Sample Alternate Items
Graphic
The nurse is observing the cardiac monitor of the client who has just undergone a surgical
procedure. The nurse notes this cardiac rhythm (refer to figure). What is the most
appropriate nursing action?
Place Figure here: Ventricular Tachycardia from: Lewis, S. (2011). Medical-surgical
nursing: Assessment and management of clinical problems (8th Ed. p. 831). St. Louis,
MO: Mosby. Figure 36-18
1.
2.
3.
4.
Begin CPR
Check for a pulse
Notify the physician
Obtain a 12 lead EKG
Answer: 2
Rationale: Ventricular tachycardia can be stable or unstable depending on whether the
client has a pulse or not. In this case, always assess the patient first before taking any
action to ensure the cardiac monitor is accurate and assess whether the patient has a
pulse.
Test-Taking Strategy: Note the steps of the nursing process, as assessment is always
first priority and the first action to take. Review: Ventricular Tachycardia
Priority Nursing Tip: Ventricular tachycardia (VT) is the presence of three or more
consecutive premature ventricular contractions (PVCs). Sustained VT can be life
threatening and can result in hypotension, pulmonary edema, decreased cerebral blood
flow, and cardiac arrest.
Level of Cognitive Ability: Synthesizing
Client Need: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health: Cardiovascular
Priority Concepts: Clinical Judgment, Perfusion
Reference: Lewis, S. (2011). Medical-surgical nursing: Assessment and management of
clinical problems (8th ed. p. 831). St. Louis, MO: Mosby.
Multiple Response
The nurse is caring for a young woman who is starting Depo Provera (DMPA) for birth
control. What statements by the client would indicate a need for further teaching?
Select all that apply.
1. I may experience some weight gain
2. I may not have regular periods while taking this medication.
3. I should return in approximately 3 months for my next injection.
4. Because it is highly effective, I can use this medication for many years.
5. Depression is a side effect, and I should let my physician know if I experience any
mood changes.
Answer: 3, 4
Rationale: Depo Provera is an injectable progestin given every 3 months to prevent
ovulation and pregnancy. It suppresses ovulation for 15 weeks, and therefore, timing of
the next injection is very important and should be no longer than exactly 3 months.
Although Depo-provera is highly effective, it should not be taken for more than 2 years
due to the risk of osteoporosis. Weight gain, irregular periods, and depression are all
known side effects.
Test-Taking Strategy: Note the negative event query when the client needs further
teaching and select the answers that are incorrect. Review: methods of contraception.
Priority Nursing Tip: An advantage of Depo-provera is that it can be used for women
that are lactating. Depo-provera injections can cause a delay in fertility after
discontinuing the medication and women who take this medication should be educated
about this if they wish to conceive.
Level of Cognitive Ability: Analyzing
Client Need: Health Promotion and Maintenance
Integrated Process: Teaching and Learning
Content Area: Pharmacology: Reproductive
Priority Concepts: Patient Education, Reproduction
Reference: James, S., Nelson, K., Ashwill, S. (2013). Nursing care of children:
Principles and practice (4th ed, p. 165). St. Louis, MO: Elsevier
Fill-in-the-blank
The client has been prescribed amoxicillin 250 mg three times daily for sinusitis. The
medication is supplied in a 500 mg tablet. The nurse should administer ________
tablet(s) every 8 hours to administer the correct dose. Fill in the blank using one decimal
point.
Answer: _____________ tablet(s)
Answer: 0.5 tablet
Rationale: Use the medication calculation formula to calculate the correct dose.
Desired dose / Available dose =
250mg/500mg = 0.5 tablets
Test-Taking Strategy: Focus on the subject, a medication calculation. Once you have
performed the calculation, verify your answer with a calculator. Be aware of nonimportant numbers in the question that can be confusing. In this question, three times a
day and 8 hours are not used in the calculation. Lastly, ensure that your answer makes
sense. Review: medication calculations.
Priority Nursing Tip: Common side effects of penicillin include nausea, vomiting,
diarrhea, rash, and super infections or secondary infections as a result of a disruption in
the body’s natural flora.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process: Implementation
Content Area: Fundamental Skills: Medications/IV Calculations
Priority Concepts: Infection, Safety
Reference: Kee, J., Hayes, E., McCuistion, L. (2012). Pharmacology: A nursing process
approach. (7th ed, p. 415-416). St. Louis, MO: Mosby
Chart/Exhibit
A 24-year-old female client is admitted to hospital for a respiratory infection. She is
treated with a course of IV ampicillin and is ready to be discharged home on oral
antibiotics. What information present in the chart would warrant the nurse to provide
further teaching?
History and Physical
Laboratory and Diagnostic
Medications
Findings
Anemia
Chest X-ray: consolidation
norgestimate and ethinyl
in left upper lobe
estradiol (Ortho Tri-Cyclen)
oral once daily
Poly Cystic Ovarian
Potassium level of 4.5
Metformin 500 mg oral
Syndrome (PCOS)
meq/L
twice daily
1.
2.
3.
4.
Anemia
Chest X-ray result
Potassium lab result
Norgestimate and ethinyl estradiol (Ortho Tri-Cyclen) prescription
Answer: 4
Rationale: Broad-spectrum antibiotics such as ampicillin are commonly used to treat
upper respiratory infections. These medications can decrease the effectiveness of oral
contraceptive medications and the client should be advised to use alternative birth control
options. Anemia has no impact on the use of ampicillin. The chest x-ray results, although
abnormal, are expected with a respiratory infection. Serum potassium level is within
normal limits.
Test-Taking Strategy: Focus on the strategic word need for further teaching. Use
knowledge of board spectrum antibiotics to select the correct answer and eliminate the
incorrect answers. Remember that antibiotics can cause a decrease in the effectiveness of
oral contraceptive pills. Review: Broad-spectrum antibiotics.
Priority Nursing Tip: Always assess for an allergy to penicillin or any of its derivatives
before administering a penicillin based medication as an allergy can be life threatening.
Level of Cognitive Ability: Synthesizing
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process: Analysis
Content Area: Fundamental Skills: Infection Control
Priority Concepts: Infection, Safety
Reference: Kee, J., Hayes, E., McCuistion, L. (2012). Pharmacology: A nursing process
approach. (7th ed, p. 416-417). St. Louis, MO: Mosby