Question 1

A nurse is giving discharge instructions to a client with myasthenia gravis about reducing the risk for aspiration when eating. Which of the following is not included in the teachings?
A)Encourage the client to sit up when eating.
B)Instruct the client to cut his food into small pieces.
C)Instruct the client to tip the chin down to swallow.
D)Advise the client to lift his head upward when drinking.

Accepted Answer

The client should not lift the head when swallowing or drinking. Lifting the head upward opens the glottis, which increases the risk for aspiration. The other instructions are included in the teaching.

Question 2

A nurse is caring for an eighty-year-old female client who is bedridden. The nurse would include the following nursing actions in the care plan, to prevent respiratory complications, except:
A)Instruct the client to bear down and hold her breath every two hours
B)Monitor the client's vital signs every four hours
C)Turn the client every two hours
D)Teach the client deep breathing and coughing exercises

Accepted Answer

Bearing down and holding the breath must be avoided. Teaching deep breathing exercises, frequent turning, and increasing the client's fluid intake can prevent pooling of thick respiratory secretions. Frequent monitoring of vital signs can help identify early signs of infections, such as an increased body temperature.

Question 3

A nurse is caring for a client with major depression who is unable to do the activities of daily living. The nurse includes which nursing action in the care plan?
A)Encourage the client's peers to confront the client and let him know the effects of noncompliance to the rest of the group.
B)Perform the ADLs for the client until the client can complete these activities independently.
C)Structure the client's day to provide adequate time for the completion of ADLs.
D)Sit with the client and work on the schedule, allowing the client to choose the time of the day when he can do his ADLs.

Accepted Answer

A client with major depression often displays lack of energy and interest to perform ADLs. The nurse can feed and bathe the client until he is well enough to complete these activities independently.

Question 4

The nurse is teaching a male client who is being prescribed amitriptyline hydrochloride (Elavil). The client needs further teaching if he states which of the following?
A)"I will avoid alcoholic beverages."
B)"It may take around two to four weeks before the medication's desirable effects are evident."
C)"I should immediately stop taking the medication once I experience erection disturbances."
D)"I may take the medication with food or milk if gastrointestinal distress occurs."

Accepted Answer

Erection or ejaculatory disturbances are a side effect of tricyclic antidepressants. In case of the development of side effects, a physician consultation is necessary for dose readjustment or change of drug. If a psychotropic medication is to be discontinued, it should be tapered gradually.

Question 5

A client arrives in the emergency department complaining of left-sided substernal chest pain, unrelieved by nitroglycerin. Which of the following is the immediate action of the nurse?
A)Administration of morphine
B)Administration of supplemental oxygen
C)Provide a calm environment with minimal stimulation
D)Assessment of the heart's electrical activity through the ECG

Accepted Answer

Administering supplemental oxygen should take priority when caring for a client suspected of myocardial infarction. Oxygen supply to the myocardium is severely inefficient during a myocardial infarction and further delay may result in irreversible damages. The other options are appropriate nursing actions, but they are done after the initiation of oxygen administration.

Question 6

A physician orders potassium chloride 25 mEq to be added to 1000 ml of normal saline solution to be administered over an 8-hour period. The label on the potassium chloride bottle reads 40 mEq per 20 ml. The nurse determines that the correct number of milliliters of potassium chloride to be added is:
A)10 ml
B)12.5 ml
C)15 ml
D)17.5 ml

Accepted Answer

To obtain the correct dose, use the medication calculation formula:
Desired_ x ml = milliliters per dose
Available
25 x 20 ml = 12.5 ml
40

Question 7

A physician orders ceftizoxime sodium, 1 mg in 50 ml normal saline to be infused over 30 minutes. The drop factor is 15 drops per ml. A nurse prepares the flow rate at how many drops per minute?
A)20 drops
B)25 drops
C)30 drops
D)35 drops

Accepted Answer

To obtain flow rate, use the IV flow rate formula:
Total volume x drop factor = drops per minute
Time in minutes
50 ml x 15gtts/ml = 25 drops per minute
30 minutes

Question 8

A physician orders regular insulin at 10 units per hour to be administered by IV infusion pump. An IV infusion bag is labeled 100 units of regular insulin in 500 ml of 5% dextrose in water. The nurse prepares to set the infusion pump at how many millimeters per hour?
A)10 ml
B)20 ml
C)50 ml
D)100 ml

Accepted Answer

Initially, determine the number of insulin in 1 ml, and then calculate for the infusion rate.
Step 1:
Known amount of insulin in solution = Amount of insulin per ml
Total volume of diluent
100 units = 0.2 unit/ml
500 ml
Step 2:
Dose per hour desired = milliliters per hour
Concentration per ml
10 units per hour = 50 milliliters per hour
0.2 unit/ml

Question 9

A nurse is giving medication instructions to a client who has been prescribed phenytoin. Which of the following statements, if made by the client, indicates a need for further teaching about taking phenytoin?
A)"I need to avoid alcohol while on this medication."
B)"I need to call my physician if my gums bleed."
C)"Pink to red urine is harmless."
D)"I should take my medication with milk."

Accepted Answer

Phenytoin should be taken with food to decrease gastrointestinal irritation, but milk must be avoided as it can impair its absorption. The other options are accurate.

Question 10

A client with chest pain is prescribed nitroglycerin ointment. The nurse determines that the medication is best applied on:
A)Any non-hairy skin area
B)Any bony prominence
C)Any muscular area
D)Any area near the heart

Accepted Answer

The nurse would apply the ointment onto a non-hairy skin area, usually the chest, back or the upper arm, using a dose-measuring application paper. The ointment is spread in a thin, uniform layer without rubbing or massaging into the skin. It is recommended to avoid nitroglycerin ointment application on distal parts of extremities, on irritated skin, or on scarred skin, which can impair its absorption.

Question 11

A nurse is teaching a client who has just been prescribed aluminum hydroxide. The nurse would instruct the client to do which of the following?
A)Swallow the tablet with a glass of water.
B)Chew the tablet thoroughly and drink ½ cup of water.
C)Crush the tablet and add it to a glass of water.
D)Take aluminum hydroxide with a laxative.

Accepted Answer

Aluminum hydroxide tables should be chewed thoroughly before drinking ½ cup of water. This medication can cause constipation; however, laxatives must be avoided to prevent laxative abuse. It is best to make use of non-pharmacologic methods to prevent constipation, such as increasing the intake of fiber.

Question 12

The physician orders the attachment of a client's nasogastric tube to intermittent suction. The nurse attaches the suction, keeping in mind that the pressure should not exceed:
A)25 mm Hg
B)20 mm Hg
C)15 mm Hg
D)10 mm Hg

Accepted Answer

If a nasogastric tube is ordered to be attached to intermittent suction, the pressure must not exceed 25 mm Hg. Using excess pressure can damage the gastric mucosa.

Question 13

The nurse is giving discharge instructions to a client diagnosed with tuberculosis. Which of the following, if stated by the client, indicates that he understands the instructions?
A)"I need to have my own set of eating utensils until I am no longer infectious."
B)"My clothes should be washed with bleach to prevent bacterial transmission."
C)"I need to cover my mouth with a tissue when coughing."
D)"I can return to work when the chest X-ray film reveals negative signs for tuberculosis."

Accepted Answer

Tuberculosis is transmitted by droplet nuclei or through the airborne route. The infection is not spread through inanimate objects. Return to work is only allowed after obtaining three negative sputum tests.

Question 14

The nurse is caring for an older client confined to bed. To reduce the risk of a pressure ulcer, the most appropriate action of the nurse is to:
A)Encourage the client to increase his intake of foods high in protein.
B)Massage the bony prominences every 2 hours.
C)Turn the client every 3 hours.
D)Apply lotion in generous amounts to keep the skin from drying.

Accepted Answer

Prevention of pressure ulcers is achieved through increased intake of foods high in protein to keep the skin healthy and to avoid skin breakdown. Inadequate protein intake encourages skin breakdown, impairing tissue healing. Massaging bony prominences and reddened areas increases the risk of skin breakdown. Turning is recommended at least once every 2 hours. Application of lotion can keep the skin moisturized; however, without proper nutrition, this intervention becomes ineffective.

Question 15

A nurse reviews the serum laboratory tests of a male client scheduled for cholecystectomy. Which of the following laboratory results should alert the nurse, as it can be a reason to postpone the surgery?
A)BUN = 20 mg/dL
B)Hematocrit = 30%
C)Platelets = 200,000 cells/µL
D)Potassium = 4.0 mEq/L

Accepted Answer

The routine screening tests before surgery include a complete blood count, coagulation studies, serum electrolyte tests, and serum creatine. The results are within the normal range except for hematocrit, which has a normal range of 42 to 52% for males.

Question 16

A nurse is obtaining the vital signs of a client with increased intracranial pressure. The nurse determines that which of the following findings suggest an increase of ICP?
A)Increased temperature, increased pulse rate, and a fall in blood pressure with widening pulse pressure
B)Increased temperature, slowing of pulse, and a rise in blood pressure with widening pulse pressure
C)Decreased temperature, slowing of pulse, and a rise in blood pressure with narrowing pulse pressure
D)Decreased temperature, increased pulse rate, and a fall in blood pressure with narrowing pulse pressure

Accepted Answer

Changes in vital signs occur during increased intracranial pressure. Increased temperature, decreased pulse rate, increased blood pressure with widening pulse pressure, and decreased respiratory rate are observed with increased ICP.

Question 17

A nurse is caring for a client who is receiving hemodialysis. Which of the following signs and symptoms should alert the nurse that the client is having disequilibrium syndrome?
A)Increased blood pressure, increased pulse rate, and fever
B)Hypotension, increased pulse rate, and hypothermia
C)Headache, confusion, and twitching
D)Restlessness, agitation, and hypotension

Accepted Answer

Disequilibrium syndrome is manifested by hypertension, headache, confusion, restlessness, agitation, vomiting, and twitching. It is caused by the more rapid removal of solutes from the blood than from the cerebrospinal fluid, resulting in cerebral edema.

Question 18

A nurse is caring for a client 24 hours after an ostomy has been created for the treatment of ulcerative colitis. The nurse determines that the following actions are appropriate except:
A)Administer Demerol 50 mg IM
B)Place petrolatum gauze over the stoma
C)Irrigate the colostomy
D)Notify the physician with the occurrence of purple-black stoma

Accepted Answer

A colostomy begins to function between three and six days after the surgery; therefore, colostomy irrigation is not appropriate at this time. Irrigation stimulates bowel emptying. Administration of pain medications and application of petrolatum gauze over the stoma are appropriate nursing actions. A pink to red and moist stoma indicates good circulation, whereas, a dusky, purplish stoma indicates inadequate blood supply to the stoma. A brown to black and dry stoma is indicative of necrosis.

Question 19

A client in her third trimester is admitted due to painless, bright red vaginal bleeding. The vital signs were obtained and the external monitor has been applied. What is the next action of the nurse?
A)Develop a nursing care plan for an emergency caesarean delivery.
B)Place the client on her left side.
C)Perform vaginal examination.
D)Insert a urinary catheter.

Accepted Answer

The nurse puts the client on her left side, improving fetal circulation. The need for an immediate caesarean delivery has to be evaluated further. The nurse must not attempt to perform a vaginal examination or insert a urinary catheter, as it could stimulate further bleeding.

Question 20

A nurse is applying a compression bandage around the client's leg. Which of the following describes the appropriate application of a compression bandage?
A)Apply the bandage at the knee and work toward the calf.
B)Stretch the bandage slightly with each turn.
C)Apply heavy pressure with each turn.
D)Apply the bandage around the knee, work toward the calf and apply the bandage down the calf again.

Accepted Answer

Stretching the elastic band slightly with each turn prevents circulatory impairment and maintains uniform tension. The bandage should be applied from the farthest to the nearest, or in this case, from the client's calf to the knee. Bandaging down is not recommended.

Quiz 1: Changes in Health

A nurse is giving discharge instructions to a client with myasthenia gravis about reducing the risk for aspiration when eating. Which of the following is not included in the teachings?

A nurse is caring for an eighty-year-old female client who is bedridden. The nurse would include the following nursing actions in the care plan, to prevent respiratory complications, except:

A nurse is caring for a client with major depression who is unable to do the activities of daily living. The nurse includes which nursing action in the care plan?

The nurse is teaching a male client who is being prescribed amitriptyline hydrochloride (Elavil) . The client needs further teaching if he states which of the following?

A client arrives in the emergency department complaining of left-sided substernal chest pain, unrelieved by nitroglycerin. Which of the following is the immediate action of the nurse?

A physician orders potassium chloride 25 mEq to be added to 1000 ml of normal saline solution to be administered over an 8-hour period. The label on the potassium chloride bottle reads 40 mEq per 20 ml. The nurse determines that the correct number of milliliters of potassium chloride to be added is:

A physician orders ceftizoxime sodium, 1 mg in 50 ml normal saline to be infused over 30 minutes. The drop factor is 15 drops per ml. A nurse prepares the flow rate at how many drops per minute?

A physician orders regular insulin at 10 units per hour to be administered by IV infusion pump. An IV infusion bag is labeled 100 units of regular insulin in 500 ml of 5% dextrose in water. The nurse prepares to set the infusion pump at how many millimeters per hour?

A nurse is giving medication instructions to a client who has been prescribed phenytoin. Which of the following statements, if made by the client, indicates a need for further teaching about taking phenytoin?

A client with chest pain is prescribed nitroglycerin ointment. The nurse determines that the medication is best applied on:

A nurse is teaching a client who has just been prescribed aluminum hydroxide. The nurse would instruct the client to do which of the following?

The physician orders the attachment of a client's nasogastric tube to intermittent suction. The nurse attaches the suction, keeping in mind that the pressure should not exceed:

The nurse is giving discharge instructions to a client diagnosed with tuberculosis. Which of the following, if stated by the client, indicates that he understands the instructions?

The nurse is caring for an older client confined to bed. To reduce the risk of a pressure ulcer, the most appropriate action of the nurse is to:

A nurse reviews the serum laboratory tests of a male client scheduled for cholecystectomy. Which of the following laboratory results should alert the nurse, as it can be a reason to postpone the surgery?

A nurse is obtaining the vital signs of a client with increased intracranial pressure. The nurse determines that which of the following findings suggest an increase of ICP?

A nurse is caring for a client who is receiving hemodialysis. Which of the following signs and symptoms should alert the nurse that the client is having disequilibrium syndrome?

A nurse is caring for a client 24 hours after an ostomy has been created for the treatment of ulcerative colitis. The nurse determines that the following actions are appropriate except:

A client in her third trimester is admitted due to painless, bright red vaginal bleeding. The vital signs were obtained and the external monitor has been applied. What is the next action of the nurse?

A nurse is applying a compression bandage around the client's leg. Which of the following describes the appropriate application of a compression bandage?