Nur125 ATI Practice Assessment B

A nurse is providing teaching for a client who is newly diagnosed with type 2 diabetes mellitus and has a prescription for glipizide. Which of the following statements by the nurse best describes the action of glipizide? "Glipizide absorbs the excess carbohydrates in your system." "Glipizide stimulates your pancreas to release insulin." "Glipizide replaces the insulin that is not being produced by your pancreas." "Glipizide prevents your liver from destroying your insulin."

"Glipizide stimulates your pancreas to release insulin." Glipizide is an oral antidiabetic medication in the pharmacological classification of sulfonylurea agents. These medications help to lower blood glucose levels in clients who have type 2 diabetes mellitus using several methods, including reducing glucose output by the liver, increasing peripheral sensitivity to insulin, and stimulating the release of insulin from the functioning beta cells of the pancreas.

A nurse is preparing a presentation about glucosamine to a group of clients. Which of the following information should the nurse incude in the teaching?

"Glucosamine can suppress joint inflammation." The nurse should include in the teaching that glucosamine suppresses joint inflammation and cartilage degradation by stimulating the activity of chondrocytes.

A nurse is preparing to administer 10 units of regular insulin and 20 units of NPH insulin to a client. What is the sequence of events the nurse should follow?

1. inspect vials for contaminants 2. roll nph vial between palms of hands 3. inject air into nph 4. inject air into regular 5. withdraw short acting 6. add intermediate insulin to syringe

A nurse is providing discharge teaching to the parent of a child who is prescribed diphenhydramine 25 mg elixir every 4 hr as needed. The amount available is diphenhydramine elixir 12.5 mg/5 mL. How many ml should the nurse administer per dose?

10 mL Desired x Quantity/Have = X 25 mg x 5 mL/12.5 mg = X mL 10 = X STEP 7: Round if necessary. STEP 8: Reassess to determine whether the amount to administer makes sense. If there are 12.5 mg/5 mL and the prescription reads 25 mg, it makes sense to administer 10 mL. The nurse should administer diphenhydramine 10 mL elixir PO.

A nurse is preparing to administer desmopressin 0.2 mg daily to a client. Available is desmopressin 0.1 mg tablets. How many tablets should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero).

2 Desired x Quantity/Have = X 0.2 mg x 1 tablet/0.1 mg = X tablet X = 2 tablets STEP 7: Round if necessary. STEP 8: Reassess to determine whether the amount to administer makes sense. If there is 0.1mg/tablet and the prescription reads 0.2 mg, it makes sense to administer 2 tablets. The nurse should administer desmopressin 2 tablets PO.

A nurse is preparing to administer digoxin 0.25 mg PO daily. The amount available is 0.125 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero).

2 Desired x Quantity/Have = X 0.25 mg x 1 tablet/0.125 mg = X tablet 2 = X

A nurse is preparing to administer potassium chloride 20 mEq suspension PO daily. The amount available is potassium chloride suspension 10 mEq /mL. How many mL should the nurse administer?

2 Desired x Quantity/Have = X 20 mEq x 1 mL/10 mEq = X mL 2 = X STEP 7: Round if necessary. STEP 8: Reassess to determine whether the amount to administer makes sense. If there are 10 mEq/mL and the provider prescribed 20 mEq, it makes sense to administer 2. The nurse should administer potassium chloride 20 mEq suspension PO daily.

A nurse is reviewing the medication administration records from the previous shift. Which of the following findings should indicate to the nurse a need for an incident report? A. A client received gentamicin intermittent IV bolus over 1 hr. B. A nurse used a 25-gauge 3/8 inch needle to administer a heparin injection. C. A nurse injected Demerol IM into the vastus lateralis site of adult. D. A client received a crushed bupropion XL tablet mixed with applesauce

A client received a crushed bupropion XL tablet mixed with applesauce Extended or sustained release medications are intended to release medication levels over a long period of time to sustain therapeutic relief. Crushing, breaking, or chewing an extended release medication releases the medication at once into the bloodstream and could be life-threatening. Mixing this medication in applesauce deviates from standard of care and requires the nurse to complete an incident report.

A nurse is caring for a client who has diabetes insipidus and is receiving vasopressin. The nurse should identify which of the following findings as an indication that the medication is effective?

A decrease in urine output The major manifestations of diabetes insipidus are excessive urination and extreme thirst. Vasopressin is used to control frequent urination, increased thirst, and loss of water associated with diabetes insipidus. A decreased urine output is the desired response.

A nurse is caring for a client who has cancer and a new prescription for ondansetron to treat chemotherapy-induced nausea. For which of the following adverse effects should the nurse monitor? A. Headache B. Dependent edema C. Polyuria D. Photosensitivity

A. Headache Headache is a common adverse effect of ondansetron. Analgesic relief is often required

A nurse is assessing a client who reports acute pain. The nurse should anticipate which of the following findings? A. Increased heart rate B. Decreased respiratory rate C. Hyperactive bowel sounds D. Decreased blood pressure

A. Increased heart rate Acute pain stimulates the sympathetic nervous system and can cause an increase in heart rate. Acute pain can cause tachypnea. Acute pain can cause pallor and diaphoresis. Acute pain can cause increased blood pressure.

A nurse is teaching a client who has a new prescription for regular insulin and NPH insulin. Which of the following instructions should the nurse include in the teaching? A. Keep the open vial of insulin at room temperature B. Inject the insulin into a large muscle C. Aspirate the medication prior to administration D. Administer the insulin in two separate injections

A. Keep the open vial of insulin at room temperature The client should keep the vial in use at room temperature to minimize tissue injury and to reduce the risk for lipodystrophy.

A nurse is assessing a client who is taking oxacillin to treat an infection. The nurse should recognize which of the following findings is a manifestation of an allergic reaction? A. Pruritis B. Diarrhea C. Dark urine D. Fever

A. Pruritis An allergic reaction is an immune response that can manifest as pruritus and urticaria and can progress to anaphylaxis.

The nurse is providing instructions about bowel cleansing with polyethylene glycol-electrolyte solution (PEG) for a client who is going to have a colonoscopy. Which of the following information should the nurse include?

Abdominal bloating might occur While PEG is well-tolerated, adverse effects include nausea, bloating, and abdominal discomfort.

A nurse is teaching a client who has a new diagnosis of asthma. Which of the following medications should the nurse instruct the client to use to abort an acute asthma attack?

Albuterol. It is an inhaled short-acting beta2 agonist (beta2-adrenergic agonist) used as a rescue medication to relieve an acute asthma attack. Albuterol dilates the airways, decreases wheezing, and improves oxygenation.

A nurse is teaching a client who has diabetes mellitis and a new prescription for a rash. Which of the following statements by the client indicates the need for further teaching? A. "I might need to decrease my regular insulin during this time." B. "I will gradually stop the prednisone when my rash goes away." C. "I might feel a little emotional when I am on this medicine." D. "I might have a hard time falling asleep while taking prednisone."

B. "I will gradually stop the prednisone when my rash goes away." The pt should discontinue glucocorticoids gradually to reduce risk for adrenal insufficiency. Manifestations of adrenal insufficiency include nausea, vomiting, confusion, & hypotension. Glucocorticoids can cause hyperglycemia, pts might req. reduced calories and increased hypoglycemic meds, mood changes, irritability, and insomnia are adverse rxns, pt should report severe psychological disturbances, like hallucinations or depression.

A nurse is teaching a client who is taking metronidazole. Which of the following sense alterations should the nurse include as an adverse effect of metronidazole? A. Olfactory changes B. Metallic taste C. Alterations in touch D. Hearing loss

B. Metallic taste Metronidazole is an antiprotozoal medication that treats giardiasis and trichomoniasis. It most common adverse effects are headaches, nausea, dry mouth, and an unpleasant metallic taste in their mouth.

A nurse is teaching a client who has a new prescription for ibuprofen to treat hip pain. Which of the following instructions should the nurse include in the teaching? A. Expect ringing in your ears. B. Take the medication with food. C. Store the medication in the refrigerator. D. Monitor for weight loss

B. Take the medication with food. To minimize gastric irritation, the client should take ibuprofen with food or immediately after a meal.

A nurse is caring for a client who asks how albuterol helps his breathing. Which of the following responses should the nurse make? (Select all that apply). A. The medication will stimulate flow of mucous. B. The medication will prevent wheezing. C. The medication will open the airways. D. The medication will reduce inflammation. E. The medication will decrease coughing episodes.

B. The medication will prevent wheezing. C. The medication will open the airways. E. The medication will decrease coughing episodes. Expectorants, such as guaifenesin, stimulate the flow of mucous to produce a productive cough. Asthma is characterized by bronchoconstriction, airway edema, and increased mucus production. Albuterol relaxes the airways, allowing for expectoration of mucus. Albuterol is used to prevent or treat wheezing. Albuterol is used to prevent or treat wheezing. Albuterol promotes bronchodilation. The primary purpose is to provide rapid relief of bronchoconstriction, thus opening the airway and improving oxygenation. Albuterol does not reduce inflammation. Glucocorticoid medications reduce inflammation. Coughing is often an early indicator of bronchospasm. Albuterol provides a rapid response to relax smooth muscle and reduce bronchoconstriction, which will decrease coughing.

A nurse at an ophthalmology clinic is providing teaching to a client who has open-angle glaucoma and a new treatment regimen of timolol and pilocarpine eye drops. Which of the following instructions should the nurse provide? A) administer the medication by touching the tip of the dropper to the square of the I B) hold pressure on the conjunctiva sac for two minutes following the application drop C) administer the medication five minutes apart D) it is not necessary to remove contact lenses before administering

C) administer the medication five minutes apart The nurse should instruct the client that, if more than one ophthalmic medication is to be administered, they should be given five minutes apart

A nurse is teaching a client who has diabetes mellitis and a new prescription for glimiperide. The nurse should teach the client to avoid which of the following drinks while taking this medication? A. Grapefruit juice B. Milk C. Alcohol D. coffee

C. Alcohol The nurse should teach the client to avoid alcohol while taking this medication to prevent a disulfiram reaction, such as nausea, headache, and hypoglycemia.

A nurse is providing teaching to a client who has emphysema and a new prescription for theophylline. Which of the following instructions should the nurse provide? A. Consume a high-protein diet. B. Administer the medication with food. C. Avoid caffeine while taking this medication. D. Increase fluids to 1L/day.

C. Avoid caffeine while taking this medication. Rationale: A. The nurse should instruct the client that a high-protein diet should be avoided, as it decreases theophylline's duration of action. B. The nurse should instruct the client that theophylline should be administered with 8 oz. of water if GU upset occurs. It should not be administered with food. C. The nurse should instruct the client that caffeine should be avoided while taking theophylline, as it can increase central nervous system stimulation. D. The nurse should instruct the client to increase fluid intake to 2L/day while taking theophylline to decrease the thickness of mucous secretions related to emphysema.

A nurse is providing discharge teaching to a client who has asthma and a new prescription for fluticasone/salmeterol. For which of the following adverse effects should the nurse instruct the client to report to the provider? A. Sedation B. Increased appetite C. White coating in the mouth D. Dry oral mucous membrane

C. White coating in the mouth

A nurse is caring for a client who has diabetes and a new prescription for 14 units of regular insulin and 28 units of NPH insulin subcutaneously at breakfast daily. What is the total number of units of insulin that the nurse should prepare in the insulin syringe? A. 14 B. 28 C. 32 D. 42

D. 42 Each order of for units of insulin is combined in the same syringe. The nurse should withdraw the regular insulin into the syringe first.

A nurse is teaching a client who has a new prescription for NPH insulin. Which of the following instructions should the nurse include? A. Discard the medication if it is cloudy B. Briskly shake the medication before filling the syringe. C. Take this medication 15 minutes before meals D. Eat a snack 8 hours after taking this medication

D. Eat a snack 8 hours after taking this medication

A nurse is providing discharge instructions to a client who has asthma and is about to take theophylline (Theo-24). The nurse should tell the client that this medication might cause which of the following adverse effects? A. Drowsiness B. Constipation C. Oliguria D. Tachycardia

D. Tachycardia A. Theophylline is more likely to cause insomnia than drowsiness. B. Theophylline is more likely to cause diarrhea than constipation. C. Theophylline is more likely to cause urinary frequency than oliguria. D. Theophylline can cause cardiac stimulation and cause tachycardia.

A nurse is teaching a client how to draw up regular insulin and NPH insulin into the same syringe. Which of the following actions should the nurse include?

Discard regular insulin that appears cloudy The nurse should teach the client to discard any regular insulin that appears cloudy, as regular insulin should be clear. NPH insulin has a cloudy appearance.

A nurse is administering timolol eye drops to a client who has glaucoma. Which of the following actions should the nurse take? A. Apply pressure to the bridge of the nose after administration. B. Wipe the eye from the outer canthus to the inner canthus before instillation. C. Drop the prescribed amount of medication into the conjunctival sac. D. Protect the distal portion of the eyedropper using clean technique.

Drop prescribed amount of medication into the conjunctival sac. MY ANSWER With the dominant hand resting on client's forehead, hold filled medication eyedropper or ophthalmic solution approximately 1 - 2 cm above conjunctival sac. Instill prescribed number of medication drops into the conjunctival sac. After instilling the drops, ask the client to close his eye gently. If the client is to receive more than one eye medication to the same eye, wait at least 5 min before administering the next medication.

A nurse caring for a client who reports taking bisacodyl to promote a daily bowel movement. Which of the following assessment questions should be the nurses priority? A. What do your bowel movements look like? B. How long have you been taking the bisacodyl? C. Do you take bisacodyl with milk? D. How often do you have a bowel movement?

How long have you been taking the bisacodyl? The greatest risk to this client is injury from dependency on laxatives, as bowel tone can be lost; therefore, the priority question the nurse should ask the client is how long he has been using bisacodyl.

A nurse is reviewing the medical record of a client who reports taking pseudoephedrine for sinus congestion as needed. The nurse should identify that pseudoephedrine is contraindicated for which of the following client conditions? A. Eczema B. Migraines C. Hypertension D. Diverticulitis

Hypertension Clients who have hypertension or acute coronary syndrome should speak with their provider prior to taking decongestants, because of the potential for vasoconstriction, which would aggravate the chronic condition.

A nurse is evaluating teaching with a client who is receiving continuous subcutaneous insulin via an external insulin pump. Which of the following statements by the client indicates a need for further teaching?

I will use insulin glargine in my insulin pump The client should use a short-acting insulin in the insulin pump. The insulin pump is designed to administer rapid-acting or short-acting insulin 24 hr a day. Insulin glargine is classified as a long-acting insulin and is administered at the same time each day to maintain stable blood glucose concentration for a 24-hr period.

A nurse is reviewing the medical record of a client who has been on levothyroxine for several months. Which of the following findings indicates a therapeutic response to the medication? Decrease in level of thyroid stimulating hormone (TSH)

In hypothyroidism, the nonfunctioning thyroid gland is unable to respond to the TSH, and no endogenous thyroid hormones are released. This results in an elevation of the TSH level as the anterior pituitary continues to release the TSH to stimulate the thyroid gland. Administration of exogenous thyroid hormones, such as levothyroxine, turns off this feedback loop, which results in a decreased level of TSH.

A nurse is caring for a client who has developed agranulocytosis as a result of taking propylthiouracil to treat hyperthyroidism. The nurse should understand that this client is at risk for which of the following conditions? A. Excessive bleeding B. Ecchymosis C. Infection D. Hyperclycemia

Infection Agranulocytosis is a failure of the bone marrow to make enough white blood cells, causing neutropenia and lowering the body defenses against infection.

A nurse is assessing a client who is taking levothyroxine. The nurse should recognize that which of the following findings is a manifestation of levothyroxine overdose?

Insomnia Levothyroxine overdose will result in manifestations of hyperthyroidism, which include insomnia, tachycardia, and hyperthermia

A nurse is providing teaching to a client who has diabetes and a new prescription for insulin glargine. Which of the following instructions should the nurse provide regarding this type of insulin?

Insulin glargine is a long duration insulin that has a duration of 18 to 24 hr. It is only dosed once a day.

A nurse is teaching a client who has a new prescription for erythromycin. Which of the following information should the nurse include? Ototoxicity is an adverse effect of erythromycin. The client should monitor and report manifestations of ototoxicity, such as tinnitus, dizziness, and vertigo.

Monitor for ringing in ears

A nurse is caring for a newborn who has respiratory depression. Which of the following medications should the nurse anticipate administering?

Naloxone

A nurse is reviewing the medication list for a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize which of the following medications can cause glucose intolerance?

Prednisone Corticosteroids such as prednisone can cause glucose intolerance and hyperglycemia. The client might require increased dosage of a hypoglycemic medication.

A nurse is providing teaching to a client who has a new diagnosis of hypothyroidism. On which of the following medications should the nurse prepare to instruct the client? a. radioactive iodine b. levothyroxine c. sumatriptan d. levofloxacin

Radioactive iodine is an anti-thyroid medication that is used to treat thyroid cancer, hyperthyroidism and as a diagnostic aid for thyroid function studies. It is not used in the treatment of hypothyroidism. !!! Levothyroxine is a synthetic thyroid hormone that is chemically identical to thyroxine (T4). It is used in the treatment of hypothyroidism. The nurse should prepare to instruct the client on the use of this medication. Sumatriptan is an anti-migraine agent used for acute treatment migraine and cluster headaches. It is not used in the treatment of hypothyroidism. Levofloxacin is a broad spectrum anti-infective of the quinolone class that is used to treat infections of the sinuses, skin, lungs, ears, airways, bones, joints, and urinary tract. It is not used in the treatment of hypothyroidism.

The nurse is reviewing the medication list for a client who has a new diagnosis of a small bowel obstruction. The nurse should withhold which of the following medications?

Senna Laxatives are contraindicated in clients who have fecal impaction, bowel obstruction, and acute abdominal surgery to prevent perforation. Because the bowel does not allow for any passage of stool with a complete small bowel obstruction, laxatives will cause increased abdominal cramping and discomfort.

A nurse is providing teaching to a client who has a new prescription for levothyroxine for hypothyroidism. The nurse should instruct the client to avoid which of the following herbal supplements? Saw palmetto Cranberry Soy Garlic

Soy Saw palmetto can increase the risk for bleeding in clients who take anticoagulants or antiplatelet medications. Cranberry juice can increase the risk for uric acid kidney stones and can also increase the risk of bleeding in clients who take warfarin. The nurse should instruct the client to avoid soy because soy can reduce the effectiveness of the levothyroxine. Garlic can increase the risk for bleeding in clients who take anticoagulants or antiplatelet medications.

A nurse is providing teaching to a client who has peptic ulcer disease and a new prescription for sucralfate tablets. Which of the following information should the nurse provide? A. "An antacid may be taken with the medication if indigestion occurs." B. "Take sucralfate 1 hr before meals" C. "Take the tablets whole" D. "Store sucralfate in the refrigerator."

Take before meals Sucralfate is a mucosal protectant. The client should take it on an empty stomach, 1 hr before meals, for maximum effectiveness.

A nurse is assessing a client before administering a seasonal influenza vaccine. The client says he read about an influenza vaccine that is given as a nasal spray and wants to receive it. The nurse should recognize which of the following findings is a contraindication for the client receiving the live attenuated influenza vaccine:

The client's age is 62 Clients must be between the ages of 2 and 49 to receive the LIAV; therefore, it is contraindicated for this client. Pregnancy and immunocompromised status are also contraindications.

A nurse at an ophthalmology clinic is providing teaching to a client who has open angle glaucoma and a new prescription for timolol eye drops. Which of the following instructions should the nurse provide?

The medication should be applied on a regular schedule for the rest of the client's life Medications prescribed for open angle glaucoma are intended to enhance aqueous outflow, or decrease its production, or both. The client must continue the eye drops on an uninterrupted basis for life to maintain intraocular pressure at an acceptable level.

A nurse is reviewing the medical record of a client who reports drinking three to four glasses of wine each night and taking 3,000 mg of acetaminophen daily. Which of the following laboratory values is the priority for the nurse to assess? A. Amylase B. Creatinine C. Aspartate aminotransferase (AST) D. Antidiuretic hormone (ADH)

The nurse should evaluate the client's amylase level to assess for pancreatitis. However, there is another laboratory value that is the nurse's priority. The nurse should evaluate the client's creatinine level to monitor renal function. However, there is another laboratory value that is the nurse's priority. The nurse should evaluate the ADH level of the client to assess for syndrome of inappropriate ADH, CNS infections, hypovolemia, and dehydration. However, there is another laboratory value that is the nurse's priority. MY ANSWER: C. Aspartate aminotransferase (AST) The greatest risk to this client is liver injury from the combined adverse effects of alcohol and acetaminophen. Therefore, the priority laboratory value for the nurse to evaluate is AST because an elevated level is an indication of liver damage.

A nurse is monitoring a client who took an overdose of acetaminophen 72 hours ago. The nurse should identify which of the following findings as a manifestation of acetaminophen poisoning. A. constipation B. Xerostomia C. Tinnitus D. Vomiting

VOMITING Diarrhea, not constipation, is an early manifestation of acetaminophen poisoning. Xerostomia, or dry mouth, is not an expected manifestation for a client who has acetaminophen poisoning. Tinnitus is an expected manifestation for a client who is taking NSAIDs, not for a client who has acetaminophen poisoning. The nurse should expect a client who has acetaminophen poisoning to have early manifestations of nausea, vomiting, abdominal distress, diarrhea, and sweating.

A nurse is planning to apply a transdermal analgesic cream prior to inserting an IV for a preschool-aged child. Which of the following actions should the nurse plan to take? (Select all that apply) A. Spread the cream over the lateral surface of both arms. B. Apply to intact skin. C. Apply the medication an hour before the procedure begins. D. Cleans the skin prior to procedure. E. Use a visual pain rating scale to evaluate the effectiveness of the treatment.

b. Apply to intact skin. c. Apply the medication an hour before the procedure begins. d. Cleanse the skin prior to procedure. e. Use a visual pain rating scale to evaluate effectiveness of the treatment.

A nurse is caring for a client who is receiving mydriatic eye drops. Which of the following manifestations indicates to the nurse that the client has developed a systemic anticholinergic effect? A. Seizures B. Bradycardia C. Constipation D. Hypothermia

constipation Mydriatic eye drops can cause systemic anticholinergic effects, such as constipation and dry mouth. Mydriatic eye drops are unlikely to cause seizures, but they can cause central nervous system effects such as delirium and coma. Mydriatic eye drops are more likely to cause tachycardia, not bradycardia. Mydriatic eye drops are more likely to cause fever than hypothermia.

A nurse is caring for a client who has HIV-1 infection and is prescribed zidovudine as part of antiretroviral therapy. The nurse should monitor the client for which of the following adverse effects of this medication: a. cardiac dysrhythmia b. metabolic alkalosis c. renal failure d. aplastic anemia

d. aplastic anemia Severe myelosuppression that results in anemia (decreased red blood cells), agranulocytosis (decreased white blood cells), and thrombocytopenia (decreased platelets) is a life-threatening adverse reaction to zidovudine therapy. Consequently, zidovudine must be used cautiously in clients already experiencing myelosuppression, and the client must be monitored with a CBC performed every few weeks for early detection of marrow failure, which may lead to aplastic anemia.

A nurse is caring for a client who has diabetes and plans to administer his regular insulin subcutaneously before he eats breakfast at 0800. After checking the client's morning glucose level, which of the following actions should the nurse take? a. give the insulin at 0700 b. give the insulin when the breakfast tray arrives c. give the insulin 30 min after breakfast w/ the client's other routine meds d. give the insulin at 0730

d. give the insulin at 0730

A nurse is providing teaching for a client who has diabetes and a new prescription for insulin glargine. Which of the following instructions should the nurse provide regarding the type of insulin?

insulin glargine has a duration for 18 to 24 hours