans: D Feedback: The patient with diabetes who is undergoing surgery is at risk for hypoglycemia and hyperglycemia. Close glycemic monitoring is necessary. Dextrose infusion and prolonged NPO status are contraindicated. There is no specific need for an insulin infusion preoperatively.

The recovery room nurse is admitting a patient from the OR following the patients successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted patient? A) Heart rate and rhythm B) Skin integrity C) Core body temperature D) Airway patency

Ans: D Feedback: The primary objective in the immediate postoperative period is to maintain ventilation and, thus, prevent hypoxemia and hypercapnia. Both can occur if the airway is obstructed and ventilation is reduced. This assessment is followed by cardiovascular status and the condition of the surgical site. The core temperature would be assessed after the airway, cardiovascular status, and wound (skin integrity).

The nurse is doing preoperative patient education with a 61-year-old male patient who has a 40-pack per year history of cigarette smoking. The patient will undergo an elective bunionectomy at a time that fits his work schedule in a few months. What would be the best instruction to give to this patient? A) Reduce smoking by 50% to prevent the development of pneumonia. B) Stop smoking at least 6 weeks before the scheduled surgery to enhance pulmonary function and decrease infection. C) Aim to quit smoking in the postoperative period to reduce the chance of surgical complications D) Stop smoking 4 to 8 weeks before the scheduled surgery to enhance pulmonary function and decrease infection.

Ans: D Feedback: The reduction of smoking will enhance pulmonary function; in the preoperative period, patients who smoke should be urged to stop 4 to 8 weeks before surgery.

The nursing instructor is talking with a group of medicalsurgical students about deep vein thrombosis (DVT). A student asks what factors contribute to the formation of a DVT. What would be the instructors best response? A) There is a genetic link in the formation of deep vein thrombi. B) Hypervolemia is often present in patients who go on to develop deep vein thrombi. C) No known factors contribute to the formation of deep vein thrombi; they just occur. D) Dehydration is a contributory factor to the formation of deep vein thrombi.

Ans: D Feedback: The stress response that is initiated by surgery inhibits the fibrinolytic system, resulting in blood hypercoagulability. Dehydration, low cardiac output, blood pooling in the extremities, and bedrest add to the risk of thrombosis formation. Hypervolemia is not a risk factor and there are no known genetic factors.

A child suffers from absence seizures and has been prescribed acetazolamide (Diamox). The nurse should know that this medication is an adjuvant medication useful in the treatment of seizures. What is the therapeutic action of Diamox? A) It slows the action potential of neurons. B) It slows the reuptake of acetylcholine. C) It suppresses the limbic and reticular systems. D) It controls fluid secretion in the CN

Ans: D Feedback: The sulfonamide diuretic acetazolamide (Diamox) controls fluid secretion in the CNS; it is thought to inhibit CNS carbonic anhydrase to decrease neuronal excitability.

An adult patient who is currently undergoing rhinoplasty has developed the characteristic signs and symptoms of malignant hyperthermia. The operating room nurse should anticipate what intervention? A) Hemodialysis B) Tracheal intubation C) IV administration of naloxone (Narcan) D) IV administration of dantrolene sodium (Dantrium)

Ans: D Feedback: The treatment for malignant hyperthermia consists of intravenous dantrolene sodium (Dantrium), oxygenation and hyperventilation, hydration, and body cooling. The patient will already be intubated. Narcan and dialysis are not indicated.

The nurse is admitting a patient to the medicalsurgical unit from the PACU. What should the nurse do to help the patient clear secretions and help prevent pneumonia? A) Encourage the patient to eat a balanced diet that is high in protein. B) Encourage the patient to limit his activity for the first 72 hours. C) Encourage the patient to take his medications as ordered. D) Encourage the patient to use the incentive spirometer every 2 hours.

Ans: D Feedback: To clear secretions and prevent pneumonia, the nurse encourages the patient to turn frequently, take deep breaths, cough, and use the incentive spirometer at least every 2 hours. These pulmonary exercises should begin as soon as the patient arrives on the clinical unit and continue until the patient is discharged. A balanced, high protein diet; visiting family in the waiting room; or taking medications as ordered would not help to clear secretions or prevent pneumonia.

A patient has developed excessive sedation and respiratory depression. The patient has been taking a benzodiazepine and has diminished liver function. Which of the following medications will reduce the effects of sedation and respiratory depression in this patient? A) Olmesartan medoxomil (Benicar) B) Pancrelipase (Pancrease) C) Pamidronate disodium (Aredia) D) Flumazenil (Romazicon)

Ans: D Feedback: Toxic effects of benzodiazepines include excessive sedation, respiratory depression, and coma. Flumazenil (Romazicon) is a specific antidote that competes with benzodiazepines for benzodiazepine receptors and reverses toxicity. Olmesartan medoxomil (Benicar) is an angiotensin II receptor antagonist that is used to treat hypertension. Pancrelipase (Pancrease) is used for enzyme replacement therapy. Pamidronate disodium is used as a bone metabolism regulator.

An adult patient is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The patients vital signs and level of consciousness stabilized, but the patient then complains of severe nausea and begins to retch. What should the nurse do next? A) Administer a dose of IV analgesic. B) Apply a cool cloth to the patients forehead. C) Offer the patient a small amount of ice chips. D) Turn the patient completely to one side.

Ans: D Feedback: Turning the patient completely to one side allows collected fluid to escape from the side of the mouth if the patient vomits. After turning the patient to the side, the nurse can offer a cool cloth to the patients forehead. Ice chips can increase feelings of nausea. An analgesic is not administered for nausea and vomiting.

A newly admitted patient with type 1 diabetes asks the nurse what caused her diabetes. When the nurse is explaining to the patient the etiology of type 1 diabetes, what process should the nurse describe? A) The tissues in your body are resistant to the action of insulin, making the glucose levels in your blood increase. B) Damage to your pancreas causes an increase in the amount of glucose that it releases, and there is not enough insulin to control it. C) The amount of glucose that your body makes overwhelms your pancreas and decreases your production of insulin. D) Destruction of special cells in the pancreas causes a decrease in insulin production. Glucose levels rise because insulin normally breaks it down.

Ans: D Feedback: Type 1 diabetes is characterized by the destruction of pancreatic beta cells, resulting in decreased insulin production, unchecked glucose production by the liver, and fasting hyperglycemia. Also, glucose derived from food cannot be stored in the liver and remains circulating in the blood, which leads to postprandial hyperglycemia. Type 2 diabetes involves insulin resistance and impaired insulin secretion. The body does not make glucose.

A patient who is receiving warfarin (Coumadin) has blood in his urinary catheter drainage bag. What medication will likely be ordered by the physician? A) Aminocaproic acid (Amicar) B) Platelets C) Protamine sulfate D) Vitamin K

Ans: D Feedback: Vitamin K is the antidote for warfarin overdose. Aminocaproic acid is used to control excessive bleeding from systemic hyperfibrinolysis. Platelets are a blood product, not a medication. Protamine sulfate is the antidote for heparin therapy.

The circulating nurse is admitting a patient prior to surgery and proceeds to greet the patient and discuss what the patient can expect in surgery. What aspect of therapeutic communication should the nurse implement? A) Wait for the patient to initiate dialogue. B) Use medically acceptable terms. C) Give preoperative medications prior to discussion. D) Use a tone that decreases the patients anxiety.

Ans: D Feedback: When discussing what the patient can expect in surgery, the nurse uses basic communication skills, such as touch and eye contact, to reduce anxiety. The nurse should use language the patient can understand. The nurse should not withhold communication until the patient initiates dialogue; the nurse most often needs to initiate and guide dialogue, while still responding to patient leading. Giving medication is not a communication skill.

A 21-year-old patient is positioned on the OR bed prior to knee surgery to correct a sports-related injury. The anesthesiologist administers the appropriate anesthetic. The OR nurse should anticipate which of the following events as the teams next step in the care of this patient? A) Grounding B) Making the first incision C) Giving blood D) Intubating

Ans: D Feedback: When the patient arrives in the OR, the anesthesiologist or anesthetist reassesses the patients physical condition immediately prior to initiating anesthesia. The anesthetic is administered, and the patients airway is maintained through an intranasal intubation, oral intubation, or a laryngeal mask airway. Grounding or blood administration does not normally follow anesthetic administration immediately. An incision would not be made prior to intubation.

Prior to a patients scheduled surgery, the nurse has described the way that members of diverse health disciplines will collaborate in the patients care. What is the main rationale for organizing perioperative care in this collaborative manner? A) Historical precedence B) Patient requests C) Physicians needs D) Evidence-based practice

Ans: D Feedback: Collaboration of the surgical team using evidence-based practice tailored to a specific case results in optimal patient care and improved outcomes. None of the other listed factors is the basis for the collaboration of the surgical team.

A client diagnosed with diabetes asks the nurse about reusing insulin syringes. Assessment reveals that the client has poor personal hygiene and difficulty with fine motor skills. The nurse also knows the client has financial difficulties. What instruction should the nurse give this client? 1. The American Diabetes Association advises that syringes are for single use only. 2. In order to save money, I advise you to reuse syringes up to three times or until the needle feels dull. 3. Only people who practice good personal hygiene can reuse syringes. 4. All clients are different, but I advise you to use a new syringe for each injection.

Correct Answer" 4 Rationale 1: This is not true; the American Diabetes Association indicates that syringes can be reused. Rationale 2: This client does not meet the criteria for suggesting the reuse of syringes. Rationale 3: The nurse should not directly confront the client with the statement about personal hygiene, as that would damage the nurseclient relationship. Rationale 4: Although the American Diabetes Association does indicate that syringes can be reused, that suggestion is not made to people who have poor personal hygiene, acute concurrent illness, open wounds on the hands, or decreased resistance to infection. In this case, the nurse has assessed that this client has poor hygiene and has difficulty with fine motor skills. The best answer is to suggest that this client use a new syringe for each injection

The nurse is providing medications to a client. After identifying the client, the nurse should take which action? 1. Inform the client as to the intended action of the medication. 2. Administer the drug. 3. Document that the drug was provided. 4. Evaluate the effectiveness of the drug.

Correct Answer: 1 Rationale 1: After identifying the client, the nurse should next instruct the client as to the intended action of the medication. Rationale 2: The medication is administered after the client has been instructed about the medication. Rationale 3: Documentation occurs after the medication has been given. Rationale 4: The medication is evaluated for effectiveness after a period of time has elapsed after administering the medication.

The client is admitted to the acute care unit with a phosphorus level of 2.3 mg/dL. Which nursing intervention would support this clients homeostasis? 1. Encourage consumption of milk and yogurt. 2. Enforce strict isolation protocols. 3. Encourage consumption of a high-calorie carbohydrate diet. 4. Strain all urine.

Correct Answer: 1 Rationale 1: A phosphorus level of 2.3 is low and the client needs additional phosphorus. Provision of phosphorus-rich foods such as milk and yogurt is a good way to provide that additional phosphorus. Rationale 2: There is no indication of the need to place this client in strict isolation. Rationale 3: A high-carbohydrate diet is not going to improve this clients phosphorus level. Rationale 4: Straining all urine is not going to improve this clients phosphorus level.

A client has a new order for a medication that does not have a termination date. The nurse would place this medication order under which classification on the clients medication administration record? 1. Standing 2. PRN 3. STAT 4. Single

Correct Answer: 1 Rationale 1: A standing order might not have a termination date. This medication may be provided to the client indefinitely. Rationale 2: A PRN order or an as-needed order permits the nurse to provide the client with the medication when, in the nurses judgment, the client needs it. Rationale 3: A STAT order indicates that the medication is to be provided immediately and only once. Rationale 4: A single order or a one-time order indicates that the medication is to be provided only once.

A client has experienced a narcotic overdose. What acidbase imbalance should the nurse expect to observe in this client? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

Correct Answer: 1 Rationale 1: Because narcotics generally act to decrease or suppress respirations, this client is probably hypoventilating. The expected acidbase imbalance would be respiratory acidosis. Rationale 2: Respiratory alkalosis is associated with hyperventilation. Rationale 3: This imbalance occurs with too much acid in the body. The respirations will increase. It is not typically seen in a client experiencing a narcotic overdose. Rationale 4: This imbalance is seen in those with prolonged periods of vomiting or other conditions where the body loses acid.

During administration of an intradermal injection, the nurse notices that the outline of the needle bevel is visible under the clients skin. How should the nurse proceed? 1. Recognize that this is an expected finding in a properly administered intradermal injection. 2. Withdraw the needle, prepare a new injection, and start again. 3. Insert the needle further into the skin at a deeper angle. 4. Turn the needle so that the bevel is down and inject the medication slowly, looking for development of a bleb.

Correct Answer: 1 Rationale 1: Intradermal injections are given at a very shallow angle so that the medication is delivered into the area between the dermal layers. When properly given, the outline of the needle bevel will be visible prior to injection of the fluid. Rationale 2: There is no need to withdraw the needle and start again. Rationale 3: Inserting the needle further into the skin and at a deeper angle would result in delivery of the fluid into the subcutaneous tissues. Rationale 4: The needle is inserted with the bevel up.

The nurse is preparing to administer a medication that the agency designates as high alert. What action should the nurse take? 1. Ask another registered nurse to verify the medication. 2. Call the pharmacist to check the efficacy of the medication. 3. Decline to administer the medication unless there is a physician present. 4. Request that the nursing supervisor administer the medication.

Correct Answer: 1 Rationale 1: Most health care agencies maintain a list of high-alert medications, including controlled substances, which require the verification of two registered nurses. Rationale 2: Although the pharmacy is a valuable resource for nurses, the high-alert designation does not require pharmacy intervention. Rationale 3: High-alert medications do not require the presence of a physician for administration. Rationale 4: High-alert medications do not require the presence of a nursing supervisor for administration.

The nurse is reviewing orders for parenteral potassium. Which order is safe for the nurse to implement? 1. Add 20 mEq of KCL to 1,000 mL of IV fluid 2. 10 mEq KCL IV over 12 minutes 3. Dilute 20 mEq KCL in 3 mL of NS and give IV push 4. 10 mEq KCL SQ

Correct Answer: 1 Rationale 1: Parenteral potassium should be well diluted and given IV. Rationale 2: If given in concentrated form, parenteral potassium is lethal to the client. Rationale 3: Parenteral potassium should be well diluted and given IV. It is not given SQ, by IV push, or in limited dilution (such as 20 mEq in 25 mL of fluid). Rationale 4: Parenteral potassium should be well diluted and given IV. It is not given SQ, by IV push, or in limited dilution (such as 20 mEq in 25 mL of fluid).

The mother of a 1-month-old infant is concerned because the infant has had vomiting and diarrhea for 2 days. What instruction should the nurse give this infants mother? 1. Have the infant be seen by a physician 2. Give the infant at least 2 ounces of juice every 2 hours. 3. Measure the infants urine output for 24 hours. 4. Provide the infant with 50 mL of glucose water.

Correct Answer: 1 Rationale 1: Parents and caregivers need to be taught the seriousness of vomiting or diarrhea in infants due to rapid fluid loss that can occur in this age group. They should also be taught the importance of bringing an infant in this situation to health care providers for evaluation. Rationale 2: Encouraging fluids for an infant who is actively vomiting will not improve fluid balance status, nor is juice the best choice of fluid. Rationale 3: Simply monitoring the loss over the next 24 hours would increase the potential for the infant to become dehydrated. Rationale 4: Encouraging fluids for an infant who is actively vomiting will not improve fluid balance status, nor is glucose water the best choice of fluid.

A client who has been prescribed a narcotic for chronic back pain is demonstrating signs of withdrawal. The nurse identifies these symptoms as being 1. physical dependence. 2. psychological dependence. 3. plateau. 4. drug allergy.

Correct Answer: 1 Rationale 1: Physiological dependence is due to biochemical changes in body tissues, especially the nervous system. These tissues come to require the substance for normal functioning. A dependent person who stops using the drug experiences withdrawal symptoms. Rationale 2: Psychological dependence is emotional reliance on a drug to maintain a sense of well-being, accompanied by feelings of need or cravings for that drug. There are varying degrees of psychological dependence, ranging from mild desire to craving and compulsive use of the drug. Rationale 3: Plateau is a maintained concentration of a drug in the plasma during a series of scheduled doses. Rationale 4: A drug allergy is an immunologic reaction to a drug. When a client is first exposed to a foreign substance, the body might react by producing antibodies. A client can react to a drug in the same manner as an antigen and thus develop symptoms of an allergic reaction.

The client has been placed on a 1200-mL oral fluid restriction. How should the nurse plan for this restriction? 1. Allow 600 mL from 73, 400 mL from 311, and 200 mL from 117. 2. Instruct the client that the 1200 mL of fluid placed in the bedside pitcher must last until tomorrow. 3. Offer the client softer, cold foods such as sherbet and custard. 4. Remove fluids from diet trays and offer them only between meals.

Correct Answer: 1 Rationale 1: The amount of fluid allowed should be divided between the three major times of the day (73, 311, 117). This helps by taking into consideration meals and medication administration. Rationale 2: The client should be given a choice regarding consumption of fluids at mealtime. Rationale 3: Sherbet and custard are counted as liquids and should be avoided. Rationale 4: The client should be given a choice regarding consumption of fluids at mealtime.

The nurse is caring for a client who is receiving intravenous fluids that are not regulated on an electronic controller. In order to calculate the rate of the IV flow in drops per minute, the nurse must know the number of drops per milliliter of fluid the tubing delivers. Where should the nurse look for this information? 1. On the packaging of the tubing 2. In the charting from the nurse who started the infusion 3. In the drug reference book 4. On the roller clamp of the tubing

Correct Answer: 1 Rationale 1: The drop factor (number of drops per milliliter of fluid) of tubing is located on the packaging. Rationale 2: The nurse would not document the drop factor of the intravenous tubing. Rationale 3: The drop factor would not be in a drug reference book. Rationale 4: The drop factor would not be on the roller clamp of the intravenous tubing

The nurse is adding medication to an existing intravenous setup. Which nursing action is indicated? 1. Close the infusion clamp. 2. Ensure that the IV bag is full prior to adding medication. 3. Do not remove the IV bag from the pole. 4. Briskly shake the IV bag after injecting the medicatio

Correct Answer: 1 Rationale 1: The nurse must close the infusion clamp prior to adding medication to an existing IV bag. Closing the clamp prevents the medication from inadvertently going directly down the tubing and into the client. Rationale 2: Medication is frequently added to IV bags that are less than completely full. The nurse must make a determination of whether the bag contains enough fluid to dilute the medication to the desired strength. Rationale 3: The bag can be taken from the IV pole for mixing. Rationale 4: The bag should receive a gentle rotation, not brisk shaking, to mix the medication and the fluid.

While preparing to administer an eye ointment, the nurse inadvertently squeezes the tube, discarding the first bead of medication. What action should the nurse take at this point? 1. Administer the eye ointment as ordered, as the first bead of ointment should be discarded anyway. 2. Notify the pharmacy and request a new, unopened tube of ointment. 3. Have a second licensed nurse witness the waste and sign the chart. 4. Continue to squeeze the tube until a clear line of ointment has been discarded from the tip.

Correct Answer: 1 Rationale 1: The nurse should administer the eye ointment as ordered, as the first bead of ointment is considered contaminated and should always be discarded. Rationale 2: There is no need to notify the pharmacy for a new tube of ointment. Rationale 3: There is no need to have the wastage witnessed by another nurse. Rationale 4: It is necessary to discard only the first bead of ointment, not an entire line.

The nurse initiates a blood transfusion for a client. What action should the nurse take next? 1. Stay with the client and closely observe him for the first 5 to 10 minutes of the transfusion. 2. Assign the UAP to sit with the client for 15 minutes. 3. Advise the client to notify the nurse if he experiences any chilling, nausea, flushing, or rapid heart rate. 4. Return to the room and take a set of vital signs in 15 minutes.

Correct Answer: 1 Rationale 1: The nurse should stay with the client and closely observe him for the first 5 to 10 minutes of the transfusion. Rationale 2: The nurse cannot delegate this assessment to the UAP. Rationale 3: The client should be advised of reactions to report, but this self-reporting is more indicated after the nurse is no longer in constant attendance. Rationale 4: The nurse should stay with the client and closely observe him for the first 5 to 10 minutes of the transfusion. The nurse cannot delegate this assessment to the UAP.

A client tells the nurse about rarely feeling thirsty. The nurse realizes that further assessment is needed to evaluate Standard Text: Select all that apply. 1. status of osmotic pressure. 2. vascular volume. 3. presence of angiotensin. 4. urine output. 5. body weight.

Correct Answer: 1, 2, 3 Rationale 1: A number of stimuli trigger the thirst center, including the osmotic pressure of body fluids. Rationale 2: A number of stimuli trigger the thirst center, including vascular volume. Rationale 3: A number of stimuli trigger the thirst center, including angiotensin. Rationale 4: Urine output does not trigger the thirst center. Rationale 5: Body weight does not trigger the thirst center.

A client sustained a significant loss of blood after a motor vehicle accident. The nurse notes that the clients urine output has decreased and suspects that which hormones have influenced this clients fluid balance? Standard Text: Select all that apply. 1. Aldosterone 2. Angiotensin 3. Antidiuretic hormone 4. Estrogen 5. Progesterone

Correct Answer: 1, 2, 3 Rationale 1: Aldosterone promotes sodium retention in the distal nephron, reducing urine output. Rationale 2: Angiotensin acts directly on the nephrons to promote sodium and water retention. Rationale 3: When serum osmolality rises, antidiuretic hormone is produced, causing the collecting ducts to become more permeable to water. This increased permeability allows more water to be reabsorbed into the blood. As more water is reabsorbed, urine output falls and serum osmolality decreases, because the water dilutes body fluids. Rationale 4: Estrogen is not a hormone that participates in fluid balance in the body. Rationale 5: Progesterone is not a hormone that participates in fluid balance in the body.

The nurse is preparing medications for a client. What should the nurse do to ensure that the correct medication is provided to the client? Standard Text: Select all that apply. 1. Make sure it is the right client. 2. Make sure it is the right medication. 3. Make sure it is the right dose. 4. Make sure it is the right route. 5. Make sure it is for the right diagnosis.

Correct Answer: 1, 2, 3, 4 Rationale 1: The right client is one of the rights of medication administration. Rationale 2: The right medication is one of the rights of medication administration. Rationale 3: The right dose is one of the rights of medication administration. Rationale 4: The right route is one of the rights of medication administration. Rationale 5: The right diagnosis is not one of the rights of medication administration.

A client is prescribed a medication to be administered through the parenteral route. The nurse would expect that this medication will be provided through which method? Standard Text: Select all that apply. 1. Subcutaneous injection 2. Intramuscular injection 3. The oral route 4. Intradermal injection 5. Intravenous infusion

Correct Answer: 1, 2, 4, 5 Rationale 1: Subcutaneous injection is considered a parenteral route of administration. Rationale 2: Intramuscular injection is considered a parenteral route of administration. Rationale 3: The oral route is not a parenteral route of administration. Rationale 4: Intradermal injection is considered a parenteral route of administration. Rationale 5: Intravenous injection is considered a parenteral route of administration.

The nurse has provided an otic medication to a client. What should the nurse document about this medications administration? Standard Text: Select all that apply. 1. Name of the drug 2. The strength 3. The appetite of the client 4. The number of drops 5. The response of the client

Correct Answer: 1, 2, 4, 5 Rationale 1: When documenting after providing an otic medication, the nurse should include the name of the drug. Rationale 2: When documenting after providing an otic medication, the nurse should include the strength. Rationale 3: When documenting after providing an otic medication, the nurse does not need to include the clients appetite. Rationale 4: When documenting after providing an otic medication, the nurse should include the number of drops. Rationale 5: When documenting after providing an otic medication, the nurse should include the response of the client.

A client is prescribed an oral medication. When reviewing this medication, the nurse realizes it might not be the route of choice for this client because the client is experiencing Standard Text: Select all that apply. 1. nausea. 2. anxiety. 3. vomiting. 4. pain from cuts and abrasions. 5. irritated gastric mucosa.

Correct Answer: 1, 3, 5 Rationale 1: Oral medications are inappropriate for a client who is nauseated. Rationale 2: Oral medications are appropriate for the client experiencing anxiety. Rationale 3: Oral medications are inappropriate for a client who is vomiting Rationale 4: Oral medications are appropriate for the client experiencing pain from cuts and abrasions. Rationale 5: Oral medications are inappropriate for a client with irritated gastric mucosa.

A client tells the nurse that the pharmacy will not fill a prescription that was written by the physician. Upon closer examination, what should the nurse determine is missing from the prescription? Standard Text: Select all that apply. 1. Rx symbol 2. Clients diagnosis 3. Clients Social Security number 4. Dispensing instructions for the pharmacist 5. Number of refills

Correct Answer: 1, 4, 5 Rationale 1: The Rx symbol is to be written on a prescription. Rationale 2: The clients diagnosis is not part of a prescription. Rationale 3: The clients Social Security number is not part of a prescription. Rationale 4: The dispensing instructions for the pharmacist are part of a prescription. Rationale 5: The number of refills must be provided on a prescription.

The nurse is preparing to discontinue a clients intravenous infusion. Which actions should the nurse take when removing the catheter from the vein? Standard Text: Select all that apply. 1. Pull the catheter out in line with the vein 2. Apply pressure to the site while removing the catheter. 3. Pull the catheter out at an angle perpendicular to the vein. 4. Bend the clients elbow if bleeding at the site persists after removal. 5. Apply pressure to the site after the catheter is removed for 2 to 3 minutes.

Correct Answer: 1, 5 Rationale 1: When removing an intravenous catheter, the nurse should pull the catheter out in line with the vein. This avoids injury to the vein. Rationale 2: Pressure should not be applied to the site while removing the catheter. Rationale 3: When removing an intravenous catheter, the nurse should pull the catheter out in line with the vein. An angle perpendicular to the vein will injure the vein. Rationale 4: Hold the clients arm above heart level, not bending at the elbow, if any bleeding persists. Raising the limb decreases blood flow to the area.

The physician has ordered 50 mL of an IV solution to infuse over the next 20 minutes. In order to accurately infuse this solution, the nurse should set the electronic controller to deliver how many mL/hr? Standard Text: Record your answer, rounding to the nearest whole number.

Correct Answer: 150 mL/hr Rationale: 50 mL/20 minutes = x mL/60 minutes. 3000/20 = 150 mL/hr

At which point of preparing medication from an ampule does the nurse anticipate using a filter needle? 1. Filter needles are not used for this preparation. 2. When drawing the medication from the ampule. 3. When administering the medication to the client. 4. Both for drawing up the medication and for administering the medication.

Correct Answer: 2 Rationale 1: A filter needle is used to draw medication from an ampule. Rationale 2: The nurse uses a filter needle to draw medication up from an ampule to remove any possible shards of glass from the liquid. Rationale 3: If the filter needle was used to inject the client, the trapped shards of glass would be injected into the muscle. Rationale 4: The nurse uses a filter needle to draw medication up from an ampule to remove any possible shards of glass from the liquid. The filter needle is then changed to a regular needle prior to administering the liquid to the client. If the filter needle was used to inject the client, the trapped shards of glass would be injected into the muscle.

The nurse is concerned that an older client is experiencing an adverse effect from a prescribed medication. What did the nurse assess to make this clinical decision? 1. Altered memory 2. Altered organ responsiveness 3. Decreased manual dexterity 4. Decreased visual acuity

Correct Answer: 2 Rationale 1: Altered memory will not cause an adverse drug effect. Rationale 2: Altered quality of organ responsiveness, resulting in adverse effects becoming pronounced before therapeutic effects are achieved, is one effect of medications on the older client. Rationale 3: Decreased manual dexterity will not cause an adverse drug effect. Rationale 4: Decreased visual acuity will not cause an adverse drug effect.

The nurse wants to assess a client for orthostatic hypotension. What action should the nurse take? 1. Assess the client for dependent edema and then raise the legs to the level of the heart and reassess for edema. 2. Measure the clients heart rate and blood pressure in both the sitting and standing position. 3. Measure the clients blood pressure before, during, and after administration of a normal saline fluid challenge. 4. Raise the clients legs above heart level and measure the blood pressure.

Correct Answer: 2 Rationale 1: Assessment of edema is not a part of the assessment of orthostatic hypotension. Rationale 2: The nurse should measure the clients blood pressure and heart rate in the sitting position and then again in the standing position. Rationale 3: Normal saline challenges are often administered to clients who are dehydrated, but they are not part of assessment of orthostatic hypotension. Rationale 4: The nurse should measure the clients blood pressure and heart rate in the sitting position and then again in the standing position.

A client has had a subclavian central venous catheter inserted. What should the nurse assess as a priority for this clients care? 1. Presence of bibasilar crackles 2. Tachycardia 3. Decreased pedal pulses 4. Headache

Correct Answer: 2 Rationale 1: Bibasilar crackles may develop secondary to fluid overload or to the disease process, but would not be particularly evident just after placement of the subclavian catheter. Rationale 2: Because insertion of a subclavian central venous catheter may result in hemothorax, pneumothorax, cardiac perforation, thrombosis, or infection, the priority finding for planning care is tachycardia. Rationale 3: A decrease in pedal pulses would not be associated with the placement of a subclavian catheter. Rationale 4: A headache would not be associated with the placement of a subclavian catheter.

The nurse is collecting equipment to administer a unit of packed red blood cells. Which IV fluid should be used to initiate the IV for this transfusion? 1. 1,000 mL of lactated Ringers solution 2. 250 mL of normal saline 3. 500 mL of 5% dextrose and water 4. 100 mL of 5% dextrose and 1/2 normal saline

Correct Answer: 2 Rationale 1: Blood and blood products should only be administered with normal saline. Other IV fluids may cause damage to the cells being administered. Rationale 2: Blood and blood products should only be administered with normal saline. Other IV fluids may cause damage to the cells being administered. Rationale 3: Blood and blood products should only be administered with normal saline. Other IV fluids may cause damage to the cells being administered. Rationale 4: Blood and blood products should only be administered with normal saline. Other IV fluids may cause damage to the cells being administered.

The hospitalized client has an order for Tylenol 325 mg 2 tablets every 4 hours prn temperature over 101F. The client complains of a headache. Can the nurse legally administer Tylenol to treat the headache? 1. Yes, as Tylenol is used both for fever and headache. 2. No, not unless the client also has a temperature over 101F. 3. Yes, but the nurse should document the reason why the medication was administered as a temperature elevation. 4. Yes, because the medication is available over the counter, an order is not required.

Correct Answer: 2 Rationale 1: In the hospital setting, the nurse can only administer medications that are prescribed for the client and can only administer those medications according to the specifics of the prescription. In this case, the medication was ordered for temperature elevation, not pain, so the nurse cannot legally administer the Tylenol to treat the clients headache. Rationale 2: In the hospital setting, the nurse can only administer medications that are prescribed for the client and can only administer those medications according to the specifics of the prescription. In this case, the medication was ordered for temperature elevation, not pain, so the nurse cannot legally administer the Tylenol to treat the clients headache. Rationale 3: The nurse should never document false information in regard to medication administration. Rationale 4: The fact that this is an over-the-counter medication and is used both for fever and headache is not pertinent to the nurses decision.

The nurse has just injected insulin subcutaneously into the clients abdomen. What action should the nurse take at this point? 1. Massage the site to encourage absorption. 2. Leave the needle embedded in the clients skin for 5 seconds after administration. 3. Remove the needle rapidly by pulling it quickly from the skin. 4. Cover the injection site with a pressure dressing for at least 15 minutes or until the bleb disappears.

Correct Answer: 2 Rationale 1: Massage is contraindicated for most medications because it alters the delivery rate from the tissues. Rationale 2: The American Diabetes Association recommends leaving the needle embedded in the clients skin for 5 seconds after injection of medication, particularly insulin. This allows for complete delivery of the dose. Rationale 3: The needle should be removed slowly and smoothly to minimize pain for the client. Rationale 4: Bleeding rarely occurs after subcutaneous injection, but short application of manual pressure (13 minutes) should cause bleeding to stop. There is no need for a pressure dressing for 15 minutes. Subcutaneous injections do not result in bleb formation.

Upon aspirating a saline lock prior to administering intravenous medication, the nurse notes that there is no blood return. What nursing action should be taken? 1. Discontinue this infiltrated lock and restart another site for medication administration. 2. Slowly infuse 1 mL of saline into the lock, assessing for infiltration. 3. Reinsert the needle into the lock and aspirate using more pressure. 4. Pull the intravenous catheter out 1/8 inch and attempt aspiration

Correct Answer: 2 Rationale 1: Simple lack of blood upon aspiration does not indicate infiltration, so there is no need to discontinue the site. Rationale 2: Although the presence of blood upon aspiration confirms that the catheter is in a vein, the absence of blood does not rule out correct placement. If no blood returns, the nurse should slowly infuse 1 mL of saline into the lock while assessing the site for infiltration. If there is no infiltration present, the nurse should administer the medication. Rationale 3: Often the reason for absence of blood return is that the vessel has collapsed around the catheter from the pressure of aspiration. Increasing the pressure will not increase the likelihood of blood return. Rationale 4: Pulling the intravenous catheter out 1/8 inch will not increase the likelihood of blood return and may make the site more unstable.

The clients arterial blood gas report reveals a pH of 6.58. How does the nurse evaluate this value? 1. There is a slight elevation. 2. This value is incompatible with life. 3. This is a low normal value. 4. This value is extremely elevated.

Correct Answer: 2 Rationale 1: The bodys pH range is normally 7.35 to 7.45. This is not an elevation. Rationale 2: The bodys pH range is normally 7.35 to 7.45. Values lower than 6.8 or higher than 7.8 are generally considered incompatible with life. If the nurse assesses that this client is physiologically more stable than would be expected with this pH, the possibility of a lab error should be considered. Rationale 3: The bodys pH range is normally 7.35 to 7.45. Values lower than 6.8 or higher than 7.8 are generally considered incompatible with life. Rationale 4: The bodys pH range is normally 7.35 to 7.45. This value is not extremely elevated.

The nurse is providing discharge teaching for a client who is being dismissed with prescriptions for a bronchodilator inhaler and a corticosteroid inhaler. What information should the nurse provide regarding the dosage schedule for these two medications? 1. Always use the corticosteroid inhaler first. 2. Use the bronchodilator first. 3. It makes no difference which inhaler is used first. 4. Use the inhalers on alternate days, not on the same day.

Correct Answer: 2 Rationale 1: The bronchodilator should be used first in order to open the airways so the corticosteroid medication can move deeply into the lungs. Rationale 2: These two types of inhalers are frequently prescribed to be used together. The bronchodilator should be used first in order to open the airways so the corticosteroid medication can move deeply into the lungs. Rationale 3: The bronchodilator should be used first in order to open the airways so the corticosteroid medication can move deeply into the lungs. Rationale 4: These two types of inhalers are frequently prescribed to be used together. The bronchodilator should be used first in order to open the airways so the corticosteroid medication can move deeply into the lungs.

An older client receiving intravenous fluids at 175 ml/hr is demonstrating crackles, shortness of breath, and distended neck veins. The nurse recognizes these findings as being which complication of intravenous fluid therapy? 1. An allergic reaction to the antibiotics in the fluid 2. Fluid volume excess 3. Pulmonary embolism 4. Speed shock

Correct Answer: 2 Rationale 1: The information provided does not support that the client is receiving an antibiotic. Rationale 2: Fluid volume excess may occur if clients, especially the very young or elderly, receive IV fluid rapidly. Rationale 3: The information provided does not support the development of a pulmonary embolism. Rationale 4: The client has been receiving fluids at the established rate and would not be experiencing symptoms of speed shock.

A client is prescribed a new medication. The pharmacy notifies the nurse that the dosage is outside of route prescribing limits. The nurse is unable to reach the prescribing physician about the order. What should the nurse do? 1. Give the medication to the client as prescribed. 2. Withhold the medication. 3. Give one-half of the medication dose prescribed. 4. Administer the medication through the oral route.

Correct Answer: 2 Rationale 1: The nurse should not give the medication as prescribed, as the pharmacy has identified that the dose prescribed is outside of dosing limits. Rationale 2: If the primary care provider cannot be reached, document all attempts to contact the primary care provider and the reason for withholding the medication. Rationale 3: The nurse should not give the client one-half of the medication dose prescribed, as this is outside of the nurses licensure. Rationale 4: The nurse should not administer the medication through the oral route, as this might not be the best route for the medication and changing the route is outside of the nurses licensure.

A client is admitted to the hospital after vomiting for 3 days. Which arterial blood gas results should the nurse expect to find in this client? 1. pH 7.30; PaCO2 50; HCO3 27 2. pH 7.47; PaCO2 43; HCO3 28 3. pH 7.43; PaCO2 50; HCO3 28 4. pH 7.47; PaCO2 30; HCO3 23

Correct Answer: 2 Rationale 1: The nurse would expect that this client is alkalotic because stomach acids have been lost, so the pH would be above 7.45. This is a metabolic problem, so the PaCO2 is likely normal. The HCO3 will likely be high (above 26). The only option that includes all of these parameters is pH 7.47; PaCO2 43; HCO3 28.

Before administering a medication to a client, the nurse checks the clients pulse, blood pressure, and laboratory values. The nurse is performing which right of medication administration? 1. Medication 2. Assessment 3. Route 4. Dose

Correct Answer: 2 Rationale 1: The nurse would not need to assess blood pressure, pulse, or laboratory values to determine the right medication. Rationale 2: Some medications require specific assessments prior to administration, such as blood pressure, pulse, or laboratory values. Medication orders can include specific parameters for administration, so these assessments must be done before administering. Rationale 3: The nurse would not need to assess blood pressure, pulse, or laboratory values to determine the right route. Rationale 4: The nurse would not need to assess blood pressure, pulse, or laboratory values to determine the right dose.

The client who regularly uses a metered-dose inhaler four times a day tells the nurse that it is difficult to tell when the canister is empty. What instruction should the nurse give this client? 1. Place the canister in a bowl of water. If the canister floats, it is not empty. 2. When you get a new canister, divide the number of puffs that is listed on the label by four. That will tell you how many days the canister will last. 3. You can tell that the canister is empty when you can no longer smell the medication when you activate the plunger. 4. When you feel like you are no longer getting maximum effect from the medication, your canister is empty.

Correct Answer: 2 Rationale 1: The old method of floating the canister in water is not accurate, as there may be propellant left in the canister after the medication is all dispensed. Rationale 2: The best way to track the number of puffs left in a canister is to start with the new canister, dividing the number of puffs listed on the label by the number of puffs taken each day. Rationale 3: Being able to smell the medication is not an indication of the amount left in the canister. Rationale 4: Waiting until there is lack of maximum effect from the medication may put the client at risk for respirator illness exacerbation.

The nurse is planning to administer medications to a new client. What is the nurses greatest priority in administering these medications? 1. Be certain the medications are given within 15 minutes of the time they are scheduled. 2. Before giving the medications, know what the intended effects are for this client. 3. Assess the clients knowledge of the action of the medications. 4. Document the administration accurately so the reimbursement is correct.

Correct Answer: 2 Rationale 1: This is important but not the greatest priority. Rationale 2: The greatest priority is to understand the intended effects of the medication for this client. The nurse should never do anything to or for a client without knowing the intended effect. Rationale 3: This is important but not the greatest priority. Rationale 4: This is important but not the greatest priority.

Ten minutes after the transfusion of a unit of packed red blood cells was initiated, the client complains of a headache. The nurse assesses that the client has slight shortness of breath and feels warm to the touch. What action by the nurse is priority? 1. Notify the clients physician. 2. Discontinue the transfusion. 3. Slow the rate of the transfusion. 4. Prepare to resuscitate the client.

Correct Answer: 2 Rationale 1: This would not be the nurses first action. Rationale 2: The priority intervention is to discontinue the transfusion. If this client is having a transfusion reaction, it will be better to limit the amount of blood transfused. The nurse would also contact the physician to collaborate on further treatment, but this action should be after the transfusion is discontinued. Rationale 3: Slowing the rate of the transfusion allows additional blood to be infused. Rationale 4: At this point, there is no need to prepare for resuscitation.

The client who has an IV with an intermittent infusion lock in place wishes to shower. What action should be taken by the nurse? 1. Have the UAP discontinue the lock. 2. Cover the lock with an occlusive dressing. 3. Place a piece of cloth tape under the lock, wrapping the top in a U shape. 4. Tell the client that a bed bath is necessary until the IV is discontinued.

Correct Answer: 2 Rationale 1: UAP cannot discontinue the lock. Rationale 2: The client can shower if the lock is covered with an occlusive dressing. Rationale 3: Cloth tape will not protect the lock. Rationale 4: The client can shower if the lock is covered with an occlusive dressing.

A client is receiving a continuous intravenous infusion. What should the nurse document in the medical record about this infusion? Standard Text: Select all that apply. 1. Latest body temperature 2. Type of solution and flow rate 3. Total intravenous intake for the shift 4. Status of the intravenous catheter site 5. Results of blood pressure measurement

Correct Answer: 2, 3, 4 Rationale 1: Body temperature may help determine fluid status; however, this is not documented in the medical record related to the clients continuous intravenous fluid infusion. Rationale 2: The type of solution and flow rate should be documented. Rationale 3: Total intravenous intake for the shift should be documented according to agency policy. Rationale 4: The status of the intravenous insertion site should be documented. Rationale 5: Blood pressure may help determine fluid status; however, this is not documented in the medical record related to the clients continuous intravenous fluid infusion.

The nurse is concerned that an older client will have difficulty self-administering medications. What did the nurse assess that caused this concern? Standard Text: Select all that apply. 1. Eats several servings of fruits and vegetables each day 2. Altered memory 3. Decreased visual acuity 4. Decreased manual dexterity 5. Limits red meat in the diet

Correct Answer: 2, 3, 4 Rationale 1: Eating several servings of fruits and vegetables each day will not influence the older clients ability to self-administer medications. Rationale 2: Altered memory is one physiological change associated with aging that influences medication administration. Rationale 3: Decreased visual acuity is one physiological change associated with aging that influences medication administration. Rationale 4: Decreased manual dexterity is one physiological change associated with aging that influences medication administration. Rationale 5: Limiting red meat in the diet will not influence the older clients ability to self-administer medications.

The nurse is instructing a new mother on the method to provide a newly prescribed medication to her 2-monthold infant. What should the nurse include in this teaching? Standard Text: Select all that apply. 1. Mix the medication into the babys formula. 2. Use a nipple so the baby can suck the medication. 3. Use a syringe or dropper to provide the medication. 4. Place a small amount of the medication along the side of the babys cheek. 5. Prepare twice the amount of medication prescribed because the baby will spit out half of it.

Correct Answer: 2, 3, 4 Rationale 1: Never mix medications into foods that are essential, as the infant may associate the food with an unpleasant taste and refuse that food in the future. Never mix medications with formula. Rationale 2: Oral medications can be provided to a baby with the use of a nipple so that the baby sucks the medication. Rationale 3: Oral medications can be provided to a baby with a syringe or dropper. Rationale 4: Oral medications can be provided to a baby by placing a small amount of liquid medication along the inside of the babys cheek and waiting for the infant to swallow. Rationale 5: The mother should never be instructed to provide the baby with twice the amount of medication that is prescribed.

The nurse determines that the effectiveness of a medication is not as great when provided to female clients as it is with male clients. The nurse suspects that this difference in effectiveness is because of which factor? Standard Text: Select all that apply. 1. Occupation 2. Hormones 3. Fat amount 4. Physical activity status 5. Fluid level

Correct Answer: 2, 3, 5 Rationale 1: Differences in the way men and women respond to drugs are not chiefly related to occupation. Rationale 2: Differences in the way men and women respond to drugs are chiefly related to hormone levels. Rationale 3: Differences in the way men and women respond to drugs are chiefly related to the distribution of body fat. Rationale 4: Differences in the way men and women respond to drugs are not chiefly related to physical activity status. Rationale 5: Differences in the way men and women respond to drugs are chiefly related to the distribution of body fluid.

The nurse is preparing to start an IV in the hand of a client who has very small veins. Which actions would be useful in dilating the veins? 1. Position the hand at heart level. 2. Stroke the vein. 3. Have the client clench and unclench the fist. 4. Slap the back of the clients hand. 5. Massage the vein.

Correct Answer: 2, 3, 5 Rationale 1: The hand should be lower than the heart to dilate the vein. Rationale 2: Stroking the vein helps to dilate the vein. Rationale 3: Having the client clench and unclench the fist is a strategy used to help dilate a vein. Rationale 4: Slapping the vein is contraindicated and may actually reduce venous filling. Rationale 5: Massaging the vein helps with vein dilation.

The nurse is caring for a client who is recovering from surgery. Which intervention should the nurse implement to decrease the clients possibility of developing hypercalcemia? 1. Measure vital signs every 4 hours. 2. Assist the client to turn, cough, and deep breathe every 2 hours. 3. Assist the client to ambulate around the room at least three times daily. 4. Irrigate the clients nasogastric tube every 2 hours.

Correct Answer: 3 Rationale 1: Measuring vital signs will not decrease the possibility of developing hypercalcemia. Rationale 2: Turning, coughing, and deep breathing every 2 hours will not prevent the development of hypercalcemia. Rationale 3: Hypercalcemia can occur from immobility. Ambulation of the client helps to prevent leaching of calcium from the bones into the serum. Rationale 4: Irrigating the nasogastric tube every 2 hours is not going to prevent the development of hypercalcemia.

The nurse is planning to administer a bitter-tasting oral medication to a 4-year-old client. What strategy should this nurse plan? 1. Give the medication in orange juice or milk to mask the taste. 2. Tell the child that the medication tastes good. 3. Ask the parents how they give medications at home. 4. Get another nurse to assist by holding the client down.

Correct Answer: 3 Rationale 1: Medication should not be placed in essential foods such as orange juice or milk, as the child may develop an aversion to the food related to the taste of the medication. Rationale 2: Being untruthful about any interventions may cause the client to lose trust in the nurse. Rationale 3: Parents are a very good source of ideas for caring for their child, and their input should be sought when performing tasks such as medication administration. Rationale 4: Having a second nurse hold the client down to administer the medication is an unnecessary use of force and will frighten the child.

A client on diuretic therapy has a serum potassium level of 3.4 mg/dL. Which food should the nurse encourage this client to choose from the dinner menu? 1. Baked chicken 2. Green beans 3. Cantaloupe 4. Iced tea

Correct Answer: 3 Rationale 1: A potassium level of 3.4 is low, so the client should be encouraged to consume potassium-rich foods. Of the foods listed, the highest in potassium is cantaloupe. Rationale 2: A potassium level of 3.4 is low, so the client should be encouraged to consume potassium-rich foods. Of the foods listed, the highest in potassium is cantaloupe. Rationale 3: A potassium level of 3.4 is low, so the client should be encouraged to consume potassium-rich foods. Of the foods listed, the highest in potassium is cantaloupe. Rationale 4: A potassium level of 3.4 is low, so the client should be encouraged to consume potassium-rich foods. Of the foods listed, the highest in potassium is cantaloupe.

A clients status is deteriorating, and the physician prescribes a medication to be administered immediately one time. The nurse would contact the pharmacy and identify this medication order as being of which type? 1. Standing 2. PRN 3. STAT 4. Single order

Correct Answer: 3 Rationale 1: A standing order might not have a termination date. This medication may be provided to the client indefinitely. Rationale 2: A PRN order or an as-needed order permits the nurse to provide the client with the medication when, in the nurses judgment, the client needs it. Rationale 3: A STAT order indicates that the medication is to be provided immediately and only once. Rationale 4: A single order or a one-time order indicates that the medication is to be provided only once.

A client is diagnosed with liver disease. The nurse realizes that which element of pharmacokinetics will be affected in this client? 1. Absorption 2. Distribution 3. Biotransformation 4. Excretion

Correct Answer: 3 Rationale 1: Absorption is the process by which a drug passes into the bloodstream. Rationale 2: Distribution is the transportation of a drug from its site of absorption to its site of action. Rationale 3: Biotransformation, also called detoxification or metabolism, is a process by which a drug is converted to a less active form. Most biotransformation takes place in the liver. Biotransformation can be altered if a person has an unhealthy liver. Rationale 4: Excretion is the process by which metabolites and drugs are eliminated from the body. Most drug metabolites are eliminated by the kidneys via the urine.

The nurse identifies that the ordered dose for a medication is twice the amount generally administered. What action should the nurse take? 1. Administer the medication as it was ordered. 2. Check to see if previous shift nurses gave the medication. 3. Collaborate with the prescriber about the order. 4. Administer only the standard dose of the medication.

Correct Answer: 3 Rationale 1: Administering the dose as ordered may harm the client. Rationale 2: The fact that previous nurses gave the medication as ordered does not make it the correct action. Rationale 3: When the nurse has doubts about the correctness of a medication or medication dose for a specific client, collaboration with the prescriber is necessary. The nurse is legally and ethically responsible for all actions taken, including medication administration. Rationale 4: The nurse cannot change the amount of medication to give without collaborating with the prescriber.

Why is the nurse writing out the name of the drug morphine sulfate instead of using the abbreviation MS? 1. The hospital has placed MS on its list of do-not-use abbreviations. 2. The Joint Commission requires that the abbreviation MS not be used. 3. Using the abbreviation MS puts the client at risk of medication error. 4. Computerized charting systems will not accept the abbreviation MS.

Correct Answer: 3 Rationale 1: Although the hospital has probably placed MS on its list of do-not-use abbreviations, The Joint Commission does require that the abbreviation not be used. Rationale 2: The Joint Commission does require that the abbreviation not be used; however ,client safety is the primary reason. Rationale 3: The best answer is that using the abbreviation MS puts the client at risk of medication error. Rationale 4: Although some computerized charting systems will not accept the abbreviation MS, the best reason is for client safety.

A client has orders for the administration of IV fluid at a keep vein open rate in preparation for administration of IV antibiotics starting at noon. When the nurse goes to the room to start the IV, the UAP is preparing to bathe the client. What should the nurse do? 1. Instruct the UAP to wait until the IV is started to bathe the client. 2. Let the UAP start the bath on the opposite side of where the nurse will be starting the IV. 3. Tell the UAP to notify the nurse as soon as the bath is completed. 4. Give the UAP permission to skip the clients bath for today.

Correct Answer: 3 Rationale 1: Because this IV is being initiated to support the administration of IV antibiotic therapy that is not scheduled to start until noon, the nurse should let the UAP give the bath and then start the IV. Rationale 2: Having the UAP bathing one side of the client while the nurse starts the IV on the opposite side would be uncomfortable and stressful for the client and could potentially compromise client modesty. This action would also not protect the IV site from movement while the UAP completes the bath. Rationale 3: Because this IV is being initiated to support the administration of IV antibiotic therapy that is not scheduled to start until noon, the nurse should let the UAP give the bath and then start the IV. This will protect the IV site from movement during the bath. Rationale 4: There is no reason to skip the bath.

After obtaining a unit of packed red blood cells for a client, the nurse learns the client needed to leave the care area for an emergency x-ray. What action should the nurse take? 1. Set up the blood with the IV fluid and y-tubing and place it on the IV stand in the clients room to initiate immediately after the client returns. 2. Place the blood in the unit refrigerator until the client returns. 3. Return the blood to the laboratory blood bank until the client returns. 4. Set up the blood with the IV fluid and y-tubing and place it in the unit medication room to initiate immediately after the client returns.

Correct Answer: 3 Rationale 1: Blood should not be held at room temperature for more than 30 minutes before the transfusion is initiated. Rationale 2: The unit refrigerator is not climate controlled for blood storage. Rationale 3: Blood should not be held at room temperature for more than 30 minutes before the transfusion is initiated. The unit must be returned to the laboratory blood bank until the client has returned from x-ray. Rationale 4: Blood should not be held at room temperature for more than 30 minutes before the transfusion is initiated.

The nurse is caring for a client who is being mechanically ventilated. Arterial blood gas analysis reveals respiratory acidosis. Which change in ventilator settings should the nurse anticipate? 1. Decrease in oxygen delivery 2. Decreased tidal volume of each breath 3. Increased respiratory rate 4. Increase in humidification of inspired air

Correct Answer: 3 Rationale 1: Decreasing oxygen will not decrease CO2 levels. Rationale 2: Decreasing the tidal volume will not decrease CO2 levels. Rationale 3: This client needs to blow off more CO2; therefore the respiratory rate would be increased. Rationale 4: Increasing the humidification will not decrease CO2 levels.

The client is to receive an intramuscular injection of a medication that is supplied in a 2-mL cartridge and a second medication that is supplied in a vial. The total amount to be administered of these medications exceeds the volume of the cartridge by 0.5 mL. How should the nurse proceed? 1. Administer the cartridge medication in one injection and the vial medication in a separate injection. 2. Call the pharmacy for advice on administering these medications. 3. Draw both of the medications up into a syringe for administration. 4. Add as much of the vial medication to the cartridge as possible prior to injection, giving the balance in a separate injection.

Correct Answer: 3 Rationale 1: Giving two separate injections, no matter how the medication is divided, should be avoided if possible. Rationale 2: There is no need for the nurse to consult the pharmacy for this standard technique. Rationale 3: When the total amount of medication to administer exceeds the volume of the cartridge, the medication is drawn up into a syringe and is administered. Rationale 4: Giving two separate injections, no matter how the medication is divided, should be avoided if possible.

The nurse is caring for an 80-year-old client with the medical diagnosis of heart failure. The client has edema, orthopnea, and confusion. Which nursing diagnosis is most appropriate for this client? 1. Heart Failure related to edema, as evidenced by confusion 2. Fluid Volume Deficit related to loss of fluids, as evidenced by edema 3. Excess Fluid Volume related to retention of fluids, as evidenced by edema and orthopnea 4. Excess Fluid Volume related to congestive heart failure, as evidenced by edema and confusion

Correct Answer: 3 Rationale 1: Heart failure is a medical diagnosis, not a nursing diagnosis. Rationale 2: This client does not exhibit fluid volume deficit. Rationale 3: Edema and orthopnea are assessment findings associated with excess fluid volume. Rationale 4: Congestive heart failure is a medical diagnosis and cannot be used as the related to factor in a nursing diagnosis.

The nurse is preparing a small amount of medication for oral administration. Which nursing action is essential? 1. Draw up the medication in a syringe with a large-gauge needle. 2. Measure the medication at the top of the meniscus. 3. Label the syringe with the medication name, amount, and route. 4. Dilute the medication with water before measuring.

Correct Answer: 3 Rationale 1: If a regular syringe is used to draw up the medication, the needle should be discarded. A syringe with a needle might also indicate that the medication is to be given parenterally and cause a medication route error. Rationale 2: If medications are measured in a cup, the correct measurement is at the bottom of the meniscus. Rationale 3: When measuring medication in a syringe, a label must be attached indicating the name of the medication, the amount, and the route. This labeling is essential to prevent the medication from being given via the wrong route. Rationale 4: Medication might be diluted after measuring, but dilution before measuring would impact the dosage of the medication.

The nurse is preparing to administer a subcutaneous injection to a client. When selecting the needle, the nurse should choose one with a 1. small gauge number. 2. long shaft. 3. long bevel. 4. short bevel.

Correct Answer: 3 Rationale 1: Needles with small gauge numbers are used for viscous medications. For subcutaneous injections, a larger gauge number should be used. Rationale 2: Long shafts are used for intramuscular injections. Rationale 3: Longer bevels provide the sharpest needles, and cause less discomfort. They are commonly used for subcutaneous and intramuscular injections. Rationale 4: Short bevels are used for intradermal and IV injections because a long bevel can become occluded if it rests against the side of a blood vessel.

The nurse suspects that a clients body is attempting to correct an acidbase imbalance. How will this imbalance be corrected? 1. Slow but efficient respiratory regulation will occur. 2. Primary regulation is through GI system losses. 3. Kidney regulation is powerfully effective. 4. The cardiovascular system is the major buffer.

Correct Answer: 3 Rationale 1: Respiratory regulation is rapid, but temporary. Rationale 2: The gastrointestinal system is not involved in the regulation of acidbase balance. Rationale 3: Renal regulation is slower, but powerfully effective. Rationale 4: The cardiovascular system is not involved in the regulation of acidbase balance.

The client complains of burning along the vein in which a medicated IV is infusing. Upon assessment, the nurse finds the IV site is slightly reddened, but not warmer than the surrounding skin, and without swelling. What action should be taken by the nurse? 1. Slow the IV infusion and reassess the area in 15 minutes. 2. Apply ice over the IV site and vein. 3. Discontinue the IV and place a warm pack on the area. 4. Call the physician for direction.

Correct Answer: 3 Rationale 1: Simply slowing the IV will not prevent further damage to the vein and will also alter the amount of IV fluid and medication the client is receiving. Rationale 2: Ice is not indicated in the treatment of phlebitis. Rationale 3: This assessment likely indicates the beginning of phlebitis. The nurse should discontinue the IV and place either a warm or cool pack on the area. Rationale 4: This assessment and evaluation are within the scope of nursing practice, so at this point, collaboration with the physician is not necessary.

A client tells the nurse about passing out after following a fasting diet for 5 days. Which acidbase imbalance should the nurse expect to assess in this client? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

Correct Answer: 3 Rationale 1: Starvation would not result in respiratory acidosis. Rationale 2: Starvation would not result in respiratory alkalosis. Rationale 3: A client who is fasting is at risk for development of metabolic acidosis. The body recognizes fasting as starvation and begins to metabolize its own proteins into ketones, which are metabolic acids. Rationale 4: Starvation would not result in metabolic alkalosis.

The nurse is providing discharge instructions to a client who has been started on furosemide (Lasix) once daily. What information is essential to include in this information? 1. Take the medication at bedtime. 2. Avoid high-potassium foods. 3. Stand up slowly from a sitting position. 4. Do not take this medication on the days you take digitalis (Lanoxin).

Correct Answer: 3 Rationale 1: The medication should be taken in the morning to prevent awakening at night to void. Rationale 2: The client should be encouraged to eat potassium-rich foods and will probably be prescribed a potassium supplement. Rationale 3: Clients who are taking diuretics must make position changes slowly in order to minimize dizziness from orthostatic hypotension. Rationale 4: Although clients who take digitalis (Lanoxin) and furosemide (Lasix) are at higher risk for the development of digitalis toxicity, the medications are often taken concurrently. The client and health care provider must monitor these clients closely for the development of digitalis toxicity.

The nurse who is to administer 2.5 mL of intramuscular pain medication to an adult client notes that the previous injection was administered in the right ventrogluteal site. In which site should the nurse plan to administer this injection? 1. The same site 2. The deltoid 3. The left ventrogluteal 4. The rectus femoris

Correct Answer: 3 Rationale 1: The same site should not be used because this is not enough time for tissue recovery. Rationale 2: The deltoid site will not accept 2.5 mL of medication. Rationale 3: Of the options given, the best choice is the left ventrogluteal. This is a site that will accept 2.5 mL of medication, and using the opposite site from the last injection will allow the first site time for recovery. Rationale 4: The rectus femoris site is generally used only for self-injection of medication and is a painful site for medication administration.

The nurse is caring for a client who is receiving IV therapy at a rate of 10 mL/hour. The 500-mL IV bottle was hung at 0900 Monday morning when the IV catheter was initiated. It is now 0900 on Tuesday morning. What nursing action should be taken? 1. Refigure the rate of the IV. 2. Infuse the remaining IV fluid before hanging a new bag. 3. Discard the remaining IV fluid and hang a new bag. 4. Discontinue the IV site and restart an IV in the opposite hand.

Correct Answer: 3 Rationale 1: There is no need to refigure the rate of the IV. Rationale 2: The nurse should not infuse the remaining IV fluid before hanging a new bag. Rationale 3: The remaining IV fluid should be discarded and a new bag hung. IV fluid should be changed every 24 hours, regardless of how much solution remains. This helps to minimize the risk of contamination. Rationale 4: There is no need to restart the IV in the opposite hand.

The nurse is preparing to administer a medication to a 6-year-old client. What is the nurses priority action? 1. Administer the exact dosage as ordered. 2. Give the dosage supplied by the pharmacy. 3. Verify that the dosage is within the safe range for this child. 4. Administer no more than one-half of the safe adult dosage.

Correct Answer: 3 Rationale 1: This dose should be compared to the standard dose listed in a reputable drug reference book. Rationale 2: Although prescribers and pharmacists are also responsible to figure the correct dose, the nurse who administers the dose is the last possible person to prevent a medication error. The nurse has the final responsibility to ensure that the dose ordered and dose supplied are correct for the client. Rationale 3: The priority action is to verify that the dosage is within the safe range for this child. This verification can be done by figuring the dose per kilogram of body weight or by use of a nomogram. Rationale 4: This dose may be more or less than one-half the adult dosage.

The nurse is reviewing a new medication order for a client, and determines that the order is incomplete when which element is missing? Standard Text: Select all that apply. 1. Clients address 2. Dispensing instructions for the pharmacist 3. Name of the medication 4. Dosage 5. Route of administration

Correct Answer: 3, 4, 5 Rationale 1: The clients address is part of a prescription but not of a medication order. Rationale 2: Dispensing instructions for the pharmacist are a part of a prescription but not of a medication order. Rationale 3: The name of the medication is an essential part of the medication order. Rationale 4: The dosage is an essential part of the medication order. Rationale 5: The route of administration is an essential part of the medication order.

While reviewing a medication order, the nurse determines that it is written using the metric system. What did the nurse observe to come to this conclusion about the medication order? Standard Text: Select all that apply. 1. Number of ounces 2. Number of drams of the solution 3. Number of milligrams of the medication 4. Number of grains of the medication 5. Number of milliliters of the solution

Correct Answer: 3, 5 Rationale 1: Ounces are a measurement in the household system. Rationale 2: Drams are a measurement in the apothecaries system. Rationale 3: Milligrams are a measurement in the metric system. Rationale 4: Grains are a measurement in the apothecaries system. Rationale 5: Milliliters are a measurement in the metric system.

The nurse is preparing to administer eardrops to a 6-year-old client. What nursing action is correct? 1. Pull the earlobe down and back to straighten the ear canal. 2. Insert the tip of the applicator into the ear canal. 3. Put the eardrops in the refrigerator for 10 minutes prior to administration. 4. Press gently on the tragus of the ear a few times after administration.

Correct Answer: 4 Rationale 1: After age 3, the pinna of the ear should be pulled up and back to straighten the ear canal. Rationale 2: The tip of the eardrop applicator should not be placed into the ear canal, but should be held just above the canal so that the drops can fall onto the side of the canal. Rationale 3: Eardrops should be warmed prior to administration, not cooled. Rationale 4: The nurse should press gently but firmly on the tragus of the ear after eardrops are administered in order to direct the drops into the ear canal.

While preparing to administer a transdermal estrogen patch, the nurse finds the previously applied patch in the clients bed linens. How can the nurse avoid this situation with the patch now being applied? 1. Shave the area where the patch is being applied. 2. Place a heating pad over the area where the patch is applied for 10 minutes after application. 3. Run a finger around the adhesive edges of the new patch before placing it on the clients skin. 4. Press firmly over the patch with the palm of the hand for about 10 seconds after applying it to the skin.

Correct Answer: 4 Rationale 1: If hair is a problem in keeping the patch on, choose a less hairy site for application or clip (do not shave) the hair. Rationale 2: Placement of a heating pad is contraindicated, as the heat could increase circulation and the rate of absorption. Rationale 3: Avoid touching the adhesive edges of the patch prior to placing it on the skin. Rationale 4: In order to affix the patch firmly to the clients skin, press firmly over the patch with the palm of the hand for about 10 seconds after application.

While hospitalized, a client was receiving 15 ml of an oral medication three times a day. When providing discharge instructions, the nurse should teach the client to take how much of this medication at home? 1. 2 teaspoons 2. 1 teaspoon 3. 2 tablespoons 4. 1 tablespoon

Correct Answer: 4 Rationale 1: In the household measurement system, 2 teaspoons is equivalent to 810 ml in the metric system. Rationale 2: In the household measurement system, 1 teaspoon is equivalent to 45 ml in the metric system. Rationale 3: In the household measurement system, 2 tablespoons is equivalent to 30 ml in the metric system. Rationale 4: In the metric system, 15 ml is equal to 1 tablespoon in the household measurement system.

The nurse is to administer four oral medications to the client via a nasogastric tube. One of the medications is a tablet that has been crushed, one is a capsule that has been opened and the powder removed, and two are supplied in liquid form. How should the nurse administer these medications? 1. Flush the tube, mix the crushed tablet and the capsule powder into the two liquids for administration, and follow by flushing the tube. 2. Mix the crushed tablet and capsule powder in warm water and administer. Flush the tube and administer the mixed liquids. 3. Flush the tube with the mixed liquids first, then administer the crushed tablet and capsule powder mixed in cold water. 4. Mix the crushed tablet and capsule powder individually in warm water. Administer each medication separately, flushing the tube before and after each administration.

Correct Answer: 4 Rationale 1: Mixing medications together may result in a chemical reaction that occludes the tube. Rationale 2: Mixing medications together may result in a chemical reaction that occludes the tube. Rationale 3: Mixing medications together may result in a chemical reaction that occludes the tube. Rationale 4: When giving medication via a nasogastric or gastric tube, the nurse should individually prepare and administer the medications, flushing the tube before and after each administration. Failure to flush the tube adequately is the leading cause of tube occlusion.

The nurse is administering a medication to a client as prescribed in order to maintain a specific amount of the medication in the clients bloodstream at all times. The nurse is ensuring that which action is being maintained for this client? 1. Peak plasma level 2. Drug half-life 3. Onset of action 4. Plateau

Correct Answer: 4 Rationale 1: Peak plasma level is the highest plasma level achieved by a single dose when the elimination rate of the drug equals the absorption rate. Rationale 2: Drug half-life is the time required for the elimination process to reduce the concentration of the drug to one-half of what it was at initial administration. Rationale 3: Onset of action is the time after administration when the body initially responds to the drug. Rationale 4: Plateau is when a concentration of a drug is maintained in the clients plasma through a series of scheduled doses.

While administering an intramuscular injection, the nurse notes blood return in the syringe barrel after aspirating. What action should the nurse take? 1. Pull the needle out 1/4 inch and inject the medication. 2. Inject the medication as planned. 3. Notify the physician immediately. 4. Discard the medication and start over.

Correct Answer: 4 Rationale 1: Simply pulling out the needle 1/4 inch does not guarantee that the needle point is not in a vessel, and the presence of blood in the syringe prevents checking the new site. Rationale 2: Blood return in the syringe barrel after aspiration indicates a strong probability that the needle tip is in a blood vessel. Injection of medication would then be intravenous, not intramuscular. Rationale 3: There is no need to notify the physician of this event. Rationale 4: The nurse should discard the medication and start over with new medication and a new syringe.

The nurse is caring for a team of four clients who are seriously ill. One of the clients has just received a new cardiac medication. How should the nurse instruct the unlicensed assistive personnel (UAP) who is also caring for this client? 1. Have the UAP assess for any unexpected effects from the medication. 2. Tell the UAP to teach the clients family what to expect from the medication. 3. Have the UAP look the medication up in a drug reference book to read about drug actions and possible side effects. 4. Give the UAP specific instructions regarding what drug actions or side effects to report to the nurse.

Correct Answer: 4 Rationale 1: The UAP does not have the skills or legal responsibility to assess the client. Rationale 2: It is the nurses responsibility to teach the client or family about the medications. Rationale 3: The nurse should not expect that the UAP can determine from the drug reference book what drug actions and possible side effects are pertinent to this client. Rationale 4: The nurse should give the UAP specific instructions about what drug actions or side effects should be reported to the nurse. The UAP does not have the skills or legal responsibility to assess the client, but can collect data to report to the nurse.

The 154-pound adult client has had vomiting and diarrhea for 4 days secondary to a viral infection. What hourly urine measurement would indicate that efforts to rehydrate this client have not yet been successful and should continue? 1. 35 mL per hour 2. 80 mL per hour 3. 50 mL per hour 4. 30 mL per hour

Correct Answer: 4 Rationale 1: This is the expected urine output and would be considered successful. Rationale 2: This volume of urine output means efforts to rehydrate the client have been successful. Rationale 3: This volume of urine output indicates efforts to rehydrate the client have been successful. Rationale 4: Normal urine output for adult clients is at least 0.5 mL/kg/hour. This client weighs 70 kg, so adequate urine output would be 35 mL/hour. A urine output of 30/mL/hr indicates that efforts at rehydration have not been successful.

An adult client is prescribed the hepatitis B vaccination. The nurse will administer this medication through which site? 1. Dorsogluteal 2. Rectus femoris 3. Vastus lateralis 4. Deltoid

Correct Answer: 4 Rationale 1: Using the dorsogluteal site can lead to nerve damage, and is not recommended as a site for intramuscular injections. Rationale 2: The rectus femoris muscle is used only occasionally for intramuscular injections because it is painful. Rationale 3: The vastus lateralis muscle is recommended for infants younger than 1 year of age, although it can be used for clients of all ages. Rationale 4: The deltoid muscle is not used often for intramuscular injections because it is a relatively small muscle and is very close to the radial nerve and radial artery. It is sometimes considered for use in adults because of rapid absorption from the deltoid area, but no more than 1 mL of solution can be administered. This site is recommended for the administration of hepatitis B vaccine in adults.

A client weighing 220 lbs. is prescribed to receive 25 mg/kg of a medication, divided over 4 equal doses. How many mg of the medication should the nurse provide for each dose? Standard Text: Round to the nearest whole number.

Correct Answer: 625 mg Global Rationale: First determine the clients weight in kg by dividing the weight in lbs. by 2.2, or 220/2.2 = 100 kg. Then multiply the prescribed dose of 25 mg x 100 kg = 2500 mg. Then divide the total mg dose by 4, or 2500/4 = 625 mg. The nurse should provide 625 mg of the medication for each dose.