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Flashcards in Test 2 COPY Deck (353)
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1

The nurse is caring for a patient who experiences a rapid rise in blood pressure. The nurse will contact the provider to discuss administering which medication?
a. Amlodipine (Norvasc)
b. Nifedipine (Procardia)
c. Nifedipine extended release (Procardia XL)
d. Verapamil (Calan)

ANS: B
The short-acting nifedipine is used to treat rapid rises in blood pressure but cannot be used for out-patient treatment at high dosages because of an increased risk for sudden cardiac death. The other drugs are not used for rapid rise in BP.

2

The nurse is caring for a patient who is taking hydrochlorothiazide (HydroDIURIL) and digoxin (Lanoxin). Which potential electrolyte imbalance will the nurse monitor for in this patient?
a. Hypermagnesemia
b. Hypernatremia
c. Hypocalcemia
d. Hypokalemia

ANS: D
Thiazide diuretics can cause hypokalemia, which enhances the effects of digoxin and can lead to digoxin toxicity. Thiazides can cause hypercalcemia.

3

A nurse prepares a client with acute renal insufficiency for a cardiac catheterization. The provider prescribes 0.9% normal saline to infuse at 125 mL/hr for renal protection. The nurse obtains gravity tubing with a drip rate of 15 drops/mL. At what rate (drops/min) should the nurse infuse the fluids? (Record your answer using a whole number, and rounding to the nearest drop.) _____ drops/min

ANS:
31 drops/min

4

The nurse is assessing parental knowledge of temper tantrums. Which are true statements regarding temper tantrums (select all that apply)?
a. Temper tantrums are a common response to anger and frustration in toddlers.
b. Temper tantrums often include screaming, kicking, throwing things, and head banging.
c. Parents can effectively manage temper tantrums by giving in to the childs demands.
d. Children having temper tantrums should be safely isolated and ignored.
e. Parents can learn to anticipate times when tantrums are more likely to occur.

ANS: A, B, D, E

Temper tantrums are a common response to anger and frustration in toddlers. They occur more often when toddlers are tired, hungry, bored, or excessively stimulated. A nap prior to fatigue or a snack if mealtime is delayed will be helpful in alleviated the times when tantrums are most likely to occur. Tantrums may include screaming, kicking, throwing things, biting themselves, or banging their head. Effective management of tantrums includes safely isolating and ignoring the child. The child should learn that nothing is gained by having a temper tantrum. Giving in to the childs demands only increases the behavior.

5

A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client has lost 20 pounds since the last visit. What action by the nurse is best?
a. Ask if the weight loss was intended.
b. Encourage a high-protein, high-fiber diet.
c. Measure for new compression stockings.
d. Review a 3-day food recall diary.

ANS: C
Compression stockings must fit correctly in order to work. After losing a significant amount of weight, the client should be re-measured and new stockings ordered if needed. The other options are appropriate, but not the most important.

6

A patient begins taking cholestyramine (Questran) to treat hyperlipidemia. The patient reports abdominal discomfort and constipation. The nurse will provide which instruction to the patient?
a. Increase fluid and slowly increase fiber intake.
b. Stop taking the medication immediately.
c. Take an over-the-counter laxative.
d. Take the medication on an empty stomach.

ANS: A
Cholestyramine can cause gastrointestinal upset and constipation, and these symptoms can be reduced with increased fluids and foods high in fiber. Stopping the medication is not indicated. Over-the-counter laxatives are not recommended until other methods have been tried. Giving the medication on an empty stomach will not relieve the discomfort.

7

Which predisposes the adolescent to feel an increased need for sleep?

a. An inadequate diet
b. Rapid physical growth
c. Decreased activity that contributes to a feeling of fatigue
d. The lack of ambition typical of this age group

ANS: B

During growth spurts, the need for sleep is increased. Rapid physical growth, the tendency toward overexertion, and the overall increased activity of this age contribute to fatigue.

8

A nursing student is caring for a client with an abdominal aneurysm. What action by the student requires the registered nurse to intervene?
a. Assesses the client for back pain
b. Auscultates over abdominal bruit
c. Measures the abdominal girth
d. Palpates the abdomen in four quadrants

ANS: D
Abdominal aneurysms should never be palpated as this increases the risk of rupture. The registered nurse should intervene when the student attempts to do this. The other actions are appropriate.

9

The nurse is caring for a hospitalized 4-year-old boy, Ryan. His parents tell the nurse that they will be back to visit at 6 PM. When Ryan asks the nurse when his parents are coming, the nurses best response is:

a. They will be here soon.
b. They will come after dinner.
c. Let me show you on the clock when 6 PM is.
d. I will tell you every time I see you how much longer it will be.

ANS: B

A 4-year-old understands time in relation to events such as meals. Children perceive soon as a very short time. The nurse may lose the childs trust if his parents do not return in the time he perceives as soon. Children cannot read or use a clock for practical purposes until age 7 years. This answer assumes that the child understands the concept of hours and minutes, which is not developed until age 5 or 6 years.

10

The nurse is assessing a patient prior to administering thrombolytic therapy. Which is an important assessment for this patient?
a. Determining whether the patient has a history of diabetes
b. Finding out about a history of renal disease
c. Assessing which medications are taken for discomfort
d. Assessing whether the patient eats green, leafy vegetables

ANS: C
Patients who take aspirin or nonsteroidal antiinflammatory drugs (NSAIDs) should be monitored closely for excessive bleeding when given thrombolytics. There are no contraindications or precautions for patients with diabetes or renal disease. Foods rich in vitamin K are of concern for patients taking warfarin.

11

A nursing student asks why the anticoagulant heparin is given to patients who have disseminated intravascular coagulation (DIC) and are at risk for excessive bleeding. The nurse will explain that heparin is used in this case for which reason?
a. To decrease the risk of venous thrombosis
b. To dissolve blood clots as they form
c. To enhance the formation of fibrous clots
d. To preserve platelet function

ANS: A
The primary use of heparin for patients with DIC is to prevent venous thrombosis, which can lead to pulmonary embolism or stroke. Heparin does not break down blood clots, enhance the formation of fibrous clots, or preserve platelet function.

12

A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment should the nurse complete prior to this procedure?
a. Clients level of anxiety
b. Ability to turn self in bed
c. Cardiac rhythm and heart rate
d. Allergies to iodine-based agents

ANS: D
Before the procedure, the nurse should ascertain whether the client has an allergy to iodine-containing preparations, such as seafood or local anesthetics. The contrast medium used during the procedure is iodine based. This allergy can cause a life-threatening reaction, so it is a high priority. Second, it is important for the nurse to assess anxiety, mobility, and baseline cardiac status.

13

The nurse is caring for a patient who has metabolic alkalosis and is experiencing fluid overload. The provider orders acetazolamide (Diamox). The patient reports right-sided flank pain after taking this medication. The nurse suspects that this patient has developed which condition?
a. Gout
b. Hemolytic anemia
c. Metabolic acidosis
d. Renal calculi

ANS: D
Carbonic anhydrase inhibitors, such as acetazolamide, are used to treat patients who are in metabolic alkalosis and need a diuretic. They can cause electrolyte imbalance, metabolic acidosis, hemolytic anemia, and renal calculi. This patient has right-sided flank pain, which occurs with renal calculi.

14

A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)?
a. Ambulate the client.
b. Apply a warm moist pack.
c. Massage the clients leg.
d. Provide an ice pack.

ANS: B
Warm moist packs will help with the pain of a DVT. Ambulation is not a comfort measure. Massaging the clients legs is contraindicated to prevent complications such as pulmonary embolism. Ice packs are not recommended for DVT.

15

A patient has a serum cholesterol level of 270 mg/dL. The patient asks the nurse what this level means. Which response by the nurse is correct?
a. You have a high risk for coronary artery disease.
b. You have a moderate risk for coronary artery disease.
c. You have a low risk for coronary artery disease.
d. You have no risk for coronary artery disease.

ANS: A
A value of 270 mg/dL for serum cholesterol puts the patient at high risk.

16

Which is probably the most important criterion on which to base the decision to report suspected child abuse?

a. Inappropriate parental concern for the degree of injury
b. Absence of parents for questioning about childs injuries
c. Inappropriate response of child
d. Incompatibility between the history and injury observed

ANS: D

Conflicting stories about the accident are the most indicative red flags of abuse. Inappropriate response of caregiver or child may be present, but is subjective. Parents should be questioned at some point during the investigation.

17

The nurse is caring for a postoperative patient. The nurse will anticipate administering which medication to this patient to help prevent thrombus formation caused by slow venous blood flow?
a. Alteplase (Activase)
b. Aspirin
c. Clopidogrel (Plavix)
d. Lowmolecular-weight heparin

ANS: D
Lowmolecular-weight heparin is an anticoagulant, which is used to inhibit clot formation and is used prophylactically to prevent postoperative deep vein thrombosis. Alteplase is a thrombolytic, which is used to break down clots after they form; alteplase is contraindicated in any patient with recent surgery. Aspirin and clopidogrel are antiplatelet drugs and are used to prevent arterial thrombosis.

18

Parent guidelines for relieving colic in an infant include:
a. avoiding touching the abdomen.
b. avoiding using a pacifier.
c. changing the infant’s position frequently.
d. placing the infant where the family cannot hear the crying.

ANS: C
Changing the infant’s position frequently may be beneficial. The parent can walk holding the infant face down and with the infant’s chest across the parent’s arm. The parent’s hand can support the infant’s abdomen, applying gentle pressure. Gently massaging the abdomen is effective in some infants. Pacifiers can be used for meeting additional sucking needs. The infant should not be placed where monitoring cannot be done. The infant can be placed in the crib and allowed to cry. Periodically, the infant should be picked up and comforted.

19

A nurse is teaching adolescent boys about pubertal changes. The first sign of pubertal change seen with boys is:

a. Testicular enlargement.
b. Facial hair
c. Scrotal enlargement.
d. Voice deepens.

ANS: A

The first sign of pubertal changes in boys is testicular enlargement in response to testosterone secretion, which usually occurs in Tanner stage 2. Slight pubic hair is present and the smooth skin texture of the scrotum is somewhat altered. As testosterone secretion increases, the penis, testes, and scrotum enlarge. During Tanner stages 4 and 5, rising levels of testosterone cause the voice to deepen and facial hair appears at the corners of the upper lip and chin.

20

A nurse cares for a client with right-sided heart failure. The client asks, Why do I need to weigh myself every day? How should the nurse respond?
a. Weight is the best indication that you are gaining or losing fluid.
b. Daily weights will help us make sure that youre eating properly.
c. The hospital requires that all inpatients be weighed daily.
d. You need to lose weight to decrease the incidence of heart failure.

ANS: A
Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 pounds. The other responses do not address the importance of monitoring fluid retention or loss.

21

A nurse is teaching parents of first-grade children general guidelines to assist their children in adapting to school. Which statement by the parents indicates they understand the teaching?

a. We will only meet with the teacher if problems occur.
b. We will discourage hobbies so our child focuses on schoolwork.
c. We will plan a trip to the library as often as possible.
d. We will expect our child to make all As in school.

ANS: C

General guidelines for parents to help their child in school include sharing an interest in reading. The library should be used frequently and books the child is reading should be discussed. Hobbies should be encouraged. The parents should not expect all As. They should focus on growth more than grades.

22

Which toy is the most developmentally appropriate for an 18- to 24-month-old child?

a. A push-pull toy
b. Nesting blocks
c. A bicycle with training wheels
d. A computer

ANS: A

Push-pull toys encourage large muscle activity and are appropriate for toddlers. Nesting blocks are more appropriate for a 12- to 15-month-old child. A bicycle with training wheels is appropriate for a preschool or young school-age child. A computer can be appropriate as early as the preschool years.

23

The nurse has just begun administering intravenous streptokinase (Streptase). The nurse assesses vital signs and notes a temperature of 37 C, a heart rate of 70 beats per minute, and a blood pressure of 88/58 mm Hg. The nurse will contact the provider to
a. request an adjustment of the streptokinase dose.
b. request an order for aminocaproic acid (Amicar).
c. request epinephrine to prevent anaphylaxis.
d. report potential hemorrhage in this patient.

ANS: A
Patients receiving streptokinase may experience hypotension when it is first administered and may require an adjustment in dosage. Aminocaproic acid is used to stop bleeding. Epinephrine is given for anaphylaxis, which is characterized by difficulty breathing. A patient with hemorrhage would typically also have tachycardia.

24

Which symptoms should the nurse expect to observe during the physical assessment of an adolescent girl with severe weight loss and disrupted metabolism associated with anorexia nervosa?

a. Dysmenorrhea and oliguria
b. Tachycardia and tachypnea
c. Heat intolerance and increased blood pressure
d. Lowered body temperature and brittle nails

ANS: D

Symptoms of anorexia nervosa include lower body temperature, severe weight loss, decreased blood pressure, dry skin, brittle nails, altered metabolic activity, and presence of lanugo hair. Amenorrhea, rather than dysmenorrhea, and cold intolerance are manifestations of anorexia nervosa. Bradycardia, rather than tachycardia, may be present.

25

A nurse is caring for a client who weighs 220 pounds and is started on enoxaparin (Lovenox). How much enoxaparin does the nurse anticipate administering? (Record your answer using a whole number.) _____ mg

ANS:
90 mg
The dose of enoxaparin is 1 mg/kg body weight, not to exceed 90 mg. This client weighs 220 pounds (110 kg), and so will get the maximal dose.

26

A nurse is conducting education classes for parents of infants. The nurse plans to discuss sudden infant death syndrome (SIDS). Which risk factors should the nurse include as increasing an infant’s risk of a SIDS incident? (Select all that apply.)
a. Breastfeeding
b. Low Apgar scores
c. Male sex
d. Birth weight in the 50th or higher percentile
e. Recent viral illness

ANS: B, C, E
Certain groups of infants are at increased risk for SIDS: those with low birth weight, low Apgar scores, or recent viral illness, and those of male sex. Breastfed infants and infants of average or above-average weight are not at higher risk for SIDS.

27

Which accomplishment would the nurse expect of a healthy 3-year-old child?

a. Jump rope
b. Ride a two-wheel bicycle
c. Skip on alternate feet
d. Balance on one foot for a few seconds

ANS: D

Three-year-olds are able to accomplish the gross motor skill of balancing on one foot. Jumping rope, riding a two-wheel bike, and skipping on alternate feet are gross motor skills of 5-year-old children.

28

What nonpharmacologic comfort measures should the nurse include in the plan of care for a client with severe varicose veins? (Select all that apply.)
a. Administering mild analgesics for pain
b. Applying elastic compression stockings
c. Elevating the legs when sitting or lying
d. Reminding the client to do leg exercises
e. Teaching the client about surgical options

ANS: B, C, D
The three Es of care for varicose veins include elastic compression hose, exercise, and elevation. Mild analgesics are not a nonpharmacologic measure. Teaching about surgical options is not a comfort measure.

29

A nurse wants to provide community service that helps meet the goals of Healthy People 2020 (HP2020) related to cardiovascular disease and stroke. What activity would best meet this goal?
a. Teach high school students heart-healthy living.
b. Participate in blood pressure screenings at the mall.
c. Provide pamphlets on heart disease at the grocery store.
d. Set up an Ask the nurse booth at the pet store.

ANS: B
An important goal of HP2020 is to increase the proportion of adults who have had their blood pressure measured within the preceding 2 years and can state whether their blood pressure was normal or high. Participating in blood pressure screening in a public spot will best help meet that goal. The other options are all appropriate but do not specifically help meet a goal.

30

A nurse is teaching a client with heart failure who has been prescribed enalapril (Vasotec). Which statement should the nurse include in this clients teaching?
a. Avoid using salt substitutes.
b. Take your medication with food.
c. Avoid using aspirin-containing products.
d. Check your pulse daily.

ANS: A
Angiotensin-converting enzyme (ACE) inhibitors such as enalapril inhibit the excretion of potassium. Hyperkalemia can be a life-threatening side effect, and clients should be taught to limit potassium intake. Salt substitutes are composed of potassium chloride. ACE inhibitors do not need to be taken with food and have no impact on the clients pulse rate. Aspirin is often prescribed in conjunction with ACE inhibitors and is not contraindicated.