A client has an order for antibiotic therapy after hospital treatment of a staph infection. Which of the following should the nurse emphasize?
A) Scheduling follow-up blood cultures
B) Completing the full course of medications
C) Visiting the provider in a few weeks
D) Monitoring for signs of recurrent infection
Review Information: The correct answer is B: Completing the full course of medications
In order for antibiotic therapy to be effective in eradicating an infection, the client must compete the entire course of prescribed therapy. When findings subside, stopping the medication early may lead to recurrence or subsequent drug resistance.
A 72 year-old client is admitted for possible dehydration. The nurse knows that older adults are particularly at risk for dehydration because they have
A) an increased need for extravascular fluid
B) a decreased sensation of thirst
C) an increase in diaphoresis
D) higher metabolic demands
Review Information: The correct answer is B: a decreased sensation of thirst
The elderly have a reduction in thirst sensation causing them to consume less fluid. Other risk factors may include fear of incontinence, inability to drink fluids independently and lack of motivation.
A male client is admitted with a spinal cord injury at level C4. The client asks the nurse how the injury is going to affect his sexual function. The nurse would respond
A) "Normal sexual function is not possible."
B) "Sexual functioning will not be impaired at all."
C) "Erections will be possible."
D) "Ejaculation will be normal."
Review Information: The correct answer is C: "Erections will be possible."
Because they are a reflex reaction, erections can be stimulated by stroking the genitalia.
An 82 year-old client complains of chronic constipation. To improve bowel function, the nurse should first suggest
A) Increasing fiber intake to 20-30 grams daily
B) Daily use of laxatives
C) Avoidance of binding foods such as cheese and chocolate
D) Monitoring a balance between activity and rest
Review Information: The correct answer is A: Increasing fiber intake to 20-30 grams daily
The incorporation of high fiber into the diet is an effective way to promote bowel elimination in the elderly.
A 4 year-old child is admitted with burns on his legs and lower abdomen. When assessing the child’s hydration status, which of the following indicates a less than adequate fluid replacement?
A) Decreasing hematocrit and increasing urine volume
B) Rising hematocrit and decreasing urine volume
C) Falling hematocrit and decreasing urine volume
D) Stable hematocrit and increasing urine volume
Review Information: The correct answer is B: Rising hematocrit and decreasing urine volume
A rising hematocrit indicates a decreased total blood volume, a finding consistent with dehydration.
A client receiving chemotherapy has developed sores in his mouth. He asks the nurse why this happened. What is the nurse’s best response?
A) "It is a sign that the medication is working."
B) "You need to have better oral hygiene."
C) "The cells in the mouth are sensitive to the chemotherapy."
D) "This always happens with chemotherapy."
Review Information: The correct answer is C: "The cells in the mouth are sensitive to the chemotherapy."
The epithelial cells in the mouth are very sensitive to chemotherapy due to their high rate of cell turnover.
You are caring for a client with deep vein thrombosis who is on Heparin IV. The latest APTT is 50 seconds. If the laboratory normal range is 16-24 seconds, you would anticipate
A) maintaining the current heparin dose
B) increasing the heparin as it does not appear therapeutic.
C) giving protamine sulfate as an antidote.
D) repeating the blood test 1 hour after giving heparin.
Review Information: The correct answer is A: maintaining the current heparin dose
The range for a therapeutic APTT is 1.5-2 times the control. Therefore the client is receiving a therapeutic dose of Heparin.
A client is admitted with a diagnosis of nodal bigeminy. The nurse knows that the atrioventricular (AV) node has an intrinsic rate of
A) 60-100 beats/minute
B) 10-30 beats/minute
C) 40-70 beats/minute
D) 20-50 beats/minute
Review Information: The correct answer is C: 40-70 beats/minute
The intrinsic rate of the AV node is within the range of 40-70 beats per minute.
A client is to receive 3 doses of potassium chloride 10 mEq in 100cc normal saline to infuse over 30 minutes each. Which of the following is a priority assessment to perform before giving this medication?
A) Oral fluid intake
B) Bowel sounds
C) Grip strength
D) Urine output
Review Information: The correct answer is D: Urine output
Potassium chloride should only be administered after adequate urine output (>20cc/hour for 2 consecutive hours) has been established. Impaired ability to excrete potassium via the kidneys can result in hyperkalemia.
The unlicensed assistive personnel (UAP) reports to the nurse that a client with cirrhosis who had a paracentesis yesterday has become more lethargic and has musty smelling breath. A critical assessment for increasing encephalopathy is
A) monitor the client's clotting status
B) assess upper abdomen for bruits
C) assess for flap-like tremors of the hands
D) measure abdominal girth changes
Review Information: The correct answer is C: assess for flap-like tremors of the hands
A client with cirrhosis of the liver who develops subtle changes in mental status and has a musty odor to the breath is at risk for developing more advanced signs of encephalopathy.
A client is scheduled for an intravenous pyelogram (IVP). After the contrast material is injected, which of the following client reactions should be reported immediately?
A) Feeling warm
B) Face flushing
C) Salty taste
Review Information: The correct answer is D: Hives
This is a sign of anaphylaxis and should be reported immediately. The other reactions are considered normal and the client should be informed that they may occur.
A client is prescribed an inhaler. How should the nurse instruct the client to breathe in the medication?
A) As quickly as possible
B) As slowly as possible
C) Deeply for 3-4 seconds
D) Until hearing whistling by the spacer
Review Information: The correct answer is C: Deeply for 3-4 seconds
The client should be instructed to breath in the medication for 3-4 seconds in order to receive the correct dosage of medication.
The nurse is caring for clients over the age of 70. The nurse knows that due to age-related changes, the elderly clients tolerate diets that are
A) high protein
B) high carbohydrates
C) low fat
D) high calories
Review Information: The correct answer is C: low fat
Due to age related changes, the diet of the elderly should include a lower quantity and higher quality of food. Fewer carbohydrates and fats are required in their diets.
A woman with a 28 week pregnancy is on the way to the emergency department by ambulance with a tentative diagnosis of abruptio placenta. Which should the nurse do first when the woman arrives?
A) administer oxygen by mask at 100%
B) start a second IV with an 18 gauge cannula
C) check fetal heart rate every 15 minutes
D) insert urethral catheter with hourly urine outputs
Review Information: The correct answer is A: administer oxygen by mask at 100%
Administering oxygen in this situation would increase the circulating oxygen in the mother’s circulation to the fetus’s circulation. This action will minimize complications.
A client in respiratory distress is admitted with arterial blood gas results of: PH 7.30; PO2 58, PCO2 34; and HCO3 19. The nurse determines that the client is in
A) metabolic acidosis
B) metabolic alkalosis
C) respiratory acidosis
D) respiratory alkalosis
Review Information: The correct answer is A: metabolic acidosis
These lab values indicate metabolic acidosis: the PH is low, PCO2 is normal, and bicarbonate level is low.
A client is diagnosed with gastroesophageal reflux disease (GERD). The nurse's instruction to the client regarding diet should be to
A) avoid all raw fruits and vegetables
B) increase intake of milk products
C) decrease intake of fatty foods
D) focus on 3 average size meals a day
Review Information: The correct answer is C: decrease intake of fatty foods
GERD may be aggravated by a fatty diet. A diet low in fat would decrease the symptoms of GERD. Other agents which should also be decreased or avoided are: cigarette smoking, caffeine, alcohol, chocolate, and meperidine (Demerol).
After surgery, a client with a nasogastric tube complains of nausea. What action would the nurse take?
A) Call the health care provider
B) Administer an antiemetic
C) Put the bed in Fowler’s position
D) Check the patency of the tube
Review Information: The correct answer is D: Check the patency of the tube
An indication that the nasogastric tube is obstructed is a client’s complaint of nausea. Nasogastric tubes may become obstructed with mucus or sediment.
A client with testicular cancer has had an orchiectomy. Prior to discharge the client expresses his fears related to his prognosis. Which principle should the nurse base the response on?
A) Testicular cancer has a cure rate of 90% with early diagnosis
B) Testicular cancer has a cure rate of 50% with early diagnosis
C) Intensive chemotherapy is the treatment of choice
D) Testicular cancer is usually fatal
Review Information: The correct answer is A: Testicular cancer has a cure rate of 90% with early diagnosis
With aggressive treatment and early detection/diagnosis the cure rate is 90%.
A client newly diagnosed with Type I Diabetes Mellitus asks the purpose of the test measuring glycosylated hemoglobin. The nurse should explain that the purpose of this test is to determine:
A) The presence of anemia often associated with Diabetes
B) The oxygen carrying capacity of the client's red cells
C) The average blood glucose for the past 2-3 months
D) The client's risk for cardiac complications
Review Information: The correct answer is C: The average blood glucose for the past 2-3 months
By testing the portion of the hemoglobin that absorbs glucose, it is possible to determine the average blood glucose over the life span of the red cell, 120 days.
A client is admitted for a possible pacemaker insertion. What is the intrinsic rate of the heart's own pacemaker?
A) 30-50 beats/minute
B) 60-100 beats/minute
C) 20-60 beats/minute
D) 90-100 beats/minute
Review Information: The correct answer is B: 60-100 beats/minute
This is the intrinsic rate of the SA node.
The nurse discusses nutrition with a pregnant woman who is iron deficient and follows a vegetarian diet. The selection of which foods indicates the woman has learned sources of iron?
A) Cereal and dried fruits
B) Whole grains and yellow vegetables
C) Leafy green vegetables and oranges
D) Fish and dairy products
Review Information: The correct answer is A: Cereal and dried fruits
Both of these foods would be a good source of iron.
Prior to administering Alteplase (TPA) to a client admitted for a cerebral vascular accident (CVA), it is critical that the nurse assess:
A) Neuro signs
B) Mental status
C) Blood pressure
Review Information: The correct answer is D: PT/PTT
TPA is a potent thrombolytic enzyme. Because bleeding is the most common side effect, it is most essential to evaluate clotting studies including PT, PTT, APTT, platelets, and hematocrit before beginning therapy.
The nurse enters the room of a client diagnosed with COPD. The client’s skin is pink, and respirations are 8 per minute. The client’s oxygen is running at 6 liters per minute. What should be the nurse’s first action?
A) Call the health care provider
B) Put the client in Fowler’s position
C) Lower the oxygen rate
D) Take the vital signs
Review Information: The correct answer is C: Lower the oxygen rate
In client’s diagnosed with COPD, the drive to breathe is hypoxia. If oxygen is delivered at too high of a concentration, this drive will be eliminated and the client’s depth and rate of respirations will decrease. Therefore the first action should be to lower the oxygen rate.
The client with goiter is treated with potassium iodide preoperatively. What should the nurse recognize as the purpose of this medication?
A) Reduce vascularity of the thyroid
B) Correct chronic hyperthyroidism
C) Destroy the thyroid gland function
D) Balance enzymes and electrolytes
Review Information: The correct answer is A: Reduce vascularity of the thyroid
Potassium iodide solution, or Lugol''s solution may be used preoperatively to reduce the size and vascularity of the thyroid gland.
One hour before the first treatment is scheduled, the client becomes anxious and states he does not wish to go through with electroconvulsive therapy. Which response by the nurse is most appropriate?
A) "I’ll go with you and will be there with you during the treatment."
B) "You’ll be asleep and won’t remember anything."
C) "You have the right to change your mind. You seem anxious. Can we talk about it?"
D) "I’ll call the health care provider to notify them of your decision."
Review Information: The correct answer is C: "You have the right to change your mind. You seem anxious. Can we talk about it?"
This response indicates acknowledgment of the client’s rights and the opportunity for the client to clarify and ventilate concerns. After this, if the client continues to refuse, the provider should be notified.
A nurse who has been named in a lawsuit can use which of these factors for the best protection in a court of law?
A) Clinical specialty certification in the associated area of practice
B) Documentation on the specific client record with a focus on the nursing process
C) Yearly evaluations and proficiency reports prepared by nurse’s manager
D) Verification of provider's orders for the plan of care with identification of outcomes
Review Information: The correct answer is B: Documentation on the specific client record with a focus on the nursing process
Documentation is the key to protect nurses when a lawsuit is filed. The thorough documentation should include all steps of the nursing process – assessment, analysis, plan, intervention, evaluation. In addition, it should include pertinent data such as times, dosages and sites of actions, assessment data, the nurse’s response to a change in the client’s condition, specific actions taken, if and when the notification occurred to the provider or other health care team members, and what was prescribed along with the client’s outcomes.
The nurse is caring for clients over the age of 70. The nurse is aware that when giving medications to older clients, it is best to
A) start low, go slow
B) avoid stopping a medication entirely
C) avoid drugs with side effects that impact cognition
D) review the drug regimen yearly
Review Information: The correct answer is A: start low, go slow
Due to physiological changes in the elderly, as well as conditions such as dehydration, hyperthermia, immobility and liver disease, the effective metabolism of drugs may decrease. As a result, drugs can accumulate to toxic levels and cause serious adverse reactions.
You are caring for a hypertensive client with a new order for captopril (Capoten). Which information should the nurse include in client teaching?
A) Avoid green leafy vegetables
B) Restrict fluids to 1000cc/day
C) Avoid the use of salt substitutes
D) Take the medication with meals
Review Information: The correct answer is C: Avoid the use of salt substitutes
Captopril can cause an accumulation of potassium or hyperkalemia. Clients should avoid the use of salt substitutes, which are generally potassium-based.
A client has bilateral knee pain from osteoarthritis. In addition to taking the prescribed non-steroidal anti-inflammatory drug (NSAID), the nurse should instruct the client to
A) start a regular exercise program
B) rest the knees as much as possible to decrease inflammation
C) avoid foods high in citric acid
D) keep the legs elevated when sitting
Review Information: The correct answer is A: start a regular exercise program
A regular exercise program is beneficial in treating osteoarthritis. It can restore self-esteem and improve physical functioning.
An arterial blood gases test (ABG) is ordered for a confused client. The respiratory therapist draws the blood and then asks the nurse to apply pressure to the area so the therapist can take the specimen to the lab. How long should the nurse apply pressure to the area?
A) 3 minutes
B) 5 minutes
C) 8 minutes
D) 10 minutes
Review Information: The correct answer is B: 5 minutes
It is necessary to apply pressure to the area for 5 minutes to prevent bleeding and the formation of hematomas.
Which of these clients should the charge nurse assign to the registered nurse (RN)?
A) A 56 year-old with atrial fibrillation receiving digoxin
B) A 60 year-old client with COPD on oxygen at 2 L/min
C) A 24 year-old post-op client with type 1 diabetes in the process of discharge
D) An 80 year-old client recovering 24 hours post right hip replacement
Review Information: The correct answer is C: A 24 year-old post-op client with type 1 diabetes in the process of discharge
Discharge teaching must be done by an RN. Practical nurses (PNs) or unlicensed assistive personnel (UAPs) can reinforce education after the RN does the initial teaching.
A hypertensive client is started on atenolol (Tenormin). The nurse instructs the client to immediately report which of these findings?
A) Rapid breathing
B) Slow, bounding pulse
C) Jaundiced sclera
D) Weight gain
Review Information: The correct answer is B: Slow, bounding pulse
Atenolol (Tenormin) is a beta-blocker that can cause side effects including bradycardia and hypotension.
An 80 year-old client is admitted with a diagnosis of malnutrition. In addition to physical assessments, which of the following lab tests should be closely monitored?
A) Urine protein
B) Urine creatinine
C) Serum calcium
D) Serum albumin
Review Information: The correct answer is D: Serum albumin
Serum albumin is a valuable indicator of protein deficiency and, later, nutritional status in adults. A normal reading for an elder’s serum albumin is between 3.0-5.0 g/dl.
Upon admission to an intensive care unit, a client diagnosed with an acute myocardial infarction is ordered oxygen. The nurse knows that the major reason that oxygen is administered in this situation is to
A) saturate the red blood cells
B) relieve dyspnea
C) decrease cyanosis
D) increase oxygen level in the myocardium
Review Information: The correct answer is D: increase oxygen level in the myocardium
Anoxia of the myocardium occurs in myocardial infarction. Oxygen administration will help relieve dyspnea and cyanosis associated with the condition but the major purpose is to increase the oxygen concentration in the damaged myocardial tissue.
The nurse is teaching a client with chronic renal failure (CRF) about medications. The client questions the purpose of aluminum hydroxide (Amphojel) in her medication regimen. What is the best explanation for the nurse to give the client about the therapeutic effects of this medication?
A) It decreases serum phosphate
B) It will reduce serum calcium
C) Amphojel increases urine output
D) The drug is taken to control gastric acid secretion
Review Information: The correct answer is A: It decreases serum phosphate
Aluminum binds phosphates that tend to accumulate in the patient with chronic renal failure due to decreased filtration capacity of the kidney. Antacids such as Amphojel are commonly used to accomplish this.
A 66 year-old client is admitted for mitral valve replacement surgery. The client has a history of mitral valve regurgitation and mitral stenosis since her teenage years. During the admission assessment, the nurse should ask the client if as a child she had
B) rheumatic fever
C) hay fever
Review Information: The correct answer is B: rheumatic fever
Clients that present with mitral stenosis often have a history of rheumatic fever or bacterial endocarditis.
During nursing rounds which of these assessments would require immediate corrective action and further instruction to the practical nurse (PN) about proper care?
A) The weights of the skin traction of a client are hanging about 2 inches from the floor
B) A client with a hip prosthesis 1 day post operatively is lying in bed with internal rotation and adduction of the affected leg
C) The nurse observes that the PN moves the extremity of a client with an external fixation device by picking up the frame
D) A client with skeletal traction states "The other nurse said that the clear, yellow and crusty drainage around the pin site is a good sign"
Review Information: The correct answer is B: A client with a hip prosthesis 1 day post operatively is lying in bed with internal rotation and adduction of the affected leg
This position should be prevented in order to prevent dislodgment of the hip prosthesis, especially in the first 48 to 72 hours post-op. The other assessments are not of concern.
A client diagnosed with gouty arthritis is admitted with severe pain and edema in the right foot. When the nurse develops a plan of care, which intervention should be included?
A) high protein diet
C) hot compresses to affected joints
D) intake of at least 3000cc/day
Review Information: The correct answer is D: intake of at least 3000cc/day
Fluid intake should be increased to prevent precipitation of urate in the kidneys.
A 55 year-old woman is taking Prednisone and aspirin (ASA) as part of her treatment for rheumatoid arthritis. Which of the following would be an appropriate intervention for the nurse?
A) Assess the pulse rate q 4 hours
B) Monitor her level of consciousness q shift
C) Test her stools for occult blood
D) Discuss fiber in the diet to prevent constipation
Review Information: The correct answer is C: Test her stools for occult blood
Both Prednisone and ASA can lead to GI bleeding, therefore monitoring for occult blood would be appropriate.
A client with testicular cancer is scheduled for a right orchiectomy. The nurse knows that an orchiectomy is the
A) surgical removal of the entire scrotum
B) surgical removal of a testicle
C) dissection of related lymph nodes
D) partial surgical removal of the penis
Review Information: The correct answer is B: surgical removal of a testicle
The affected testicle is surgically removed along with its tunica and spermatic cord.