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problems. The nurse is experienced as a
medical-surgical nurse, but transplant
recipients require more specialized
knowledge.
Content – Nursing Management: Category of
Health Alteration – Management: Integrated
Nursing Process – Diagnosis: Client Needs – Safe
Effective Care Environment, Management of Care:
Cognitive Level – Analysis.
59. 1. Living donors are able to donate some
organs. The kidneys, a portion of the
liver, and a lung may be donated, and
the donor will still have functioning
organs. An identical twin is the best
possible match. However, in the situation in this question, the identical twin
would also have CF because the genes
would be identical. The next best
chance for a compatible match comes
from a sibling with both parents in
common.
2. The father would have only half of the
genetic makeup of the child.
3. There are at least 27 HLA types. A match
requires at least 7, and preferably 10 to
11 points.
4. This is not an acceptable match; the client
would reject the organ.
TEST-TAKING HINT: If the test taker did not
know the rationale, then a choice between
options “1” and “2” would be the best
option because of the direct familial
relationships.
60. 1. Skin is taken from cadaver donors, so it is
given once.
2. Bones are taken from cadaver donors, so it
is given once.
3. A kidney can be donated while the donor
is living or both can be donated as cadaver
organs, but either way the donation is only
once.
4. The human body reproduces bone
marrow daily. There is a bone marrow
registry for participants willing to
undergo the procedure to donate to
clients when a match is found.
TEST-TAKING HINT: The test taker could
eliminate option “3” because the stem
asks for repeated times and the client
cannot live without kidney function. The
client would have to be placed on dialysis
or he or she would die.
Content – Surgical: Category of Health
Alteration – Patient Advocacy: Integrated
Nursing Process – Implementation: Client
Needs – Safe Effective Care Environment,
Management of Care: Cognitive Level – Analysis.
Content – Surgical: Category of Health Alteration –
Respiratory: Integrated Nursing Process – Planning:
Client Needs – Safe Effective Care Environment,
Management of Care: Cognitive Level – Synthesis.
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copyright law.
CHAPTER 18 END-OF-LIFE ISSUES
END-OF-LIFE ISSUES COMPREHENSIVE
EXAMINATION
1. The 38-year-old client was brought to the emergency department with CPR in
progress and expired 15 minutes after arrival. Which intervention should the nurse
implement for postmortem care?
1. Do not allow significant others to see the body.
2. Do not remove any tubes from the body.
3. Prepare the body for the funeral home.
4. Send the client’s clothing to the hospital laundry.
2. The primary nurse caring for the client who died is crying with the family at the
bedside. Which action should the charge nurse implement?
1. Request the primary nurse to come out in the hall.
2. Refer the nurse to the employee assistance program.
3. Allow the nurse and family this time to grieve.
4. Ask the chaplain to relieve the nurse at the bedside.
3. The nurse is discussing advance directives with the client. The client asks the nurse,
“Why is this so important to do?” Which statement would be the nurse’s best
response?
1. “The federal government mandates this form must be completed by you.”
2. “This will make sure your family does what you want them to do.”
3. “Don’t you think it is important to let everyone know your final wishes?”
4. “Because of technology, there are many options for end-of-life care.”
4. The client who is of the Jewish faith died during the night. The nurse notified the
family, who do not want to come to the hospital. Which intervention should the nurse
implement to address the family’s behavior?
1. Take no further action because this is an accepted cultural practice.
2. Notify the hospital supervisor and report the situation immediately.
3. Call the local synagogue and request the rabbi go to the family’s home.
4. Assume the family does not care about the client and follow hospital protocol.
5. The hospice nurse is making the final visit to the wife whose husband died a little
more than a year ago. The nurse realizes the husband’s clothes are still in the closet
and chest of drawers. Which action should the nurse implement first?
1. Discuss what the wife is going to do with the clothes.
2. Refer the wife to a grief recovery support group.
3. Do not take any action because this is normal grieving.
4. Remove the clothes from the house and dispose of them.
6. The nurse is giving an in-service on end-of life-issues. Which activity should the nurse
encourage the participants to perform?
1. Discuss with another participant the death of a client.
2. Review the hospital postmortem care policy.
3. Justify not putting the client in a shroud after dying.
4. Write down their own beliefs about death and dying.
7. The 78-year-old Catholic client is in end-stage congestive heart failure and has a
DNR order. The client has AP 50, RR 10, and BP 80/50, and Cheyne-Stokes
respirations. Which action should the nurse implement?
1. Bring the crash cart to the bedside.
2. Apply oxygen via nasal cannula.
3. Notify a priest for last rites.
4. Turn the bed to face the sunset.
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8. The Hispanic client who has terminal cancer is requesting a curandero to come to
the bedside. Which intervention should the nurse implement?
1. Tell the client it is against policy to allow faith healers.
2. Assist with planning the visit from the curandero.
3. Refer the client to the pastoral care department.
4. Determine the reason the client needs the curandero.
9. Which interventions should the nurse implement at the time of a client’s death?
Select all that apply.
1. Allow gaps in the conversation at the client’s bedside.
2. Avoid giving the family advice about how to grieve.
3. Tell the family the nurse understands their feelings.
4. Explain this is God’s will to prevent further suffering.
5. Allow the family time with the body in private.
10. The male client asks the nurse, “Should I designate my wife as durable power of
attorney for health care?” Which statement would be the nurse’s best response?
1. “Yes, she should be because she is your next of kin.”
2. “Most people don’t allow their spouse to do this.”
3. “Will your wife be able to support your wishes?”
4. “Your children are probably the best ones for the job.”
11. The client has been declared brain dead and is an organ donor. The nurse is
preparing the wife of the client to enter the room to say good-bye. Which
information is most important for the nurse to discuss with the wife?
1. Inform the wife the client will still be on the ventilator.
2. Instruct the wife to only stay a few minutes at the bedside.
3. Tell the wife it is all right to talk to the client.
4. Allow another family member to go in with the wife.
12. Which client would the nurse exclude from being a potential organ/tissue donor?
1. The 60-year-old female client with an inoperable primary brain tumor.
2. The 45-year-old female client with a subarachnoid hemorrhage.
3. The 22-year-old male client who has been in a motor-vehicle accident.
4. The 36-year-male client recently released from prison.
13. The intensive care nurse is caring for a deceased client who is an organ donor, and
the organ donation team is in route to the hospital. Which statement would be an
appropriate goal of treatment for the client?
1. The urinary output is 20 mL/hr via a Foley catheter.
2. The systolic blood pressure is greater than 90 mm Hg.
3. The pulse oximeter reading remains between 88% and 90%.
4. The telemetry shows the client in sinus tachycardia.
14. The nurse is teaching a class on ethical principles in nursing. Which statement
supports the definition of beneficence?
1. The duty to prevent or avoid doing harm.
2. The duty to actively do good for clients.
3. The duty to be faithful to commitments.
4. The duty to tell the truth to the clients.
15. Which action by the unlicensed assistive personnel (UAP) would warrant immediate
intervention by the nurse?
1. The UAP is holding the phone to the ear of a client who is a quadriplegic.
2. The UAP refuses to discuss the client’s condition with the visitor in the room.
3. The UAP put a vest restraint on an elderly client found wandering in the hall.
4. The UAP is assisting the client with arthritis to open up personal mail.
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CHAPTER 18 END-OF-LIFE ISSUES
16. The nurse is teaching a class on chronic pain to new graduates. Which information is
most important for the nurse to discuss?
1. The nurse must believe the client’s report of pain.
2. Clients in chronic pain may not show objective signs.
3. Alternate pain-control therapies are used for chronic pain.
4. Referral to a pain clinic may be necessary.
17. The client with chronic low back pain is having trouble sleeping at night. Which
nonpharmacological therapy should the nurse teach the client?
1. Acupuncture.
2. Massage therapy.
3. Herbal remedies.
4. Progressive relaxation techniques.
18. The client diagnosed with cancer is unable to attain pain relief despite receiving large
amounts of narcotic medications. Which intervention should be included in the plan
of care?
1. Ask the HCP to increase the medication.
2. Assess for any spiritual distress.
3. Change the client’s position every two (2) hours.
4. Turn on the radio to soothing music.
19. The client diagnosed with chronic pain is laughing and joking with visitors. When
the nurse asks the client to rate the pain on a 1-to-10 scale, the client rates the pain
as 10. According to the pain scale, how would the nurse chart the client’s pain?
1. The client’s pain is between a zero (0) and two (2) on the faces scale.
2. The client’s pain is a “10” on a 1-to-10 pain scale.
3. The client is unable to accurately rate the pain on a scale.
4. The client’s pain is moderate on the pain scale.
0
No
hurt
Alternate
0
coding
0
No
Pain
1
Hurts
little bit
2
1
2
2
3
4
Hurts
Hurts
Hurts
little more even more whole lot
4
6
8
3
Mild
Pain
4
5
6
Moderate
Pain
7
8
Severe
Pain
5
Hurts
worst
10
9
10
Unbearable
Pain
20. The client diagnosed with diabetes mellitus type 2 wants to be an organ donor and
asks the nurse, “Which organs can I donate?” Which statement is the nurse’s best
response?
1. “It is wonderful you want to be an organ donor. Let’s discuss this.”
2. “You can donate any organ in your body, except the pancreas.”
3. “You have to donate your body to science to be an organ donor.”
4. “You cannot donate any organs, but you can donate some tissues.”
21. The client with multiple sclerosis who is becoming very debilitated tells the home
health nurse the Hemlock Society sent information on euthanasia. Which question
should the nurse ask the client?
1. “Why did you get in touch with the Hemlock Society?”
2. “Did you know this is an illegal organization?”
3. “Who do you know who has committed suicide?”
4. “What religious beliefs do you practice?”
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MED-SURG SUCCESS
22. Which intervention should the nurse implement to provide culturally sensitive health
care to the European-American Caucasian elderly client who is terminal?
1. Discuss health-care issues with the oldest male child.
2. Determine if the client will be cremated or have an earth burial.
3. Do not talk about death and dying in front of the client.
4. Encourage the client’s autonomy and answer questions truthfully.
23. Which action by the primary nurse would require the unit manager to intervene?
1. The nurse uses a correction fluid to correct a charting mistake.
2. The nurse is shredding the worksheet at the end of the shift.
3. The nurse circles an omitted medication time on the MAR.
4. The nurse documents narcotic wastage with another nurse.
24. Which action should the nurse implement for the Chinese client’s family who are
requesting to light incense around the dying client?
1. Suggest the family bring potpourri instead of incense.
2. Tell the client the door must be shut at all times.
3. Inform the family the scent will make the client nauseated.
4. Explain fire code does not allow any burning in a hospital.
25. The nurse is caring for the client who has active tuberculosis of the lungs. The client
does not have a DNR order. The client experiences a cardiac arrest, and there is no
resuscitation mask at the bedside. The nurse waits for the crash cart before beginning
resuscitation. According to the ANA Code of Ethics for Nurses (see below), which
disciplinary action should be taken against the nurse?
1. Report the action to the State Board of Nurse Examiners.
2. The nurse should be terminated for failure to perform duties.
3. No disciplinary action should be taken against the nurse.
4. Refer the nurse to the American Nurses Association.
Table 18-1 The American Nurses Association Code of Ethics for Nurses
Text/Image rights not available.
The American Nurses Association Code of Ethics for Nurses with interpretative statements. Copyright 2001, American
Nurses Publishing, American Nurses Foundation/American Nurses Association, Washington, DC. Reprinted with
permission.
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CHAPTER 18 END-OF-LIFE ISSUES
26. The wife of a client receiving hospice care being cared for at home calls the nurse to
report the client is restless and agitated. Which interventions should the nurse
implement? List in order of priority.
1. Request an order from the health-care provider for antianxiety medications.
2. Call the medical equipment company and request oxygen for the client.
3. Go to the home and assess the client and address the wife’s concerns.
4. Reassure and calm the wife over the telephone.
5. Notify the chaplain about the client’s change in status.
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END-OF-LIFE ISSUES COMPREHENSIVE EXAMINATION
ANSWERS AND RATIONALES
1. 1. There is no reason the family members
should not be able to see the client; this is
important to allow the significant others
closure.
2. This death should be reported to the
medical examiner because the death
occurred less than 24 hours after
hospital admission and an autopsy may
be required. Therefore, the nurse must
leave all tubes in place; the medical
examiner will remove the tubes.
3. This is a medical examiner case, and the
nurse should not prepare the body by
removing tubes or washing the body prior
to taking the client to a funeral home.
4. The client’s clothing should be given to the
family, or to the police if foul play is
suspected.
Content – Medical: Category of Health Alteration –
Patient Advocacy: Integrated Nursing Process –
Implementation: Client Needs – Safe Effective Care
Environment, Management of Care: Cognitive
Level – Synthesis.
2. 1. The nurse is providing care for the family
and should not have to leave the bedside.
2. An employee assistance program is available
at many facilities for counseling employees
who are having psychosocial issues, but this
nurse is being humane.
3. Crying was once considered unprofessional, but today it is recognized as simply an expression of empathy and caring.
4. The chaplain may come to the client’s room
and offer support but should not relieve the
nurse who has developed a therapeutic
nurse–client relationship with the client.
Content – Nursing Management: Category of Health
Alteration – Management: Integrated Nursing
Process – Implementation: Client Needs – Safe
Effective Care Environment, Management of Care:
Cognitive Level – Application.
3. 1. Advance directives (AD) are not mandated
by the federal government. The nurse must
discuss this with the client, but the client
does not have to complete it.
2. ADs can be overridden by the family because the health-care provider is worried
about being sued by family survivors.
3. This response is not answering the client’s
question and it is argumentative.
4. Technology now allows for the body to
maintain life functions indefinitely in
some futile situations. ADs allow clients
to make decisions which hopefully will
be honored at the time of their death.
Content – Fundamentals: Category of Health
Alteration – Patient Advocacy: Integrated Nursing
Process – Implementation: Client Needs – Safe
Effective Care Environment, Management of Care:
Cognitive Level – Application.
4. 1. Many of the Jewish faith do not believe
in viewing or touching the dead body.
The body is sent to the funeral home for
burial within 24 hours, and a closed
casket is preferred.
2. The hospital supervisor does not need to be
notified the family did not want to come to
the hospital.
3. The nurse needs to take care of the client,
not the family, and should not call to
request a rabbi to go visit the family.
4. The nurse must be aware of cultural
differences and not be judgmental.
Content – Fundamentals: Category of Health
Alteration – Patient Advocacy: Integrated Nursing
Process – Implementation: Client Needs – Psychosocial
Integrity: Cognitive Level – Application.
5. 1. The nurse must first confront the wife
about moving on through the grieving
process. After one (1) year, the wife
should be seriously thinking about what
to do with her husband’s belongings.
2. This is an appropriate intervention, but the
nurse must first talk directly to the client.
3. After one (1) year, the wife should be
progressing through the grieving process
and needs encouragement to remove her
husband’s belongings.
4. This will need to be done at some point,
but it is not the nurse’s responsibility. This
action is crossing professional boundaries
unless the wife asks the nurse to do this.
Content – Medical: Category of Health Alteration –
Patient Advocacy: Integrated Nursing Process –
Implementation: Client Needs – Psychosocial Integrity:
Cognitive Level – Application.
6. 1. This activity will not help the nurse address
his or her own fear of death.
2. This activity will not help the nurse address
his or her own fear of death.
3. This activity will not help the nurse address
his or her own fear of death.
4. Many nurses are reluctant to discuss
death openly with their clients because
of their own anxieties about death.
Therefore, coming face to face with the
706
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CHAPTER 18 END-OF-LIFE ISSUES
nurse’s own mortality will address the
fear of death.
Content – Medical: Category of Health Alteration –
Patient Advocacy: Integrated Nursing Process –
Planning: Client Needs – Psychosocial Integrity:
Cognitive Level – Synthesis.
7. 1. The client has a DNR; therefore, there is
no need to bring the crash cart to the
bedside.
2. The client has a DNR and the nurse needs
to help the client die peacefully.
3. The Catholic religion requires last rites
be performed immediately before or
after death.
4. The client is Catholic, and there is no
specific way for the bed to be placed.
Content – Medical: Category of Health Alteration –
Patient Advocacy: Integrated Nursing Process –
Implementation: Client Needs – Psychosocial Integrity:
Cognitive Level – Application.
8. 1. The hospital should not prevent the client
from practicing his or her culture, and
denying faith healers would be denying the
client’s spiritual guidance.
2. The nurse should support the client’s
culture as long as it is not contraindicated in the client’s care. This client is
terminal; therefore, allowing the curandero, who is a folk healer and religious
person in the Hispanic culture, would be
appropriate.
3. There is no reason to refer this client to the
pastoral care department; the nurse can assist the client.
4. The nurse does not need to know why the
client wants the curandero; the nurse
should support the client’s request without
prejudice.
Content – Medical: Category of Health Alteration –
Patient Advocacy: Integrated Nursing Process –
Implementation: Client Needs – Psychosocial Integrity:
Cognitive Level – Application.
9. 1. The nurse needs to be sensitive to the
family, and simply being present to
support the family emotionally is important; the nurse does not have to talk.
2. The nurse should avoid the impulse to
give advice; each person grieves in his or
her own way.
3. The nurse should not tell the family he or
she understands; even if the test taker has
lost a loved one, the test taker should never
select an option which says the nurse understands another person’s feelings.
4. This is projecting the nurse’s personal
religious beliefs on the family and could
cause more anger at God when the family
needs to be able to draw on their own
spiritual beliefs.
5. The family needs time for closure, and
allowing the family to stay at the bedside is meeting the family’s need to say
good-bye.
Content – Medical: Category of Health Alteration –
Patient Advocacy: Integrated Nursing Process –
Implementation: Client Needs – Psychosocial Integrity:
Cognitive Level – Application.
10. 1. The client can designate anyone he wishes
to be the durable power of attorney.
2. This is not true; many spouses are designated as the durable power of attorney for
health care.
3. No matter who the client selects as the
power of attorney, the most important
aspect is to make sure the person,
whether it be the wife, child, or friend,
will honor the client’s wishes no matter
what happens.
4. The children must be at least 18 years old
and willing to honor the client’s wishes.
Content – Medical: Category of Health Alteration –
Patient Advocacy: Integrated Nursing Process –
Implementation: Client Needs – Psychosocial Integrity:
Cognitive Level – Application.
11. 1. This is the most important action
because, when the wife walks in the
room, the client’s chest will be rising
and falling, the monitor will show a
heartbeat, and the client will be
warm. Many family members do not
realize this and think the client is
still alive. The organs must be
perfused until retrieved for organ
donation.
2. The wife should be encouraged to stay a
short time and leave the facility before
the client is taken to the operating
room, but it is not the most important
intervention.
3. It is all right for the wife to talk to the
client, but because the client is brain dead
and cannot hear her, it is not the most
important intervention.
4. It is all right for another family member
to go into the room, but it is not the most
important intervention.
Content – Medical: Category of Health Alteration –
Patient Advocacy: Integrated Nursing Process –
Planning: Client Needs – Psychosocial Integrity:
Cognitive Level – Synthesis.
12. 1. Primary brain tumors rarely metastasize
outside the skull, and this client can be a
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donor; cancers other than primary brain
tumors prevent organ/tissue donation.
2. This is an excellent potential donor
because all other organs are probably
healthy.
3. This is an excellent candidate because this
is a young person with a traumatic death,
not a chronic illness.
4. A male client who has been in prison is
at risk for being HIV positive, which
excludes him from being an organ/
tissue donor.
Content – Medical: Category of Health Alteration –
Patient Advocacy: Integrated Nursing Process –
Diagnosis: Client Needs – Psychosocial Integrity:
Cognitive Level – Analysis.
13. 1. The urinary output should be at least
30 mL/hr.
2. The systolic blood pressure must be
maintained at this rate to keep the
client’s organs perfused until removal.
3. The pulse oximeter should be greater
than 93%.
4. The client’s heart must be beating, but it
can be normal sinus rhythm or even sinus
bradycardia.
Content – Surgical: Category of Health Alteration –
Patient Advocacy: Integrated Nursing Process –
Diagnosis: Client Needs – Physiological Integrity,
Reduction of Risk Potential: Cognitive Level –
Analysis.
14. 1. This is the ethical principle of
nonmalfeasance.
2. This is the ethical principle of
beneficence.
3. This is the ethical principle of fidelity.
4. This is the ethical principle of veracity.
Content – Fundamentals: Category of Health
Alteration – Patient Advocacy: Integrated Nursing
Process – Implementation: Client Needs – Safe
Effective Care Environment, Management of Care:
Cognitive Level – Application.
15. 1. The client has a right to private phone
conversations but, because the client is a
quadriplegic, holding the phone to the ear
does not require immediate intervention.
2. This is the appropriate action for the UAP
and should be praised.
3. Restraints are not allowed unless there
is a health-care provider’s order with
documentation by the nurse of the
client being a danger to himself or
others. The UAP’s putting the client in
restraints warrants immediate
intervention because it is battery.
4. The client has a right to send and receive
mail, and the UAP is helping the client
open the mail; therefore, this does not
require immediate intervention.
Content – Management: Category of Health
Alteration – Nursing Management: Integrated
Nursing Process – Implementation: Client Needs –
Safe Effective Care Environment, Management of
Care: Cognitive Level – Synthesis.
16. 1. The most important information for a
nurse caring for a client with acute or
chronic pain is to believe the client.
Pain is subjective, and the nurse should
not be judgmental.
2. This is a true statement because the
client’s sympathetic nervous system cannot
remain in a continual state of readiness.
This results in no objective data to
support the pain and a normal pulse and
blood pressure. However, it is not the
most important information a new
graduate should know.
3. Transcutaneous electrical nerve stimulation (TENS), distraction, imagery,
acupuncture, and acupressure are all
alternate pain therapies which may be
used for chronic pain, but it is not the
most important information the new
graduate should know.
4. Pain clinics treat clients with chronic
pain, but it is not the most important
information a new graduate should know.
Content – Medical: Category of Health Alteration –
Pain: Integrated Nursing Process – Planning:
Client Needs – Safe Effective Care Environment,
Management of Care: Cognitive Level – Synthesis.
17. 1. Acupuncture is an alternative therapy, but
a nurse cannot teach it and the client cannot do this to himself or herself.
2. A client cannot perform massage therapy
on himself or herself.
3. The nurse should not prescribe herbal
remedies.
4. Progressive relaxation techniques
involve visualizing a specific muscle
group and mentally relaxing each muscle; this can be taught to the client, and
it will allow the client to relax, which
will foster sleep.
Content – Medical: Category of Health Alteration –
Pain: Integrated Nursing Process – Planning:
Client Needs – Physiological Integrity, Physiological
Adaptation: Cognitive Level – Synthesis.
18. 1. The client is already receiving large
amounts of medication. The nurse should
assess for other causes of pain.
2. Pain has many components, and spiritual distress or psychosocial needs will
affect the client’s perception of pain;
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CHAPTER 18 END-OF-LIFE ISSUES
remember, assessment is the first step
of the nursing process.
3. Usually clients will naturally assume the
most comfortable position, and forcing
them to move may increase their pain.
4. The client may or may not like this type
of music, but it would not be the first
intervention.
Content – Medical: Category of Health Alteration –
Pain: Integrated Nursing Process – Planning: Client
Needs – Physiological Integrity, Pharmacological and
Parenteral Therapies: Cognitive Level – Synthesis.
19. 1. The Faces pain scale was devised to help
children identify pain when they are unable to understand the concept of numbers. The nurse can use this pain scale
when caring for adults who are unable to
use the 1-to-10 numerical scale. This
client rated the pain at a 10.
2. Pain is whatever the client says it is
and occurs whenever the client says it
does. Pain is a wholly subjective symptom, and the nurse should not question
the client’s perception of pain. The
client’s pain is a 10.
3. The client did rate the pain on the pain
scale. Laughing and talking with visitors
may occur with excruciating chronic pain.
The client in chronic pain must learn to
adapt to pain and try to live as normal a
life as possible.
4. The client rated the pain at a 10.
Content – Medical: Category of Health
Alteration – Pain: Integrated Nursing Process –
Implementation: Client Needs – Safe Effective Care
Environment, Management of Care: Cognitive
Level – Application.
20. 1. This is not answering the client’s question.
2. A client with type 2 diabetes has organ
damage as a result of the high glucose
over time; therefore, most organs are not
usable.
3. This is a false statement. The client does
not have to will his or her body to science
to be a tissue/organ donor.
4. The client can donate corneas, skin,
and some joints, but organ donation
from clients with type 2 diabetes
mellitus usually is not allowed.
Content – Medical: Category of Health Alteration –
Patient Advocacy: Integrated Nursing Process –
Implementation: Client Needs – Safe Effective Care
Environment, Management of Care: Cognitive
Level – Analysis.
21. 1. The nurse should not ask the client “why”
he or she does something; this is
judgmental.
2. This answer option is giving erroneous
information because it is not illegal; it is
an organization which supports active
euthanasia.
3. This question is not relevant to the
situation.
4. This question must be asked because
Judeo-Christian belief supports the
view that suicide is a violation of natural law and the laws of God. The tenets
of the Hemlock Society are in direct
opposition to Judeo-Christian beliefs.
If the client is agnostic, then this organization may be helpful to the client.
Content – Medical: Category of Health Alteration –
Patient Advocacy: Integrated Nursing Process –
Implementation: Client Needs – Psychosocial Integrity:
Cognitive Level – Application.
22. 1. Many Middle Eastern cultures practice
this, but the Caucasian culture does not.
2. Caucasians as a culture do not necessarily
have a preference, but this does not affect
culturally sensitive health care.
3. Frequently Caucasians do not like to talk
about death and dying, but this is an individual preference of the client and the
nurse should allow the discussion.
4. The western Caucasian society values
autonomy and truth telling in individual decision making.
Content – Medical: Category of Health Alteration –
Patient Advocacy: Integrated Nursing Process –
Implementation: Client Needs – Psychosocial Integrity:
Cognitive Level – Application.
23. 1. The client’s chart is a legal document,
and if a mistake occurs, it should be
corrected by marking one line through
the entry in such a way the entry can
still be read in a court of law. Erasing,
using a correction fluid, or obliterating
the entry is illegal.
2. This is the correct method for disposing
of any paper which has client information
on it which is not a part of the client’s
permanent medical record.
3. This is the correct method to indicate a
medication was not administered to
the client; the circle means the person
should go to the nurse’s notes to read
the reason why the medication was not
administered.
4. All narcotics not administered to the client
must be verified when being wasted and
then documented.
Content – Nursing Management: Category of
Health Alteration – Management: Integrated
Nursing Process – Implementation: Client Needs –
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Safe Effective Care Environment, Management of
Care: Cognitive Level – Application.
24. 1. The nurse must support the client’s
culture. Potpourri provides the scent
without having the burning incense,
which is against fire code, and thus is a
compromise which supports the client’s
culture.
2. Having the door shut does not matter;
open flames are not allowed in any
health-care facility.
3. This is not necessarily true, and if it is part
of the cultural beliefs about dying, then
the nurse should medicate the client if he
or she becomes nauseated.
4. This is a fact, but the nurse should
attempt to compromise and support
the client and family’s cultural needs,
especially at the time of death.
Content – Medical: Category of Health Alteration –
Patient Advocacy: Integrated Nursing Process –
Implementation: Client Needs – Psychosocial Integrity:
Cognitive Level – Application.
26.
In order of priority: 4, 3, 2, 1, 5.
4. The nurse should calm and reassure
the wife over the telephone.
3. The nurse should then visit the client
immediately to assess the change in
condition.
2. Restlessness and agitation are symptoms of lack of oxygen. Therefore,
calling the medical equipment company to send oxygen would be the
next intervention.
1. Terminal restlessness is difficult for the
family to watch and the client to
experience, so antianxiety medications
would be the next logical intervention.
5. Referral to the chaplain is needed
because death may be imminent.
Content – Medical: Category of Health Alteration –
Patient Advocacy: Integrated Nursing Process –
Implementation: Client Needs – Safe Effective Care
Environment, Management of Care: Cognitive
Level – Analysis.
25. 1. There is no need to report this action to
the state board; this is not malpractice.
2. This action does not warrant the nurse
being terminated.
3. The Code states, “The nurse owes the
same duty to self as to others, including
the responsibility to preserve integrity
and safety.” Therefore, if the nurse realizes he or she could contract TB if unprotected mouth-to-mouth resuscitation
is performed, then not doing this action
does not violate the Code of Ethics.
4. The ANA cannot discipline nurses; it is a
voluntary nurse’s organization.
Content – Medical: Category of Health
Alteration – Patient Advocacy: Integrated
Nursing Process – Implementation: Client Needs
– Safe Effective Care Environment, Management of
Care: Cognitive Level – Application.
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Pharmacology
19
Education makes a people easy to lead, but difficult to drive; easy to
govern, but impossible to enslave.
—Lord Brougham
This chapter contains test-taking hints specific to pharmacology-related questions. Many
of the general hints discussed in Chapter 1 provided with the answer rationales in the other
chapters are also helpful. Remember, however, test-taking hints are useful for discriminating information and choosing among answer options, but they cannot substitute for
knowledge. Nurses must be familiar with medications—their specific uses, modes of administration, side effects, possible adverse reactions, and ways to gauge their effectiveness
in treating specific disorders/diseases.
KEYWORDS
ABBREVIATIONS
agranulocytosis
ataxia
doll’s eye test
echinacea
mydriasis
tetany
Apical Pulse (AP)
As Needed (PRN)
Beats per Minute (BPM)
By Mouth (PO)
Computed Tomography (CT)
Gastrointestinal (GI)
Health-Care Provider (HCP)
Hour of Sleep (h.s.)
Intramuscular (IM)
Intravenous (IV)
Intravenous Push (IVP)
Licensed Practical Nurse (LPN)
Medication Administration Record (MAR)
Nasogastric (N/G)
Nonsteroidal Anti-Inflammatory Drug (NSAID)
Over-the-Counter (OTC)
Supraventricular Tachycardia (SVT)
TEST-TAKING HINTS FOR PHARMACOLOGY
QUESTIONS
The test taker must know medications and memorize specific facts about the different
medications, including their uses, dosages, and side effects. This knowledge is part of administering medications safely. There are some specific tips to assist the test taker to learn about
medications, and they will apply to the 101 questions in this chapter.
711
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It is important to learn the different classifications of drugs—for example, diuretics, antibiotics, nonsteroidal anti-inflammatory drugs (NSAIDs). The test taker should learn the actions, uses, side effects, adverse effects, possible interactions, and method of administration
(for example, oral, intravenous, intramuscular) of these drugs. Generally speaking, the various
drugs in each classification will be similar in these factors.
Do not be too broad in the classifications. For example, do not combine all medications
administered for hypertension in the same category. Angiotensin-converting enzyme (ACE)
inhibitors, beta blockers, and calcium channel blockers, for example, are all used to treat
hypertension, but they are different categories of medications, acting differently in the
body and producing different effects. Diuretics and oral medications for diabetes mellitus
fall into different specific classifications and must be learned by the specific classification.
Each classification has its own effects on the body, side effects, and adverse effects, and each
has steps the nurse must take before administering the medication.
When administering medications for a group of clients, the test taker must realize time
is a realistic problem. The nurse will be unable to look up 50 to 60 medications and administer them all within the dosing time frame, so it is imperative that nurses learn the most
common medications.
One tip for learning the medications is for the test taker to complete handmade drug
cards. This is better than buying ready-made cards because, in making the card, the test
taker must involve more than one sense—reading, deciding which information to put on the
card, and writing the pertinent information. Using more than one sense will assist the test
taker to memorize the information.
Drug Cards
When the test taker is deciding which information is the most important to write on a drug
card, there are five (5) questions which can be used as a guide.
1. What is the scientific rationale for administering the medication?
The test taker should always ask “why” this intervention is being implemented.
• What classification is the medication the nurse is administering to the client?
• Why is this client receiving this medication?
• What action does the medication have in the body?
The answers to these questions provide the scientific rationale for administering the medication. It is also important to remember in many cases a medication may be in a particular
classification but the client is receiving the medication for a different reason—for example,
the anticonvulsant depakote (Tegretol) is also administered as an anti-mania medication.
EXAMPLE #1
Digoxin (Lanoxin) 0.25 mg PO
• The classification of this medication is a cardiac glycoside.
• The medication is administered to clients with congestive heart failure or rapid atrial
fibrillation.
• Cardiac glycosides increase the contractility of the heart and decrease the heart rate.
EXAMPLE #2
Furosemide (Lasix) 40 mg IVP
• The classification of this medication is a loop diuretic.
• The medication is administered to clients with essential hypertension.
• This medication helps remove excess fluid from the body.
• Loop diuretics remove water from the kidneys along with potassium.
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CHAPTER 19 PHARMACOLOGY
2. When should the administration of a medication be questioned?
• Does the medication have a therapeutic serum level?
• Which vital signs must be monitored?
• Which physiological parameters should be monitored when the medication is being
administered?
The answers to these questions will provide the nurse with information to base a decision on which medication orders should be questioned.
EXAMPLE #1
Digoxin (Lanoxin)
• Is the apical pulse less than 60 bpm?
• Is the digoxin level within the therapeutic range?
• Is the potassium level within normal range?
EXAMPLE #2
Furosemide (Lasix)
• Is the potassium level within normal range?
• Does the client have signs/symptoms of dehydration?
• Is the client’s blood pressure below 90/60?
3. How can the nurse ensure the safety of the administration of medications?
• What interventions must be taught to the client to ensure the medication is
administered safely in the hospital setting?
• What interventions must be taught for taking the medication safely at home?
EXAMPLE #1
Digoxin (Lanoxin)
• Explain to the client the importance of getting serum levels regularly.
• Teach the client to take the radial pulse and to not take the medication if the pulse is
less than 60.
• Tell the client to take the medication daily or as ordered and notify the HCP if not
taking the medication.
EXAMPLE #2
Furosemide (Lasix)
• Teach the client about orthostatic hypotension.
• Instruct the client to drink water to replace insensible fluid loss.
• Because the medication is intravenous push (IVP), how many minutes should the
medication be pushed over? What primary IV is hanging; is it compatible with
Lasix?
4. What are the possible side effects and possible adverse reactions associated with
a specific medication?
• What are the side effects of this medication?
• What are the possible adverse reactions associated with this medication?
Side effects are not expected but are not unusual. Adverse reactions are any situations
which would require notifying the health-care provider or discontinuing the medication.
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EXAMPLE #1
Digoxin (Lanoxin)
• Inform the client of the signs of toxicity, which are nausea, vomiting, anorexia, and
yellow haze.
EXAMPLE #2
Furosemide (Lasix)
• Side effects include dizziness and light-headedness.
• Adverse effects include hypokalemia and tinnitus (if Lasix is administered too quickly).
5. How can the effectiveness of a medication be monitored?
EXAMPLE #1
Digoxin (Lanoxin)
• Have the signs/symptoms of congestive heart failure improved?
• Is the client able to breathe easier?
• How many pillows does the client need to sleep on when lying down?
• Is the client able to perform activities of daily living without shortness of breath?
EXAMPLE #2
Furosemide (Lasix)
• Is the client’s urinary output greater than the intake?
• Has the client lost any weight?
• Does the client have sacral or peripheral edema?
• Does the client have jugular vein distention?
• Is the client’s blood pressure decreased?
SAMPLE DRUG CARDS
Front of Card
Classification of Drug:
Route:
Action of Drug:
Uses:
Nursing Implications (When would I question giving the medication?)
How will I monitor to see if it is working?
Back of Card
Side Effects:
Teaching Needs:
Drug Names:
It is suggested the test taker complete these cards from a pharmacology textbook and not
a drug handbook because most test questions come from a pharmacology book.
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CHAPTER 19 PHARMACOLOGY
Example #1: Digoxin
FRONT OF CARD
Classification of Drug: Cardiac Glycosides
Route: PO/IV
Action: Positive ionotropic action; increases force of ventricular contraction and thereby
increases cardiac output; slows the heart, allowing for increased filling time.
Uses: Congestive heart failure and rapid atrial cardiac dysrhythmias.
Nursing Implications: Check apical pulse for 1 full minute, hold if ⬍60. Check digoxin
level (0.5–2.0 normal; ⬎2.0 is toxic). Check K+ level (3.5–5.5 mEq/L is normal).
Hypokalemia is the most common cause of dysrhythmias in clients receiving digoxin.
Monitor for S/S of CHF, crackles in lungs, I & O, edema. Question if the AP is ⬍60 or
abnormal lab values.
IVP more than 5 minutes: maintenance dose 0.125–0.25 mg q day.
Effective: Breathing improves, activity tolerance improves, atrial rate decreases.
BACK OF CARD
Side Effects: Toxic = yellow haze or nausea and vomiting, ventricular rate decreases. If a
diuretic is given simultaneously, might increase the likelihood of hypokalemia.
Teaching Needs: To take pulse and hold digoxin if it is ⬍60 and notify HCP.
K+ replacement: Eat food high in K+ or may need supplemental K+.
Report weight gain of 3 lbs or more.
Drug names: Digoxin (Generic)
Lanoxin
Lanoxicaps
Example #2: Furosemide
FRONT OF CARD
Classification of Drug: Loop Diuretic
Route: PO/IVP
Actions: Blocks reabsorption of sodium and chloride in the loop of Henle, which
prevents the passive reabsorption of water and leads to diuresis.
Uses: CHF, fluid volume overload, pulmonary edema, HTN.
Nursing Implications: I & O, monitor K+ level, check skin turgor, monitor for leg
cramps, provide K+-rich foods or supplements, give early in the day to prevent nocturia.
If giving IVP: Give at prescribed rate (Lasix 20 mg/min), ototoxic if given faster.
Effective: Decrease in weight, output ⬎ intake, less edema, lungs sound clear.
BACK OF CARD
Side Effects: Hypokalemia, muscle cramps, hyponatremia, dehydration.
Teaching Needs: Take early in the day.
Eat foods high in K+.
Drug Names: Furosemide (Lasix)
Bumetanide (Bumex)
Torsemide (Demadex)
Ethacrynic acid (Edecrin)
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MEDICATIONS ADMINISTRATION
IN A MEDICAL-SURGICAL SETTING
COMPREHENSIVE EXAMINATION
The test taker is encouraged to use the guidelines/test-taking hints given previously when
taking the following medication test. The test is comprehensive for medications administered in a medical-surgical setting.
1. The client asks the clinic nurse if he should take 2,000 mg of vitamin C a day to
prevent getting a cold. On which scientific rationale should the nurse base the
response?
1. Vitamin C in this dosage will help cure the common cold.
2. This vitamin must be taken with echinacea to be effective.
3. This dose of vitamin C is not high enough to help prevent colds.
4. Megadoses of vitamin C may cause crystals to form in the urine.
2. The client recently has had a myocardial infarction. Which medications should the
nurse anticipate the health-care provider recommending to prevent another heart
attack?
1. Vitamin K and a nonsteroidal anti-inflammatory drug.
2. Vitamin E and a daily low-dose aspirin.
3. Vitamin A and an anticoagulant.
4. Vitamin B complex and an iron supplement.
3. The client diagnosed with essential hypertension calls the clinic and tells the nurse she
needs something for the flu. Which information should the nurse tell the client?
1. OTC medications for the flu should not be taken because of your hypertension.
2. If OTC medications do not relieve symptoms within three (3) days, contact the HCP.
3. Tell the client to ask the pharmacist to recommend an OTC medication for the flu.
4. Make an appointment for the client to receive the influenza vaccine.
4. Which laboratory test should the nurse monitor for the client receiving the
intravenous steroid Solu-Medrol?
1. Potassium level.
2. Sputum culture and sensitivity.
3. Glucose level.
4. Arterial blood gases.
5. The client diagnosed with asthma is prescribed the mast cell inhibitor cromolyn.
Which statement by the client indicates the need for further teaching?
1. “I will take two puffs of my inhaler before I exercise.”
2. “I will rinse my mouth with water after taking the medication.”
3. “After inhaling the medication, I will hold my breath for 10 seconds.”
4. “When I start to wheeze, I will use my inhaler immediately.”
6. The client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) is
receiving the aminoglycoside antibiotic vancomycin. Peak and trough levels are
ordered for the dose the nurse is administering. Which priority intervention should
the nurse implement?
1. Ask the client if he has had any diarrhea.
2. Monitor the aminoglycoside peak level.
3. Determine if the trough level has been drawn.
4. Check the client’s culture and sensitivity report.
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CHAPTER 19 PHARMACOLOGY
7. The nurse is caring for an elderly client who is eight (8) hours postoperative hip
replacement and is reporting incisional pain. Which intervention is priority for this
client?
1. Assist the client to sit in the bedside chair.
2. Initiate pain medication at the lowest dose.
3. Assess the client’s pupil size and accommodation.
4. Monitor the client’s urinary output hourly.
8. The client is diagnosed with pernicious anemia. Which health-care provider order
should the nurse anticipate in treating this condition?
1. Subcutaneous iron dextran.
2. Intramuscular vitamin B12.
3. Intravenous folic acid.
4. Oral thiamine medication.
9. The client with type 2 diabetes mellitus is prescribed glyburide (Micronase), a
sulfonylurea. Which statement indicates the client understands the medication
teaching?
1. “I should carry some hard candy when I go walking.”
2. “I must take my insulin injection every morning.”
3. “There are no side effects I need to worry about.”
4. “This medication will make my muscles absorb insulin.”
10. The unlicensed assistive personnel (UAP) reports the client’s glucometer reading is
380 mg/dL. The client is on regular sliding-scale insulin which reads:
Glucometer Reading
Units of Insulin
<150
0
151–250
5
251–350
8
351–450
10
451+
Notify the HCP
How much insulin should the nurse administer to the client? _________
11. The nurse administers 18 units of Humulin N, an intermediate-acting insulin, at
1630. Which priority invention should the nurse implement?
1. Monitor the client’s hemoglobin A1c.
2. Make sure the client eats the evening meal.
3. Check the a.c. blood glucometer reading.
4. Ensure the client eats a snack.
12. The nurse is administering the following 1800 medications. Which medication
should the nurse question before administering?
1. The sliding-scale insulin to the client who has just been released to have the
evening meal.
2. The antibiotic to the client who is one (1) day postoperative exploratory
abdominal surgery.
3. Metformin (Glucophage), a biguanide, to the client having a CT scan in the
morning.
4. Protonix, a proton pump inhibitor, to the client diagnosed with peptic ulcer
disease.
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13. The nurse is administering the long-acting insulin glargine (Lantus) to the client at
2200. The nurse asks the charge nurse to check the dosage. Which action should the
charge nurse implement?
1. Ask the nurse why the insulin is being given late.
2. Check the MAR versus the dosage in the syringe.
3. Instruct the nurse to complete a medication error form.
4. Have the nurse notify the health-care provider.
14. The nurse is preparing to administer Synthroid, a thyroid hormone replacement, to
the client diagnosed with hypothyroidism. Which assessment data would indicate the
client is receiving too much medication?
1. Bradypnea and weight gain.
2. Lethargy and hypotension.
3. Irritability and tachycardia.
4. Normothermia and constipation.
15. The client is receiving a continuous intravenous infusion of heparin, an anticoagulant.
Based on the most recent laboratory data:
PT 13.2
Control: 12.1
INR 1.3
PTT 72
Control: 39
which action should the nurse implement?
1. Continue to monitor the infusion.
2. Prepare to administer protamine sulfate.
3. Have the lab reconfirm the results.
4. Assess the client for bleeding.
16. The elderly client is admitted to the emergency department from a long-term care
facility. The client has multiple ecchymotic areas on the body. The client is receiving
digoxin, a cardiac glycoside; Lasix, a loop diuretic; Coumadin, an anticoagulant; and
Xanax, an antianxiety medication. Which order should the nurse request from the
health-care provider?
1. A STAT serum potassium level.
2. An order to admit to the hospital for observation.
3. An order to administer Valium intravenous push.
4. A STAT international normalized ratio (INR).
17. The client with postmenopausal osteoporosis is prescribed the bisphosphonate
alendronate (Fosamax). Which discharge instruction should the nurse discuss with
the client?
1. The medication must be taken with the breakfast meal only.
2. Remain upright for at least 30 minutes after taking medication.
3. The tablet should be chewed thoroughly before swallowing.
4. Stress the importance of having monthly hormone levels.
18. The nurse is administering a.m. medications. Which medication should the nurse
administer first?
1. The daily digoxin to the client diagnosed with congestive heart failure.
2. The loop diuretic to the client with a serum potassium level of 3.1 mEq/L.
3. The mucosal barrier Carafate to the client diagnosed with peptic ulcer disease.
4. Solu-Medrol IVP to a client diagnosed with chronic lung disease.
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CHAPTER 19 PHARMACOLOGY
19. The HCP ordered an angiotensin-converting enzyme (ACE) inhibitor for the client
diagnosed with a myocardial infarction. Which statement best explains the rationale
for administering this medication to this client?
1. It will help prevent the development of congestive heart failure.
2. This medication will help decrease the client’s blood pressure.
3. ACE inhibitors increase the contractility of the heart muscle.
4. They will help decrease the development of atherosclerosis.
20. The client is receiving the angiotensin-converting enzyme (ACE) inhibitor enalapril
(Vasotec). When would the nurse question administering this medication?
1. The client is not receiving potassium supplements.
2. The client complains of a persistent irritating cough.
3. The blood pressure for two (2) consecutive readings is 110/70.
4. The client’s urinary output is 400 mL for the last eight (8) hours.
21. The nurse is preparing to administer the morning dose of digoxin, a cardiac
glycoside, to a client diagnosed with congestive heart failure. Which data would
indicate the medication is effective?
1. The apical heart rate is 72 beats per minute.
2. The client denies having any anorexia or nausea.
3. The client’s blood pressure is 120/80 mm Hg.
4. The client’s lungs sounds are clear bilaterally.
22. The client diagnosed with multiple sclerosis (MS) is receiving Lioresal (baclofen),
a muscle relaxant. Which information should the nurse teach the client/family?
1. The importance of tapering off medication when discontinuing medication.
2. Baclofen may cause diarrhea, so the client should take antidiarrheal medication.
3. The client should not be allowed to drive alone while taking this medication.
4. The need for follow-up visits to obtain a monthly white blood cell count.
23. The nursing is administering digoxin, a cardiac glycoside, to the client with
congestive heart failure. Which interventions should the nurse implement?
Select all that apply.
1. Check the apical heart rate for one (1) full minute.
2. Monitor the client’s serum sodium level.
3. Teach the client how to take his or her radial pulse.
4. Evaluate the client’s serum digoxin level.
5. Assess the client for buffalo hump and moon face.
24. The client’s vital signs are T 99.2˚F, AP 59, R 20, and BP 108/72. Which medication
would the nurse question administering?
1. Theodur, a bronchodilator.
2. Inderal, a beta blocker.
3. Ampicillin, an antibiotic.
4. Cardizem, a calcium channel blocker.
25. The client in end-stage renal disease is a Jehovah’s Witness. The HCP orders
erythropoietin (Epogen), a biologic response modifier, subcutaneously for anemia.
Which action should the nurse take?
1. Question this order because of the client’s religion.
2. Encourage the client to talk to his or her minister.
3. Administer the medication subcutaneously as ordered.
4. Obtain the informed consent prior to administering.
26. The elderly male client is admitted for acute severe diverticulitis. He has been taking
Xanax, a benzodiazepine, for nervousness three (3) to four (4) times a day PRN for
six (6) years. Which intervention should the nurse implement first?
1. Prepare to administer an intravenous antianxiety medication.
2. Notify the HCP to obtain an order for the client’s Xanax PRN.
3. Explain Xanax causes addiction and he should quit taking it.
4. Assess for signs/symptoms of medication withdrawal.
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27. The nurse is administering an ophthalmic drop to the right eye. Which anatomical
location would be correct when administering eyedrops?
A
D
B
C
1. A
2. B
3. C
4. D
28. The nurse is administering the loop diuretic furosemide (Lasix) to the client diagnosed
with essential hypertension. Which assessment data would warrant the nurse to
question administering the medication?
1. The client’s potassium level is 4.2 mEq/L.
2. The client’s urinary output is greater than the intake.
3. The client has tented skin turgor and dry mucous membranes.
4. The client has lost two (2) pounds in the last 24 hours.
29. The client who has had a kidney transplant tells the nurse he has been taking
St. John’s wort, an herb, for depression. Which action should the nurse take first?
1. Praise the client for taking the initiative to treat the depression.
2. Remain nonjudgmental about the client’s alternative treatments.
3. Refer the client to a psychologist for counseling for depression.
4. Instruct the client to quit taking the medication immediately.
30. The nurse is administering an antacid to a client with gastroesophageal reflux disease.
Which statement best describes the scientific rationale for administering this
medication?
1. This medication will suppress gastric acid secretion.
2. This medication will decrease the gastric pH.
3. This medication will coat the stomach lining.
4. This medication interferes with prostaglandin production.
31. The client is diagnosed with essential hypertension and is receiving a calcium
channel blocker. Which assessment data would warrant the nurse holding the
client’s medication?
1. The client’s oral temperature is 102˚F.
2. The client complaints of a dry, nonproductive cough.
3. The client’s blood pressure reading is 106/76.
4. The client complains of being dizzy when getting out of bed.
32. The client complains of leg cramps at night. Which medication should the nurse
anticipate the HCP ordering to help relieve the leg cramps?
1. Quinine, an antimalarial.
2. Soma, a muscle relaxant.
3. Ambien, a sedative-hypnotic.
4. Darvon, an opioid analgesic.
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CHAPTER 19 PHARMACOLOGY
33. The nurse is preparing to administer the initial dose of an antibiotic in the emergency
department. Which interventions should the nurse implement? Select all that apply.
1. Assess for drug allergies.
2. Collect needed specimens for culture.
3. Check the client’s armband.
4. Ask the client his or her birthday.
5. Draw peak and trough levels.
34. For which client should the nurse question administering the muscarinic cholinergic
agonist oxybutynin (Ditropan)?
1. The client diagnosed with overactive bladder.
2. The client diagnosed with type 2 diabetes.
3. The client diagnosed with glaucoma.
4. The client diagnosed with peripheral vascular disease.
35. The nurse is administering a topical ointment to the client’s rash on the right leg.
Which intervention should the nurse implement first?
1. Don nonsterile gloves.
2. Cleanse the client’s right leg.
3. Check the client’s armband.
4. Wash the hands for 15 seconds.
36. The client is exhibiting multifocal premature ventricular contractions. Which
antidysrhythmic medication should the nurse anticipate the HCP ordering for
this dysrhythmia?
1. Adenosine.
2. Epinephrine.
3. Atropine.
4. Lidocaine.
37. The client in the intensive care department is receiving 2 mcg/kg/min of dopamine,
an ionotropic vasopressor. Which intervention should the nurse include in the plan
of care?
1. Monitor the client’s blood pressure every two (2) hours.
2. Assess the client’s peripheral pulses every shift.
3. Use a urometer to assess hourly output.
4. Ensure the IV tubing is not exposed to the light.
38. The client is receiving thrombolytic therapy for a diagnosed myocardial infarction
(MI). Which assessment data indicate the therapy is successful?
1. The client’s ST segment is becoming more depressed.
2. The client is exhibiting reperfusion dysrhythmias.
3. The client’s cardiac isoenzyme CK-MB is not elevated.
4. The D-dimer is negative at two (2) hours post-MI.
39. The client with arthritis is self-medicating with aspirin, a nonsteroidal antiinflammatory medication. Which complication should the nurse discuss with the
client?
1. Tinnitus.
2. Diarrhea.
3. Tetany.
4. Paresthesia.
40. The client is receiving a loop diuretic for congestive heart failure. Which medication
would the nurse expect the client to be receiving while taking this medication?
1. A potassium supplement.
2. A cardiac glycoside.
3. An ACE inhibitor.
4. A potassium cation.
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41. The nurse is reviewing laboratory values for the female client diagnosed with cancer.
Based on the laboratory report, which biologic response modifier would the nurse
anticipate administering to the client?
Laboratory Test
Client Values
Red blood cells
4.11
Normal Values
6
M: 4.7–6.1 (× 10 )/mm3
6
F: 4.2–5.4 (× 10 )/mm3
Hemoglobin
12.2
M: 13.5–17.5 g/dL
F: 11.5–15.5 g/dL
Hematocrit
37
M: 40%–52%
F: 36%–48%
3
White blood cells
2.0
4.5–11.0 (× 10 )/mm3
Platelets
160
140–400 (× 10 )/mm3
3
1. Interferon.
2. Neupogen.
3. Neumega.
4. Procrit.
42. The client admitted with pneumonia is taking Imuran, an immunosuppressive agent.
Which question should the nurse ask the client regarding this medication?
1. “Do you know this medication has to be tapered off when discontinued?”
2. “Have you been exposed to viral hepatitis B or C recently?”
3. “Why are you taking this medication, and how long have you taken it?”
4. “Do you have a lot of allergies or sensitivities to different medications?”
43. The elderly client is in a long-term care facility. If the client does not have a daily
bowel movement in the morning, he requests a cathartic, bisacodyl (Dulcolax).
Which action is most important for the nurse to take?
1. Ensure the client gets a cathartic daily.
2. Discuss the complications of a daily cathartic.
3. Encourage the client to increase fiber in the diet.
4. Refuse to administer the medication to the client.
44. The client received Narcan, a narcotic antagonist, following a colonoscopy. Which
action by the nurse has the highest priority?
1. Document the occurrence in the nurse’s notes.
2. Prepare to administer narcotic medication IV.
3. Administer oxygen via nasal cannula.
4. Assess the client every 15 to 30 minutes.
45. The client diagnosed with chronic obstructive pulmonary disease is being discharged
and is prescribed the steroid prednisone. Which scientific rationale supports why the
nurse instructs the client to taper off the medication?
1. The pituitary gland must adjust to the decreasing dose.
2. The beta cells of the pancreas have to start secreting insulin.
3. This will allow the adrenal gland time to start functioning.
4. The thyroid gland will have to start producing cortisol.
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CHAPTER 19 PHARMACOLOGY
46. The client is diagnosed with tuberculosis and prescribed rifampin and isoniazid
(INH), both antituberculosis medications. Which instruction is most important for
the public health nurse to discuss with the client?
1. The client will have to take the medications for 9 to 12 months.
2. The client will have to stay in isolation as long as he or she is taking medications.
3. Explain the client cannot eat any type of pork products while taking the
medication.
4. The urine may turn turquoise in color, but this is an expected occurrence and
harmless.
47. The employee health nurse is observing a student nurse administer a PPD tuberculin
test to a new employee. Which behavior would warrant immediate intervention by
the employee health nurse?
1. The student nurse inserts the needle at a 45-degree angle.
2. The student nurse cleanses the forearm with alcohol.
3. The student nurse circles the injection site with ink.
4. The student nurse instructs the employee to return in three (3) days.
48. The female client diagnosed with herpes simplex 2 is prescribed valacyclovir
(Valtrex), an antiviral. Which information should the nurse discuss with the client?
1. Do not get pregnant while on this medication; it will harm the fetus.
2. The medication does not prevent the transmission of the disease.
3. There are no side effects when taking this medication by mouth.
4. The client should get monthly liver function study tests.
49. The client diagnosed with coronary artery disease is prescribed an HMG-CoA
reductase inhibitor to help reduce the cholesterol level. Which assessment data
should be reported to the health-care provider?
1. Complaints of flatulence.
2. Weight loss of two (2) pounds.
3. Complaints of muscle pain.
4. No bowel movement for two (2) days.
50. The client with coronary artery disease is prescribed one (1) baby aspirin a day.
Which instructions should the nurse provide the client concerning this medication?
1. Take the medication on an empty stomach.
2. Do not take Tylenol while taking this drug.
3. If experiencing joint pain, notify the HCP.
4. Notify the HCP if stools become dark and tarry.
51. The nurse is preparing to administer phenytoin (Dilantin), 100 mg intravenous push,
to the client with a head injury who has an IV of D5W at 50 mL/hr. Which
intervention should the nurse implement?
1. Flush the IV tubing before and after with normal saline.
2. Administer the medication if the Dilantin level is 22 mcg/mL.
3. Push the Dilantin intravenously slowly over five (5) minutes.
4. Expect the intravenous tubing to turn cloudy when infusing medication.
52. The client diagnosed with epilepsy is being discharged from the hospital with a
prescription for phenytoin (Dilantin) by mouth. Which discharge instructions
should the nurse discuss with the client?
1. The client should purchase a self-monitoring Dilantin machine.
2. The client should see the dentist at least every six (6) months.
3. The client should never drive when taking this medication.
4. The client should drink no more than one (1) glass of wine a day.
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53. The female client with Trichomonas vaginalis is prescribed metronidazole (Flagyl), an
antibacterial medication. Which statement indicates the client does not understand
the discharge teaching?
1. “I will not be able to drink any alcohol while taking this drug.”
2. “My boyfriend will need to take this same medication.”
3. “I cannot transmit the disease through oral sex.”
4. “I must make sure I take all the pills no matter how I feel.”
54. The client diagnosed with angina must receive a two (2)-inch nitroglycerin paste
(Nitro-Bid) application. Which interventions should the nurse implement? Select
all that apply.
1. Wear gloves when administering.
2. Remove the old Nitro-Bid paper.
3. Apply the paper on a hairy spot.
4. Put medication only on the legs.
5. Report any headache to the HCP.
55. The nurse is hanging 1,000 mL of IV fluids to run for eight (8) hours. The intravenous
tubing is a microdrip. How many gtt/min should the IV rate be set at? ________
56. The client with osteoarthritis is prescribed a nonsteroidal anti-inflammatory drug
(NSAID). Which intervention should the nurse implement?
1. Time the medication to be given with meals.
2. Notify the HCP if abdominal striae develop.
3. Do not administer if oral temperature is greater than 102˚F.
4. Monitor the liver function tests and renal studies.
57. The client in the intensive care department has a nasogastric tube for continuous
feedings. The nurse is preparing to administer nifedipine (Procardia XL) via the
N/G tube. Which procedure should the nurse follow?
1. Crush the medication and dissolve it in water.
2. Administer and flush the N/G tube with cranberry juice.
3. Give the medication orally with pudding.
4. Do not administer medication and notify the HCP.
58. The employee health nurse is discussing hepatitis B vaccines with new employees.
Which statement best describes the proper administration of the hepatitis B vaccine?
1. The vaccine must be administered once a year.
2. Two (2) mL of vaccine should be given in each hip.
3. The vaccine is given in three (3) doses over a six (6)-month time period.
4. The vaccine is administered intradermally into the deltoid muscle.
59. The unlicensed assistive personnel (UAP) reported an intake of 1,000 mL and a
urinary output of 1,500 mL for a client who received a thiazide diuretic this
morning. Which nursing task could the nurse delegate to the nursing assistant?
1. Instruct the UAP to restrict the client’s fluid intake.
2. Request the UAP to insert a Foley catheter with an urimeter.
3. Tell the UAP urinary outputs are no longer needed.
4. Ask the UAP to document fluids on the bedside I & O record.
60. The charge nurse is observing the new graduate administering a fentanyl (Duragesic)
patch to a client diagnosed with cancer. Which action by the new graduate requires
intervention by the charge nurse?
1. The new graduate documents the date and time on the patch.
2. The new graduate removes the patch 24 hours after it is placed on the client.
3. The new graduate rotates the application site on the client’s body.
4. The new graduate checks the client’s name band and date of birth.
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CHAPTER 19 PHARMACOLOGY
61. The 68-year-old client is admitted to the emergency department with complaints of
slurred speech, right-sided weakness, and ataxia. The emergency room physician
ordered thrombolytic therapy for the client. Which action should the nurse
implement first?
1. Administer thrombolytic therapy via protocol.
2. Send the client for a STAT CT of the head.
3. Arrange for admission to the intensive care department.
4. Check to determine if the client is cross sensitive to the thrombolytic.
62. The client is admitted to the burn unit and prescribed pantoprazole (Protonix), a
proton pump inhibitor (PPI). Which statement best supports the scientific rationale
for administering this medication to a client with a severe burn?
1. This medication will help prevent a stress ulcer.
2. This medication will help prevent systemic infections.
3. This medication will provide continuous vasoconstriction.
4. This medication will stimulate new skin growth.
63. The nurse administered an IV broad-spectrum antibiotic scheduled every six
(6) hours to the client with a systemic infection at 0800. At 1000, the culture
and sensitivity prompted the HCP to change the IV antibiotic. When transcribing
the new antibiotic order, when would the initial dose be administered?
1. Schedule the dose for 1400.
2. Schedule the dose for the next day.
3. Check with the HCP to determine when to start.
4. Administer the dose within one (1) hour of the order.
64. The client is receiving a continuous heparin drip, 20,000 units/500 mL D5W, at
23 mL/min. How many units of heparin is the client receiving an hour? ________
65. The client with epilepsy is prescribed carbamazepine (Tegretol), an anticonvulsant.
Which discharge instruction should the nurse include in the teaching?
1. Wear SPF 15 sunscreen when outside.
2. Obtain regular serum drug levels.
3. Be sure to floss teeth daily.
4. Instruct the client to take tub baths only.
66. The client diagnosed with bipolar disorder has been taking valproic acid (Depakote),
an anticonvulsant, for four (4) months. Which assessment data would warrant the
medication being discontinued?
1. The client’s eyes are yellow.
2. The client has mood swings.
3. The client’s BP is 164/94.
4. The client’s serum level is 75 mcg/mL.
67. The client is complaining of nausea, and the nurse administers the antiemetic
promethazine (Phenergan), IVP. Which intervention has priority for this client after
administering this medication?
1. Instruct the client to call the nurse before getting out of bed.
2. Evaluate the effectiveness of the medication.
3. Assess the client’s abdomen and bowel sounds.
4. Tell the client not to eat or drink for at least one (1) hour.
68. The client on bedrest is receiving enoxaparin (Lovenox), a low molecular weight
heparin. Which anatomical site is recommended for administering this medication?
1. The abdominal wall one (1) inch away from the umbilicus.
2. The vastus lateralis with a 23-gauge needle.
3. In the deltoid area subcutaneously.
4. In the anterolateral abdomen.
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69. The male client comes to the emergency department and reports he stepped on
a rusty nail at home about two (2) hours ago. Which question would be most
important for the nurse to ask during the admission assessment?
1. “What have you used to clean the puncture site?”
2. “Did you bring the nail with you so we can culture it?”
3. “Do you remember when you had your last tetanus shot?”
4. “Are you able to put any weight on your foot?”
70. The nurse is administering carbidopa/levodopa (Sinemet) to the client. Which
assessment should the nurse perform to determine if the medication is effective?
1. Assess the client’s muscle strength.
2. Assess for cogwheel movements.
3. Assess the carbidopa serum level.
4. Assess the client’s blood pressure.
71. The client with coronary artery disease is prescribed atorvastatin (Lipitor) to help
decrease the client’s cholesterol level. Which intervention should the nurse discuss
with the client concerning this medication?
1. The client should eat a low-cholesterol, low-fat diet.
2. The client should take this medication with each meal.
3. The client should take this medication in the evening.
4. The client should monitor daily cholesterol levels.
72. The client is in end-stage renal disease and is receiving sodium polystyrene sulfonate
(Kayexalate) via an enema. Which data indicate the medication is effective?
1. The client has 30 mL/hr of urine output.
2. The serum phosphorus level has decreased.
3. The client is in normal sinus rhythm.
4. The client’s serum potassium level is 5.0 mEq/L.
73. The client has the following arterial blood gases: pH 7.19, PaCO2 33, PaO2 95, and
HCO3 19. Which medication would the nurse prepare to administer based on the
results?
1. Intravenous sodium bicarbonate.
2. Oxygen via nasal cannula.
3. Epinephrine intravenous push.
4. Magnesium hydroxide orally.
74. The client diagnosed with migraine headaches is prescribed propranolol (Inderal), a
beta blocker, for prophylaxis. Which information should the nurse teach the client?
1. Instruct to take medication at the first sign of headache.
2. Teach the client to take his or her radial pulse for one (1) minute.
3. Explain this drug may make the client thirsty and have a dry mouth.
4. Discuss the need to increase artificial light in the home.
75. The client is experiencing supraventricular tachycardia (SVT). Which
antidysrhythmic medication should the nurse prepare to administer?
1. Atropine.
2. Amiodarone.
3. Adenosine.
4. Dobutamine.
76. The client diagnosed with Parkinson’s disease is taking levodopa (L-dopa) and is
experiencing an “on/off” effect. Which action should the nurse take regarding this
medication?
1. Document the occurrence and take no action.
2. Request the HCP to increase the dose of medication.
3. Discuss the client’s imminent death as a result of this complication.
4. Explain this is a desired effect of the medication.
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CHAPTER 19 PHARMACOLOGY
77. The client in the emergency department requires sutures for a laceration on the left
leg. Which information is most pertinent prior to suturing the wound?
1. The client tells the nurse she has never had sutures.
2. The spouse refuses to leave the room during suturing.
3. The client shares she is scared of needles.
4. The client reports hives after having dental surgery.
78. The client diagnosed with diabetes insipidus is receiving vasopressin intranasally.
Which assessment data indicate the medication is effective?
1. The client reports being able to breathe through the nose.
2. The client complains of being thirsty all the time.
3. The client has a blood glucose of 99 mg/dL.
4. The client is urinating every three (3) to four (4) hours.
79. The nurse is administering an otic drop to the 45-year-old client. Which procedure
should the nurse implement when administering the drops?
1. Place the drops when pulling the ear down and back.
2. Place the drops when pulling the ear up and back.
3. Place the drops in the lower conjunctival sac.
4. Place the drops in the inner canthus and apply pressure.
80. The male client with a chronic urinary tract infection is prescribed trimethoprimsulfamethoxazole (Bactrim). Which statement indicates the client needs more
teaching?
1. “I will drink six (6) to eight (8) glasses of water a day.”
2. “I am going to have to take this medication forever.”
3. “I can stop taking this medication if there is no more burning.”
4. “I may get diarrhea with this medication, but I can take Imodium.”
81. The 54-year-old female client with severe menopausal symptoms is prescribed
hormone replacement therapy (HRT). Which secondary health screening activity
should the nurse recommend for HRT?
1. A Pap smear every six (6) months.
2. A yearly mammogram.
3. A bone density test every three (3) months.
4. A serum calcium level monthly.
82. The LPN is administering 0800 medications to clients on a medical floor. Which
action by the LPN would warrant immediate intervention by the nurse?
1. The LPN scores the medication to give the correct dose.
2. The LPN checks the client’s armband and birth date.
3. The LPN administers sliding-scale insulin intramuscularly.
4. The LPN is 30 minutes late hanging the IV antibiotic.
83. The client in end-stage renal disease is receiving aluminum hydroxide (Amphogel).
Which assessment data indicate the medication is effective?
1. The client denies complaints of indigestion.
2. The client is not experiencing burning on urination.
3. The client has had a normal, soft bowel movement.
4. The client’s phosphate level has decreased.
84. The client diagnosed with diabetes mellitus type 2 is scheduled for bowel resection in
the morning. Which medication should the nurse question administering to the
client?
1. Ticlopidine (Ticlid), a platelet aggregate inhibitor.
2. Ticarcillin (Timentin), an extended-spectrum antibiotic.
3. Pioglitazone (Actos), a thiazolidinedione.
4. Bisacodyl (Dulcolax), a cathartic laxative.
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85. The client with type 2 diabetes is diagnosed with gout and prescribed allopurinol
(Zyloprim). Which instruction should the nurse discuss when teaching about this
medication?
1. The client will probably develop a red rash on the body.
2. The client should drink two (2) to three (3) liters of water a day.
3. The client should take this medication on an empty stomach.
4. The client will need to increase oral diabetic medications.
86. The client is receiving atropine, an anticholinergic, to minimize the side effects
of routine medications. Which intervention will help the client tolerate this
medication?
1. Teach the client about orthostatic hypotension.
2. Instruct the client to eat a low-residue diet.
3. Encourage the client to chew sugarless gum.
4. Discuss the importance of daily isometric exercises.
87. The client is showing ventricular ectopy, and the HCP orders amiodarone
(Cordarone) intravenously. Which interventions should the nurse implement?
Select all that apply.
1. Monitor telemetry continuously.
2. Assess the client’s respiratory status.
3. Evaluate the client’s liver function studies.
4. Confirm the original order with another nurse.
5. Prepare to defibrillate the client at 200 joules.
88. The HCP has ordered an intramuscular antibiotic. After reconstituting the
medication, the clinic nurse must administer 4.8 mL of the medication. Which
action should the nurse implement first when administering this medication?
1. Inform the HCP the amount of medication is too large.
2. Administer the medication in the gluteal muscle.
3. Discard the medication in the sharps container.
4. Divide the medication and give 2.4 mL in each hip.
89. The client diagnosed with status asthmaticus is prescribed intravenous
aminophylline, a bronchodilator. Which assessment data would warrant
immediate intervention?
1. The theophylline level is 12 mcg/mL.
2. The client has expiratory wheezing.
3. The client complains of muscle twitching.
4. The client is refusing to eat the meal.
90. To which client would the nurse question administering the osmotic diuretic
mannitol (Osmitrol)?
1. The client with 4+ pitting pedal edema.
2. The client with decorticate posturing.
3. The client with widening pulse pressure.
4. The client with a positive doll’s eye test.
91. The male client is self-medicating with the H-2 antagonist cimetidine (Tagamet).
Which complication can occur while taking this medication?
1. Melena.
2. Gynecomastia.
3. Pyrosis.
4. Eructation.
92. The client is complaining of low-back pain and is prescribed the muscle relaxant
carisoprodol (Soma). Which teaching intervention has priority?
1. Explain this medication causes GI distress.
2. Discuss the need to taper off this medication.
3. Warn this medication will cause drowsiness.
4. Instruct the client to limit alcohol intake.
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CHAPTER 19 PHARMACOLOGY
93. The client diagnosed with adult-onset asthma is being discharged. Which medication would the nurse expect the health-care provider to prescribe?
1. A nonsteroidal anti-inflammatory medication.
2. An antihistamine medication.
3. An angiotensin-converting enzyme inhibitor.
4. A proton pump inhibitor.
94. The client is complaining of incisional pain. Which intervention should the nurse
implement first?
1. Administer the pain medication STAT.
2. Determine when the last pain medication was given.
3. Assess the client’s pulse and blood pressure.
4. Teach the client distraction techniques to address pain.
95. The nurse is evaluating the client’s home medications and notes the client with
angina is taking an antidepressant. Which intervention should the nurse implement
since the client is taking this medication?
1. Ask the client if there is a plan for suicide.
2. Assess the client’s depression on a 1-to-10 scale.
3. Explain this medication cannot be taken because of the angina.
4. Request a referral to the hospital psychologist.
96. The nurse is assessing the elderly client first thing in the morning. The client is
confused and sleepy. Which intervention should the nurse implement first?
1. Determine if the client received a sedative last night.
2. Allow the client to continue to sleep and do not disturb.
3. Encourage the client to ambulate in the room with assistance.
4. Notify the health-care provider about the client’s status.
97. The nurse is preparing to administer 37.5 mg of meperidine (Demerol) IM to a
client who is having pain. The medication comes in a 50-mg/mL vial. Which action
should the nurse implement?
1. Notify the pharmacist to bring the correct vial.
2. Have another nurse verify wastage of medication.
3. Administer one (1) mL of medication to the client.
4. Request the HCP to increase the client’s dose.
98. The client is to receive 3,000 mg of medication daily in a divided dose every
eight (8) hours. The medication comes 500 mg per tablet. How many tablets
will the nurse administer at each dose? __________
99. The 38-year-old client with chronic asthma is prescribed a leukotriene receptor antagonist. Which is the scientific rationale for administering this medication?
1. This medication is used prophylactically to control asthma.
2. This medication will cure the client’s chronic asthma.
3. It will stabilize mast cell activities and reduce asthma attacks.
4. It will cause the bronchioles to dilate and increase the airway.
100. The female nurse realizes she did not administer a medication on time to the client
diagnosed with a myocardial infarction. Which action should the nurse implement?
1. Administer the medication and take no further action.
2. Notify the director of nurses of the medication error.
3. Complete a medication error report form.
4. Report the error to the Peer Review Committee.
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101. The nurse has received the morning report and has the following medications due
or being requested. In which order should the nurse administer the medications?
List in order of priority.
1. Administer furosemide (Lasix), a loop diuretic, IVP daily to a client diagnosed
with heart failure who is dyspneic on exertion.
2. Administer morphine, a narcotic analgesic, IVP PRN to a client diagnosed with
lower back pain who is complaining of pain at a “10” on a 1-to-10 scale.
3. Administer neostigmine (Prostigmin), a cholinesterase inhibitor, PO to a client
diagnosed with myasthenia gravis.
4. Administer lidocaine, an antidysrhythmic, IVP PRN to a client in normal sinus
rhythm with multifocal premature ventricular contractions.
5. Administer vancomycin, an aminoglycoside antibiotic, to a client diagnosed with
a Staphylococcus infection who has a trough level of 14 mg/dL.
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MEDICATIONS ADMINISTRATION IN A MEDICAL-SURGICAL
SETTING COMPREHENSIVE EXAMINATION ANSWERS
AND RATIONALES
1. 1. The normal recommended daily dose of
vitamin C is 60 to 100 mg for healthy
adults, but nothing cures the virus which
causes the common cold.
2. Echinacea is an herbal preparation thought
to limit the severity of a cold and is sold in
OTC preparations, but it does not have to
be taken with vitamin C.
3. This dose is already too high, and watersoluble vitamins in excess of the body’s
needs are excreted in the urine.
4. Megadoses can lead to crystals in the
urine, and crystals can lead to the formation of renal calculi (stones) in the
kidneys. Therefore, megadoses should
not be taken because there is no
therapeutic value.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Analysis.
2. 1. Vitamin K helps prevent clotting, and
NSAIDs are recommended for inflammatory disorders and to relieve mild to
moderate pain.
2. Vitamin E is an antioxidant and is useful
in the treatment and prevention of
coronary artery disease, and aspirin
is an antiplatelet which prevents platelet
aggregation.
3. Vitamin A is required for healthy eyes,
gums, teeth and for fat metabolism. Anticoagulants are prescribed for clients with a
high risk for clot formation.
4. Vitamin B complex is used for healthy function of the nervous system, cell repair, and
formation of red blood cells; iron supplements are recommended for clients with
iron-deficiency anemia.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Planning: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Synthesis.
3. 1. OTC decongestant medications used for
the flu cause vasoconstriction of the
blood vessels, which would increase the
client’s hypertension and therefore
should be avoided. The client should let
the flu run its course.
2. OTC medications should not be taken by
the client with essential hypertension.
3. The nurse should provide the information
to the client about what medications to
take and should not refer the client to
the pharmacist.
4. It is too late for the flu vaccine because the
client is already ill with the flu.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Analysis.
4. 1. The potassium level is not affected by the
administration of steroids.
2. Culture and sensitivity reports should be
monitored to determine if the proper antibiotic is being administered.
3. Steroids are excreted as glucocorticoids
from the adrenal gland and are responsible for insulin resistance by the cells,
which may cause hyperglycemia.
4. There is no reason why the nurse would
question administering a steroid based on
an arterial blood gas result.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Assessment: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Analysis.
5. 1. Cromolyn is used prophylactically to prevent exercise-induced asthma attacks. It is
administered in routine daily doses to
prevent asthma attacks.
2. Rinsing the mouth will help prevent the
growth of bacteria secondary to medication
left in the mouth.
3. Holding the breath for 10 seconds keeps
the medication in the lungs.
4. This medication is used to stabilize the
mast cells in the lungs. During an
asthma attack, the mast cells are already
unstable; therefore, this medication will
not be effective in treating the acute
asthma attack. This statement would
require the nurse to reteach about the
medication.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Evaluation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Synthesis.
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6. 1. Diarrhea may indicate the client may have a
superinfection, but it is not the priority
intervention at this time because the
antibiotic would still be administered.
2. The peak level is not drawn until one (1) hour
after the medication has been infused.
3. The trough level must be drawn prior to
administering this dose; therefore, it is
the priority intervention.
4. The culture and sensitivity (C&S) has
already been done because it is known the
client has MRSA.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Analysis.
7. 1. At eight (8) hours postoperative the client
should be on bedrest, and moving the client
to a chair will not help the incisional pain
and could cause hip dislocation.
2. Normal developmental changes in the
organs of the elderly, especially the kidneys and liver, result in lower doses of
pain medication needed to achieve
therapeutic levels.
3. This is a neurological assessment, which is
not pertinent to the extremity assessment.
4. The urinary output would not affect the
administration of pain medication.
Content – Pharmacology: Category of Health
Alteration – Pain: Integrated Nursing Process –
Implementation: Client Needs – Safe Effective Care
Environment, Management of Care: Cognitive
Level – Analysis.
8. 1. Iron dextran is administered for irondeficiency anemia intravenously or
intramuscularly, not subcutaneously.
2. Vitamin B12 is administered for pernicious anemia because there is insufficient intrinsic factor produced by the
rugae in the stomach to be able to
absorb and use vitamin B12 from food
sources.
3. Folic acid is administered orally or intravenously for folic acid deficiency, which is
usually associated with chronic alcoholism.
4. Thiamine is administered intravenously in
high doses to clients detoxifying from
chronic alcoholism to prevent rebound
nervous system dysfunction.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Planning: Client Needs –
Physiological Integrity, Pharmacological and
Parenteral Therapies: Cognitive Level – Synthesis.
9. 1. This medication stimulates the pancreas to secrete insulin. Therefore, the
client is at risk for developing hypoglycemic reactions, especially during
exercise.
2. This is an oral hypoglycemic medication.
3. There are side effects to every medication;
this medication can cause hypoglycemia.
4. The medication stimulates the pancreas to
produce more insulin, but it does not affect the muscles’ absorption of glucose.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Evaluation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Synthesis.
10.
10 units.
The nurse should administer the dosage
for the appropriate parameters.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Application.
11. 1. This test monitors the client’s average
blood glucose level over the previous three
(3) months.
2. The evening meal would prevent hypoglycemia for regular insulin administered
at 1630.
3. The before-meal (a.c.) blood glucose level
done at 1630 would not be affected by the
insulin administered after that time.
4. The intermediate-acting insulin peaks
6 to 8 hours after being administered;
therefore, the nighttime snack (h.s.)
will prevent late-night hypoglycemia.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Analysis.
12. 1. The nurse would not question administering insulin to a client about to eat.
2. The client who is one (1) day postoperative would be receiving a prophylactic
antibiotic.
3. Glucophage must be held 24 to 48 hours
prior to receiving contrast media (dye)
because Glucophage, along with the
contrast dye, can damage kidney
function.
4. The client with peptic ulcer disease would
be ordered a proton pump inhibitor to
help decrease gastric acid production.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
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copyright law.
CHAPTER 19 PHARMACOLOGY
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Analysis.
13. 1. This insulin is scheduled for bedtime.
2. The charge nurse should double-check
the dosage against the MAR to make
sure the client is receiving the correct
dose; this insulin does not peak and
works for 24 hours.
3. There is not a medication error at this
time.
4. The HCP would only need to be notified
if a serious medication error has occurred.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Application.
14. 1. These are signs/symptoms of hypothyroidism, which indicates not enough
medication.
2. These indicate not enough medication is
being administered.
3. Irritability and tachycardia are
signs/symptoms of hyperthyroidism,
which indicates the client is receiving
too much medication.
4. Normothermia indicates a normal
temperature, which does not indicate
hypothyroidism or hyperthyroidism, and
constipation is a sign of hypothyroidism.
16. 1. A STAT potassium level would be needed
for problems with digoxin or a diuretic,
not for bleeding.
2. The nurse needs more information before
requesting an admission into the hospital.
3. Valium IVP does not help bleeding.
4. Ecchymotic areas are secondary to
bleeding. The nurse should order an
INR to rule out warfarin (Coumadin)
toxicity.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Analysis.
17. 1. The medication must be taken first thing
in the morning before breakfast on an
empty stomach; no food, juice, or coffee
should be consumed for at least
30 minutes.
2. Remaining in the upright position minimizes the risk of esophagitis; the drug
should be taken with eight (8) ounces
of water.
3. The tablet should be swallowed, not
chewed, and should not be allowed to
dissolve until it is the stomach.
4. There is no monthly hormone level to
determine the effectiveness of this
medication; it is determined by a
bone density test.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Assessment: Client Needs – Safe
Effective Care Environment, Management of Care:
Cognitive Level – Analysis.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Planning: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Synthesis.
15. 1. The therapeutic heparin level is 1.5 to
2 times the control, which is 58 to
78; therefore, a PTT of 72 is within
therapeutic range so the nurse should
continue to monitor the infusion.
PT/INR are used to monitor the oral
anticoagulant warfarin (Coumadin).
2. Protamine sulfate is the antidote for
heparin toxicity, but the client is in the
therapeutic range.
3. There is no need for the laboratory to
reconfirm the results.
4. The nurse would not need to assess for
bleeding because the results are within the
therapeutic range.
18. 1. A daily digoxin dose is not priority
medication.
2. This potassium level is very low, and the
nurse should not administer the loop
diuretic.
3. The mucosal barrier must be administered on an empty stomach; therefore,
it should be administered first.
4. An IVP medication is not priority over
administering a medication which must
be given on an empty stomach.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Analysis.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Safe Effective Care Environment, Management of
Care: Cognitive Level – Analysis.
19. 1. Attempting to prevent CHF is the
rationale for administering ACE
inhibitors to clients diagnosed with
MIs. This medication is administered
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for a variety of medical diagnoses, such
as heart failure and stroke, and to help
prevent diabetic nephropathy.
2. ACE inhibitors are prescribed to help
decrease blood pressure, but the stem
states the client has had an MI, not
essential hypertension.
3. Cardiac glycosides such as digoxin, not
ACE inhibitors, increase the contractility
of the heart.
4. Antilipidemics, not ACE inhibitors,
help decrease the development of
atherosclerosis.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Analysis.
2. This medication causes constipation and
urinary retention.
3. The client should not be allowed to drive
at all when taking this medication because
it causes drowsiness, and the spasticity of
MS makes driving dangerous for the
client.
4. White blood cell levels do not need to be
monitored because the drug does not
cause bone marrow suppression.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Planning: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Synthesis.
20. 1. ACE inhibitors may increase potassium
levels. The client should avoid potassium
salt substitutes and supplements; therefore, the nurse would not question the fact
the client is not receiving potassium
supplements.
2. An adverse effect of ACE inhibitors is
the possibility of a persistent irritating
cough, which might precipitate the
HCP’s changing the client’s medication.
3. This blood pressure indicates the
medication is effective.
4. A urinary output of 30 mL/hr indicates
the kidneys are functioning properly.
23. 1. If the apical heart rate is less than
60, the nurse should question
administering this medication.
2. The client’s potassium level, not the
sodium level, should be monitored.
3. The client should be taught to monitor
the radial pulse at home and not to
take the medication if the pulse is less
than 60 because this medication will
further decrease the heart rate.
4. The digoxin level should be between
0.8 and 2 ng/mL to be therapeutic.
5. The client with digoxin toxicity would
complain of anorexia, nausea, and yellow
haze; buffalo hump and moon face would
be assessed for the client taking prednisone, a glucocorticoid.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Assessment: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Analysis.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Analysis.
21. 1. The apical heart rate is assessed prior to
administering the dose, but it does not
indicate the medication is effective.
2. Anorexia and nausea are signs of digoxin
toxicity and do not indicate if the
medication is effective.
3. Digoxin has no effect on the client’s blood
pressure.
4. Digoxin is administered for heart
failure and dysrhythmias. Clear lung
sounds indicate the heart failure is
being controlled by the medication.
24. 1. The respiratory rate and pulse rate would
not affect the administration of this
medication.
2. The apical heart rate (AP) of 59 would
cause the nurse to question administering this medication because beta
blockers decrease the sympathetic
stimulation to the heart, thereby
deceasing the heart rate.
3. These vital signs would not warrant the
nurse questioning administering an
antibiotic.
4. The blood pressure is higher than 90/60;
therefore, the nurse would not question
administering the calcium channel blocker.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Assessment: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Analysis.
22. 1. Abrupt discontinuation of baclofen is
associated with hallucinations, paranoia, and seizures.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Analysis.
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CHAPTER 19 PHARMACOLOGY
25. 1. Epogen stimulates the client’s own bone
marrow to produce red blood cells; therefore, this is not a violation of the client’s
religious beliefs about blood products.
2. There is no reason for the client to have
problems receiving this medication because of religious beliefs, so the client
does not need to talk to the minister.
3. This medication does not violate the
Jehovah Witnesses’ beliefs concerning
receiving blood products; therefore,
the nurse should administer the
medication via the correct route.
4. This is not an invasive procedure or
investigational medication and thus
informed consent is not needed.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Psychosocial Integrity: Cognitive Level – Analysis.
26. 1. Because the client is NPO as a result of
the admitting diagnosis, the client needs
alternative antianxiety medication to prevent withdrawal symptoms, but this is not
the first intervention.
2. The client will be NPO as a result of the
diverticulitis, and Xanax is administered
orally; therefore, another route of medication administration is needed, but this is
not the first intervention.
3. This is correct information, but it is not
the priority intervention.
4. Xanax has a greater dependence problem than all the other benzodiazepines;
therefore, the nurse must assess for
withdrawal symptoms first. Then the
nurse can implement the other interventions. The client needs to be
withdrawn slowly from the benzodiazepines, but assessment is priority.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Analysis.
27. 1. This is the outer canthus, and medications
are not administered to this area.
2. The correct placement of ophthalmic
drops is to administer the medication
in the lower conjunctival sac.
3. This is the sclera, and the correct
placement of eyedrops is in the lower
conjunctival sac.
4. This is the inner canthus, where pressure
can be applied gently after instilling
eyedrops to help prevent the systemic
absorption of ophthalmic medications.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client
Needs – Physiological Integrity, Pharmacological
and Parenteral Therapies: Cognitive Level –
Application.
28. 1. This potassium level is within normal
limits; therefore, the nurse would
administer the medication.
2. This indicates the medication is effective
and the nurse should not question
administering the medication.
3. This indicates the client is dehydrated
and the nurse should discuss this with
the HCP prior to administering
another dose, which could increase
the dehydration and could cause
renal failure.
4. This indicates the medication is effective.
Daily weight changes reflect fluid gain
and loss.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Assessment: Client Needs – Safe
Effective Care Environment, Management of Care:
Cognitive Level – Analysis.
29. 1. The nurse should investigate any herbs a
client is taking, especially if the client has
a condition which requires long-term
medication, such as antirejection
medication.
2. The nurse should remain nonjudgmental
but must intervene if the alternative
treatment poses a risk to the client.
3. The client may need to be referred
for psychological counseling, but it
is not the first action the nurse
should take.
4. St. John’s wort decreases the effects
of many medications, including oral
contraceptives, antiretrovirals, and
transplant immunosuppressant drugs.
Rejection of the client’s kidney could
occur if the client continues to use
St. John’s wort.
Content – Pharmacology: Category of Health
Alteration – Complementary and Alternative
Medications: Integrated Nursing Process –
Implementation: Client Needs – Physiological
Integrity, Pharmacological and Parenteral Therapies:
Cognitive Level – Analysis.
30. 1. This is the rationale for H-2 antagonists
and proton pump inhibitors.
2. Antacids neutralize gastric acidity.
3. This is the rationale for mucosal barrier
agents.
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4. Prostaglandin is responsible for production of gastric acid. Antacids do not
interfere with prostaglandin production.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Analysis.
31. 1. The client’s temperature would not affect
the administration of this medication.
2. ACE inhibitors sometimes cause the client
to develop a cough which requires discontinuing the medication, but this is a
calcium channel blocker.
3. This blood pressure reading indicates the
client’s medication is effective.
4. This indicates orthostatic hypotension,
and the nurse should assess the
client’s BP before administering
the medication.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Assessment: Client Needs – Safe
Effective Care Environment, Management of Care:
Cognitive Level – Analysis.
32. 1. An unlabeled use for quinine is the
prophylaxis and treatment of nocturnal
leg cramps which are associated with
arthritis, diabetes, varicose veins, and
arteriosclerosis.
2. A muscle relaxant is prescribed for muscle
spasms, and leg cramps are not always the
result of muscle spasms.
3. The question is addressing the relief of leg
cramps, and sleeping pills will not help leg
cramps.
4. The client does not need an opioid analgesic because it may cause addiction; this
type of medication is given for acute pain
for a short period. Prolonged use of Darvon compounds also predisposes the client
to renal cell carcinoma.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Planning: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Synthesis.
33. 1. The nurse should always assess for
allergies, but especially when administering antibiotics, which are notorious
for allergic reactions.
2. If specimens are not obtained for C&S
prior to administering the first dose of
antibiotic, the results will be skewed.
3. One (1) of the five (5) rights is to
administer the medication to the “right
client.” Checking the armband on the
client with the MAR and medication is
a way to ensure this.
4. The 2005 Joint Commission standards
require two forms of identification
prior to administering medications.
The client’s armband and medical
record number provide one form of
identifying information, and the client’s
birthday is the second form of identification in most health-care facilities.
This is a nationwide emphasis to help
prevent medication errors.
5. The stem does not state it is an aminoglycoside antibiotic, and it is the initial dose,
which means there is no medication in the
system even if it were an aminoglycoside
antibiotic.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Safe Effective Care Environment, Safety and Infection
Control: Cognitive Level – Application.
34. 1. This medication is prescribed for clients
with an overactive bladder.
2. There is no contraindication for a client
with type 2 diabetes receiving this
medication.
3. These drugs cause mydriasis, which
increases the intraocular pressure,
which could lead to blindness.
Glaucoma is caused by increased
intraocular pressure.
4. There is no contraindication for a client
with peripheral vascular disease receiving
this medication.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Assessment: Client Needs – Safe
Effective Care Environment, Safety and Infection
Control: Cognitive Level – Analysis.
35. 1. The nurse should use nonsterile gloves to
apply ointment but should first wash his
or her hands.
2. The client’s leg should be cleansed prior
to administering a new application of ointment, but it is not the first intervention.
3. The nurse should always check the client’s
armband, but it is not the first intervention when the nurse enters the room.
4. Hand washing is the first intervention
which must be done when the nurse
enters the client’s room before any contact with the client; it is also the last intervention the nurse does after caring
for the client and leaving the room.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
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CHAPTER 19 PHARMACOLOGY
Nursing Process – Implementation: Client Needs –
Safe Effective Care Environment, Safety and Infection
Control: Cognitive Level – Application.
36. 1. Adenosine is ordered for supraventricular
tachycardia.
2. Epinephrine is administered during a code
to vasoconstrict the periphery and shunt
the blood to the central circulating system.
3. Atropine is used for asystole or symptomatic sinus bradycardia.
4. Lidocaine is the drug of choice for
ventricular irritability. It suppresses
ventricular ectopy.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Planning: Client Needs – Safe
Effective Care Environment, Management of Care:
Cognitive Level – Synthesis.
37. 1. The blood pressure must be continuously
monitored more often, at least every 10 to
15 minutes.
2. The peripheral pulses should be monitored more frequently than every shift,
but dopamine has no direct effect on the
peripheral pulses.
3. The client’s urine output should be
monitored because low-dose dopamine
is administered to maintain renal
perfusion; higher doses can cause
vasoconstriction of the renal arteries.
4. Dopamine is not inactivated when exposed
to light.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Safe Effective Care Environment, Management of
Care: Cognitive Level – Application.
38. 1. The ST segment becoming more depressed indicates a worsening of the
oxygenation of the myocardial tissue.
2. Reperfusion dysrhythmias indicate
the ischemic heart tissue is receiving
oxygen and is viable heart tissue.
3. The creatine kinase CK-MB isoenzyme
elevates when there is necrotic heart tissue
and does not indicate if thrombolytic
therapy is successful.
4. D-dimer is used to diagnose pulmonary
embolus.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Assessment: Client Needs –
Physiological Integrity, Reduction of Risk Potential:
Cognitive Level – Analysis.
39. 1. Tinnitus, ringing in the ears, is a sign
of aspirin toxicity and needs to be
reported to the HCP; the aspirin
should be stopped immediately.
2. Diarrhea is a complication of many medications but not with aspirin.
3. Tetany is muscle twitching secondary to
hypocalcemia.
4. Aspirin does not cause paresthesia, which
is numbness or tingling.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Planning: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Synthesis.
40. 1. Loop diuretics cause loss of potassium
in the urine output; therefore, the
client should be receiving potassium
supplements. Hypokalemia can lead to
life-threatening cardiac dysrhythmias.
2. A cardiac glycoside, digoxin, is administered for congestive heart failure, but it is
not necessary when administering a loop
diuretic.
3. An ACE inhibitor is not prescribed along
with a loop diuretic. It may be ordered for
congestive heart failure.
4. A potassium cation, Kayexalate, is ordered
to remove potassium through the bowel
for clients with hyperkalemia.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Planning: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Synthesis.
41. 1. Interferon is administered to treat hepatitis and some cancers, but it does not
stimulate the bone marrow.
2. Neupogen is a granulocyte-stimulating
factor which stimulates the bone
marrow to produce white blood
cells (WBCs), which this client needs
because the normal WBC count is
× 103)/mm3.
4.5 to 11.0 (×
3. Neumega stimulates the production of
platelets, but the client’s platelet count of
160 is normal [100 to 400 (× 103)/mm3].
4. Procrit stimulates the production of red
blood cells and hemoglobin, but a hemoglobin of 12.2 is normal for a woman
(11.5 to 15.5 g/dL).
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Assessment: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Synthesis.
42. 1. This medication must be taken for life because the client has to have received some
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MED-SURG SUCCESS
type of transplant or have severe rheumatoid arthritis for it to be prescribed.
2. Exposure to hepatitis does not have
anything to do with receiving this
medication.
3. Imuran is not a drug of choice for
treating pneumonia; therefore, the
nurse must find out why the client is
taking it (either for a renal transplant
or for severe rheumatoid arthritis).
4. Imuran does not affect the antigen–
antibody reaction.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Assessment: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Analysis.
43. 1. A daily cathartic is a colonic stimulant,
which results in dependency and a narrowing of the lumen of the colon, which
increases constipation.
2. Although the client may think a
medication for bowel movements is
necessary, the nurse should teach the
client this medication can cause serious
complications, such as dependency and
narrowing of the colon.
3. Fiber will help increase the roughage,
which may help prevent constipation, but
the most important action is to empower
the client to make informed decisions
about medications.
4. The nurse should not refuse to administer
the medication; the nurse should talk to
the client and, if needed, the HCP before
administering the medication.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Application.
44. 1. This should be documented in the client’s
nurse’s notes because this is a PRN medication, but it is not the priority medication.
2. The nurse would not administer another
narcotic, which is what caused the need
for Narcan in the first place.
3. Oxygen will not help reverse respiratory
depression secondary to a narcotic
overdose.
4. Narcan is administered when the client
has received too much of a narcotic.
Narcan has a short half-life of about
30 minutes and the client will be at risk
for respiratory depression for several
hours; therefore, the nurse should
assess the client frequently.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Analysis.
45. 1. The pituitary gland is not directly affected
by the steroid and is not why the medication must be gradually tapered.
2. Steroids do not affect the pancreas’s
production of insulin.
3. When the client is receiving exogenous
steroids, the adrenal glands stop
producing cortisol, and if the medication is not tapered, the client can have
a severe hypotensive crisis, known
as adrenal gland insufficiency or
addisonian crisis.
4. The adrenal gland, not the thyroid gland,
produces cortisol.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Analysis.
46. 1. This medication is taken up to one
(1) year, and the public health department will pay for the medications and
make sure the client complies because
it is a public health risk.
2. The client is in isolation until three
(3) consecutive early-morning sputum
cultures are negative, which is usually in
about two (2) to four (4) weeks.
3. Pork products do not interact with these
medications.
4. The client’s urine and all body fluids may
turn orange from the rifampin.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Planning: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Synthesis.
47. 1. This medication should be administered intradermally with the needle
barely inserted under the skin so a
wheal (bubble) forms after the
injection.
2. Cleansing the forearm with an alcohol
swab is standard procedure and would not
warrant immediate intervention.
3. Circling the site is an appropriate intervention so, when the skin test is read and
no reaction is occurring, the nurse will
be able document a negative skin test
reading.
4. The skin test is read in three (3) days to
determine the results.
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copyright law.
CHAPTER 19 PHARMACOLOGY
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Evaluation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Synthesis.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Planning: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Synthesis.
48. 1. This classification of medication is used to
prevent transmission of this virus to the
fetus during pregnancy; therefore, it does
not harm the fetus and the client can be
pregnant while taking this medication.
2. Only condoms or abstinence will prevent transmission of the herpes virus.
3. There are side effects to every drug; this
one causes headache, dizziness, nausea,
and anorexia.
4. This medication does not directly affect
the liver, and liver function tests (LFTs)
are not required monthly.
51. 1. Dilantin will crystallize in the tubing
and is not compatible with any IV fluid
except normal saline. The IV tubing
must be flushed before the medication
is administered.
2. The therapeutic Dilantin level is 10 to
20 mcg/mL; therefore, this is a toxic level.
3. The medication is pushed at 50 mg/min.
4. If the tubing turns cloudy, it means it is not
compatible, and the nurse must stop the
IVP immediately and discontinue the IV.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Planning: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Synthesis.
49. 1. Flatulence (“gas”) is an expected side
effect which is not life threatening and
does not need to be reported to the HCP.
2. A weight loss of two (2) pounds would not
need to be reported to the HCP because
this medication does not affect the client’s
weight.
3. Muscle pain may indicate arthralgias,
myositis, or rhabdomyolysis, which are
complications which would cause the
HCP to discontinue the medication
because its continued use may lead to
liver failure.
4. Not having a bowel movement may be
important to the client, but clients do not
have to have daily bowel movements.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Analysis.
50. 1. Aspirin causes GI distress and should be
taken with food.
2. Tylenol is recommended for pain and can
be safely taken with a daily baby aspirin.
3. Aspirin (acetylsalicylic acid [ASA]) does
not cause joint pain; in fact, it may
provide some relief because of its antiinflammatory action, but when aspirin is
taken daily, it is an antiplatelet medication.
4. ASA is known to cause gastric upset
which can lead to gastric bleeding, and
dark, tarry stools may indicate upper
GI bleeding.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Application.
52. 1. There is no machine for home use which
monitors Dilantin levels. Levels are
usually checked every six (6) months
to one (1) year by venipuncture and
laboratory tests.
2. Dilantin causes gingival hyperplasia,
and mouth care and dental care are
priority to help prevent rotting of
the teeth.
3. Some states allow seizure-free clients with
epilepsy to drive, but some states don’t.
The word “never” in this distracter should
eliminate it as a possible correct answer.
4. Alcohol should be strictly prohibited when
taking anticonvulsant medications.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Planning: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Synthesis.
53. 1. Alcohol creates a disulfiram-like
reaction to the medication, which
causes severe nausea, vomiting, and
extreme hypertension.
2. Trichomonas vaginalis is an asymptomatic
sexually transmitted disease in males. If
the male partner is not simultaneously
treated, then he can reinfect the female.
3. This sexually transmitted disease can
be transmitted via oral routes.
4. This is a concept which must be taught to
all clients taking antibiotics: Take all the
medications as prescribed.
Content – Pharmacology: Category of
Health Alteration – Drug Administration:
Integrated Nursing Process – Evaluation: Client
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Needs – Physiological Integrity, Pharmacological and
Parenteral Therapies: Cognitive Level – Synthesis.
54. 1. If the nurse does not wear the gloves,
the nurse can absorb the medication
and get a headache.
2. The old nitroglycerin paste must be
removed because it could cause an
overdose of the medication.
3. The paper should be applied to a clean,
dry, hairless area.
4. The medication can be placed on the
chest, arms, back, or legs.
5. A headache is a common side effect and
should not be reported to HCP.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Application.
55.
125 gtt/min.
A microdrip is 60 gtt/mL. The formula
for this dosage problem is as follows:
1,000 mL × 60 = 60,000 = 125 gtt/min
480 min
480
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Application.
56. 1. This medication is harsh on the lining
of the stomach and should be taken
with meals.
2. Abdominal striae occur with steroids, not
NSAIDs.
3. The temperature does not affect the administration of this medication. NSAIDs
would be prescribed for fever.
4. The liver and kidneys are responsible for
metabolizing and excreting all medications, but the tests are not routinely monitored for NSAIDs.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Application.
57. 1. The XL means the medication is extended
release and cannot be crushed.
2. Whole capsules or tablets cannot be
administered through a feeding tube.
3. The client has a feeding tube and is not
able to swallow; therefore, the nurse
should not administer the medications
orally.
4. Tablets which are enteric coated or
extended release cannot be crushed
and administered via the N/G tube.
This would allow 24 hours worth of
medication into the client’s system at
one time. The nurse should ask the
HCP to change the medication to a
form which is not enteric coated and
not extended release. Then it can be
crushed and administered through the
feeding tube.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Application.
58. 1. The vaccine is administered in a series of
three (3) injections and is reported to be
effective for life, but boosters may be
given every five (5) years.
2. This is the incorrect administration for
hepatitis B vaccine.
3. Hepatitis B is given in three (3) doses—
initially, then at one (1) month, and
then again at six (6) months.
4. Hepatitis B vaccine is given intramuscularly in the deltoid muscle.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Application.
59. 1. An output greater than intake indicates
the medication is effective, and there is no
need to restrict the fluid intake.
2. There is no reason to insert a Foley
catheter in the client who is urinating
without difficulties.
3. As long as the client is receiving diuretics,
the client should be on intake and output
monitoring.
4. The UAP can document the client’s
fluid intake and output numbers on the
bedside record; this is one of the UAP’s
duties.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Planning: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Synthesis.
60. 1. This is a correct intervention when applying a patch; therefore, the charge nurse
would not have to intervene.
2. The fentanyl patch takes about
24 hours to develop full analgesic
effect; the patch should be replaced
every 72 hours.
3. The sites should be rotated to prevent
irritation to the skin.
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CHAPTER 19 PHARMACOLOGY
4. A new IV antibiotic must be initiated
as soon as possible, at least within
one (1) hour. A broad-spectrum antibiotic is ordered until C&S results are
determined. Then, an antibiotic which
will specifically target the infectious
organism must be started immediately.
4. This is the correct way to administer all
medications.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Evaluation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Synthesis.
61. 1. The nurse should prepare to administer
the medication, but it is not the first
intervention.
2. A CT scan must be done to rule out a
hemorrhagic CVA because, if it is a hemorrhagic stroke, thrombolytic therapy
will increase bleeding in the head.
3. The client receiving thrombolytic therapy
will be in the ICU because the client
needs constant surveillance during therapy. Heparin will be started, but this is
not the first intervention.
4. The nurse should check to determine if
the client is allergic to medications, but in
this situation the client must have a CT
before any other action is taken. Cross
sensitivity usually occurs with antibiotics,
not thrombolytic therapy.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Analysis.
62. 1. PPIs decrease gastric secretion and
are prescribed for clients to prevent
Curling’s stress ulcer. PPIs are
ordered for most clients in the
intensive care department, not just
clients with burns.
2. PPIs do not treat infections; antibiotics
treat infections.
3. PPIs do not cause continuous constriction.
Dopamine might do this.
4. Positive nitrogen balance accomplished
through nutritional interventions will help
promote tissue regeneration.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Analysis.
63. 1. The new antibiotic must be started as
soon as the medication arrives from the
pharmacy.
2. Waiting until the next day could cause serious harm, with the client possibly going
into septic shock.
3. The HCP does not determine when the
medications are administered; this is a
nursing intervention.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Application.
64.
920 units/hr.
20,000 units ÷ 500 mL = 40 units/mL
40 units/mL × 23 mL/hr = 920 units/hr
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Application.
65. 1. Tegretol is photosensitive, but the client
must wear SPF of at least 30 to be
protected.
2. This medication has a therapeutic level
which must be maintained to help
prevent seizures. The therapeutic
range is from 6 to 12 mcg/mL.
3. Dilantin, another anticonvulsant, causes
hyperplastic gingivitis, but carbamazepine
does not.
4. The client with seizure disorder should
only take showers because, if a seizure
occurs in the bathtub, the client could
drown.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Planning: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Synthesis.
66. 1. Yellow eyes would indicate the client is
experiencing some type of hepatic
toxicity, which would warrant the
medication being discontinued immediately. During the first few months
of treatment, the client is closely
monitored for hepatic toxicity because
deaths have occurred.
2. The medication dose may need to be increased, but Depakote is administered to
prevent the mood swings.
3. The BP is slightly elevated, but it is not
related to the medication.
4. The therapeutic serum Depakote level is
50 to 100 mcg/mL; therefore, the client is
within therapeutic range.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
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MED-SURG SUCCESS
Nursing Process – Assessment: Client Needs – Safe
Effective Care Environment, Management of Care:
Cognitive Level – Analysis.
67. 1. Safety is priority when administering a
phenothiazine because it causes
sedative-like effects.
2. Evaluation is not priority over safety.
3. The nurse should have assessed the client’s
GI system prior to administering the
antiemetic, not after.
4. Withholding fluids/food is an appropriate
intervention to help prevent emesis, but it
is not priority over safety after administering this medication.
2. Cogwheel motion (jerky, uneven movements) is a symptom of Parkinson’s
disease, and if the client is not experiencing these types of movements, then
the medication is effective.
3. There is no such thing as a carbidopa
therapeutic level. The client’s signs/
symptoms determine the effectiveness
of the medication.
4. The client’s blood pressure should be
assessed to determine if the client is having hypotension, which is a side effect of
the medication, but this does not determine the effectiveness of the medication.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Analysis.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Assessment: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Analysis.
68. 1. This is the correct area to administer subcutaneous heparin, but not Lovenox.
2. This is in the client’s anterior thigh, which
may be used for insulin administration but
not for Lovenox, and a 25-gauge 1/2-inch
needle is used to administer Lovenox.
3. This is the upper arm area, which is used
for subcutaneous insulin, but not Lovenox.
4. Lovenox is administered in the “love
handles,” which is in the anterolateral
abdomen; this helps prevent abdominal
wall trauma.
71. 1. This diet is recommended for clients with
coronary artery disease, but it is not an intervention specific for this medication.
2. This medication is taken once a day in the
evening.
3. Atorvastatin (Lipitor) is taken at
night to enhance the enzymes which
metabolize cholesterol.
4. There is no machine to test daily
cholesterol levels. The cholesterol level is
checked every three (3) to six (6) months.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Knowledge.
69. 1. This may be a question the nurse asks, but
it doesn’t matter because the nurse will
clean the site again.
2. The nail does not matter and it will not be
cultured; it is assumed the nail is contaminated.
3. The tetanus shot must be received
every 10 years to prevent tetany, also
known as “lockjaw.”
4. Being able to walk on the foot is not a priority question. Determining the status of
the tetanus shot is priority.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Assessment: Client Needs – Safe
Effective Care Environment, Safety and Infection
Control: Cognitive Level – Analysis.
70. 1. Sinemet does not affect the client’s muscle
strength; it affects the smoothness of
muscle movement.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Planning: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Synthesis.
72. 1. The client in end-stage renal disease does
not normally urinate, and urine output
does not determine if this medication is
effective.
2. Kayexalate does not affect phosphorus
levels.
3. The client being in normal sinus rhythm
is good, but it does not determine if the
medication is effective.
4. Kayexalate is a cation and exchanges
sodium ions for potassium ions in the
intestines, thereby lowering the serum
potassium level. Therefore, a serum
potassium level within normal limits
would indicate the medication is
effective. Normal potassium levels
are 3.5 to 5.5 mEq/L.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Assessment: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Analysis.
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CHAPTER 19 PHARMACOLOGY
73. 1. The ABG results indicate metabolic
acidosis, and the treatment of choice is
sodium bicarbonate.
2. Oxygen is the treatment of choice for
respiratory acidosis.
3. Epinephrine is administered in a code
situation.
4. This is milk of magnesia, which is an
antacid/laxative, but it is not the treatment
for metabolic acidosis.
2. Increasing the dose increases the peripheral action of the drug on the heart and
vessels. Because 75% of the drug never
crosses the blood–brain barrier, the dose
may not be increased.
3. This effect does not mean the client is
dying. It means the medication is
wearing off.
4. This is not the desired effect of the
medication.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Planning: Client Needs – Safe
Effective Care Environment, Management of Care:
Cognitive Level – Synthesis.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Analysis.
74. 1. Propranolol is taken prophylactically,
which means the client should take the
medication routinely whether the client
has a headache or not.
2. Beta blockers decrease the heart rate.
If the radial pulse is less than 60 bpm,
the client should hold the medication
and notify the health-care provider.
3. This medication will mask tachycardia in
clients with diabetes, an early symptom of
hypoglycemia. Thirst and dry mouth are
signs of hyperglycemia, but this client
does not have diabetes.
4. Beta blockers do not affect the client’s
visual acuity; therefore, a change in
light is not necessary.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Planning: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Synthesis.
75. 1. Atropine is used in clients with asystole or
symptomatic sinus bradycardia.
2. Amiodarone is a Class C medication used
for ventricular dysfunction.
3. Adenosine is the drug of choice for
clients with SVT.
4. Dobutamine is used for clients in heart
failure.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Safe Effective Care Environment, Management of
Care: Cognitive Level – Analysis.
76. 1. Loss of effect of the medication occurs
near the end of a dosing interval and
indicates the plasma drug level has
declined to subtherapeutic value.
This is an expected occurrence with
the medication and the chronic nature
of the disease.
77. 1. This information really doesn’t have
bearing on the current situation.
2. The spouse can stay in the room if able
to stay calm and not upset the client.
3. The nurse should address the client’s
fear, but it is not the most pertinent
information.
4. A local anesthetic will be administered to numb the area prior to
suturing. The same classification
of drugs is used to numb the mouth
before dental procedures, and this
client may be allergic to the numbing
medication.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Assessment: Client Needs – Safe
Effective Care Environment, Safety and Infection
Control: Cognitive Level – Analysis.
78. 1. The medication is administered through
the nose, but it has no effect on the client’s
ability to breathe.
2. Being thirsty all the time would indicate
the medication is not effective.
3. Neither the medication nor the disease
process has anything to do with the
glucose level. A disease which affects the
glucose level is diabetes mellitus, not
diabetes insipidus.
4. Diabetes insipidus is characterized by
the client not being able to concentrate
urine and excreting large amounts of
dilute urine. If the client is able to
delay voiding for three (3) to four
(4) hours, it indicates the medication
is effective.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Assessment: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Analysis.
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MED-SURG SUCCESS
79. 1. This is the correct procedure for instilling
eardrops for children.
2. “Otic” refers to the ear. Instilling
eardrops in the adult must be done
by pulling the ear up and back to
straighten the eustachian tube.
3. This is the correct procedure for placing
ophthalmic drops in the eye.
4. Pressure is applied to the inner canthus to
prevent eye medication from entering the
systemic circulation.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Application.
3. One (1) of the five (5) rights is the
correct route. Insulin cannot be
administered intramuscularly. It must
be administered subcutaneously or
intravenously; therefore, this action
warrants immediate intervention.
4. One (1) of the five (5) rights is the right
time, and the LPN has 30 minutes to one
(1) hour to administer medications depending on hospital policy; therefore,
this would not require intervention by
the nurse.
Content – Nursing Management: Category of
Health Alteration – Management: Integrated
Nursing Process – Evaluation: Client Needs – Safe
Effective Care Environment, Management of Care:
Cognitive Level – Synthesis.
80. 1. The client should increase fluid intake to
help flush the bacteria through the kidneys
and bladder.
2. The client has a chronic UTI, which will
require antibiotics on a daily basis to keep
the bacteria count under control.
3. The key to answering this question
is the word “chronic,” which
indicates a continuing problem;
this statement would be appropriate
for an acute UTI.
4. Diarrhea is a sign of superinfection, which
occurs when the antibiotic kills the good
flora in the bowel. However, the client
must keep taking the antibiotic, and Imodium is an OTC antidiarrheal.
83. 1. This is an antacid, but it is not being administered to this client for that reason.
2. The client is in end-stage renal disease
(ESRD), but burning on urination is not a
sign of ESRD; it is a sign of urinary tract
infection.
3. A side effect of this medication is constipation, but having a normal bowel movement does not indicate the medication is
effective.
4. This medication decreases absorption
of phosphates in the intestines, thereby
decreasing serum phosphate levels.
The normal phosphate level is 2.5 to
4.5 mg/dL.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Evaluation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Synthesis.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Assessment: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Analysis.
81. 1. A Pap smear is usually done yearly and is
used to detect cervical cancer; HRT does
not increase the risk.
2. The risk of developing breast
cancer increases when the client
is receiving HRT.
3. A bone density test is used to detect osteoporosis, and HRT improves bone density.
4. Calcium levels are not affected by HRT.
84. 1. Any medication which will prolong
bleeding, as a platelet aggregate
inhibitor does, should not be administered to the client for at least two
(2) to three (3) days prior to surgery.
2. The nurse should not question administering an antibiotic before surgery, especially not before gastrointestinal surgery.
3. This is a medication for type 2 diabetes
and should be administered the day before
the surgery.
4. The client will be receiving medications to
evacuate the bowel.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Planning: Client Needs –
Physiological Integrity, Reduction of Risk Potential:
Cognitive Level – Synthesis.
82. 1. One (1) of the five (5) rights is the correct
dose, and some medications must be
divided prior to administering.
2. One (1) of the five (5) rights is the correct
client, and this is making sure it is the
correct client.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Safe Effective Care Environment, Management of
Care: Cognitive Level – Analysis.
85. 1. This rash indicates a sensitivity reaction,
and the medication may need to be
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CHAPTER 19 PHARMACOLOGY
discontinued permanently or the dose
should be decreased.
2. Increased fluid intake minimizes the
risk of renal calculi formation.
3. To minimize gastric irritation, the medication should be taken with food or milk.
4. Allopurinol increases the effects of oral
diabetic medications; therefore, the dose
should be decreased.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Planning: Client Needs –
Physiological Integrity, Pharmacological and
Parenteral Therapies: Cognitive Level – Synthesis.
86. 1. Atropine in this dosage will not cause orthostatic hypotension, but it will increase
the pulse rate.
2. The client should increase the fiber in the
diet because this medication may cause
constipation.
3. An expected side effect of anticholinergic medication is a dry mouth, and
chewing gum will help relieve the
dryness.
4. Isometric exercises are muscle-building
exercises (weight lifting, or “pumping
iron”), which will not help the client
tolerate this medication and should not
be recommended for any client.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Application.
87. 1. Telemetry should be monitored during
therapy to ensure the client does not
develop worsening of dysrhythmias.
2. The client taking amiodarone is at risk
for pulmonary toxicity and developing
adult respiratory distress syndrome
(ARDS); therefore, the nurse should
monitor the client’s respiratory status.
3. When the client is receiving medications intravenously, monitoring the
liver and renal function is appropriate;
this drug causes hepatomegaly.
4. Intravenous vasoactive medications are
inherently dangerous; fatalities have
occurred from amiodarone, so the
nurse confirming the order with another nurse is appropriate.
5. The nurse should never defibrillate a
client who has a heartbeat, and nothing in
the stem states the client is in ventricular
fibrillation.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Safe Effective Care Environment, Management of
Care: Cognitive Level – Analysis.
88. 1. This medication amount is too much and
must be divided into two injections to be
given safely, but the nurse can do this independently and does not need to notify
the HCP.
2. The nurse should not administer 4.8 mL
in one (1) injection. No more than three
(3) mL should be administered in an
intramuscular injection.
3. There is no reason for the nurse to discard
this medication. Divide the medication
and give two (2) injections.
4. The nurse should never administer
more than three (3) mL in an intramuscular injection because a larger
amount could cause damage to the
muscle. The nurse should divide the
dose and administer two (2) injections.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Analysis.
89. 1. The client’s drug level is within the therapeutic range of 10 to 20 mcg/mL.
2. Expiratory wheezing would be expected in
the client with status asthmaticus and
therefore would not warrant intervention.
3. Muscle twitching indicates the client is
receiving too much medication and
may experience a seizure.
4. The client is having trouble breathing,
and eating requires energy. Therefore, the
client may not want to eat a meal or the
client may not like the hospital food,
which would not warrant immediate
intervention.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Assessment: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Synthesis.
90. 1. The client with pitting pedal edema is
in fluid volume overload, which should
make the nurse question administering
an osmotic diuretic because this medication will pull more fluid from the
tissues into the circulatory system,
causing further fluid volume overload.
2. An osmotic diuretic is administered for
increased intracranial pressure; therefore,
a client who is exhibiting decorticate
posturing would need this medication.
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3. A widening pulse pressure indicates increased intracranial pressure; therefore,
the client needs the osmotic diuretic.
4. The doll’s eye test indicates increased intracranial pressure, which is why the HCP
would prescribe the osmotic diuretic.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Assessment: Client Needs – Safe
Effective Care Environment, Safety and Infection
Control: Cognitive Level – Analysis.
91. 1. Melena is black, tarry stool, which should
not occur from taking this medication.
2. Gynecomastia, or breast development
in men, is a complication of this
medication.
3. Pyrosis, or heartburn, is why the client
would be taking this medication.
4. Eructation, or belching, is not a
complication of this medication.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Planning: Client Needs –
Physiological Integrity, Pharmacological and
Parenteral Therapies: Cognitive Level – Synthesis.
92. 1. Muscle relaxants do not cause GI distress.
2. Muscle relaxants, with the exception of
baclofen, do not need to be tapered off.
3. Initially muscle relaxants cause drowsiness, so safety is an important issue.
4. As a safety precaution, the client should
avoid drinking alcohol while taking muscle
relaxants.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Planning: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Synthesis.
93. 1. The client may be given a steroid, such as
prednisone, but not an NSAID.
2. An antihistamine is prescribed to decrease
symptoms of a cold or the flu, but it is not
prescribed for asthma.
3. An ACE inhibitor prevents deterioration
of heart muscle and kidneys, but it is not a
drug of choice for the respiratory system.
4. Because 80% to 90% of adult-onset
asthma is caused by gastroesophageal
reflux disease, a proton pump inhibitor
would be prescribed to decrease
acid reflux into the esophagus and
subsequent aspiration.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Planning: Client Needs –
Physiological Integrity, Pharmacological and
Parenteral Therapies: Cognitive Level – Synthesis.
94. 1. The pain medication should be administered as soon as possible but not before
assessing for complications which might
be causing pain.
2. The nurse must not administer the medication too close to the last dose, but this
is not the first intervention the nurse
would implement.
3. The first step of the nursing process is
to assess, and the nurse must determine
if this is routine postoperative pain the
client should have or if this is a complication which requires immediate intervention. Decreased blood pressure and
increased pulse indicates hemorrhaging.
4. Teaching distraction techniques is an
appropriate intervention, but the nurse
should medicate the client.
Content – Pharmacology: Category of Health
Alteration – Pain: Integrated Nursing Process –
Implementation: Client Needs – Safe Effective Care
Environment, Safety and Infection Control: Cognitive
Level – Analysis.
95. 1. Just because a client is taking an antidepressant, this does not mean he or she is
suicidal.
2. The nurse should determine if the
client is in a depressed state or if the
medication is effective, so the nurse
should ask the client to rate the
depression on a 1-to-10 scale, with
1 being no depression and 10 being
the most depressed.
3. Antidepressants must be tapered off
because of rebound depression.
4. The client taking an antidepressant
medication does not automatically
need a referral to a psychologist.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Physiological Integrity, Pharmacological and Parenteral
Therapies: Cognitive Level – Analysis.
96. 1. Many times, especially with elderly
clients, sedatives extend the desired
effects longer than expected; therefore,
the nurse should check to see if
the client received any sleeping
medication.
2. The nurse should assess why the client is
sleepy and then allow the client to sleep if
the sleepiness is a result of receiving a
sedative the previous night.
3. If an elderly client is confused and drowsy,
the client should not be allowed to ambulate, even if assistance is being provided,
because of safety issues.
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CHAPTER 19 PHARMACOLOGY
4. The nurse must determine if this is an
expected occurrence or a decrease in
neurological function before notifying the
health-care provider.
3. This is the scientific rationale for mast
cell inhibitors.
4. This is the scientific rationale for
bronchodilators.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Safe Effective Care Environment, Management of
Care: Cognitive Level – Analysis.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client
Needs – Physiological Integrity, Pharmacological and
Parenteral Therapies: Cognitive Level – Analysis.
97. 1. Medication does not always come in the
exact amount of the HCP’s order.
2. Because this is a narcotic, the nurse
preparing the medication must
have someone to verify and
document the wastage of 12.5 mg
of the Demerol.
3. This would be a medication error because
the order is for 37.5 mg, not 50 mg.
4. This would not be an appropriate
intervention. The nurse can safely and
accurately administer the prescribed
dose to the client. If the pain is not
controlled with the amount, then the
HCP should be notified.
100. 1. Although many nurses will do this, the
correct and ethical action is to take
responsibility for the error and just
be thankful the client did not have a
problem.
2. There is a chain of command to report
medication errors, which includes the
charge nurse and the health-care
provider, not the director of nurses.
3. The ethical and correct action is to
report and document the medication
error; remember to always assess the
client.
4. The Peer Review Committee would not
be involved in one medication error unless the client died or a life-threatening
complication occurred, or if the nurse
has a pattern of behavior with multiple
medication errors.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Safe Effective Care Environment, Safety and Infection
Control: Cognitive Level – Application.
98.
2 tablets.
The nurse needs to determine how many
doses are to be given in 1 day (24 hours) if
doses are to be eight (8) hours apart.
24 ÷ 8 = 3 doses
If 3,000 mg are to be given in three
(3) doses, then determine how much
is given in each dose:
3,000 ÷ 3 = 1,000 mg per dose
If the medication comes in 500-mg
tablets, then to give 1,000 mg, the nurse
must give:
1,000 ÷ 500 = 2 tablets
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client
Needs – Physiological Integrity, Pharmacological
and Parenteral Therapies: Cognitive Level –
Application.
99. 1. This medication decreases inflammation by stabilizing the leukotrienes in
the lung which initiate an asthma
attack.
2. Children may outgrow asthma attacks,
whereas adult asthmatics can control their
disease, but there is no cure for asthma at
this time.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client
Needs – Safe Effective Care Environment,
Safety and Infection Control: Cognitive
Level – Application.
101.
In order of priority: 4, 3, 2, 1, 5.
4. Although the lidocaine is a PRN
order, this client is exhibiting a
life-threatening dysrhythmia,
multifocal premature ventricular
contractions.
3. The client diagnosed with myasthenia
gravis must have this medication as
close to the specific time as possible.
This medication allows skeletal
muscle to function; if this medication
is delayed, the client may experience
respiratory distress.
2. Pain is a priority and should be
attended to after administering
medications to clients in lifethreatening situations.
1. This client is symptomatic, and the
loop diuretic should relieve some of
the symptoms of dyspnea.
5. Intravenous antibiotics are priority,
but this client has received several
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MED-SURG SUCCESS
doses of the medication or there
would not be a trough level, so this
client’s medication could wait until
the other medications have been
administered.
Content – Pharmacology: Category of Health
Alteration – Drug Administration: Integrated
Nursing Process – Implementation: Client Needs –
Safe Effective Care Environment, Management of
Care: Cognitive Level – Analysis.
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20
Comprehensive
Final Examination
There is no substitute for knowledge.
—Kathryn Colgrove, RN, MS, OCN
This book is designed to assist the test taker to recognize elements of test construction and
to be able to think critically to arrive at the correct answer. Many hints have appeared in the
previous chapters. Some are general hints that apply to preparing for class and subsequently
to taking examinations (Chapter 1), some are specific tips for the different types of questions about disorders/diseases of the different body systems (Chapters 2–18), and some are
specific to pharmacology (Chapter 19). The test taker should now apply these hints, use all
the knowledge gained in class and study, and take the comprehensive examination.
COMPREHENSIVE FINAL EXAMINATION
1. The 44-year-old female client calls the clinic and tells the nurse she felt a lump while performing breast
self-examination (BSE). Which question should the nurse ask the client?
1. “Are you taking birth control pills?”
2. “Do you eat a lot of chocolate?”
3. “When was your last period?”
4. “Are you sexually active?”
2. Which problem is priority for the 24-year-old client diagnosed with endometriosis who is admitted to the
gynecological unit?
1. Hemorrhage.
2. Pain.
3. Constipation.
4. Dyspareunia.
3. The 28-year-old client diagnosed with testicular cancer is scheduled for a unilateral orchiectomy. Which
intervention should have priority in the client’s plan of care?
1. Encourage the client to bank his sperm.
2. Discuss completing an advance directive.
3. Explain follow-up chemotherapy and radiation.
4. Allow the client to express his feelings regarding having cancer.
4. The nurse is teaching a class on sexually transmitted diseases to high school sophomores. Which
information should be included in the discussion?
1. Oral sex decreases the chance of transmitting a sexual disease.
2. Sexual activity during menses decreases transmission of diseases.
3. Frequent sexual activity is necessary to transmit a sexual disease.
4. Unprotected sex puts the individual at risk for many diseases.
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5. The nurse has taught Kegel exercises to the client who is para 5, gravida 5. Which
information indicates the exercises have been effective?
1. The client reports no SOB when walking up stairs.
2. The client has no complaints of stress incontinence.
3. The client denies being pregnant at this time.
4. The client has lost 10 lbs in the last two (2) months.
6. Which diagnostic procedure does the nurse anticipate being ordered for the
27-year-old female client who is reporting irregular menses and complaining of
lower left abdominal pain during menses?
1. Pelvic sonogram.
2. Complete blood count (CBC).
3. Kidney, ureter, bladder (KUB) x-ray.
4. Computed tomography (CT) of abdomen.
7. The client diagnosed with Stage IV prostate cancer is receiving chemotherapy. Which
laboratory value should the nurse assess prior to administering the chemotherapy?
1. Prostate-specific antigen (PSA).
2. Serum calcium level.
3. Complete blood count (CBC).
4. Alpha-fetoprotein (AFP).
8. Which client should the charge nurse of the day surgery unit assign to a new
graduate nurse in orientation?
1. The client who had an arthroscopy with an AP of 110 and BP of 94/60.
2. The client with open reduction of the ankle who is confused.
3. The client with a total hip replacement who is being transferred to the ICU.
4. The client diagnosed with low back pain who has had a myelogram.
9. The client in the long-term care facility has severe osteoarthritis. Which nursing task
should the nurse delegate to the unlicensed assistive personnel (UAP)?
1. Feed the client the breakfast meal.
2. Give the client Maalox, an antacid.
3. Monitor the client’s INR results.
4. Assist the client to the shower room.
10. The primary nurse is applying antiembolism hose to the client who had a total hip
replacement. Which situation warrants immediate intervention by the charge nurse?
1. Two fingers can be placed under the top of the band.
2. The peripheral capillary refill time is ⬍3 seconds.
3. There are wrinkles in the hose behind the knees.
4. The nurse does not place a hose on the foot with a venous ulcer.
11. The 54-year-old female client is diagnosed with osteoporosis. Which interventions
should the nurse discuss with the client? Select all that apply.
1. Instruct the client to swim 30 minutes every day.
2. Encourage drinking milk with added vitamin D.
3. Determine if the client smokes cigarettes.
4. Recommend the client not go outside.
5. Teach about safety and fall precautions.
12. The 33-year-old client had a traumatic amputation of the right forearm as a result of
a work-related injury. Which referral by the rehabilitation nurse is most appropriate?
1. Physical therapist.
2. Occupational therapist.
3. Worker’s compensation.
4. State rehabilitation commission.
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CHAPTER 20 COMPREHENSIVE FINAL EXAMINATION
13. The client has a fractured right tibia. Which assessment data warrant immediate
intervention?
1. The client complains of right calf pain.
2. The nurse cannot palpate the radial pulse.
3. The client’s right foot is cold to touch.
4. The nurse notes ecchymosis on the right leg.
14. The nurse identifies the problem “high risk for complications” for the client with a
right total hip replacement who is being discharged from the hospital. Which
problem would have the highest priority?
1. Self-care deficit.
2. Impaired skin integrity.
3. Abnormal bleeding.
4. Prosthetic infection.
15. The client has sustained severe burns on both the anterior right and left leg and the
anterior chest and abdomen. According to the rule of nines, what percentage of the
body has been burned? _____
9%
9%
18%
Anterior–18%
1%
Posterior–18%
18%
9%
16. The nurse is planning the care for the client with multiple stage IV pressure ulcers.
Which complication results from these pressure ulcers?
1. Wasting syndrome.
2. Osteomyelitis.
3. Renal calculi.
4. Cellulitis.
17. The client comes to the clinic complaining of itching on the left wrist near a wristwatch.
The nurse notes an erythematous area along with pruritic vesicles around the left wrist.
Which condition should the nurse suspect?
1. Contact dermatitis.
2. Herpes simplex 1.
3. Impetigo.
4. Seborrheic dermatitis.
18. Which diagnostic test should the nurse expect to be ordered for the client who has a
nevus which is purple and brown with irregular borders?
1. Bone scan.
2. Skin biopsy.
3. Carcinoembryonic antigen (CEA).
4. Sonogram.
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19. The client with a closed head injury is admitted to the neurointensive care unit
following a motor-vehicle accident. Which goal is an appropriate short-term goal
for the client?
1. The client will maintain optimal level of functioning.
2. The client will not develop extremity contractures.
3. The client’s intracranial pressure will not be ⬎15 mm Hg.
4. The client will be able to verbalize feelings of anger.
20. The 25-year-old client who has a C6 spinal cord injury is crying and asks the nurse,
“Why did I have to survive? I wish I was dead.” Which statement is the nurse’s best
response?
1. “Don’t talk like that. At least you are alive and able to talk.”
2. “God must have something planned for your life. Pray about it.”
3. “You survived because the people at the accident saved your life.”
4. “This must be difficult to cope with. Would you like to talk?”
21. The client is newly diagnosed with epilepsy. Which statement indicates the client
needs clarification of the discharge teaching?
1. “I can drive as soon as I see my HCP for my follow-up visit.”
2. “I should get at least eight (8) hours of sleep at night.”
3. “I should take my medication every day even if I am sick.”
4. “I will take showers instead of taking tub baths.”
22. The nurse observes the unlicensed assistive personnel (UAP) taking vital signs on an
unconscious client. Which action by the UAP warrants intervention by the nurse?
1. The UAP uses a vital sign machine to check the BP.
2. The UAP takes the client’s temperature orally.
3. The UAP verifies the blood pressure manually.
4. The UAP counts the respirations for 30 seconds.
23. The client diagnosed with a brain tumor who had radiation treatment and developed
alopecia asks, “When will my hair grow back?” Which statement is the nurse’s best
response?
1. “Your hair should start growing back within three (3) weeks.”
2. “Are you concerned your hair will not grow back?”
3. “It may take months, if your hair grows back at all.”
4. “It may take a couple of years for the hair to grow back.”
24. Which assessment data indicate the treatment for the client diagnosed with bacterial
meningitis is effective?
1. There is a positive Brudzinski’s sign and photophobia.
2. The client tolerates meals without nausea.
3. There is a positive Kernig’s sign and an elevated temperature.
4. The client is able to flex the neck without pain.
25. The client is being evaluated to rule out Parkinson’s disease. Which diagnostic test
confirms this diagnosis?
1. A positive magnetic resonance imaging (MRI) scan.
2. A biopsy of the substantia nigra.
3. A stereotactic pallidotomy.
4. There is no test that confirms this diagnosis.
26. The client diagnosed with a transient ischemic attack (TIA) is being discharged from
the hospital. Which medication should the nurse expect the HCP to prescribe?
1. The oral anticoagulant warfarin (Coumadin).
2. The antiplatelet medication, a baby aspirin.
3. The beta blocker propranolol (Inderal).
4. The anticonvulsant valproic acid (Depakote).
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CHAPTER 20 COMPREHENSIVE FINAL EXAMINATION
27. The nurse has just received the shift assessment. Which client should the nurse assess
first?
1. The client with encephalitis who has myalgia.
2. The client who is complaining of chest pain.
3. The client who refuses to eat hospital food.
4. The client who is scheduled to go to the whirlpool.
28. Which client should the charge nurse on the substance abuse unit assign to the
licensed practical nurse (LPN)?
1. The client with chronic alcoholism who has been on the unit three (3) days.
2. The client who is complaining of palpitations and has a history of cocaine abuse.
3. The client diagnosed with amphetamine abuse who tried to commit suicide.
4. The client diagnosed with cannabinoid abuse who is threatening to leave AMA.
29. The telemetry nurse is monitoring the following clients. Which client should the
telemetry nurse instruct the primary nurse to assess first?
1. The client who has occasional premature ventricular contractions (PVCs).
2. The client post–cardiac surgery who has three (3) unifocal PVCs in a minute.
3. The client with a myocardial infarction who had two (2) multifocal PVCs.
4. The client diagnosed with atrial fibrillation who has an AP of 116 and no P wave.
30. The nurse is teaching the client in a cardiac rehabilitation unit. Which dietary
information should the nurse discuss with the client?
1. No more than 30% of daily food intake should be fats.
2. Eighty percent of calories should come from carbohydrates.
3. Red meat should comprise at least 50% of daily intake.
4. Monounsaturated fat in the daily diet should be increased.
31. The client diagnosed with end-stage congestive heart failure is being cared for by the
home health nurse. Which intervention should the nurse teach the caregiver?
1. Report any time the client starts having difficulty breathing.
2. Notify the HCP if the client gains more than 3 lbs in a week.
3. Teach how to take the client’s apical pulse for one (1) full minute.
4. Encourage the client to participate in 30 minutes of exercise a day.
32. The client is diagnosed with aortic stenosis. Which assessment data indicate a
complication is occurring?
1. Barrel chest and clubbing of the fingers.
2. Intermittent claudication and rest pain.
3. Pink, frothy sputum and dyspnea on exertion.
4. Bilateral wheezing and friction rub.
33. The client who has just received a permanent pacemaker is admitted to the telemetry
floor. The nurse writes the problem “knowledge deficit.” Which interventions should
be included in the plan of care? Select all that apply.
1. Take tub baths instead of showers the rest of his or her life.
2. Do not hold electrical devices near the pacemaker.
3. Carry the pacemaker identification card at all times.
4. Count the radial pulse one (1) full minute every morning.
5. Notify the HCP if the pulse is 12 beats slower than the preset rate.
34. Which question should the nurse ask the client who is being admitted to rule out
infective endocarditis?
1. “Do you have a history of a heart attack?”
2. “Have you had a cardiac valve replacement?”
3. “Is there a family history of rheumatic heart disease?”
4. “Do you take nonsteroidal anti-inflammatory medications?”
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35. The client diagnosed with arterial occlusive disease is prescribed an antiplatelet
medication, clopidogrel (Plavix). Which assessment data indicate the medication is
effective?
1. The client’s pedal pulse is bounding.
2. The client’s blood pressure has decreased.
3. The client does not exhibit signs of a stroke.
4. The client has decreased pain when ambulating.
36. The client diagnosed with atherosclerosis has coronary artery disease. The client
experiences sudden chest pain when walking to the nurse’s station. Which intervention
should the nurse implement first?
1. Administer sublingual nitroglycerin.
2. Apply oxygen via nasal cannula.
3. Obtain a STAT electrocardiogram.
4. Have the client sit in a chair.
37. The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a
medical floor. Which nursing task could be delegated to the UAP?
1. Retake the BP on a client who received a STAT nitroglycerin sublingual.
2. Notify the health care provider of the client’s elevated blood pressure.
3. Obtain and document the routine vital signs on all the clients on the floor.
4. Call the laboratory technician and discuss a hemolyzed blood specimen.
38. The client with venous insufficiency tells the nurse, “The doctor just told me about
my disease and walked out of the room. What am I supposed to do?” Which
statement is the nurse’s best response?
1. “I will have your HCP come back and discuss this with you.”
2. “One thing you can do elevate your legs above your heart while watching TV.”
3. “You will probably need to have surgery within a few months.”
4. “This will go away after you lose about 20 pounds and start walking.”
39. The client is admitted with rule-out leukemia. Which assessment data support the
diagnosis of leukemia?
1. Cervical lymph node enlargement.
2. An asymmetrical dark-purple nevus.
3. Petechiae covering the trunk and legs.
4. Brownish-purple nodules on the face.
40. The client diagnosed with non-Hodgkin’s lymphoma tells the nurse, “I am so tired.
I just wish I could die.” Which stage of the grieving process does this statement
represent?
1. Anger.
2. Denial.
3. Bargaining.
4. Acceptance.
41. The nurse writes the goal “the client will list three (3) food sources of vitamin B12”
for the client diagnosed with pernicious anemia. Which foods listed by the client
indicate the goal has been met?
1. Brown rice, dried fruits, and oatmeal.
2. Beef, chicken, and pork.
3. Broccoli, asparagus, and kidney beans.
4. Liver, cheese, and eggs.
42. The client diagnosed with stomach cancer has developed disseminated intravascular
coagulopathy (DIC). Which collaborative intervention should the nurse expect to
implement?
1. Prepare to administer intravenous heparin.
2. Assess for frank hemorrhage from venipuncture sites.
3. Monitor for decreased level of consciousness.
4. Prepare to administer total parenteral nutrition.
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CHAPTER 20 COMPREHENSIVE FINAL EXAMINATION
43. The nurse is administering 250 mL of packed red blood cells with 50 mL of
preservative. The client has no jugular vein distention and has clear breath sounds. After
the first 15 minutes, at what rate should the nurse set the IV infusion pump? _______
44. The 24-year-old African American female client tells the nurse she has a brother
with sickle cell disease. She is engaged to be married and is concerned about giving
this disease to her future children. Which information is most important to provide
to the client?
1. Tell the client that she won’t pass this on if she has never had symptoms.
2. Encourage the client to discuss this concern with her fiancé.
3. Recommend that she and her fiancé see a genetic counselor.
4. Discuss the possibility of adopting children after she gets married.
45. The nurse is at home preparing for the 7 a.m. to 7 p.m. shift and has the flu
with a temperature of 100.4˚F. Which action should the nurse take?
1. Notify the hospital the nurse will not be coming into work.
2. Go to work and wear an isolation mask when caring for the clients.
3. Request an alternative assignment not involving direct client care.
4. Take over-the-counter cold medication and report to work on time.
46. The client is being admitted into the hospital with a diagnosis of pneumonia. Which
HCP order should the nurse implement first?
1. Initiate intravenous antibiotics.
2. Collect a sputum specimen for culture.
3. Obtain a clean voided midstream urinalysis.
4. Request a chest x-ray to confirm the diagnosis.
47. Which medical client problem should the nurse include in the plan of care for a
client diagnosed with cardiomyopathy?
1. Heart failure.
2. Activity intolerance.
3. Paralytic ileus.
4. Atelectasis.
48. The client comes to the emergency department complaining of pain in the right
forearm. The nurse notes a large area of redness and edema over the forearm, and
the client has an elevated temperature. Which condition should the nurse suspect?
1. Cellulitis.
2. Intravenous drug abuse.
3. Raynaud’s phenomenon.
4. Thromboangiitis obliterans.
49. The client is performing breast self-examination (BSE) by the American Cancer
society’s recommended steps and has completed palpating the breast. Which step is
next when completing the BSE?
1. Stand before the mirror and examine the breast.
2. Lean forward and look for dimpling or retractions.
3. Examine the breast using a circular motion.
4. Pinch the nipple to see if any fluid can be expressed.
50. Which assessment information is the most critical indicator of a neurological deficit?
1. Changes in pupil size.
2. Level of consciousness.
3. A decrease in motor function.
4. Numbness of the extremities.
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51. The nurse is initiating a blood transfusion. Which interventions should the nurse
implement? Select all that apply.
1. Assess the client’s lung fields.
2. Have the client sign a consent form.
3. Start an IV with a 22-gauge IV catheter.
4. Hang 250 mL of D5W at a keep-open rate.
5. Check the chart for the HCP’s order.
52. The nurse is assessing the client with psoriasis. Which data support this diagnosis?
1. Appearance of red, elevated plaques with silvery white scales.
2. A burning, prickling row of vesicles located along the torso.
3. Raised, flesh-colored papules with a rough surface area.
4. An overgrowth of tissue with an excessive amount of collagen.
53. Which comment by the client diagnosed with rule-out Guillain-Barré (GB)
syndrome is most significant when completing the admission interview?
1. “I had a bad case of gastroenteritis a few weeks ago.”
2. “I never use sunblock and I use a tanning bed often.”
3. “I started smoking cigarettes about 20 years ago.”
4. “I was out of the United States for the last 2 months.”
54. Which laboratory result warrants immediate intervention by the nurse for the female
client diagnosed with systemic lupus erythematosus (SLE)?
1. A hemoglobin and hematocrit of 13 g/dL and 40%.
2. A erythrocyte sedimentation rate of 9 mm/hr.
3. A serum albumin level of 4.5 g/dL.
4. A white blood cell count of 15,000/mm3.
55. The client diagnosed with gastroesophageal reflux disease (GERD) has undergone
surgery for a hiatal hernia repair. The client has a nasogastric tube in place.
Intravenous fluid replacement is to be at 125 mL/hr plus the amount of drainage.
The drainage from 0800 to 0900 is 45 mL. At which rate should the IV pump be set
for the next hour? ______
56. Which assessment data indicate to the nurse the client has a conductive hearing loss?
1. The Rinne test results in air-conducted sound being louder than bone-conducted.
2. The client is unable to hear accurately when conducting the whisper test.
3. The Weber test results in the sound being heard better in the affected ear.
4. The tympanogram results in the ticking watch heard better in the unaffected ear.
57. The client reports a twisting motion of the knee during a basketball game. The client
is scheduled for arthroscopic surgery to repair the injury. Which information should
the nurse teach the client about postoperative care?
1. The client should begin strengthening the surgical leg.
2. The client should take pain medication routinely.
3. The client should remain on bedrest for two (2) weeks.
4. The client should return to the doctor in six (6) months.
58. The nurse is preparing the client newly diagnosed with asthma for discharge. Which
data indicate the teaching about the peak flowmeter has been effective?
1. “I can continue my usual activities without medication if I am in the yellow zone.”
2. “It takes one (1) to two (2) days to establish my personal best.”
3. “When I can’t talk while walking, I need to take my quick-relief medicine.”
4. “When I am in the red zone, I must take my quick-relief medication and not
exercise.”
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CHAPTER 20 COMPREHENSIVE FINAL EXAMINATION
59. Which assessment data indicate the client has developed a deep vein thrombosis
(DVT) in the left leg?
1. A negative Homans’ sign of the left leg.
2. Increased left-leg calf circumference.
3. Elephantiasis of the left lower leg.
4. Brownish pigmentation of the left lower leg.
60. The 85-year-old client diagnosed with severe end-stage chronic obstructive
pulmonary disease has a chest x-ray incidentally revealing an eight (8)-cm abdominal
aortic aneurysm (AAA). Which intervention should the nurse implement?
1. Discuss possible end-of-life care issues.
2. Prepare the client for abdominal surgery.
3. Teach the client how to do pursed-lip breathing.
4. Talk with the family about the client’s condition.
61. The unlicensed assistive personnel (UAP) notifies the nurse the client diagnosed with
chronic obstructive pulmonary disease is complaining of shortness of breath and
would like his oxygen level increased. Which intervention should the nurse
implement?
1. Notify the respiratory therapist (RT).
2. Ask the UAP to increase the oxygen.
3. Obtain a STAT pulse oximeter reading.
4. Tell the UAP to leave the oxygen alone.
62. Which psychosocial client problem should the nurse write for the client diagnosed
with cancer of the lung and metastasis to the brain?
1. Altered role performance.
2. Grieving.
3. Body image disturbance.
4. Anger.
63. The client diagnosed with cancer of the larynx has had a partial laryngectomy.
Which client problem has the highest priority?
1. Impaired communication.
2. Ineffective coping.
3. Risk for aspiration.
4. Social isolation.
64. The client receiving a continuous heparin drip complains of sudden chest pain
on inspiration and tells the nurse, “Something is really wrong with me.” Which
intervention should the nurse implement first?
1. Increase the heparin drip rate.
2. Notify the health-care provider.
3. Assess the client’s lung sounds.
4. Apply oxygen via nasal cannula.
65. The nurse is assessing the client with a pneumothorax who has a closed-chest drainage
system. Which data indicate the client’s condition is stable?
1. There is fluctuation in the water-seal compartment.
2. There is blood in the drainage compartment.
3. The trachea deviates slightly to the left.
4. There is bubbling in the suction compartment.
66. The client is admitted to the intensive care unit diagnosed with rule-out adult
respiratory distress syndrome (ARDS). The client is receiving 10 L/min of oxygen via
nasal cannula. Which arterial blood gases indicate the client does not have ARDS?
1. pH 7.38, PaO2 82, PaCO2 45, HCO3 26.
2. pH 7.35, PaO2 74, PaCO2 43, HCO3 24.
3. pH 7.48, PaO2 90, PaCO2 34, HCO3 22.
4. pH 7.32, PaO2 50, PaCO2 55, HCO3 28.
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67. The client has gastroesophageal reflux disease. Which HCP order should the nurse
question?
1. Elevate the head of the client’s bed with blocks.
2. Administer pantoprazole (Protonix) four (4) times a day.
3. A regular diet with no citrus or spicy foods.
4. Activity as tolerated and sit up in a chair for all meals.
68. The client is diagnosed with an acute exacerbation of Crohn’s disease. Which
assessment data warrant immediate attention?
1. The client’s WBC count is 10.0 (× 103)/mm3.
2. The client’s serum amylase is 100 units/dL.
3. The client’s potassium level is 3.3 mEq/L.
4. The client’s blood glucose is 148 mg/dL.
69. Which information should the nurse discuss with the client to prevent an acute
exacerbation of diverticulosis?
1. Increase the fiber in the diet.
2. Drink at least 1,000 mL of water a day.
3. Encourage sedentary activities.
4. Take cathartic laxatives daily.
70. The client diagnosed with peptic ulcer disease is being discharged. Which nursing
task can be delegated to the unlicensed assistive personnel (UAP)?
1. Complete the discharge instructions sheet.
2. Remove the client’s saline lock.
3. Clean the client’s room after discharge.
4. Check the client’s hemoglobin and hematocrit.
71. The client diagnosed with colon cancer tells the nurse, “All I do is sit and watch TV
all day. I can barely go to the bathroom.” According to the Oncology Nursing
Society’s cancer fatigue scale, how would the nurse document the fatigue objectively?
TText/Image rights not available.
e
x
t
/
I
m
a
g
e
r
1.i Mild fatigue.
2.g Moderate fatigue.
3.h Extreme fatigue.
4.t Worst fatigue ever.
s home health nurse must see all of the following clients. Which client should the
72. The
n
nurse
assess first?
1.o The client who is postoperative from an open cholecystectomy who has green
t drainage coming from the T-tube.
2.a The client diagnosed with congestive heart failure who complains of shortness of
v breath while fixing meals.
3.a The client diagnosed with AIDS dementia whose family called and reported that
i the client is vomiting “coffee grounds stuff.”
4.l The client diagnosed with end-stage liver failure who has gained three (3) pounds
a and is not able to wear house shoes.
b
l
e
.
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CHAPTER 20 COMPREHENSIVE FINAL EXAMINATION
73. Which data indicate to the nurse the client with end-stage liver failure is improving?
1. The client has a tympanic wave.
2. The client is able to perform asterixis.
3. The client is confused and lethargic.
4. The client’s abdominal girth has decreased.
74. The nurse is discussing funeral arrangements with the family of a deceased client
whose organs and tissues are being donated today. Which information should the
nurse discuss with family?
1. The family can request an open casket funeral.
2. Your loved one must wear a long-sleeved shirt.
3. You might want to have a private viewing only.
4. This will not delay the timing of the funeral.
75. The public health nurse is discussing hepatitis with a client who is traveling to a third
world country in one (1) month. Which recommendation should the nurse discuss
with the client?
1. A gamma globulin injection.
2. A hepatitis A vaccination.
3. A PPD skin test on the left arm.
4. A hepatitis B vaccination.
76. The client with chronic pancreatitis is admitted with an acute exacerbation of the
disease. Which laboratory result warrants immediate intervention by the nurse?
1. The client’s amylase is elevated.
2. The client’s WBC count is WNL.
3. The client’s blood glucose is elevated.
4. The client’s lipase is within normal limits.
77. The client had abdominal surgery and is receiving bag #5 of total parenteral
nutrition (TPN) via a subclavian line infusing at 126 mL/hr. The nurse realizes bag
#6 is not on the unit and TPN bag #5 has 50 mL left to infuse. Which intervention
should the nurse implement?
1. Decrease the rate of bag #5 to a keep-open rate.
2. Prepare to hang a 1,000-mL bag of normal saline.
3. When bag #5 is empty, convert to a heparin lock.
4. Infuse D10W at 126 mL/hr via the subclavian line.
78. Which priority problem should the clinic nurse identify for the client who is greater
than ideal body weight and weighs 87 kg?
1. Risk for complications.
2. Altered nutrition.
3. Body image disturbance.
4. Activity intolerance.
79. Which assessment data indicate to the nurse the client with diarrhea is experiencing
a complication?
1. Moist buccal mucosa.
2. A 3.6-mEq/L potassium level.
3. Tented tissue turgor.
4. Hyperactive bowel sounds.
80. The client with type 2 diabetes mellitus asks the nurse, “What does it matter if my
glucose level is high? I don’t feel bad.” Which statement by the nurse is most
appropriate?
1. “The high glucose level can damage your eyes and kidneys over time.”
2. “The glucose level causes microvascular and macrovascular problems.”
3. “As long as you don’t feel bad, everything will probably be all right.”
4. “A high blood glucose level will cause you to get metabolic acidosis.”
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81. The client with type 1 diabetes asks the nurse, “What causes me to get dehydrated
when my glucose level is elevated?” Which statement would be the nurse’s best
response?
1. “The kidneys are damaged and cannot filter out the urine.”
2. “The glucose causes fluid to be pulled from the tissues.”
3. “The sweating as a result of the high glucose level causes dehydration.”
4. “You get dehydrated with a high glucose because you are so thirsty.”
82. The client calls the clinic first thing in the morning and tells the nurse, “I have been
vomiting and having diarrhea since last night.” Which response is appropriate for the
nurse to make?
1. Encourage the client to eat dairy products.
2. Have the client go to the emergency room.
3. Request the client obtain a stool specimen.
4. Tell the client to stay on a clear liquid diet.
83. Which signs/symptoms should the nurse expect to assess in the client diagnosed with
Addison’s disease?
1. Hypotension and bronze skin pigmentation.
2. Water retention and osteoporosis.
3. Hirsutism and abdominal striae.
4. Truncal obesity and thin, wasted extremities.
84. The client diagnosed with neurogenic diabetes insipidus (DI) asks the nurse, “What
is wrong with me? Why do I urinate so much?” Which statement by the nurse is
most appropriate?
1. “The islet cells in your pancreas are not functioning properly.”
2. “Your pituitary gland is not secreting a necessary hormone.”
3. “Your kidneys are in failure and you are overproducing urine.”
4. “The thyroid gland is speeding up all your metabolism.”
85. The client is admitted into the medical unit diagnosed with heart failure and is
prescribed the thyroid hormone levothyroxine (Synthroid) orally. Which intervention
should the nurse implement?
1. Call the pharmacist to clarify the order.
2. Administer the medication as ordered.
3. Ask the client why he or she takes Synthroid.
4. Request serum thyroid function levels.
86. Which client should the nurse consider at risk for developing acute renal failure?
1. The client diagnosed with essential hypertension.
2. The client diagnosed with type 2 diabetes.
3. The client who had an anaphylactic reaction.
4. The client who had an autologous blood transfusion.
87. The client diagnosed with chronic renal failure is receiving peritoneal dialysis.
Which assessment by the nurse warrants immediate intervention?
1. The dialysate return is cloudy.
2. There is a greater dialysate return than input.
3. The client complains of abdominal fullness.
4. The client voided 50 mL during the day.
88. Which action by the unlicensed assistive personnel (UAP) requires intervention by
the nurse?
1. The UAP used two (2) washcloths when washing the perineal area.
2. The UAP emptied the indwelling catheter and documented the amount.
3. The UAP applied moisture barrier cream to the anal area.
4. The UAP is wiping the client’s perineal area from back to front.
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CHAPTER 20 COMPREHENSIVE FINAL EXAMINATION
89. The unlicensed assistive personnel (UAP) empties the indwelling urinary catheter for
a client who is four (4) hours postoperative transurethral resection of the prostate
and informs the nurse the urine the urine is red with some clots. Which intervention
should the nurse implement first?
1. Assess the client’s urine output immediately.
2. Notify the HCP that the client has gross hematuria.
3. Explain this is expected with this surgery.
4. Medicate for bladder spasms to decrease bleeding.
90. The client with a history of substance abuse presents to the emergency room
complaining of right flank pain, and the urinalysis indicates microscopic blood.
Which intervention should the nurse implement?
1. Determine the last illegal drug use.
2. Insert a #22 French indwelling catheter.
3. Give the client a back massage.
4. Medicate the client for pain.
91. Which assessment data would made the nurse suspect the client has cancer of the
bladder?
1. Gross painless hematuria.
2. Burning on urination.
3. Terminal dribbling.
4. Difficulty initiating the stream.
92. The client asks the nurse, “What are the risk factors for developing multiple
sclerosis?” Which statement is a risk factor for multiple sclerosis (MS)?
1. A genetic predisposition is the most important factor.
2. Living in the southern United States predisposes a person to MS.
3. Use of tobacco product is the number-one risk for developing MS.
4. A sedentary lifestyle can cause a person to develop MS.
93. The elderly client from the long-term care facility is admitted into the hospital
diagnosed with septicemia. Which area of the body is the most appropriate place
for the nurse to assess the hydration status of the client?
A
B
C
D
1. A
2. B
3. C
4. D
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94. The student nurse accidentally punctured her finger with a contaminated needle.
Which action should the student nurse take first?
1. Notify the infection control nurse.
2. Allow the puncture site to bleed.
3. Report to the emergency room.
4. Cleanse the site with Betadine.
95. Which psychosocial problem should the nurse identify as priority for a client
diagnosed with rheumatoid arthritis?
1. Alteration in comfort.
2. Ineffective coping.
3. Anxiety.
4. Altered body image.
96. The client is admitted to the medical unit complaining of severe abdominal pain.
Which intervention should the nurse implement first?
1. Assess for complications.
2. Medicate for pain.
3. Turn the television on.
4. Teach relaxation techniques.
97. The female client is admitted to the orthopedic floor with a spiral fracture of the
arm and multiple contusions and abrasions covering the trunk of the body. Her
husband accompanies her. During the admission interview, which intervention is
priority?
1. Notify the local police department of the client’s admission.
2. Provide privacy to discuss how the injuries occurred to the client.
3. Refer the client to the social worker for names of women’s shelters.
4. Ask the client if she prefers the husband to stay in the room.
98. Which interventions should the emergency department nurse implement for a
client who has an AP of 122 and a BP of 80/50? Select all that apply.
1. Put the client in reverse Trendelenburg position.
2. Start an intravenous line with an 18-gauge catheter.
3. Have the client complete the admission process.
4. Cover the client with blankets and keep warm.
5. Request the lab draw a type and crossmatch.
99. The client is eight (8) hours postoperative small bowel resection. Which data
indicate the client has had a complication from the surgery?
1. A hard, rigid, boardlike abdomen.
2. High-pitched tinkling bowel sounds.
3. Absent bowel sounds.
4. Complaints of pain at “6” on the pain scale.
100. Which intervention will help prevent the nurse from being sued for malpractice
throughout his or her professional practice?
1. Keep accurate and legible documentation of client care.
2. A kind, caring, and compassionate bedside manner at all times.
3. Maintain knowledge of medications for disease processes.
4. Follow all health-care provider orders explicitly.
101. According to the nursing process, which interventions should the nurse implement
when caring for a client diagnosed with a right-sided cerebrovascular accident
(stroke) and who has difficulty swallowing? List the interventions in order of the
nursing process.
1. Write the client problem of “altered tissue perfusion.”
2. Assess the client’s level of consciousness and speech.
3. Request dietary to send a full liquid tray with Thick-It.
4. Instruct the UAP to elevate the head of the bed 30 degrees.
5. Note the amount of food consumed on the dinner tray.
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AND RATIONALE
1. 1. Birth control pills regulate the hormones in
the body but will not cause changes in the
breast tissue.
2. There is a theory that chocolate increases
breast discomfort in women with fibrocystic
breast changes.
3. During the menstrual cycle, pregnancy,
and menopause, variations in breast
tissue occur and must be distinguished
from pathological disease. BSE is best
performed on days five (5) to seven
(7) after menses, counting the first
day of menses as day one (1).
4. Sexual manipulation of the breast does not
cause malignant changes in breast tissue.
Content – Medical: Category of Health Alteration –
Reproductive: Integrated Nursing Process –
Assessment: Client Needs – Physiological Integrity,
Reduction of Risk Potential: Cognitive Level – Analysis.
2. 1. Anemia due to endometriosis occurs over
time and is not an acute complication such
as hemorrhaging.
2. Pain is the primary complaint of the
client; the pain occurs as a result of ectopic tissue bleeding into the abdominal
cavity during menses.
3. Endometriosis does not cause constipation,
and this would not be a priority problem.
The client may experience pain during a
bowel movement.
4. Dyspareunia is pain during intercourse, and
this client is in the hospital (and unlikely to
be having sex there).
Content – Medical: Category of Health Alteration –
Reproductive: Integrated Nursing Process – Diagnosis:
Client Needs – Safe Effective Care Environment,
Management of Care: Cognitive Level – Analysis.
3. 1. With a remaining testicle, the client will
be able to maintain sexual potency, but
radiation and chemotherapy may cause
the client to become sterile. Therefore,
banking his sperm will allow him to
father a child later in life.
2. Testicular cancer has a 90% cure rate with
standard therapy; therefore, completing an
advance directive is not priority.
3. The client will not be undergoing
chemotherapy for at least six (6) weeks to
allow the client to heal; therefore, this is
not a priority intervention.
4. This is important, but when preparing the
client for surgery, the priority intervention
is to accomplish presurgical interventions.
Content – Medical: Category of Health Alteration –
Reproductive: Integrated Nursing Process –
Implementation: Client Needs – Safe Effective Care
Environment, Management of Care: Cognitive
Level – Synthesis.
4. 1. Oral sex still involves mucous membrane–to–
mucous membrane contact and disease
transmission is possible; herpes simplex 2 is
simply herpes simplex 1 transferred to the
genitalia.
2. This is a myth.
3. The more often the person engages in
sexual contact and the more partners he
or she has, the more likely the person
will contract an STD; however, one time
is enough to contract a deadly STD, such
as AIDS.
4. According to developmental theories,
adolescents think they are invincible and
nothing will happen to them. This attitude leads adolescents to participate in
high-risk behaviors without regard to
consequences.
Content – Medical: Category of Health Alteration –
Reproductive: Integrated Nursing Process – Planning:
Client Needs – Health Promotion and Maintenance:
Cognitive Level – Synthesis.
5. 1. Kegel exercises do not have anything to do
with activity endurance.
2. Kegel exercises are exercises that
strengthen the perineal muscles.
Multiple pregnancies weaken the
pelvic muscles, resulting in bladder
incontinence; a report of no stress
incontinence indicates the Kegel
exercises are effective.
3. Kegel exercises do not affect pregnancy.
4. Kegel exercises do not have anything to do
with weight loss.
Content – Medical: Category of Health Alteration –
Reproductive: Integrated Nursing Process –
Evaluation: Client Needs – Physiological Integrity,
Physiological Adaptation: Cognitive Level – Synthesis.
6. 1. The pelvic sonogram, which visualizes
the ovary using sound waves, is a diagnostic test for an ovarian cyst, which
would be suspected with the client’s
signs/symptoms.
2. A CBC may be ordered to rule out appendicitis, but this client does not have right
lower abdominal pain.
3. A KUB x-ray is ordered for a client with
possible kidney stones.
763
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MED-SURG SUCCESS
4. A CT of the abdomen would not visualize
contents in the pelvis.
Content – Medical: Category of Health Alteration –
Reproductive: Integrated Nursing Process – Planning:
Client Needs – Physiological Integrity, Reduction of
Risk Potential: Cognitive Level – Synthesis.
7. 1. PSA is a tumor marker monitored to
determine the progress of the disease and
treatment, but it is not monitored prior to
chemotherapy.
2. Serum calcium levels may be monitored to
determine metastasis to the bone, but it
would not be done prior to chemotherapy.
3. The CBC is monitored to determine if
the client is at risk for developing an
infection or bleeding as a result of side
effects of the chemotherapy medications. The chemotherapy could be held
or decreased based on these results.
4. AFP is a tumor marker monitored to
determine the progress of the disease and
treatment, but it is not monitored prior to
chemotherapy.
Content – Medical: Category of Health Alteration –
Oncology: Integrated Nursing Process – Assessment:
Client Needs – Physiological Integrity, Reduction of
Risk Potential: Cognitive Level – Analysis.
8. 1. This client is showing signs/symptoms of
hypovolemic shock and should not be
assigned to an inexperienced nurse.
2. Confusion could be a sign of many complications after surgery, so this client should
not be assigned to an inexperienced nurse.
3. This client is being transferred to the ICU,
which indicates the client is not stable;
therefore, this client should not be assigned
to an inexperienced nurse.
4. A myelogram is a routine diagnostic test.
With minimal instruction, an inexperienced nurse could care for this client.
Content – Nursing Management: Category of Health
Alteration – Management: Integrated Nursing
Process – Planning: Client Needs – Safe Effective Care
Environment, Management of Care: Cognitive Level –
Synthesis.
9. 1. The nurse should encourage the client to
maintain independent functioning, and delegating the UAP to feed the client would be
encouraging dependence.
2. Although this is an over-the-counter medication, a UAP cannot administer any medication to a client.
3. The UAP cannot assess or evaluate any of
the client’s diagnostic information.
4. The UAP could assist the client to
ambulate to the shower room and
assist with morning care.
Content – Nursing Management: Category of
Health Alteration – Management: Integrated
Nursing Process – Planning: Client Needs – Safe
Effective Care Environment, Management of Care:
Cognitive Level – Synthesis.
10. 1. This would not warrant intervention
because this indicates the hose are not
too tight.
2. This indicates the hose are not too tight.
3. There should be no wrinkles in the
hose after application. Wrinkles could
cause constriction in the area, resulting
in clot formation or skin breakdown;
therefore, this would warrant immediate intervention by the charge nurse.
4. Antiembolism hose should not be put over
a wound; they would restrict the circulation to the wound and cause a decrease in
wound healing.
Content – Nursing Management: Category of
Health Alteration – Management: Integrated
Nursing Process – Evaluation: Client Needs – Safe
Effective Care Environment, Management of Care:
Cognitive Level – Synthesis.
11. 1. The nurse should suggest walking daily
because bones need stress to maintain
strength.
2. Vitamin D helps the body absorb
calcium.
3. Smoking interferes with estrogen’s
protective effects on bones, promoting
bone loss.
4. Lack of exposure to sunlight results in
decreased vitamin D, which is necessary for calcium absorption and normal
bone mineralization. The client should
go outside.
5. The client is at risk for fractures;
therefore, a fall could result in serious
complications.
Content – Medical: Category of Health Alteration –
Musculoskeletal: Integrated Nursing Process –
Planning: Client Needs – Physiological Integrity,
Physiological Adaptation: Cognitive Level – Synthesis.
12. 1. The physical therapist addresses lower
extremity strength, gait training, and
transfers.
2. The occupational therapist addresses
activities of daily living and fine motor
skills in the upper extremities, which
would be an appropriate referral.
3. Worker’s compensation is an insurance
provider for the employer and employee
to cover medical expenses and loss of
wages. This is not an appropriate referral
by the rehabilitation nurse.
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CHAPTER 20 COMPREHENSIVE FINAL EXAMINATION
4. The client may need this referral, but after
the occupational therapist has worked with
the client and determined the ability to
perform skills.
Content – Medical: Category of Health Alteration –
Musculoskeletal: Integrated Nursing Process –
Implementation: Client Needs – Physiological
Integrity, Physiological Adaptation: Cognitive
Level – Application.
13. 1. The nurse would expect the client with a
fractured right leg to have pain but it
would not warrant immediate intervention.
2. The nurse would assess the client’s pedal
or posterior tibial pulse for a client with a
fractured right tibia.
3. Any abnormal neurovascular assessment data, such as coldness, paralysis,
or paresthesia, warrant immediate
intervention by the nurse.
4. Ecchymosis is bruising and would be
expected in the client who has a
fractured tibia.
Content – Medical: Category of Health Alteration –
Musculoskeletal: Integrated Nursing Process –
Assessment: Client Needs – Physiological Integrity,
Reduction of Risk Potential: Cognitive Level – Analysis.
14. 1. The client is being discharged, so a
self-care deficit would not be a potential
complication.
2. The client is being discharged and is
ambulating; therefore, impaired skin
integrity should not be a problem.
3. The client would have been taking a
prophylactic anticoagulant but would not
be at risk for abnormal bleeding.
4. The client must inform all HCPs, especially the dentist, of the hip prosthesis because the client should be taking
prophylactic antibiotics prior to any invasive procedure. Any bacteria invading
the body may cause an infection in the
joint, and this may result in the client
having the prosthesis removed.
Content – Surgical: Category of Health
Alteration – Musculoskeletal: Integrated Nursing
Process – Diagnosis: Client Needs – Safe Effective
Care Environment, Management of Care: Cognitive
Level – Analysis.
15.
36%.
Each leg is 18%, with the anterior surface
(front) being 9%. Because the anterior of
both legs is burned (9% each), that would
be 18%. That 18% plus the anterior surface of the trunk, which is 18%, totals
36% of the total body surface burned.
Content – Medical: Category of Health
Alteration – Integumentary: Integrated Nursing
Process – Assessment: Client Needs – Physiological
Integrity, Reduction of Risk Potential: Cognitive
Level – Analysis.
16. 1. Wasting syndrome occurs in clients with
protein-calorie malnutrition. This syndrome leads to the pressure ulcers not
healing, but it is not a complication of the
pressure ulcers.
2. Stage IV pressure ulcers frequently
extend to the bone tissue, predisposing
the client to developing a bone
infection—osteomyelitis—which
can rarely be treated effectively.
3. Renal calculi may be a result of immobility, but they are not a complication of
pressure ulcers.
4. Cellulitis is an inflammation of the skin,
which is not a complication of pressure
ulcers.
Content – Medical: Category of Health Alteration –
Integumentary: Integrated Nursing Process –
Planning: Client Needs – Physiological Integrity,
Physiological Adaptation: Cognitive Level – Synthesis.
17. 1. Contact dermatitis is a type of dermatitis caused by a hypersensitivity
response. In this case, it is a hypersensitivity reaction to metal salts in
the watch the client is wearing. Anytime the nurse assesses redness or
irritation in areas where jewelry
(such as rings, watches, necklaces)
or clothing (such as socks, shoes, or
gloves) are worn, the nurse should
suspect contact dermatitis.
2. Herpes simplex 1 virus occurs in oral or
nasal mucous membranes.
3. Impetigo is a superficial infection of the
skin caused by staph or strep infection and
occurs on the body, face, hands, or neck.
4. Seborrheic dermatitis is a chronic inflammation of the skin involving the scalp,
eyebrows, eyelids, ear canals, nasolabial
folds, axillae, and trunk.
Content – Medical: Category of Health
Alteration – Integumentary: Integrated Nursing
Process – Diagnosis: Client Needs – Safe Effective
Care Environment, Management of Care: Cognitive
Level – Comprehension.
18. 1. A bone scan would not be ordered unless a
biopsy proves malignant melanoma.
2. This is an abnormal-appearing mole on
the skin, and the HCP would order a
biopsy to confirm skin cancer.
3. A CEA is a test used to mark the presence
or prognosis of several cancers but not
skin cancer.
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4. A sonogram would not be ordered to diagnose skin cancer.
4. If the client has a seizure in the bathtub,
the client could drown.
Content – Medical: Category of Health
Alteration – Integumentary: Integrated Nursing
Process – Planning: Client Needs – Physiological
Integrity, Reduction of Risk Potential: Cognitive
Level – Synthesis.
Content – Medical: Category of Health Alteration –
Neurological: Integrated Nursing Process –
Evaluation: Client Needs – Physiological Integrity,
Physiological Adaptation: Cognitive Level – Synthesis.
19. 1. This could be an appropriate long-term
goal for the client based on the extent of
injury, but it is not an appropriate shortterm goal.
2. This is an appropriate long-term goal to
prevent immobility complications, but it is
not an appropriate short-term goal.
3. The worse-case scenario with a closed
head injury is increased intracranial
pressure resulting in death. An appropriate short-term goal would be the
ICP remaining within normal limits,
which is 5 to 15 mm Hg.
4. This is a psychosocial goal, which would
not be a short-term goal, and the client
may not be angry. The stem did not indicate the client is angry.
Content – Medical: Category of Health
Alteration – Neurological: Integrated Nursing
Process – Planning: Client Needs – Safe Effective
Care Environment, Management of Care: Cognitive
Level – Synthesis.
20. 1. This is negating the client’s feelings and
will abruptly end any conversation the
client may want or need to have.
2. This is imposing the nurse’s religious beliefs on the client and these are clichés,
which do not address the client’s feelings.
3. This is explaining why the client survived,
but the client isn’t really asking for information. The client is expressing and showing emotions that must be addressed by
the nurse.
4. This is a therapeutic response which
allows the client to ventilate feelings.
Content – Medical: Category of Health Alteration –
Neurological: Integrated Nursing Process –
Implementation: Client Needs – Psychosocial Integrity:
Cognitive Level – Application.
21. 1. This statement indicates the client
does not understand the discharge
teaching. The client will not be able to
drive until the client is seizure free for
a certain period of time. The laws in
each state differ.
2. Lack of sleep is a risk factor for having
seizures.
3. Noncompliance with medication is a risk
factor for having a seizure.
22. 1. Using the vital sign machine to take the
client’s BP is an appropriate intervention.
2. The body temperature of an unconscious client should never be taken by
mouth because the client is unable to
safely hold the thermometer.
3. Verifying the blood pressure manually is
an appropriate intervention if the UAP
questions the automatic blood pressure
reading. This action should be praised.
4. Counting the respiration for 30 seconds
and multiplying by two (2) is appropriate.
Content – Medical: Category of Health Alteration –
Neurological: Integrated Nursing Process –
Evaluation: Client Needs – Safe Effective Care
Environment, Management of Care: Cognitive
Level – Synthesis.
23. 1. This is incorrect information for radiation
therapy. It is correct for chemotherapy.
2. This is a therapeutic response, which does
not answer the client’s question.
3. Radiation therapy can cause permanent
damage to the hair follicles and the
hair may not grow back at all; the
nurse should answer the client’s
question honestly.
4. This is not a true statement.
Content – Medical: Category of Health
Alteration – Oncology: Integrated Nursing
Process – Implementation: Client Needs –
Physiological Integrity, Physiological Adaptation:
Cognitive Level – Application.
24. 1. A positive Brudzinski’s sign—flexion of the
knees and hip when the neck is flexed—
indicates the presence of meningitis.
Therefore, the treatment is not effective.
Sensitivity to light is a common symptom
of meningitis.
2. This does not indicate whether the
meningitis is resolving.
3. Kernig’s sign—the leg cannot be extended
when the client is lying with the thigh
flexed on the abdomen—is a sign of
meningitis. An elevated temperature
indicates the client still has meningitis.
4. The client does not have nuchal
rigidity, which indicates the client’s
treatment is effective.
Content – Medical: Category of Health
Alteration – Neurological: Integrated Nursing
Process – Assessment: Client Needs – Physiological
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CHAPTER 20 COMPREHENSIVE FINAL EXAMINATION
Integrity, Physiological Adaptation: Cognitive
Level – Analysis.
25. 1. An MRI is not able to confirm the
diagnosis of Parkinson’s disease.
2. This is the portion of the brain where
Parkinson’s disease originates, but this
area lies deep in the brain and cannot be
biopsied.
3. This is a surgery that relieves some of the
symptoms of Parkinson’s disease. To be
eligible for this procedure, the client
must have failed to achieve an adequate
response with medical treatment.
4. Many diagnostic tests are completed to
rule out other diagnoses, but Parkinson’s disease is diagnosed based on the
clinical presentation of the client and
the presence of two of the three cardinal manifestations: tremor, muscle
rigidity, and bradykinesia.
Content – Medical: Category of Health
Alteration – Neurological: Integrated Nursing
Process – Planning: Client Needs – Physiological
Integrity, Reduction of Risk Potential: Cognitive
Level – Synthesis.
26. 1. An oral coagulant is ordered if the
TIA was caused by atrial fibrillation,
and that information is not presented
in the stem.
2. Atherosclerosis is the most common
cause of a TIA or stroke, and taking a
baby aspirin every day helps prevent
clot formation around plaques.
3. If the client had hypertension, a beta
blocker may be prescribed, but this
information is not in the stem.
4. Anticonvulsant medications are not
prescribed to help prevent TIAs.
Content – Medical: Category of Health Alteration –
Neurological: Integrated Nursing Process –
Planning: Client Needs – Physiological Integrity,
Pharmacological and Parenteral Therapies: Cognitive
Level – Synthesis.
27. 1. Myalgia is muscle pain, which is expected
in a client diagnosed with encephalitis.
2. The client complaining of chest pain is
priority. Remember Maslow’s hierarchy
of needs.
3. Refusing to eat hospital food is not a
priority.
4. The client going to the whirlpool is stable
and is not a priority over chest pain.
Content – Medical: Category of Health
Alteration – Neurological: Integrated Nursing
Process – Assessment: Client Needs – Safe Effective
Care Environment, Management of Care: Cognitive
Level – Analysis.
28. 1. The client should be assessed for delirium
tremens and should be assigned to a
registered nurse.
2. Palpitations indicate cardiac involvement,
and because the client has a history of
cocaine abuse, this client should be
assigned to a registered nurse.
3. This client is at high risk for injury to self
and should be assigned to a registered
nurse and be on one-to-one precautions.
4. The client has a right to leave against
medical advice (AMA), and marijuana
abuse is not life threatening to him or
to others. Therefore, the LPN could
be assigned to this client.
Content – Nursing Management: Category of
Health Alteration – Management: Integrated
Nursing Process – Planning: Client Needs – Safe
Effective Care Environment, Management of Care:
Cognitive Level – Synthesis.
29. 1. An occasional PVC does not warrant intervention; it is normal for most clients.
2. Less than six (6) unifocal PVCs in one
(1) minute is not life threatening.
3. Multifocal PVCs indicate the ventricle
is irritable, and this client is at risk for
a cardiac event such as ventricular
fibrillation.
4. Atrial fibrillation is not life threatening,
and the nurse would expect the client not
to have a P wave when exhibiting this
dysrhythmia.
Content – Nursing Management: Category of
Health Alteration – Cardiovascular: Integrated
Nursing Process – Planning: Client Needs – Safe
Effective Care Environment, Management of Care:
Cognitive Level – Synthesis.
30. 1. This is a correct statement. The recommended proportions of food are
50% carbohydrates, 30% or less from
fat, and 20% protein.
2. Only 50% of the calories should come
from carbohydrates.
3. Red meat is an excellent source of protein
but should only comprise 20% of the diet,
and red meat is very high in fat.
4. Polyunsaturated fats, not the monounsaturated fats, are the better fats.
Content – Medical: Category of Health Alteration –
Cardiovascular: Integrated Nursing Process –
Planning: Client Needs – Physiological Integrity, Basic
Care and Comfort: Cognitive Level – Synthesis.
31. 1. The client diagnosed with CHF will be
short of breath on exertion and with activity. The significant other should report
difficulty breathing not subsiding with rest
or stopping the activity.
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2. Two (2) to three (3) pounds of weight
gain reflects fluid retention as a result
of heart failure, which warrants
notifying the HCP.
3. The caregiver must not administer the
digoxin if the radial pulse is less than
60 bpm. The apical pulse is more difficult
to assess in a client than the radial pulse.
4. The client in end-stage CHF is dying and
should not exercise daily; activity intolerance as a result of decreased cardiac output
is the number-one life-limiting problem.
Content – Medical: Category of Health Alteration –
Cardiovascular: Integrated Nursing Process –
Planning: Client Needs – Physiological Integrity,
Physiological Adaptation: Cognitive Level – Synthesis.
2. Cardiac valve replacement and valve
disorders are risk factors for developing infective endocarditis. This is why
clients must receive prophylactic antibiotic treatment before dental work
and invasive procedures.
3. A personal history of rheumatic fever, not
a family history, increases the risk of
developing infective endocarditis.
4. NSAIDs have no effect on the development of infective endocarditis.
Content – Medical: Category of Health Alteration –
Cardiovascular: Integrated Nursing Process –
Assessment: Client Needs – Physiological Integrity,
Reduction of Risk Potential: Cognitive Level – Analysis.
32. 1. Barrel chest and clubbing of the fingers
are signs of chronic lung disease.
2. Intermittent claudication and rest pain are
signs of peripheral arterial disease.
3. Pink, frothy sputum and dyspnea on
exertion are signs of congestive heart
failure, which occurs when the heart
can no longer compensate for the
strain of an incompetent valve.
4. Friction rub occurs with pericarditis, and
bilateral wheezing occurs with asthma.
35. 1. The client’s pedal pulse does not evaluate
the effectiveness of this medication.
2. This medication is not administered to
help decrease blood pressure.
3. This medication inhibits platelet
aggregation and is considered effective
when there is a decrease in atherosclerotic events, an example of which is a
stroke.
4. This medication will not help the pain
associated with arterial occlusive
disease.
Content – Medical: Category of Health Alteration –
Cardiovascular: Integrated Nursing Process –
Assessment: Client Needs – Physiological Integrity,
Reduction of Risk Potential: Cognitive Level –
Synthesis.
Content – Medical: Category of Health Alteration –
Drug Administration: Integrated Nursing Process –
Evaluation: Client Needs – Physiological Integrity,
Pharmacological and Parenteral Therapies: Cognitive
Level – Synthesis.
33. 1. Once the chest incision heals, the client
can shower or bathe, whichever the client
prefers.
2. Electrical devices may interfere with
the functioning of the pacemaker.
3. This alerts any HCP as to the presence
of a pacemaker.
4. The client should be taught to take the
radial pulse for one (1) full minute before getting out of bed. If the count is
more than five (5) bpm less than the
preset rate, the HCP should be notified immediately because this may indicate the pacemaker is malfunctioning.
5. The client should notify the HCP if the
pulse is five (5) bpm less than the preset
rate. This may indicate pacemaker
malfunction.
36. 1. Sublingual nitroglycerin is the medication
of choice for angina, but it is not the first
intervention.
2. Applying oxygen is appropriate, but it is
not the first intervention.
3. A STAT ECG should be ordered, but it is
not the first intervention.
4. Stopping the client from whatever
activity the client is doing is the first
intervention because this decreases
the oxygen demands of the heart
muscle and may decrease or eliminate
the chest pain.
Content – Medical: Category of Health Alteration –
Cardiovascular: Integrated Nursing Process –
Planning: Client Needs – Physiological Integrity,
Physiological Adaptation: Cognitive Level – Synthesis.
37. 1. This client is unstable and received
medication for chest pain. The nurse
cannot delegate any task for a client
who is unstable.
2. The UAP cannot notify the HCP because
UAPs are not allowed to take verbal or
telephone orders.
34. 1. Having a history of a myocardial infarction is not a risk factor for developing
infective endocarditis.
Content – Nursing Management: Category of Health
Alteration – Cardiovascular: Integrated Nursing
Process – Implementation: Client Needs – Safe
Effective Care Environment, Management of Care:
Cognitive Level – Analysis.
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CHAPTER 20 COMPREHENSIVE FINAL EXAMINATION
3. The UAP can take routine vital signs.
The nurse must evaluate the vital signs
and take action if needed. The nurse
should not delegate teaching, assessing, evaluating, or any client who is
unstable.
4. This is outside the level of a UAP’s
expertise.
Content – Nursing Management: Category of
Health Alteration – Management: Integrated
Nursing Process – Planning: Client Needs – Safe
Effective Care Environment, Management of Care:
Cognitive Level – Synthesis.
41. 1. Brown rice, dried fruit, and oatmeal are
sources of nonheme iron. Nonheme iron
comes from vegetable sources.
2. Beef, chicken, and pork are sources of
heme iron or animal sources of iron.
3. Broccoli, asparagus, and kidney beans are
sources of folic acid.
4. Liver, cheese, and eggs are sources of
vitamin B12.
Content – Medical: Category of Health Alteration –
Hematology: Integrated Nursing Process –
Evaluation: Client Needs – Physiological Integrity,
Basic Care and Comfort: Cognitive Level – Synthesis.
38. 1. This might be what the nurse wants to do,
but the nurse should teach the client about
the disease process.
2. Elevating the legs above the heart as
much as possible will help decrease
edema.
3. There are no surgical procedures to
correct venous insufficiency.
4. Losing weight and walking are excellent
lifestyle modifications, but there is no
guarantee the venous insufficiency will
resolve.
42. 1. Heparin interferes with the clotting
cascade and may prevent further clotting factor consumption resulting from
uncontrolled thromboses formation.
2. Assessment is an independent intervention; it is not collaborative and does not
require an HCP’s order.
3. Assessment is an independent intervention; it is not collaborative and does not
require an HCP’s order.
4. TPN is not a treatment for a client
with DIC.
Content – Medical: Category of Health Alteration –
Cardiovascular: Integrated Nursing Process –
Implementation: Client Needs – Physiological
Integrity, Physiological Adaptation: Cognitive Level –
Application.
Content – Medical: Category of Health
Alteration – Hematology: Integrated Nursing
Process – Implementation: Client Needs – Safe
Effective Care Environment, Management of Care:
Cognitive Level – Application.
39. 1. Cervical lymph node enlargement would
indicate Hodgkin’s lymphoma.
2. An asymmetrical dark-purple nevus would
indicate malignant melanoma.
3. Petechiae covering the trunk and legs
is one of the indicators of bone marrow
problems, which could be leukemia.
4. Brownish-purple nodules on the face indicate Kaposi’s sarcoma, a complication
of AIDS.
Content – Medical: Category of Health Alteration –
Hematology: Integrated Nursing Process –
Assessment: Client Needs – Physiological Integrity,
Reduction of Risk Potential: Cognitive Level – Analysis.
40. 1. This statement does not represent the
anger stage of grieving.
2. This statement does not represent the
denial stage of grieving.
3. This statement does not represent the
bargaining stage of grieving.
4. This statement indicates the client is
ready to die and is in the acceptance
stage of the grieving process.
Content – Medical: Category of Health
Alteration – Oncology: Integrated Nursing
Process – Diagnosis: Client Needs – Psychosocial
Integrity: Cognitive Level – Analysis.
43.
150 mL/hr.
The nurse should infuse the blood in
two (2) hours because the client does
not have signs/symptoms of fluid volume
overload.
Content – Medical: Category of Health Alteration –
Hematology: Integrated Nursing Process –
Implementation: Client Needs – Safe Effective Care
Environment, Safety and Infection Control: Cognitive
Level – Application.
44. 1. This is a false statement. The client could
have the sickle cell trait.
2. This should be discussed with her
fiancé, but it is not the most important
information.
3. Referral to a genetic counselor is the
most important information to give the
client. If she and her fiancé both have
the sickle cell trait, there is a 25%
chance of a child having sickle cell
disease with each pregnancy.
4. Adoption may be a choice, but at this time
the most important information is to refer
the couple to a genetic counselor.
Content – Medical: Category of Health
Alteration – Hematology: Integrated Nursing
Process – Implementation: Client Needs –
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Physiological Integrity, Physiological Adaptation:
Cognitive Level – Application.
45. 1. The nurse should stay at home because
the nurse will expose all other personnel and clients to the illness. Flu,
especially with a fever, places the nurse
at risk for a secondary pneumonia.
2. The nurse is ill, and many errors are made
when the nurse is not functioning at 100%.
3. Even if the nurse doesn’t have direct client
care, the nurse will expose other employees to the virus.
4. OTC medications will not prevent the
transmission of flu to others, nor will they
prevent the nurse from developing a secondary pneumonia.
Content – Nursing Management: Category of
Health Alteration – Management: Integrated
Nursing Process – Implementation: Client Needs –
Safe Effective Care Environment, Safety and Infection
Control: Cognitive Level – Application.
46. 1. The nurse should not administer antibiotics
until the culture specimen is obtained.
2. The sputum must be collected first to
identify the infectious organism so appropriate antibiotics can be prescribed.
Administering broad-spectrum antibiotics prior to collecting sputum could
alter the C&S results.
3. This is not priority over sputum culture
and getting the antibiotic started.
4. Always treat the client first.
Content – Medical: Category of Health
Alteration – Respiratory: Integrated Nursing
Process – Implementation: Client Needs – Safe
Effective Care Environment, Management of Care:
Cognitive Level – Application.
47. 1. Medical client problems indicate the
nurse and the HCP must collaborate to
care for the client; the client must have
medications for heart failure.
2. Without an HCP’s order, the nurse can
instruct the client to pace activities and
teach about rest versus activity.
3. Paralytic ileus is a medical problem but
would not be expected in a client with
cardiomyopathy.
4. Atelectasis occurs when airways collapse,
which would not occur in a client with
cardiomyopathy.
Content – Medical: Category of Health Alteration –
Cardiovascular: Integrated Nursing Process –
Diagnosis: Client Needs – Physiological Integrity,
Physiological Adaptation: Cognitive Level – Analysis.
48. 1. Cellulitis is the most common infectious cause of limb edema as a result of
bacterial invasion of the subcutaneous
tissue. This assessment would make
the nurse suspect this condition.
2. Intravenous drug use can cause cellulitis,
but the assessment did not include track
marks or needle insertion sites.
3. Raynaud’s phenomenon is a form of intermittent arteriolar vasoconstriction resulting in coldness, pain, and pallor of fingertips or toes. The client should keep warm
to prevent vasoconstriction of extremities.
4. Buerger’s disease (thromboangiitis obliterans) is a relatively uncommon occlusive
disease limited to medium and small
arteries and veins. The cause is
unknown, but there is a strong
association with tobacco use.
Content – Medical: Category of Health
Alteration – Cardiovascular: Integrated Nursing
Process – Assessment: Client Needs – Physiological
Integrity, Reduction of Risk Potential: Cognitive
Level – Analysis.
49. 1. This step is the first step in BSE.
2. This is step three (3) in the BSE process.
3. This is included in steps four (4) and five
(5) and is described as using a systematic
process of examining the breast. Using
circular motions and dividing the breast
into wedges or vertical strips to palpate
the entire breast is encouraged. This step
was described in the stem as having been
completed.
4. The last step of BSE after palpation is
to express the nipple by gently squeezing the nipple. Any discharge should be
brought to the attention of an HCP.
Nipple discharge can be caused by
many factors such as carcinoma, papilloma, pituitary adenoma, cystic breasts,
and some medications.
Content – Medical: Category of Health Alteration –
Reproductive: Integrated Nursing Process –
Implementation: Client Needs – Health Promotion
and Maintenance: Cognitive Level – Knowledge.
50. 1. Changes in pupil size are a late sign of a
neurological deficit.
2. A change in level of consciousness is
the first and most critical indicator of
any neurological deficit.
3. A decrease in motor function occurs with
a neurological deficit, but it is not the
most critical indicator.
4. Numbness of the extremities occurs with a
neurological deficit, but it is not the most
critical indicator.
Content – Medical: Category of Health
Alteration – Neurological: Integrated Nursing
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CHAPTER 20 COMPREHENSIVE FINAL EXAMINATION
Process – Assessment: Client Needs – Physiological
Integrity, Reduction of Risk Potential: Cognitive
Level – Analysis.
51. 1. The nurse must make a decision on
the amount of blood to infuse per
hour. If the client is showing any sign
of heart or lung compromise, the nurse
would infuse the blood at the slowest
possible rate.
2. Blood products require the client to
give specific consent to receive blood.
3. The IV should be started with an
18-gauge catheter if possible; the smallest
possible catheter is a 20-gauge. Smaller
gauge catheters break down the blood cells.
4. Blood is not compatible with D5W; the
nurse should hang 0.9% normal saline
(NS) to keep open.
5. The nurse should verify the HCP’s
order before having the client sign
the consent form.
Content – Medical: Category of Health Alteration –
Hematology: Integrated Nursing Process –
Implementation: Client Needs – Safe Effective Care
Environment, Safety and Infection Control: Cognitive
Level – Application.
52. 1. Most clients with psoriasis have red,
raised plaques with silvery white scales.
2. A burning, prickling row of vesicles
located along the torso is the description
of herpes zoster.
3. A raised, flesh-colored papule with a rough
surface area is a description of a wart.
4. An overgrowth of tissue with an excessive
amount of collagen is the definition of
keloids.
Content – Medical: Category of Health Alteration –
Neurological: Integrated Nursing Process –
Assessment: Client Needs – Physiological Integrity,
Reduction of Risk Potential: Cognitive Level –
Analysis.
53. 1. The cause of GB syndrome is unknown,
but a precipitating event usually occurs
one (1) to three (3) weeks prior to the
onset. The precipitating event may be a
respiratory or gastrointestinal viral or
bacterial infection.
2. These are not precipitating events or risk
factors for developing GB syndrome.
3. Smoking is not a risk factor for developing
GB syndrome.
4. GB syndrome is not more prominent in
foreign countries than in the United
States.
Content – Medical: Category of Health Alteration –
Immune System: Integrated Nursing Process –
Assessment: Client Needs – Physiological Integrity,
Reduction of Risk Potential: Cognitive Level –
Analysis.
54. 1. A normal hemoglobin is 12 to 15 g/dL,
and normal hematocrit is 36% to 45%.
2. A normal ESR is between 1 and 20 mm/hr
for a female client.
3. A normal albumin level is between 3.5 and
5.0 g/dL.
4. The client with SLE is at an increased
risk for infection, and this WBC count
indicates an infection requiring medical
intervention.
Content – Medical: Category of Health Alteration –
Immune System: Integrated Nursing Process –
Assessment: Client Needs – Physiological Integrity,
Reduction of Risk Potential: Cognitive Level –
Analysis.
55.
170 mL/hr.
125 mL + 45 mL = 170 mL
The IV pump should be set at this rate.
Content – Surgical: Category of Health Alteration –
Drug Administration: Integrated Nursing Process –
Implementation: Client Needs – Physiological Integrity,
Pharmacological and Parenteral Therapies: Cognitive
Level – Application.
56. 1. The Rinne test result indicates a normal
hearing; in conductive hearing loss, boneconducted sound is heard as long as or
longer than air-conducted sound.
2. The whisper test is used to make a general
estimation of hearing, but it is not used to
specifically diagnose for conductive hearing loss.
3. The Weber test uses bone conduction
to test lateralization of sound by placing a tuning fork in the middle of the
skull or forehead. A normal test results
in the client hearing the sound equally
in both ears.
4. The tympanogram (impedance audiometry) measures middle-ear muscle reflex to
sound stimulation and compliance of the
tympanic membrane by changing air
pressure in a sealed ear canal. It does
not specifically support the diagnosis of
conductive hearing loss.
Content – Medical: Category of Health
Alteration – Neurosensory: Integrated Nursing
Process – Assessment: Client Needs – Physiological
Integrity, Reduction of Risk Potential: Cognitive
Level – Analysis.
57. 1. The client should begin exercises that
will strengthen the surgical leg as soon
as the surgery is completed.
2. Pain medication should be taken as
needed, not routinely.
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3. The client may ambulate with the restrictions ordered by the surgeon.
4. The client will return to see the surgeon
prior to six (6) months. The surgeon
will need to monitor for healing and
complications.
Content – Surgical: Category of Health Alteration –
Musculoskeletal: Integrated Nursing Process –
Planning: Client Needs – Physiological Integrity,
Reduction of Risk Potential: Cognitive Level –
Synthesis.
58. 1. Yellow means caution. The client should
follow some, but not all, usual activities.
2. The client’s personal best takes two (2) to
three (3) weeks to establish.
3. When a client can’t talk while walking,
there is shortness of breath which indicates the client does not have tight control, but this has nothing to do with the
peak flowmeter.
4. When the client is in the red zone,
the client should take the quick-relief
medication and should not exercise or
follow regular routines.
Content – Medical: Category of Health Alteration –
Respiratory: Integrated Nursing Process – Evaluation:
Client Needs – Physiological Integrity, Physiological
Adaptation: Cognitive Level – Synthesis.
4. Although the client is 85 years old, the
nurse should discuss all health-care issues
with the client and not the family. This is
a violation of HIPAA.
Content – Medical: Category of Health Alteration –
Respiratory: Integrated Nursing Process –
Implementation: Client Needs – Safe Effective
Care Environment, Management of Care: Cognitive
Level – Application.
61. 1. The nurse can take care of this situation
and does not need to notify the RT.
2. The UAP cannot increase oxygen. The
nurse should treat oxygen as a medication.
Also, increasing the oxygen level could
cause the client to stop breathing as a
result of carbon dioxide narcosis.
3. The pulse oximeter reading will be low
because the client has COPD.
4. The oxygen level for a client with
COPD must remain between 2 and
3 L/min because the client’s stimulus
for breathing is low blood oxygen
levels. If the client receives increased
oxygen, the stimulus for breathing will
be removed and the client will stop
breathing.
Content – Medical: Category of Health
Alteration – Respiratory: Integrated Nursing
Process – Implementation: Client Needs – Safe
Effective Care Environment, Management of Care:
Cognitive Level – Application.
59. 1. A positive Homans’ sign would
indicate a DVT.
2. The calf with deep vein thrombosis
becomes edematous, so there is an
increase in the size of the calf when
compared to the other leg.
3. Elephantiasis is characterized by tremendous edema usually of the external genitalia
and legs and is not associated with DVT.
Elephantiasis is a lymphatic problem, not a
venous problem.
4. The brownish discoloration is a sign/
symptom of chronic venous insufficiency.
62. 1. Metastasis indicates advanced disease;
therefore, altered role performance would
not be an appropriate client problem.
2. Metastasis indicates advanced disease,
and the client should be allowed to
express feelings of loss and grieving;
the client is dying.
3. Body image is a psychosocial problem but
would not be applicable in this scenario.
4. Anger is part of the grieving process.
Content – Medical: Category of Health Alteration –
Neurosensory: Integrated Nursing Process –
Assessment: Client Needs – Physiological Integrity,
Reduction of Risk Potential: Cognitive Level – Analysis.
Content – Medical: Category of Health Alteration –
Oncology: Integrated Nursing Process – Diagnosis:
Client Needs – Psychosocial Integrity: Cognitive
Level – Analysis.
60. 1. The client with end-stage COPD
would not be a candidate for an AAA
repair, although the size of the
aneurysm places the client at risk for
rupture. Although many nurses do not
like to address end-of-life issues, this
would be an important and timely
intervention.
2. The client is not a surgical candidate because of the comorbid condition and age.
3. The client should know how to pursed-lip
breathe at this point in the disease process.
63. 1. The client has a partial laryngectomy and
the voice quality may change, but the
client can still speak.
2. This is a psychosocial problem, but it is
not priority over a potential physiological
problem.
3. As a result of the injury to the musculature of the throat area, this client is
at high risk for aspirating.
4. This is a psychosocial problem, but it is
not priority over a potential physiological
problem.
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CHAPTER 20 COMPREHENSIVE FINAL EXAMINATION
Content – Surgical: Category of Health Alteration –
Oncology: Integrated Nursing Process – Diagnosis:
Client Needs – Safe Effective Care Environment,
Safety and Infection Control: Cognitive Level –
Analysis.
64. 1. The heparin drip may be increased because the client has now thrown a pulmonary embolus (PE), but this needs an
HCP’s order.
2. The HCP will be notified because the
client has a suspected embolus, but it is
not the first intervention.
3. The client has probably thrown a pulmonary embolus, and assessing the lungs
will not do anything for a client who
may die. PEs are life threatening, and
assessing the client is not priority in a
life-threatening situation.
4. The client probably has a pulmonary
embolus, and the priority is to provide
additional oxygen so oxygenation of
tissues can be maintained.
Content – Medical: Category of Health Alteration –
Drug Administration: Integrated Nursing Process –
Implementation: Client Needs – Safe Effective Care
Environment, Management of Care: Cognitive Level –
Application.
65. 1. Fluctuation in the water-seal compartment with respirations indicates the
system is working properly and the
client is stable.
2. Blood in the drainage compartment indicates there is a problem because the client
is diagnosed with a pneumothorax and
there should not be any bleeding.
3. Any deviation of the trachea indicates a
tension pneumothorax, a potentially lifethreatening complication.
4. Bubbling in the suction compartment does
not indicate a stable or unstable client.
Content – Medical: Category of Health Alteration –
Respiratory: Integrated Nursing Process –
Assessment: Client Needs – Physiological Integrity,
Reduction of Risk Potential: Cognitive Level –
Analysis.
66. 1. These are normal ABGs, which would
not be expected if the client has ARDS.
2. This client has an oxygen level below
80 to 100; therefore, this client may be
developing early ARDS.
3. This is respiratory alkalosis, which would
not be expected in a client with ARDS.
4. These are the expected ABGs of a client
with ARDS. There is a low oxygen level
despite high oxygen administration.
Content – Medical: Category of Health Alteration –
Respiratory: Integrated Nursing Process – Assessment:
Client Needs – Physiological Integrity, Reduction of Risk
Potential: Cognitive Level – Analysis.
67. 1. The HOB is elevated to prevent reflux of
stomach contents into the esophagus.
2. Proton pump inhibitors are only
administered one or twice a day; they
should not be given four (4) times a
day because the medication decreases
gastric acidity and the stomach needs
some gastric acid to digest foods. The
nurse would question this order.
3. The client is not prescribed any special
diet; limiting spicy and citrus foods
decreases acid in the stomach.
4. Sitting upright after all meals decreases
the reflux of stomach contents into the
esophagus.
Content – Medical: Category of Health Alteration –
Gastrointestinal: Integrated Nursing Process –
Implementation: Client Needs – Safe Effective Care
Environment, Safety and Infection Control: Cognitive
Level – Analysis.
68. 1. This white blood cell (WBC) level is
WNL and would not warrant immediate
intervention.
2. This amylase level is within normal limits
(50 to 180 units/dL).
3. This potassium level is low as a result
of excessive diarrhea and puts the
client at risk for cardiac dysrhythmias.
Therefore, these assessment data
warrant immediate intervention.
4. The client’s blood glucose level is elevated,
but it would not warrant immediate intervention for a client with Crohn’s disease
who has hypokalemia.
Content – Medical: Category of Health Alteration –
Gastrointestinal: Integrated Nursing Process –
Assessment: Client Needs – Physiological Integrity,
Reduction of Risk Potential: Cognitive Level –
Synthesis.
69. 1. Increasing fiber will help prevent constipation, the number-one reason for
an acute exacerbation of diverticulosis,
which results in diverticulitis.
2. The client should increase fluid intake
to prevent constipation, to at least
2,500 mL/day.
3. The client should exercise daily to prevent
constipation.
4. The client should take bulk-forming
laxatives, which helps prevent constipation
by adding bulk to the stool. Cathartic
laxatives are harsh colonic stimulants and
should not be taken on a daily basis.
Content – Medical: Category of Health Alteration –
Gastrointestinal: Integrated Nursing Process –
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Planning: Client Needs – Physiological Integrity,
Physiological Adaptation: Cognitive Level – Synthesis.
70. 1. The discharge instruction sheet is teaching, which cannot be delegated to an UAP.
2. The UAP can remove a saline lock
from a stable client.
3. The UAP does not clean hospital rooms;
this is the housekeeping department’s
responsibility.
4. The nurse cannot delegate evaluation,
which is checking the client’s laboratory
data prior to discharge; this is out of the
UAP’s area of expertise.
Content – Medical: Category of Health
Alteration – Gastrointestinal: Integrated Nursing
Process – Planning: Client Needs – Safe Effective
Care Environment, Management of Care: Cognitive
Level – Synthesis.
71. 1. Mild fatigue represents fatigue that the
client has only occasionally.
2. Moderate fatigue would be fatigue occurring about 40% to 60% of the time.
3. Extreme fatigue occurs 70% to 90% of
the time, which is indicated by the
client still being able to watch TV and
get to the bathroom.
4. The worst fatigue ever occurs all the time
and the client spends most of the day
sleeping and is not able to stay awake to
watch television.
Content – Medical: Category of Health
Alteration – Oncology: Integrated Nursing
Process – Implementation: Client Needs – Safe
Effective Care Environment, Management of Care:
Cognitive Level – Application.
72. 1. The T-tube is inserted into the common
bile duct to drain bile until healing
occurs, and bile is green, so this is
expected.
2. The client with CHF would be expected
to experience dyspnea on exertion.
3. Coffee-ground emesis indicates
gastrointestinal bleeding, and this
client should be seen first.
4. The client in end-stage liver failure is
unable to assimilate protein from the diet,
which leads to fluid volume retention and
resulting weight gain. This is expected for
this client.
Content – Nursing Management: Category of
Health Alteration – Management: Integrated
Nursing Process – Assessment: Client Needs – Safe
Effective Care Environment, Management of Care:
Cognitive Level – Analysis.
73. 1. The tympanic wave indicates ascites,
which is not an indicator of improving
health.
2. Asterixis is a flapping of the hands, which
indicates an elevated ammonia level.
3. Confusion and lethargy indicate increased
ammonia level.
4. A decrease in the abdominal girth
indicates an improvement in the
ascitic fluid.
Content – Medical: Category of Health Alteration –
Gastrointestinal: Integrated Nursing Process –
Assessment: Client Needs – Physiological Integrity,
Reduction of Risk Potential: Cognitive Level –
Analysis.
74. 1. The procurement of organs/tissues
from the client will not be noticeable if
there is an open casket funeral.
2. There is no reason for the client to wear a
long-sleeved shirt because skin is not
removed from the arms.
3. There is no reason for a private viewing as
a result of the organ/tissue donation.
4. The funeral may or may not have to be
delayed depending on when the procurement team can make arrangements; the
nurse should not give false information to
the family.
Content – Nursing Management: Category of
Health Alteration – Management: Integrated
Nursing Process – Planning: Client Needs – Safe
Effective Care Environment, Management of Care:
Cognitive Level – Synthesis.
75. 1. A gamma globulin injection is administered to provide passive immunity to
clients who have been exposed to hepatitis.
2. Hepatitis A is contracted through the
fecal-oral route of transmission; poor
sanitary practices in third world
countries place the client at risk
for hepatitis A.
3. This is a test to determine exposure to
tuberculosis and does not have anything
to do with hepatitis.
4. The hepatitis B vaccination administered
for exposure to blood/body fluids, not
throught the fecal-oral route. This vaccination is not priority for individuals
traveling to a third world country.
Content – Medical: Category of Health Alteration –
Gastrointestinal: Integrated Nursing Process –
Planning: Client Needs – Safe Effective Care
Environment, Safety and Infection Control: Cognitive
Level – Synthesis.
76. 1. The client’s amylase would be elevated in
an acute exacerbation of pancreatitis.
2. The WBC count is not elevated in this
disease process.
3. In clients with chronic pancreatitis, the
beta cells of the pancreas are affected
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CHAPTER 20 COMPREHENSIVE FINAL EXAMINATION
and therefore insulin production is affected. An elevated glucose level would
warrant the nurse assessing the client.
4. Lipase is an enzyme that is excreted by the
pancreas. Normal lipase levels indicate a
normally functioning pancreas.
Content – Medical: Category of Health Alteration –
Gastrointestinal: Integrated Nursing Process –
Assessment: Client Needs – Physiological Integrity,
Reduction of Risk Potential: Cognitive Level –
Synthesis.
77. 1. The client could experience hypoglycemia
if the rate of infusion is decreased. TPN
must be tapered when discontinuing.
2. Normal saline does not have glucose, so
the client would be at risk for hypoglycemia.
3. The client must be tapered off TPN to
prevent hypoglycemia; therefore, the line
cannot be converted to a heparin lock.
4. Dextrose 10% has enough glucose to
prevent hypoglycemia and should be
administered until bag #6 arrives
to the unit.
Content – Medical: Category of Health Alteration –
Drug Administration: Integrated Nursing Process –
Implementation: Client Needs – Physiological
Integrity, Pharmacological and Parenteral Therapies:
Cognitive Level – Application.
78. 1. This client is overweight but not morbidly
obese, which would place the client at risk
for complications.
2. “Altered nutrition: more than body
requirements” is an appropriate client
problem for a client who weighs
175 pounds.
3. This is a psychosocial problem, which is
not priority over a physiological problem.
4. The client may or may not be active, but
altered nutrition is priority.
Content – Medical: Category of Health Alteration –
Gastrointestinal: Integrated Nursing Process –
Diagnosis: Client Needs – Physiological Integrity,
Basic Care and Comfort: Cognitive Level – Analysis.
79. 1. A moist mouth indicates the client is not
dehydrated.
2. This is within normal limits for
potassium—3.5 to 5.5 mEq/L.
3. Tented tissue turgor indicates
dehydration, which is a complication
of diarrhea.
4. Hyperactive bowel sounds would be
expected in a client who has diarrhea.
Content – Medical: Category of Health Alteration –
Gastrointestinal: Integrated Nursing Process –
Assessment: Client Needs – Physiological Integrity,
Reduction of Risk Potential: Cognitive Level – Analysis.
80. 1. The long-term complications of
increased blood glucose levels to
organs are the primary reasons for
keeping the blood glucose level
controlled.
2. This is the medical explanation for
keeping the glucose under control,
but this answer is not appropriate for
laypeople.
3. The client with type 2 diabetes often
doesn’t feel bad, but the organs are still
being damaged as a result of increased
blood glucose levels.
4. Metabolic acidosis occurs in clients with
type 1 diabetes, not type 2. Clients with
type 2 diabetes have hyperosmolar hyperglycemic nonketotic syndrome (HHNS).
Content – Medical: Category of Health
Alteration – Endocrine: Integrated Nursing
Process – Implementation: Client Needs –
Physiological Integrity, Physiological Adaptation:
Cognitive Level – Application.
81. 1. This is not the rationale as to why the
client becomes dehydrated.
2. The glucose in the bloodstream is
hyperosmolar, which causes water from
the extracellular space to be pulled into
the vessels, resulting in dehydration.
3. The client has diaphoresis in
hypoglycemia, not hyperglycemia.
4. The dehydration causes the client to be
thirsty; the thirst does not cause the
dehydration.
Content – Medical: Category of Health
Alteration – Endocrine: Integrated Nursing
Process – Implementation: Client Needs –
Physiological Integrity, Physiological Adaptation:
Cognitive Level – Application.
82. 1. Dairy products contain milk and increase
flatus and peristalsis. These products
should be discouraged.
2. Symptoms lasting less than 24 hours would
not warrant the client going to the emergency department; if anything, an appointment at a clinic would be appropriate.
3. A stool specimen may be needed at some
point but not this early in the disease
process.
4. A clear liquid diet is recommended
because it maintains hydration without
stimulating the gastrointestinal tract;
diarrhea/vomiting lasting longer than
24 hours, along with dehydration and
weakness, would warrant the client
being evaluated.
Content – Medical: Category of Health
Alteration – Gastrointestinal: Integrated Nursing
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Process – Implementation: Client Needs –
Physiological Integrity, Physiological Adaptation:
Cognitive Level – Application.
83. 1. These are signs/symptoms of Addison’s
disease, which is adrenal cortex
insufficiency.
2. These are signs/symptoms of Cushing’s
syndrome, which is adrenal cortex
hyperfunction.
3. These are signs/symptoms of Cushing’s
syndrome, which is adrenal cortex
hyperfunction.
4. These are signs/symptoms of Cushing’s
syndrome, which is adrenal cortex
hyperfunction.
Content – Medical: Category of Health Alteration –
Endocrine: Integrated Nursing Process – Assessment:
Client Needs – Physiological Integrity, Reduction of
Risk Potential: Cognitive Level – Analysis.
84. 1. This would cause the client to have diabetes mellitus.
2. The pituitary gland secretes vasopressin, the antidiuretic hormone
(ADH) causing the body to conserve
water, and if the pituitary is not secreting ADH, the body will produce large
volumes of dilute urine.
3. There are two types of diabetes insipidus:
neurogenic DI and nephrogenic DI. In
neurogenic DI, the pituitary gland fails to
produce ADH; in nephrogenic DI, the
kidneys fail to respond to ADH.
4. The thyroid gland has nothing to do
with DI.
Content – Medical: Category of Health Alteration –
Gastrointestinal: Integrated Nursing Process –
Implementation: Client Needs – Physiological Integrity,
Physiological Adaptation: Cognitive Level – Application.
85. 1. There is no reason to question or clarify
this order; the nurse is responsible for
clarifying the order with the HCP, not the
pharmacist.
2. Many elderly clients have comorbid
conditions requiring daily medications
which are not the primary reason for
admission into the hospital.
3. The nurse should know why the client is
taking this medication; this medication
is prescribed for only one reason,
hypothyroidism.
4. The serum thyroid function levels are
monitored by the HCP usually yearly
after maintenance doses have been
established.
Content – Medical: Category of Health Alteration –
Cardiovascular: Integrated Nursing Process –
Implementation: Client Needs – Safe Effective Care
Environment, Safety and Infection Control: Cognitive
Level – Application.
86. 1. The client diagnosed with essential hypertension is at risk for chronic renal failure.
2. The client diagnosed with diabetes type 2
is at risk for chronic renal failure.
3. Anaphylaxis leads to circulatory
collapse, which decreases perfusion
of the kidneys and can lead to acute
renal failure.
4. This is a transfusion of the client’s own
blood, which should not cause a reaction.
Content – Medical: Category of Health Alteration –
Renal: Integrated Nursing Process – Assessment:
Client Needs – Physiological Integrity, Reduction of
Risk Potential: Cognitive Level – Analysis.
87. 1. A cloudy dialysate indicates an infection and must be reported immediately
to prevent peritonitis.
2. The dialysate should be greater than
the intake so fluid is being removed
from the body.
3. After infusing 1,000 mL of dialysate,
abdominal fullness is not unexpected.
4. The client voiding any amount does not
warrant immediate intervention.
Content – Medical: Category of Health Alteration –
Renal: Integrated Nursing Process – Assessment:
Client Needs – Physiological Integrity, Reduction of
Risk Potential: Cognitive Level – Synthesis.
88. 1. Using two (2) washcloths to clean the
client’s perineal area is an appropriate action to prevent a urinary tract infection.
2. This action does not require intervention.
3. Moisture barrier cream is not considered a
medication and can be applied by the
UAP after the perineum is cleaned.
4. The UAP should wipe the area from
front to back to prevent fecal contamination of the urinary meatus, which
could result in a urinary tract infection.
Content – Nursing Management: Category of
Health Alteration – Management: Integrated
Nursing Process – Evaluation: Client Needs – Safe
Effective Care Environment, Management of Care:
Cognitive Level – Synthesis.
89. 1. This is a normal postoperative expectation
with this procedure.
2. This is gross hematuria, but it is expected
with this type of surgery and the nurse
should not call the surgeon.
3. The client has a three (3)-way indwelling 30-mL catheter inserted in
surgery. This type of catheter instills
an irrigant into the bladder to flush the
clots and blood from the bladder;
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CHAPTER 20 COMPREHENSIVE FINAL EXAMINATION
bloody urine is expected after this
surgery.
4. The stem does not indicate the client is
having bladder spasms and bladder spasms
are not causing the bleeding. Clots left in
the bladder and not flushed out can cause
bladder spasms.
Content – Surgical: Category of Health
Alteration – Genitourinary: Integrated Nursing
Process – Implementation: Client Needs – Safe
Effective Care Environment, Management of Care:
Cognitive Level – Analysis.
90. 1. This is not pertinent to the client’s current
situation.
2. The nurse should strain all the client’s
urine, but a large indwelling catheter does
not need to be inserted into this client;
this isn’t a bladder stone, it is a ureteral
stone.
3. A back massage is a nice thing to do, but it
will not help renal colic caused by ureteral
calculi.
4. The client should be medicated for
pain, which is excruciating, and the
client’s history of substance abuse
should not be an issue.
Content – Medical: Category of Health
Alteration – Genitourinary: Integrated Nursing
Process – Implementation: Client Needs – Safe
Effective Care Environment, Management of Care:
Cognitive Level – Analysis.
91. 1. This is the most common presenting
symptom of bladder cancer.
2. Burning on urination is a symptom of a
urinary tract infection.
3. Terminal dribbling is a symptom of
benign prostatic hypertrophy.
4. Difficulty initiating a urine stream is a
symptom of benign prostatic hypertrophy
or neurogenic bladder.
Content – Medical: Category of Health Alteration –
Genitourinary: Integrated Nursing Process –
Assessment: Client Needs – Physiological Integrity,
Reduction of Risk Potential: Cognitive Level –
Analysis.
92. 1. A genetic predisposition exists and is
indicated by the presence of a specific
cluster of human leukocyte antigens on
the cell wall.
2. There is a higher incidence of MS in
people who live in the northeastern
United States and Canada, but there
is no known reason for this occurrence.
3. Tobacco use is a risk factor for many
diseases, but not MS.
4. A sedentary lifestyle does not predispose a
person to develop MS.
Content – Medical: Category of Health Alteration –
Immune System: Integrated Nursing Process –
Assessment: Client Needs – Health Promotion and
Maintenance: Cognitive Level – Analysis.
93. 1. The client’s thigh area is not the best place
to assess for skin turgor.
2. The client’s hand has decreased subcutaneous tissue and has been exposed to the
sun, which results in decreased tissue elasticity, so this is not the best place to assess
for skin turgor.
3. The tissue on the chest is protected
from sun exposure and has adequate
subcutaneous tissue to provide a more
accurate assessment of hydration
status.
4. The eyeball will lose its elasticity secondary to dehydration, but most people do
not like the eyes being touched.
Content – Medical: Category of Health Alteration –
Emergency: Integrated Nursing Process – Assessment:
Client Needs – Physiological Integrity, Reduction of Risk
Potential: Cognitive Level – Analysis.
94. 1. The infection control nurse must be
notified, but it is not the first action.
2. Allowing the site to bleed allows any
pathogen to bleed out; the student
nurse should not apply pressure or
attempt to stop the flow of blood.
3. This would be done to document the occurrence and start early prophylaxis if necessary, but it is not the first intervention.
4. This is an appropriate intervention once
the wound is allowed to bleed; this is a
needle stick, so the nursing student will
not bleed to death.
Content – Nursing Management: Category of
Health Alteration – Management: Integrated
Nursing Process – Implementation: Client Needs –
Safe Effective Care Environment, Management of
Care: Cognitive Level – Application.
95. 1. Alteration in comfort is a client problem,
but it not a psychosocial problem.
2. Ineffective coping is a problem that is not
applicable to all clients with rheumatoid
arthritis and is a very individualized problem; the test taker would need more information before selecting this as a correct
answer.
3. Anxiety is a problem that is not applicable to all clients with rheumatoid
arthritis and is a very individualized
problem; the test taker would need
more information before selecting this
as a correct answer.
4. Altered body image is an expected psychosocial problem for all clients with
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MED-SURG SUCCESS
rheumatoid arthritis because of the
joint deformities.
Content – Medical: Category of Health Alteration –
Immune System: Integrated Nursing Process –
Diagnosis: Client Needs – Psychosocial Integrity:
Cognitive Level – Analysis.
96. 1. The nurse must rule out any complication requiring immediate intervention
before masking the pain with medication. Pain indicates a problem in some
instances; pain is expected after
surgery, but complications should
always be ruled out.
2. The nurse should not medicate for pain
until ruling out complications.
3. The television provides distraction, but it
is not the first intervention. Assessment is
the first intervention.
4. Teaching relaxation techniques will help
the client’s pain, but the first intervention
must be assessment to rule out any
complication.
Content – Medical: Category of Health Alteration –
Pain: Integrated Nursing Process – Implementation:
Client Needs – Safe Effective Care Environment,
Management of Care: Cognitive Level – Analysis.
97. 1. The police can be notified if the woman
requests this course of action; otherwise
this cannot be done, but it is not priority
at this time.
2. The nurse must ensure the husband
cannot hear the client discussing how
she was injured. The client needs to
feel safe when answering these questions because a spiral fracture indicates
a twisting motion and the bruises are
on areas covered with clothing. The
nurse should suspect abuse with these
types of injuries.
3. The nurse should refer to the social
worker if it is determined the client has
been abused, but the nurse should not
refer during the admission interview.
4. The nurse should make every attempt to
interview the client without the possible
abuser present; the client will probably be
afraid to tell the nurse she wants the husband to leave the room if he is the abuser.
Content – Nursing Management: Category of
Health Alteration – Client Advocacy: Integrated
Nursing Process – Implementation: Client Needs –
Safe Effective Care Environment, Management of
Care: Cognitive Level – Application.
98. 1. The client would be placed in the Trendelenburg position, which is with the head
lower than the feet.
2. The client is in shock and may need
blood transfusions; therefore, a largebore catheter should be started to
infuse fluids, plasma expanders, and
possible blood.
3. The admission process cannot be
completed by the client because the
condition is life threatening.
4. The client will be cold as a result of
vasoconstriction of the periphery
resulting from a low pulse and blood
pressure.
5. The client will more than likely need
blood transfusions that require a type
and crossmatch.
Content – Medical: Category of Health
Alteration – Emergency: Integrated Nursing
Process – Implementation: Client Needs – Safe
Effective Care Environment, Management of Care:
Cognitive Level – Analysis.
99. 1. A hard, rigid, boardlike abdomen is
the hallmark sign of peritonitis, which
is a life-threatening complication of
abdominal surgery.
2. This occurs when the client has a nasogastric tube connected to suction and has
minimal peristalsis, and is not a complication of the surgery.
3. The client has had general anesthesia for
this surgery, and absent bowel sounds at
eight (8) hours postoperative does not
indicate a complication.
4. The client with this type of surgery is expected to have pain at a “6” or higher on
a 1-to-10 scale; this is not considered a
complication.
Content – Surgical: Category of Health
Alteration – Gastrointestinal: Integrated Nursing
Process – Assessment: Client Needs – Physiological
Integrity, Reduction of Risk Potential: Cognitive
Level – Analysis.
100. 1. Documentation can help the nurse
defend his or her actions if a lawsuit
occurs, but it will not help prevent a
lawsuit.
2. Research indicates nurses who form
a trusting nurse–client relationship
are less likely to be sued; if the
nurse were to make an error, the
client and family are often more
forgiving.
3. Knowledge of medications will prevent
medication errors but will not keep the
nurse from being sued. Nurses are
human and can make mistakes with
medications even if they are
knowledgeable.
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CHAPTER 20 COMPREHENSIVE FINAL EXAMINATION
4. The nurse is a client advocate and is
legally, morally, and ethically required to
question the HCP’s orders when caring
for assigned clients.
Content – Nursing Management: Category of
Health Alteration – Management: Integrated
Nursing Process – Implementation: Client Needs –
Safe Effective Care Environment, Management of
Care: Cognitive Level – Application.
101.
In order of the nursing process: 2, 1,
3, 4, 5.
2. This is the assessment step, the first
step of the nursing process.
1. Diagnosis is the second step in the
nursing process. In this case, it is
“altered tissue perfusion.”
3. Planning is the third step of the nursing process.
4. Implementation is the fourth step in
the nursing process.
5. Evaluation is the last step of the nursing process.
Content – Medical: Category of Health Alteration –
Neurological: Integrated Nursing Process –
Implementation: Client Needs – Safe Effective
Care Environment, Management of Care:
Cognitive Level – Analysis.
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Glossary of English Words
Commonly Encountered
on Nursing Examinations
Abnormality — defect, irregularity, anomaly, oddity
Comprehensive — complete, inclusive, broad, thorough
Absence — nonappearance, lack, nonattendance
Abundant — plentiful, rich, profuse
Conceal — hide, cover up, obscure, mask, suppress,
secrete
Accelerate — go faster, speed up, increase, hasten
Conceptualize — form an idea
Accumulate — build up, collect, gather
Concern — worry, anxiety, fear, alarm, distress, unease,
trepidation
Accurate — precise, correct, exact
Achievement — accomplishment, success, reaching,
attainment
Acknowledge — admit, recognize, accept, reply
Activate — start, turn on, stimulate
Adequate — sufficient, ample, plenty, enough
Angle — slant, approach, direction, point of view
Application — use, treatment, request, claim
Approximately — about, around, in the region of, more
or less, roughly speaking
Arrange — position, place, organize, display
Associated — linked, related
Attention — notice, concentration, awareness, thought
Concisely — briefly, in a few words, succinctly
Conclude — make a judgment based on reason, finish
Confidence — self-assurance, certainty, poise, selfreliance
Congruent — matching, fitting, going together well
Consequence — result, effect, outcome, end result
Constituents — elements, components, parts that make
up a whole
Contain — hold, enclose, surround, include, control,
limit
Continual — repeated, constant, persistent, recurrent,
frequent
Authority — power, right, influence, clout, expert
Continuous — constant, incessant, nonstop,
unremitting, permanent
Avoid — keep away from, evade, let alone
Contribute — be a factor, add, give
Balanced — stable, neutral, steady, fair, impartial
Barrier — barricade, blockage, obstruction, obstacle
Convene — assemble, call together, summon, organize,
arrange
Best — most excellent, most important, greatest
Convenience — expediency, handiness, ease
Capable — able, competent, accomplished
Coordinate — organize, direct, manage, bring together
Capacity — ability, capability, aptitude, role, power, size
Create — make, invent, establish, generate, produce,
fashion, build, construct
Central — middle, mid, innermost, vital
Challenge — confront, dare, dispute, test, defy,
face up to
Creative — imaginative, original, inspired, inventive,
resourceful, productive, innovative
Characteristic — trait, feature, attribute, quality, typical
Critical — serious, grave, significant, dangerous, life
threatening
Circular — round, spherical, globular
Cue — signal, reminder, prompt, sign, indication
Collect — gather, assemble, amass, accumulate, bring
together
Curiosity — inquisitiveness, interest, nosiness, snooping
Commitment — promise, vow, dedication, obligation,
pledge, assurance
Deduct — subtract, take away, remove, withhold
Damage — injure, harm, hurt, break, wound
Commonly — usually, normally, frequently, generally,
universally
Deficient — lacking, wanting, underprovided, scarce,
faulty
Compare — contrast, evaluate, match up to, weigh or
judge against
Defining — important, crucial, major, essential,
significant, central
Compartment — section, part, cubicle, booth, stall
Defuse — resolve, calm, soothe, neutralize, rescue,
mollify
Complex — difficult, multifaceted, compound,
multipart, intricate
Complexity — difficulty, intricacy, complication
Component — part, element, factor, section, constituent
Delay — hold up, wait, hinder, postpone, slow down,
hesitate, linger
Demand — insist, claim, require, command, stipulate, ask
781
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Page 782
GLOSSARY
Describe — explain, tell, express, illustrate, depict,
portray
Essential — necessary, fundamental, vital, important,
crucial, critical, indispensable
Design — plan, invent, intend, aim, propose, devise
Etiology — assigned cause, origin
Desirable — wanted, pleasing, enviable, popular, sought
after, attractive, advantageous
Exaggerate — overstate, inflate
Detail — feature, aspect, element, factor, facet
Excessive — extreme, too much, unwarranted
Deteriorate — worsen, decline, weaken
Exhibit — show signs of, reveal, display
Determine — decide, conclude, resolve, agree on
Expand — get bigger, enlarge, spread out, increase,
swell, inflate
Dexterity — skillfulness, handiness, agility, deftness
Dignity — self-respect, self-esteem, decorum, formality,
poise
Excel — stand out, shine, surpass, outclass
Expect — wait for, anticipate, imagine
Dimension — aspect, measurement
Expectation — hope, anticipation, belief, prospect,
probability
Diminish — reduce, lessen, weaken, detract, moderate
Experience — knowledge, skill, occurrence, know-how
Discharge — release, dismiss, set free
Expose — lay open, leave unprotected, allow to be seen,
reveal, disclose, exhibit
Discontinue — stop, cease, halt, suspend, terminate,
withdraw
External — outside, exterior, outer
Disorder — complaint, problem, confusion, chaos
Facilitate — make easy, make possible, help, assist
Display — show, exhibit, demonstrate, present, put on
view
Factor — part, feature, reason, cause, think, issue
Dispose — get rid of, arrange, order, set out
Fragment — piece, portion, section, part, splinter, chip
Dissatisfaction — displeasure, discontent, unhappiness,
disappointment
Function — purpose, role, job, task
Distinguish — separate and classify, recognize
Focus — center, focal point, hub
Furnish — supply, provide, give, deliver, equip
Distract — divert, sidetrack, entertain
Further — additional, more, extra, added,
supplementary
Distress — suffering, trouble, anguish, misery, agony,
concern, sorrow
Generalize — take a broad view, simplify, make
inferences from particulars
Distribute — deliver, spread out, hand out, issue,
dispense
Generate — make, produce, create
Disturbed — troubled, unstable, concerned, worried,
distressed, anxious, uneasy
Girth — circumference, bulk, weight
Diversional — serving to distract
Don — put on, dress oneself in
Dramatic — spectacular
Drape — cover, wrap, dress, swathe
Gentle — mild, calm, tender
Highest — uppermost, maximum, peak, main
Hinder — hold back, delay, hamper, obstruct, impede
Humane — caring, kind, gentle, compassionate,
benevolent, civilized
Dysfunction — abnormality, impairment
Ignore — pay no attention to, disregard, overlook,
discount
Edge — perimeter, boundary, periphery, brink, border,
rim
Imbalance — unevenness, inequality, disparity
Effective — successful, useful, helpful, valuable
Efficient — not wasteful, effective, competent,
resourceful, capable
Elasticity — stretch, spring, suppleness, flexibility
Eliminate — get rid of, eradicate, abolish, remove,
purge
Embarrass — make uncomfortable, make selfconscious, humiliate, mortify
Emerge — appear, come, materialize, become known
Emphasize — call attention to, accentuate, stress,
highlight
Ensure — make certain, guarantee
Environment — setting, surroundings, location,
atmosphere, milieu, situation
Episode — event, incident, occurrence, experience
Immediate — insistent, urgent, direct
Impair — damage, harm, weaken
Implant — put in
Impotent — powerless, weak, incapable, ineffective,
unable
Inadvertent — unintentional, chance, unplanned,
accidental
Include — comprise, take in, contain
Indicate — point out, be a sign of, designate, specify,
show
Ineffective — unproductive, unsuccessful, useless, vain,
futile
Inevitable — predictable, expected, unavoidable,
foreseeable
Influence — power, pressure, sway, manipulate, affect,
effect
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copyright law.
GLOSSARY
Initiate — start, begin, open, commence, instigate
Insert — put in, add, supplement, introduce
Origin — source, starting point, cause, beginning,
derivation
Inspect — look over, check, examine
Pace — speed
Inspire — motivate, energize, encourage, enthuse
Parameter — limit, factor, limitation, issue
Institutionalize — place in a facility for treatment
Participant — member, contributor, partaker, applicant
Integrate — put together, mix, add, combine, assimilate
Perspective — viewpoint, view, perception
Integrity — honesty
Position — place, location, point, spot, situation
Interfere — get in the way, hinder, obstruct, impede,
hamper
Interpret — explain the meaning of, make
understandable
Practice — do, carry out, perform, apply, follow
Precipitate — cause to happen, bring on, hasten,
abrupt, sudden
Predetermine — fix or set beforehand
Intervention — action, activity
Predictable — expected, knowable
Intolerance — bigotry, prejudice, narrow-mindedness
Preference — favorite, liking, first choice
Involuntary — instinctive, reflex, unintentional,
automatic, uncontrolled
Prepare — get ready, plan, make, train, arrange,
organize
Irreversible — permanent, irrevocable, irreparable,
unalterable
Prescribe — set down, stipulate, order, recommend,
impose
Irritability — sensitivity to stimuli, fretfulness, quick
excitability
Previous — earlier, prior, before, preceding
Justify — explain in accordance with reason
Likely — probable, possible, expected
Logical — using reason
Longevity — long life
Lowest — inferior in rank
Maintain — continue, uphold, preserve, sustain, retain
Majority — the greater part of
Mention — talk about, refer to, state, cite, declare,
point out
Minimal — least, smallest, nominal, negligible, token
Minimize — reduce, diminish, lessen, curtail, decrease
to smallest possible
Mobilize — activate, organize, assemble, gather
together, rally
Primarily — first, above all, mainly, mostly, largely,
principally, predominantly
Primary — first, main, basic, chief, most important, key,
prime, major, crucial
Priority — main concern, given first attention to, order
of importance
Production — making, creation, construction, assembly
Profuse — a lot of, plentiful, copious, abundant,
generous, prolific, bountiful
Prolong — extend, delay, put off, lengthen, draw out
Promote — encourage, support, endorse, sponsor
Proportion — ratio, amount, quantity, part of,
percentage, section of
Provide — give, offer, supply, make available
Rationalize — explain, reason
Modify — change, adapt, adjust, revise, alter
Realistic — practical, sensible, reasonable
Moist — slightly wet, damp
Receive — get, accept, take delivery of, obtain
Multiple — many, numerous, several, various
Recognize — acknowledge, appreciate, identify,
be aware of
Natural — normal, ordinary, unaffected
Negative — no, harmful, downbeat, pessimistic
Negotiate — bargain, talk, discuss, consult, cooperate,
settle
Notice — become aware of, see, observe, discern, detect
Notify — inform, tell, alert, advise, warn, report
Nurture — care for, raise, rear, foster
Obsess — preoccupy, consume
Occupy — live in, inhabit, reside in, engage
Occurrence — event, incident, happening
Recovery — healing, mending, improvement,
recuperation, renewal
Reduce — decrease, lessen, ease, moderate, diminish
Reestablish — reinstate, restore, return, bring back
Regard — consider, look upon, relate to, respect
Regular — usual, normal, ordinary, standard, expected,
conventional
Relative — comparative, family member
Relevance — importance of
Odorous — scented, stinking, aromatic
Reluctant — unwilling, hesitant, disinclined,
indisposed, averse
Offensive — unpleasant, distasteful, nasty, disgusting
Remove — take away, get rid of, eliminate, eradicate
Opportunity — chance, prospect, break
Reposition — move, relocate, change position
Organize — put in order, arrange, sort out, categorize,
classify
Require — need, want, necessitate
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GLOSSARY
Resist — oppose, defend against, keep from, refuse to
go along with, defy
Statistics — figures, data, information
Resolution — decree, solution, decision, ruling,
promise
Success — achievement, victory, accomplishment
Resolve — make up your mind, solve, determine,
decide
Response — reply, answer, reaction, retort
Restore — reinstate, reestablish, bring back, return to,
refurbish
Restrict — limit, confine, curb, control, contain, hold
back, hamper
Retract — take back, draw in, withdraw, apologize
Reveal — make known, disclose, divulge, expose, tell,
make public
Review — appraisal, reconsider, evaluation, assessment,
examination, analysis
Subtract — take away, deduct
Surround — enclose, encircle, contain
Suspect — think, believe, suppose, guess, deduce, infer,
distrust, doubtful
Sustain — maintain, carry on, prolong, continue,
nourish, suffer
Synonymous — same as, identical, equal, tantamount
Thorough — careful, detailed, methodical, systematic,
meticulous, comprehensive, exhaustive
Tilt — tip, slant, slope, lean, angle, incline
Translucent — see-through, transparent, clear
Unique — one and only, sole, exclusive, distinctive
Universal — general, widespread, common, worldwide
Ritual — custom, ceremony, formal procedure
Unoccupied — vacant, not busy, empty
Rotate — turn, go around, spin, swivel
Unrelated — unconnected, unlinked, distinct,
dissimilar, irrelevant
Routine — usual, habit, custom, practice
Satisfaction — approval, fulfillment, pleasure,
happiness
Satisfy — please, convince, fulfill, make happy, gratify
Secure — safe, protected, fixed firmly, sheltered,
confident, obtain
Sequential — chronological, in order of occurrence
Significant — important, major, considerable,
noteworthy, momentous
Slight — small, slim, minor, unimportant, insignificant,
insult, snub
Unresolved — unsettled, uncertain, unsolved, unclear,
in doubt
Various — numerous, variety, range of, mixture of,
assortment of
Verbalize — express, voice, speak, articulate
Verify — confirm, make sure, prove, attest to, validate,
substantiate, corroborate, authenticate
Vigorous — forceful, strong, brisk, energetic
Volume — quantity, amount, size
Withdraw — remove, pull out, take out, extract
Source — basis, foundation, starting place, cause
Specific — exact, particular, detail, explicit, definite
Stable — steady, even, constant
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Appendix
NORMAL LABORATORY VALUES
These values are obtained from Davis’s Comprehensive Handbook of Laboratory and Diagnostic
Tests with Nursing Implications. Laboratory results may differ slightly depending on the resource manual or the laboratory normal values.
Test
Adult
pH
7.35 to 7.45
PCO2
35 to 45 mm Hg
HCO3
22 to 26 mEq/L
PaO2
80 to 100 mm Hg
O2 saturation
93% to 100%
Test
Adult
Cholesterol
Less than 200 mg/dL
HDL
40 to 65 mg/dL
LDL
Less than 200 mg/dL
Creatinine
0.6 to 1.2 mg/dL
Glucose
60 to 110 mg/dL
Potassium
3.5 to 5.5 mEq/L
Sodium
135 to 145 mEq/L
Triglycerides
Less than 150 mg/dL
Blood urea nitrogen
10 to 31 mg/dL
Test
Adult
Hematocrit (Hct)
Male: 43% to 49%
Female: 38% to 44%
Hemoglobin (Hgb)
Male: 13.2 to 17.3 g/dL
Female: 11.7 to 15.5 g/dL
Activated partial thromboplastin
time (APTT)
25 to 35 seconds
Prothrombin time (PT)
10 to 13 seconds
Red blood cell count (RBC)
Male: 4.7 to 5.1 × 10 cells/mm3
6
6
Female: 4.2 to 4.8 × 10 cells/mm3
3
White blood cell count (WBC)
4.5 to 11.0 × 10 cells/mm3
Platelets
150 to 450 × 10 /mm3
Erythrocyte sedimentation rate (ESR)
Male: 0 to 20 mm/hr
3
Female: 0 to 30 mm/hr
785
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APPENDIX
Test
Adult
Digoxin (Lanoxin)
0.8 to 2.0 ng/mL
International normalized ratio (INR)
2 to 3
2.5 to 3.5 if the client has a mechanical heart valve
Lithium
0.6 to 1.2 mEq/L
Phenytoin (Dilantin)
10 to 20 mcg/mL
Theophylline (Aminophyllin)
10 to 20 mcg/mL
Valproic acid (Depakote)
50 to 100 mcg/mL
Vancomycin trough level
10 to 20 mcg/mL
Vancomycin peak level
30 to 40 mcg/mL
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Index
A
Abdominal aortic aneurysms, 119–120, 141, 757
Abdominal hysterectomy, 412, 414–416
Abdominal pain, 261, 269, 301, 311, 331, 414, 671, 762
Abdominal perineal resection, 259, 260, 311
Abdominal surgery, 268–269, 631, 651
Absolute neutrophil count, 181
Abstinence, sexual, 552
ACE inhibitors, 114, 734
Acetaminophen, 61, 598
Acidic foods, 274
Acidosis, 342
Acne, 497, 511
Acoustic neuroma, 583, 587
Acquired immunodeficiency syndrome (AIDS), 272, 496, 498,
536–538, 563–565
Acupuncture, 672
Acute bacterial prostatitis, 374, 390
Acute epigastric pain, 314
Acute gastritis, 312
Acute glomerulonephritis, 374
Acute myeloid leukemia, 153
Acute otitis media, 573
Acute pain, 635–636
Acute pancreatitis, 359
Acute pericardial effusion, 99
Acute pyelonephritis, 373
Acute renal failure, 368–369, 760
Acute respiratory distress syndrome (ARDS), 207–208, 235, 449
Acute sinusitis, 192
Addisonian crisis, 350
Addison’s disease, 332–333, 359, 760, 776
Adenocarcinoma of colon, 259
Adenosine, 743
Adolescent pregnancy, 600
Adrenal cortex insufficiency, 776
Adrenal disorders, 332–334
Adrenal gland hypofunction, 349
Adrenal insufficiency, 364
Adrenalectomy, 358
Adrenocorticotrophic hormone (ACTH), 349
Adult-onset asthma, 197, 275
Adult Protection Services (APS), 618
Adult respiratory distress syndrome (ARDS), 745, 757
Advance directives, 677–679
African American heritage, 25, 107, 160, 383, 501, 511, 658, 755
Afrin nasal spray, 662
Agnosia, 8
Airway edema, 614
Al-A-Teen, 69
Alanon, 69
Albumin, 164
Albuterol, 249
Alcohol consumption, 186
Alcoholic cirrhosis, 264
Alcoholism, 21, 60, 360
Aldosteronism, 358, 363
Allergic rhinitis, 539
Allergies/allergic reactions, 538–540
Allopurinol (Zyloprim), 728
Aloe vera, 674
Alpha-adrenergic blockers, 114
Altered tissue perfusion, 17, 42, 155
Alternative health care, 657–661
Aluminum hydroxide (Amphogel), 727
Alzheimer’s disease, 57, 65–66
American Cancer Society, 260
Aminoglycoside antibiotics, 261, 579
Aminophylline, 239, 240, 250, 728
Amiodarone (Cordarone), 97, 728, 745
Ammonia, 291, 293
Amphetamine abuse, 21
Ampicillin, 675
Amputation, 458–460, 621, 750
Amsler grid, 589
Amyotrophic lateral sclerosis (ALS), 21–22, 55, 59
Anaphylactic reactions, 540, 561, 564–565
Anaphylaxis, 776
Anemia, 155–156, 168, 180, 181, 185–186, 670, 675
Anesthesia, 634, 642, 644, 648
Aneurysms, 132
Angina, 75–77, 78, 724, 729
Angiotensin-converting enzyme (ACE) inhibitors, 74, 124, 719
Ankle fractures, 460
Ankylosing spondylitis, 563, 568
Anorexia nervosa, 270–271, 313
Anosmia, 61, 71
Antacids, 276, 720
Anthrax, 593–594, 606
Antibacterial medications, 724
Antibiotic therapy, 209, 212, 240, 248, 251, 261, 308, 414, 429,
512, 520, 540, 557, 579, 675, 721, 725, 728
Anticholinergic medications, 586, 745
Anticipatory grieving, 415
Anticoagulation therapy, 575
Anticonvulsant medications, 36, 725
Antidepressant medications, 729
Antidiuretic hormone (ADH), 67, 365, 776
Antidysrhythmic medications, 80, 721, 726
Antiembolism hose, 750
Antiemetics, 725
Antiglutamate, 22
Antihistamines, 239, 249
Antineoplastic medications, 167, 560
Antiplatelet medications, 129, 754
Antipyretic medications, 17, 603
Antiseizure medications, 36
Antitubercular medications, 239, 723
Antivenin, 616
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INDEX
Antiviral medications, 499
Anxiety, 13, 197, 671
Aortic stenosis, 104, 753
Aortoiliac disease, 141, 146
Aphasia, 9
Aphthous stomatitis, 308
Apical pulse, 103, 105, 734
Aplastic anemia, 181
Appendectomy, 651
Appendicitis, 651
Arboviral encephalitis, 56
Arm fractures, 460, 762
Arterial hypertension, 114–115
Arterial occlusive disease, 115–117, 754
Arteriovenous fistula, 370
Arthralgias, 739
Arthritis, 721. See also Osteoarthritis; Rheumatoid arthritis
Arthroscopic surgery, 756
Artificial nails, 650
Asbestosis, 235–236
Ascites, 264, 320
Aseptic meningitis, 17
Aspiration pneumonia, 194, 238
Aspirin, 87, 93, 563, 568, 721, 723
Asthma, 197–198, 235, 240, 275, 716, 729, 746, 756
Ataxia, 47
Atelectasis, 229
Atherosclerosis, 117–118, 143, 754, 767
Atopic dermatitis, 521
Atorvastatin (Lipitor), 726, 742
Atrial fibrillation, 9, 70, 81, 105, 658
Atropine, 97, 728
Aural rehabilitation, 587
Auras, 14, 37, 69
Auscultation, 280
Automated external defibrillator, 595
Autonomic dysreflexia, 70
Ayurveda, 664
B
Baclofen (Lioresal), 563–564
Bacteremia, 179
Bacterial infections, 211
Bacterial inflammatory reaction, 511
Bacterial meningitis, 16, 59, 752
Bacterial pneumonia, 237
Bacterial skin infection, 496–498
Balance disturbance, 582, 586
Balneotherapy, 524
Barium enema, 284, 309, 322
Barrett’s esophagus, 276
Bartholin’s cyst, 442
Basal-cell carcinoma, 495
Bee stings, 556, 564–565, 621
Bell’s palsy, 55, 63
Benadryl, 514, 570, 674
Beneficence, 708
Benign prostatic hypertrophy, 374–375
Benign uterine fibroid tumors, 414
Benzodiazepines, 719, 734
Beta blockers, 77, 90, 114, 142, 147, 743
Betadine, 388, 557
Biguanide, 327, 339
Bilateral orchiectomy, 417
Bilateral stapedectomy, 582
Bilirubin, 295
Biohazard bags, 603
Biopsy, 165
Bioterrorism, 593–595
Bipolar disorder, 725
Birth control, 671
Birth control pills, 670
Bisacodyl (Dulcolax), 722
Bisphosphonate alendronate (Fosamax), 718
Blackheads, 497
Bladder cancer, 377–378, 761
Bladder irrigation, 373
Bladder spasms, 392
Bladder training, 403
Bleeding disorders, 157–158
Blisters, 477
Blood-brain barrier, 40
Blood crossmatching, 187
Blood cultures, 101
Blood glucose levels, 589
Blood pressure, 114, 134–136, 661. See also Hypertension;
Hypotension
Blood transfusions, 156, 158–160, 181–183, 756
Bloody sputum, 215
Bloody stools, 272, 320
Blurred vision, 572
Body image, 46, 225
Body mass index (BMI), 310
Body temperature, 336
Boils, 497
Bone density, 469
Bone marrow, 152, 162, 180, 181, 186, 700
Bone metastasis, 434
Borborygmi, 297
Botulism, 615
Botulism antitoxin, 297
Bowel obstruction, 311
Bowel perforation, 286
Bowel sounds, 477
Bowel training, 34
Brachytherapy, 428
Braden scale, 505
Bradycardia, 111, 603
Brain abscess, 56, 64
Brain cancer, 201
Brain death, 10, 680, 684, 702, 707
Brain tumors, 15–16, 752
BRAT diet, 307
Breast biopsy, 410–411, 443
Breast cancer, 15, 410–411
Breast disorders, 410–411
Breast self-examination, 422, 445, 749, 755
Breathing exercises, 32
Bronchiectasis, 238, 248
Bronchiolitis obliterans, 238, 247
Bronchitis, 196, 670
Bronchodilator reversibility test, 243
Bronchodilators, 216, 219, 248, 728
Bronchoscopy, 202
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INDEX
Bronchospasms, 240
Buccal cyanosis, 74
Buck’s traction, 461, 475, 482
Buerger’s disease, 141, 143, 146, 149
Bulimia nervosa, 270–271
Burns, 157, 491–493, 522, 725, 751
C
C6 spinal cord injury, 12
C7 spinal cord injury, 60
Cabbage leaves, 674
Calcitonin, 458, 481
Calcium, 347, 470
Calcium carbonate (Tums), 458
Calcium channel blockers, 76, 720
Calcium phosphate renal calculi, 376
Caldwell-Luc procedure, 193
Cancer, 681, 683, 703, 724
Cancer vaccines, 201
Candidiasis, 316
Canker sores, 317
Capillary refill time, 250
Carbamazepine (Tegretol), 725
Carbidopa/levodopa (Sinemet), 18, 59, 726
Carbohydrates, 295, 380
Carbon monoxide poisoning, 599, 614, 620
Carbuncles, 498, 512, 673
Cardiac catheterization, 77
Cardiac disorders
angina/myocardial infarction, 75–77
comprehensive examination, 102–106
congestive heart failure, 74–75
coronary artery disease, 77–78
dysrhythmias and conduction problems, 80–81
inflammatory cardiac disorders, 82–83
keywords/abbreviations, 73–74
valvular heart disease, 79–80
Cardiac enzymes, 75
Cardiac glycosides, 719
Cardiac rehabilitation, 88
Cardiac tamponade, 82
Cardiac valve replacement, 768
Cardiogenic shock, 110–111
Cardiomyopathy, 102, 755
Cardiopulmonary resuscitation (CPR), 105, 111, 596
Cardioversion, 105, 110
Carditis, 82
Carisoprodol (Soma), 728
Carpal tunnel syndrome, 480, 486
Cast syndrome, 487
Casts, 482
Cataracts, 572, 576, 584
Cathartics, 271
Catheterization, 77, 373, 400
Catholic faith, 701, 707
Cell phones, 107
Cell saver apparatus, 159, 175
Cellulitis, 141, 147, 497, 510
Cerebral edema, 28, 29
Cerebrovascular accident (stroke), 7–8, 494, 762
Cervical cancer, 413
Cervical disk degeneration, 454
Cervical neck injury, 454
Chancre sore, 450
Chemical peels, 521
Chemoprophylaxis, 42
Chemotherapy, 153, 165, 377, 430, 750
Chest pain, 76, 77, 88, 98, 108, 135, 551, 757
Chest trauma, 205–207
Chest tubes, 207–208, 229, 231, 239
Chickenpox, 499, 514, 515
Child abuse, 617
Child Protective Services, 617
Chinese heritage, 704
Chlamydia infection, 418, 420, 437
Choking, 548
Cholecystectomy, 262–263, 289, 309, 318
Cholesterol levels, 117
Cholinergic agonists, 721
Cholinesterase inhibitor, 534
Chondroitin, 456
Chronic atrial fibrillation, 81
Chronic back pain, 682
Chronic bronchitis, 196
Chronic gastritis, 312
Chronic inflammatory arthritis, 568
Chronic kidney disease, 369–371
Chronic lymphocytic leukemia, 152
Chronic myeloid leukemia, 182
Chronic obstructive pulmonary disease (COPD), 195–197,
237, 242, 669, 679, 722, 757, 772
Chronic pain, 467, 681–682, 703, 708
Chronic pancreatitis, 329–330
Chronic prostatitis, 374
Chronic pyelonephritis, 373–374, 388
Chronic renal failure, 760
Chronic sinusitis, 192–193
Chronic venous insufficiency, 122–123
Chvostek’s sign, 362, 386
Cigarette smoking. See Smoking
Cimetidine (Tagamet), 728
Circulating nurse responsibilities, 631–632
Circumcision, 444, 450
Cirrhosis, 264, 311
Claudication, 130
Clomiphene (Clomid), 443
Clopidogrel (Plavix), 754
Closed-chest drainage system, 757
Closed head injury, 10–11, 752, 766
Clostridium botulism, 266
Clostridium difficile, 308
Clotting factor, 188
Coagulation, 652
Coal tar, 523
Coal workers’ pneumoconiosis, 244
Cocaine overdose, 622
Cochlea nerve, 582
Code of ethics, 704
Codeine allergy, 631
Codes, 595–596
Coffee-ground emesis, 774
Cogwheel motion, 742
Cold caloric test, 29
Cold foot, 469
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INDEX
Colon cancer, 259–260, 309, 311, 313, 758
Colon polyps, 313
Colonoscopy, 261, 284, 722
Colorectal disease, 259–260
Colostomy, 259–260, 283, 284, 313, 314, 507
Comatose patients, 11, 660
Common cold virus, 192
Compartment syndrome, 488
Complete heart block, 81
Compound fracture, 489
Compression stockings, 138, 142
Computed tomography (CT) scans, 25, 480
Concussions, 9
Condoms, 671, 675
Conduction problems, 80–81
Congestive heart failure, 74–75, 103–105, 156, 500, 669, 679,
719, 721, 753
Conscious sedation, 633
Constipation, 271–273
Contact dermatitis, 519–520, 524, 765
Contaminated needles, 266, 762
Continent urinary diversion, 397
Contraceptive foam, 658
Coping behaviors, 49
Coping mechanisms, 691
Copper bracelets, 668
Cord blood banking, 685
Coronary artery bypass surgery, 76, 81
Coronary artery disease, 77–78, 117–118, 723, 726, 754
Cortical sensory ability, 588
Corticosteroids, 32, 247, 513, 524, 531
Cough syrup, 295
Coughing, 94, 638
Coughing up blood, 222
Coup-contrecoup, 66
Cranial nerves, 581, 582
Craniotomy, 9, 16
Crash carts, 96, 610
Creatinine, 379
Creutzfeldt-Jakob disease, 55, 56
Critical incident stress management (CISM), 597
Crohn’s disease, 256–257, 312, 758
Cromolyn, 716
Cross-contamination, 605
Crying, 551, 706
Cryotherapy, 417, 435
Cryptorchidism, 436
Cultural nursing, 657–661
Cupping, 673
Curling’s stress ulcer, 741
Cushing’s disease, 333–334, 358, 363
Cushing’s syndrome, 333, 358
Cutaneous lupus erythematosus, 536
Cutaneous urinary diversion procedure, 377–378
Cyanosis, 476
Cystic fibrosis, 238, 247, 685
Cystitis, 388
Cystoceles, 411–412, 425
D
Dance movement therapy, 660
Dantrolene, 643
Death and dying, 679–680
Death rates, 200
Decongestant medications, 667, 731
Decontamination areas, 594
Decorticate posturing, 15
Decreased cardiac output, 204
Deep breathing, 665
Deep vein thrombosis, 32, 68, 120–122, 142, 148, 239, 426,
433, 479, 482, 757
Deer ticks, 510
Defibrillation, 97
Degenerative/herniated disk disease, 454–455
Dehydration, 298, 321, 342, 384, 555, 691, 775
Delirium tremens, 20, 292
Dementia, 563
Dentures, 223
Depression, 66, 558, 720
Dermabrasion, 521
Dermatitis, 765
Dextrose, 341
Diabetes insipidus, 334–335, 351–352, 365, 371, 727, 743, 760
Diabetes mellitus, 141, 326–329, 338, 357, 459, 584, 679, 703,
717, 727, 728, 759
Diabetic ketoacidosis, 328–329, 372
Diabetic retinopathy, 339
Dialysis, 369–371, 683, 760
Diaphoresis, 592
Diarrhea, 266, 271–273, 311, 372, 759, 760
Diastolic blood pressure, 134
Dietary Approaches to Stop Hypertension (DASH) diet,
115, 135
Digoxin, 104, 718, 719, 734
Dilantin, 739
Dilated cardiomyopathy, 102
Directly observed therapy, 240
Disasters/triage, 596–598
Disseminated intravascular coagulopathy (DIC), 157, 171,
182, 754
Disuse syndrome, 49
Diuretics, 406
Diverticulosis/diverticulitis, 260–261, 309, 719, 758
Dizziness, 12
Do not resuscitate (DNR) orders, 678–679, 681
Dog bites, 55
Donepezil (Aricept), 57
Dopamine, 721, 737
Droplet isolation, 243
Droplet precautions, 41
Dry mucous membranes, 340
Duodenal ulcer, 258
Durable power of attorney, 678, 702
Dyscrasias, 51
Dysmenorrhea, 413, 429
Dysphagia, 542, 544
Dyspnea, 22, 155, 156, 169, 194, 246, 539
Dyspnea on exertion (DOE), 92
Dysrhythmias, 80–81
E
Ear disorders, 573–574
Ear infections, 578
Ear surgery, 574
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INDEX
Eardrops, 579
Eating disorders, 269–271
Echinacea, 240, 249, 662
Edema, 280, 526
Edrophonium chloride test, 533, 549
Elbow padding, 650
Elder abuse, 618
Electroencephalograms (EEG), 13, 35, 58
Electrolyte replacement, 328
Elephantiasis, 143, 149
Emergency nursing
bioterrorism, 593–595
codes, 595–596
disasters/triage, 596–598
keywords/abbreviations, 591
poisoning, 598–599
shock, 592–593
violence, physical abuse, neglect, 599–601
Emergency Operation Plan (EOP), 597
Emphysema, 237
Enalapril (Vasotec), 719
Encephalitis, 23–24, 52
End-of-life issues
abbreviations, 677
advance directives, 677–679
chronic pain, 681–682
death and dying, 679–680
ethical/legal issues, 682–684
organ/tissue donation, 684–685
End-stage liver failure, 310–311
End-stage renal disease, 180, 264, 683
Endocarditis, 753
Endocrine disorders
adrenal disorders, 332–334
comprehensive examination, 357–361
diabetes mellitus, 326–329
keywords/abbreviations, 325–326
pancreatic cancer, 331–332
pancreatitis, 329–330
pituitary disorders, 334–336
thyroid disorders, 336–337
Endometriosis, 414, 427, 749
Endoscopic retrograde cholangiopancreatogram (ERCP), 262,
330, 331
Enemas, 321, 726
Enoxaparin (Lovenox), 725
Enucleation, 573, 577
Epididymitis, 418
Epidural hematoma, 10
Epilepsy, 14, 58, 723, 725, 752
Epinephrine, 570
EpiPen, 556
Epistaxis, 622
Epogen, 163, 175
Erythropoietin, 186, 370, 382, 719
Esophageal bleeding, 263
Esophageal diverticula, 310
Esophageal ulcerations, 225
Esophagogastroduodenoscopy, 254, 279
Essential hypertension, 114–115, 142–143, 716
Estrogen, 427
Etanercept, 540
Ethical/legal issues, 682–684
Ethical principles, 702
Ethics committee, 687
Eucalyptus, 670, 674
Euthanasia, 703
Evil eye, 663
Eviscerated abdominal wound, 268
Evisceration, 299
Excess fluid volume, 264, 382
Exercise-induced asthma, 198
Exercise stress tests, 102
Experimental therapy, 19
Expressive aphasia, 9, 27
External fixator, 482, 488
Eye disorders, 572–573
Eyedrops, 573, 576
F
Faces scale, 646
Facial reconstruction, 521
Falls, 683
Family Planning Clinic, 670
Fat embolism, 475, 481, 487
Fecal diversion, 495, 507
Fecal impaction, 271
Femoral angiograms, 116
Femoral neck fracture, 461
Femoral-popliteal bypass surgery, 116–117, 144
Femur fracture, 460, 481
Fentanyl (Duragesic), 724
Fentanyl patch, 740
Ferrous gluconate, 155
Fetal tissue transplantation, 45
Fever, 18, 42, 655
Fiber, 773
Fiberoptic colonoscopy, 313
Fibroid tumors, 414
Fibromyalgia, 562, 566
Fibula fracture, 460
Flaccidity, 39
Flashback reactions, 47
Flu, 716, 755
Fluid and electrolyte balance, 371–372, 503, 638
Fluid replacement, 278
Fluid resuscitation, 503
Fluid volume deficit, 182, 312, 401, 525
Fluid volume excess, 371, 401, 406
Folic acid deficiency anemia, 156, 169
Folliculitis barbae, 522
Food poisoning, 310
Foot ulcer, 116
Forearm fracture, 484, 623
Fosamax, 480
Fractured leg, 58
Fractures, 460–461. See also specific fracture type
Frostbite, 621
Full-thickness burns, 157, 492–493, 522
Fungal/parasitic skin infection, 499–501
Furosemide (Lasix), 720
Furuncle, 511
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INDEX
G
Gag reflex, 345
Gag response, 16
Gallbladder disorders, 262–263
Gallbladder removal, 288
Gangrene, 459
Gas tamponade, 572, 581, 586
Gastric bleeding, 258
Gastric bypass surgery, 155, 270
Gastric distention, 609
Gastric lavage, 598
Gastric ulcer, 257–258
Gastritis, 312
Gastroenteritis, 266–268, 296
Gastroesophageal reflux disease (GERD), 254–255, 308, 720,
746, 756, 758
Gastrointestinal disorders
abdominal surgery and, 268–269
colorectal disease, 259–260
comprehensive examination, 308–314
constipation/diarrhea disorders, 271–273
diverticulosis/diverticulitis, 260–261
eating disorders, 269–271
gallbladder disorders, 262–263
gastroenteritis, 266–268
gastroesophageal reflux (GERD), 254–255
hepatitis, 265–266
inflammatory bowel disease, 255–257
keywords/abbreviations, 253–254
liver failure, 263–265
peptic ulcer disease, 257–258
Gastrostomy tube feeding, 22
General anesthesia, 634
Genetic counseling, 769
Genitourinary disorders
acute renal failure, 368–369
benign prostatic hypertrophy, 374–375
bladder cancer, 377–378
chronic kidney disease, 369–371
comprehensive examination, 399–402
fluid and electrolyte disorders, 371–372
keywords/abbreviations, 367–368
renal calculi, 375–377
urinary tract infections, 372–374
Geriatric Depression Scale, 66
German heritage, 658
Ginseng, 670, 674
Glargine (Lantus), 718
Glasgow Coma Scale, 29, 57–58
Glaucoma, 572–573, 575, 581, 585, 736
Glomerular filtration rate, 390
Glomerulonephritis, 374, 389
Glossopharyngeal nerve paralysis, 55
Glucocorticoid inhaled medication, 198
Glucocorticoid therapy, 238
Glucophage, 732
Glucosamine, 456
Glucose, 30, 653, 775
Glyburide (Micronase), 717
Goiters, 356
Gonorrhea, 420, 439
Good luck charms, 664
Good Samaritan Act, 70
Gout, 728
Green bile, 287
Greenstick fracture, 623
Grieving, 154, 680, 706
Guided imagery, 660–661, 667, 676
Guillain-Barré syndrome, 121, 532–533, 561–562,
756, 771
Gunshot injury, 10, 369, 622
Gynecological examinations, 413
Gynecomastia, 746
H
Hallux valgus, 480
Halo device, 12
Hand washing, 294, 736
Hansen’s disease, 520–521, 525
Head injury, 9–11, 57–58
Headache, 9, 12, 44, 61, 64, 70
Healing contusion, 509
Health Insurance Portability and Accountability
Act (HIPAA), 46
Hearing impaired patients, 660
Hearing loss, 573, 583, 756
Heart failure, 244
Heart transplantation, 107, 685
Heartburn, 254
Height loss, 469
Heimlich valve, 628
Helicobacter pylori, 258
Hemarthrosis, 158, 172
Hematological disorders
anemia, 155–156
bleeding disorders, 157–158
blood transfusions, 158–160
comprehensive examination, 180–184
keywords/abbreviations, 151–152
leukemia, 152–153
lymphoma, 153–155
sickle cell anemia, 160–161
Hematoma, 10
Hemiparesis, 38
Hemlock Society, 703
Hemoglobin laboratory tests, 589
Hemoglobin levels, 479
Hemophilia, 157–158, 172, 182
Hemorrhages, 121, 473, 644
Hemorrhagic stroke, 9
Hemorrhoidectomy, 314
Hemorrhoids, 287, 313
Hemothorax, 208–209
Heparin, 148, 227, 482, 718, 725
Heparin drip, 142, 204, 725, 757
Heparin sodium, 121
Hepatic encephalopathy, 263, 310–311, 319
Hepatic toxicity, 741
Hepatitis, 265–266, 310, 759, 774
Hepatitis B vaccines, 319, 724
Herbs, 648, 662, 668, 672
Hereditary spherocytosis, 181, 186
Hernia, 756
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Heroin, 20, 48
Herpes simplex virus, 498, 512, 723
Herpes zoster virus, 498, 513–514
Heterograft, 503
Hiatal hernia, 309
High-density lipoprotein levels, 117
Hindu heritage, 659
Hip fracture, 461, 482
Hip replacement surgery, 121, 717
Hip spica cast, 482
Hispanic heritage, 702, 707
Hoarseness, 244
Hodgkin’s disease, 154, 165
Hodgkin’s lymphoma, 154
Holter monitor, 78, 92
Homans’ sign, 144
Homeless clients, 617, 671
Hormone replacement therapy, 727
Hospice care nurse, 680, 701, 705
Hospice organizations, 680
Hot flashes, 434
Hot spots, 279
Humalog, 326
Human immunodeficiency virus (HIV), 536–538, 562, 567
Human leukocyte antigens, 697
Human papillomavirus (HPV), 419
Humerus fracture, 461, 482
Humulin N, 326, 717
Humulin R, 327
Huntington’s chorea, 56
Hyperglycemia, 327
Hyperkalemia, 108, 369, 385
Hyperosmolar hyperglycemic nonketotic syndrome (HHNS),
327–328
Hyperparathyroidism, 357–358
Hyperpyrexia, 356
Hypersensitivity reactions, 561
Hypertension, 27, 716, 720
Hyperthermia, 641–642
Hyperthyroidism, 336–337, 358, 733
Hypnotherapy, 664
Hypocalcemia, 385
Hypokalemia, 109, 277, 297
Hypomagnesemia, 360
Hyporeflexia, 544
Hypotension, 68, 379, 593, 633
Hypothyroidism, 336
Hypovolemia, 291, 548
Hypovolemic shock, 317, 654
Hypoxemia, 215, 234
Hypoxia, 212, 475, 479, 625
Hysterectomy, 412, 416
I
Ibuprofen, 593
Ice packs, 474, 476, 643
Ideal body weight, 270
Idiopathic thrombocytopenic purpura, 158, 173, 182
Ileal conduit, 378, 395, 401
Ileostomy, 256, 257, 278
Immobility, 52
Immobilizer, 476
Immune system disorders
acquired immunodeficiency syndrome (AIDS), 536–538
allergies and allergic reactions, 538–540
comprehensive examination, 561–565
Guillain-Barré syndrome, 532–533
keywords/abbreviations, 529–530
multiple sclerosis, 530–531
myasthenia gravis, 533–535
rheumatoid arthritis, 540–541
systemic lupus erythematosus, 535–536
Immunosuppressive medications, 165, 541, 559
Impaired gas exchange, 194, 199, 212
Impaired skin integrity, 314
Impetigo, 497, 498, 512
Implantable cardioverter defibrillator, 102
Imuran, 722, 738
Incisional pain, 729
Indwelling catheter, 373, 400
Ineffective gas exchange, 196
Infective endocarditis, 82–83
Infertility, 440
Inflamed peritoneum, 299
Inflammatory bowel disease, 255–257, 312, 323
Inflammatory cardiac disorders, 82–83
Influenza A, 193
Influenza vaccines, 192, 217, 237, 245
Informed consent, 648
Inhalers, 218
Insect bites, 670
Insect venom allergies, 539, 564
Insulin, 326–329, 360, 362, 732, 744
Insulinoma, 359
Integumentary disorders
bacterial skin infection, 496–498
burns, 491–493
comprehensive examination, 519–522
fungal/parasitic skin infection, 499–501
keywords/abbreviations, 491
pressure ulcers, 493–495
skin cancer, 495–496
viral skin infection, 498–499
Intestinal surgery, 631
Intracranial surgery, 59
Intraocular pressure, 577
Intraoperative care, 631–633
Intravesical chemotherapy, 377
Intrinsic lung cancer, 236, 244
Iodine, 557
Iron-deficiency anemia, 155, 180
Iron supplementation, 156, 670
Irregular menses, 750
Irritable bowel syndrome (IBS), 314, 323
Isoniazid, 723
J
Jackson Pratt drain, 269, 438
Jaundice, 264
Jehovah’s Witness, 719
Jewish faith, 472, 659, 668, 701, 706
Jock itch, 516
Joint replacements, 461–463
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Joint stiffness, 457, 552
Justice, 697
K
Kaposi’s sarcoma tumor, 509
Kayexalate, 742
Kegel exercises, 425, 447, 750, 763
Kernig’s sign, 41, 59, 68
Ketoacidosis, diabetic, 328–329
Kidney perfusion, 366
Kidney stones, 362, 377
Kidney transplants, 370, 684–685, 720
Knee arthroscopy, 480
Kwell lotion, 500, 516
L
Lacerations, 621–622, 727
Lactulose (Chronulac), 264
Laminectomy, 454
Lanoxin, 105
Laparoscopic cholecystectomy, 309
Laparoscopy, 415
Laparotomy, 415
Laryngectomy, 202–203, 236, 757
Laryngitis, 193, 211
Laryngoscopy, 223
Larynx cancer, 202–203, 757
Laser-assisted in situ keratomileusis (LASIK) surgery, 573, 577
Lasix, 718
Latex allergy, 404, 425, 538
Laughter, 673
Laxatives, 318, 323, 425
Left shoulder pain, 635
Leg cramps, 75, 86, 321, 720, 736
Leg pain, 115
Legal/ethical issues, 682–684
Legionnaires’ disease, 236, 245
Leprosy, 520–521, 525
Leukemia, 152–153, 163, 181, 754
Leukocytosis, 181, 182, 187
Leukotriene receptor antagonists, 729
Levodopa, 726
Levothyroxine (Synthroid), 336, 760
Lidocaine, 96, 737
Lift pads, 493
Lightheadedness, 12
Lioresal (Baclofen), 719
Liquid intake, 211
Lithotomy position, 649, 653
Lithotripsy, 376
Liver biopsy, 263
Liver failure, 263–265, 310, 319, 759
Liver transplants, 684
Living donors, 700
Lobectomy, 201
Log rolling, 465
Long arm cast, 482
Long-term care facility routines, 659
Loop diuretics, 78, 91, 114–115, 721, 737
Loose teeth or caries, 637
Lou Gehrig’s disease, 21–22, 55, 59
Lovenox, 481
Low back pain, 133
Low-cholesterol diets, 92
Low molecular weight heparin, 121, 143
Low platelet counts, 189
Lower esophageal sphincter dysfunction, 254
Lower respiratory infection, 193–195
Lumbar laminectomy, 454
Lumbar puncture, 17, 23, 42, 533
Lumbar strain, 455
Lung abscess, 240
Lung cancer, 199–202, 220–221, 238, 244, 679, 757
Lung sounds, 643
Lung transplants, 685
Luteinizing hormone-releasing hormone (LHRH) agonist
therapy, 417
Lyme disease, 498, 510, 512
Lymph node dissection, 681
Lymphangiogram, 153
Lymphomas, 153–155, 167
Lysergic acid diethylamide (LSD), 20
M
Macular degeneration, 572, 575
Macular rash, 497
Mafenide acetate (Sulfamylon), 492
Magnetic resonance imaging (MRI), 15, 33, 64, 481, 530
Malignant melanomas, 496, 509
Malnutrition syndrome, 553
Malpractice, 683–684, 697, 762
Mammograms, 422
Mandible fracture, 621
Mannitol (Osmitrol), 728
Marfan’s syndrome, 95, 143, 148
Masklike facies, 45, 68
Massage, 543
Mast cell drugs, 218
Mast cell stabilizer medications, 197
Mastectomy, 143, 410–411, 423, 681
Mastitis, 447
Mastoid surgery, 588
Mastoidectomy, 574, 583
Material safety data sheet (MSDS), 596
Mechanical valve replacement, 79–80
Mechanical ventilation, 207–208, 239, 240
Medic Alert bands, 228
Medication questions, 657
Melanin, 508
Memory deficits, 45
Mèniére’s disease, 574, 578
Meningitis, 16–17, 209
Meningococcal meningitis, 16–17, 41
Menopause, 727
Menorrhagia, 155, 168
Menstrual cycle, 269
Meperidine (Demerol), 729
Metabolic acidosis, 369
Metabolic alkalosis, 324
Metastatic brain tumor, 16
Methicillin-resistant Staphylococcus aureus (MRSA), 71, 716
Metronidazole (Flagyl), 724
Mexican heritage, 658, 668
Migraine headaches, 60, 659, 726
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INDEX
Mild intermittent asthma, 197
Milk thistle, 266
Miotic cholinergic medication, 573
Mitral valve insufficiency, 79
Mitral valve prolapse, 80
Mitral valve stenosis, 79
Morning medications, 541
Morphine, 186, 498, 681, 692, 693
Mosquitos, 69
Motion sickness, 582, 586
Motor-vehicle accidents, 11, 60–61, 158, 622
Motor weakness, 534
Mouth-to-mouth resuscitation, 596
Mouth ulcers, 313, 322
Mucosal barrier agents, 275
Multifocal premature ventricular contractions, 80, 721
Multiple sclerosis, 530–531, 563, 719, 761
Mumps, 450
Murmurs, 93
Muscle cramping, 115
Muscle flaccidity, 544
Muscle relaxants, 719, 728
Musculoskeletal disorders
amputation, 458–460
comprehensive examination, 480–484
degenerative/herniated disk disease, 454–455
fractures, 460–461
joint replacements, 461–463
keywords/abbreviations, 453
osteoarthritis, 455–457
osteoporosis, 457–458
Music therapy, 666, 676
Muslim faith, 680
Myasthenia gravis, 533–535, 564
Mydriasis, 736
Myelograms, 764
Myeloid leukemia, 152
Myocardial infarction, 75–77, 102–103, 105, 593, 611, 716,
721, 729
Myocardial ischemia, 550
Myocarditis, 83
Myopia, 573
Myositis, 739
Myxedema coma, 336
N
Narcan (Naloxone), 54, 643, 644, 650, 654, 722, 738
Narcotic addiction, 345
Narcotic medication prescriptions, 692
Nasal sprays, 658
Nasogastric tubes, 261, 282, 724, 756
Nausea, 269
Navajo heritage, 668
Near-drownings, 620
Needle count, 649, 654
Needle puncture, 762
Neglect, 599–601
Neostigmine (Prostigmen), 534
Nephrectomy, 401–402
Nephritic syndrome, 406
Nephrostomy tubes, 404
Nephrotic syndrome, 401
Neupogen, 737
Neurogenic flaccid bladder, 399
Neurogenic shock, 592
Neurological deficit, 755
Neurological disorders
amyotrophic lateral sclerosis, 21–22
brain tumors, 15–16
cerebrovascular accident (stroke), 8–9
comprehensive examination, 55–62
encephalitis, 23–24
head injury, 9–11
keywords/abbreviations, 7–8
meningitis, 16–17
Parkinson’s disease, 18–19
seizures, 13–14
spinal cord injury, 11–13
substance abuse, 19–21
Neurovascular assessment, 485
Neurovascular compromise, 474
Neutropenia, 152, 181
Nevus, 751
Nicotine, 469
Nifedipine (Procardia XL), 724
Nissen fundoplication, 309, 318
Nitroglycerin, 77, 103, 109, 724
Non-Hodgkin’s lymphoma, 153, 155, 754
Noncompliance, 383
Nonsteroidal anti-inflammatory drugs (NSAIDs), 17, 82, 93,
99, 280, 379, 429, 456, 467, 541, 560, 593, 603, 724
Norton scale, 505
Nosebleeds, 470, 627
Nosocomial urinary tract infection, 373
Nuchal rigidity, 209
Numbness, 8, 476
Nurse Practice Acts, 696
Nutrition, immobile patient and, 272, 312
O
O+ blood, 159
Oat cell carcinoma, 202
Obesity, 155, 270–271, 318, 448, 464, 466
Occipital area lacerations, 10
Occlusive dressings, 523
Occupation-related acquired seizures, 13
Occupational therapists, 559, 764
Oculovestibular test, 29
Oil retention enemas, 304
Olfactory nerve, 587
Omeprazole (Prilosec), 315
Onychomycosis, 500
Open reduction and internal fixation (ORIF), 481
Opioid narcotics, 635
Optic nerve, 583
Oral cancer, 316
Oral candidiasis, 553
Oral cavity assessment, 308
Oral tobacco, 308
Orchiectomy, 417, 418, 749
Orchitis, 444, 450
Organ donation, 684–685, 702, 759
Organ rejection, 698
Orthostatic hypotension, 85, 125, 298, 736
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Osmotic diuretics, 29, 728
Osteoarthritis, 455–457, 724, 750
Osteoporosis, 457–458, 480, 485, 718, 750
Osteosarcoma, 481
Otalgia (ear pain), 578
Otic drops, 574, 727
Otitis, 574
Otitis media, 573–574
Otoscope, 574
Ototoxic medication, 574
Ovarian cancer, 415–416
Ovarian cysts, 415, 430, 446, 451
Ovarian disorders, 414–416
Ovarian hyperstimulation, 443
Over-the-counter medications, 662, 667
Oxybutynin (Ditropan), 721
Oxygen administration, 32, 50
Oxygen saturation, 30
Oxygenation, diminished, 214
P
P waves, 81
Pacemaker, 753
Paget’s disease, 442, 447
Pain. See Acute pain; Chronic pain
Pain assessment, 488
Pain clinics, 681
Pain management techniques, 660
Pain medications, 20, 560, 635, 645–647, 671
Painful swallowing, 313
Pancreatic cancer, 331–332, 360
Pancreatic enzymes, 330, 344, 345
Pancreatic islet tumors, 332
Pancreatitis, 329–330, 359–360, 364, 759, 774–775
Pancytopenia, 169
Pantoprazole (Protonix), 725
Pap smear, 428
Paracentesis, 264
Paralysis, 476, 494, 545
Paralytic ileus, 269, 300
Paresthesia, 476
Parkinson’s disease, 18–19, 59, 62, 726, 752
Paroxysmal nocturnal dyspnea, 94
Partial-thickness burns, 492–493, 522
Passive range-of-motion exercises, 121
Paternalism, 397
Patient Self-Determination Act of 1991, 679, 688
PCA pump, 269, 636
Pedal pulse, 116, 149
Pediculosis, 402, 499
Pelvic floor exercises, 444
Pelvic floor relaxation disorders, 411–413
Pelvic inflammatory disease, 420, 443
Pelvic sonograms, 763
Pelvic ulcer disease, 758
Pelvis fracture, 461, 621
Penicillin, 82, 540
Peptic ulcer, 257–258, 279, 308, 315
Percutaneous balloon valvulopathy, 79
Percutaneous endoscopic gastrostomy feeding tube, 194, 272
Percutaneous renal biopsy, 401
Percutaneous transluminal coronary angioplasty (PCTA), 76
Peri-pad count, 429
Pericardial effusion, 105
Pericardiocentesis, 83, 101
Pericarditis, 82–83, 105, 550
Perioperative care
acute pain, 635–636
intraoperative care, 631–633
keywords/abbreviations, 629
postoperative care, 633–634
preoperative care, 630–631
Periorbital lesions, 515
Peripheral vascular disorders
abdominal aortic aneurysms, 119–120
arterial hypertension, 114–115
arterial occlusive disease, 115–117
atherosclerosis, 117–118
comprehensive examination, 141–145
deep vein thrombosis, 120–122
keywords/abbreviations, 113–114
peripheral venous disease, 122–123
Peripheral venous disease, 122–123
Peripheral vision, 585, 589
Peritoneal dialysis, 760
Peritoneal lavage, 620, 624
Peritonitis, 268, 281, 286, 300, 301, 316, 322, 778
Permanent hearing loss, 583
Pernicious anemia, 316, 717
Personal protective equipment, 593
Pessary, 413, 427
Pet dander allergies, 666
Pet visits, 665
Petechiae, 487, 769
Phantom pain, 473–474
Pharmacology
drug cards and, 712–715
keywords/abbreviations, 711
medications administration and, 716–730
test-taking hints for, 711–715
Phenothiazine, 742
Phenytoin (Dilantin), 14, 723
Pheochromocytomas, 358, 363
Phimosis, 444
Phlebitis, 386
Photophobia, 44
Physical abuse, 599–601
Physical therapy, 468
Pill rolling, 68
Pitting pedal edema, 745
Pituitary disorders, 334–336
Pituitary tumor, 15
Plasma D-dimer test, 226
Plasmapheresis, 534
Pleural effusions, 550
Pleuritic chest pain, 214
Pleurodesis, 237
Pneumoconiosis, 236
Pneumocystis pneumonia, 539, 569
Pneumonia, 144, 193–195, 229, 237, 240, 242, 288, 550, 592,
638, 722, 755
Pneumothorax, 205, 229, 239, 757
Poison ivy, 519, 539, 557
Poison oak, 520, 524
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Poisoning, 598–599
Polycystic kidney disease, 400, 405
Polycythemia vera, 181
Polymyositis, 563, 567
Polysomnography, 237, 245
Portal hypertension, 291, 320
Post-anesthesia care unit, 159
Postconcussion syndrome, 28
Postmastectomy pain, 681
Postmortem care, 669
Postoperative care, 633–634
Postoperative fever, 655
Postoperative urination, 650
Posttraumatic stress disorder (PTSD), 601
Potassium, 109, 387, 639, 773
Potassium supplements, 312
Prednisone, 242, 256, 722
Premature ventricular contractions, 238
Preoperative care, 630–631
Preoperative checklists, 648–649
Prescriptions, patient, 662
Pressure bandages, 139
Pressure ulcers, 493–495, 521, 751, 765
Prick epicutaneous test, 561
Primary adrenal cortex insufficiency, 332–333
Pro-thrombolytic therapy, 56
Procrit, 175
Proctitis, 450
Progressive muscle relaxation, 676
Progressive relaxation techniques, 708
Promethazine (Phenergan), 725
Propranolol (Inderal), 726
Prostate cancer, 416–417, 443, 750
Prostate disorders, 416–418
Prostate-specific antigens, 441
Prostatectomy, 417–418
Prostatitis, 374
Protective equipment, 593
Protein-calorie malnutrition, 537
Proton pump inhibitors, 308, 317, 725, 773
Pruritus (itching), 264, 499, 514, 519, 520
Pseudofolliculitis barbae, 497
Psoriasis, 519, 523, 756, 771
Psychiatric units, 683
Ptosis, 547
Pubic lice, 407
Public health department nurse, 671
Pulmonary embolism, 204–205, 226, 239
Pulmonary function tests, 218
Pulseless ventricular tachycardia, 110
Purulent drainage, 210
Pyelonephritis, 373, 388
Pyridostigmine (Mestinon), 535
Pyrosis, 276, 309, 318
Q
Quinine, 736
R
Radiation brachytherapy, 413
Radiation exposure, 594, 607
Radiation therapy, 16, 162, 165, 202–203, 448, 766
Radical neck dissection, 203, 224
Radioactive iodine therapy, 355
Ranitidine (Zantac), 315
Rape, 600–601, 618
Rape crisis counseling centers, 619
Rapid weight gain, 135
Rash, 497, 498, 519, 523, 539, 721
Raynaud’s phenomenon, 141, 146, 550
Reach to Recovery, 424
Reactive airway disease, 197–198. See also Asthma
Rectocele, 412
Rectovaginal fistula, 442
Red blood cell deficiency, 180
Red blood cells excess, 187
Regional enteritis, 278
Reimplantation, 621
Relaxation, 543, 659, 671
Renal biopsy, 401
Renal calculi, 375–377, 745
Renal failure, 380
Renal trauma, 622
Reperfusion dysrhythmias, 737
Reproductive disorders
breast disorders, 410–411
comprehensive examination, 441–445
keywords/abbreviations, 409
ovarian disorders, 414–416
pelvic floor relaxation disorders, 411–413
prostate disorders, 416–418
sexually transmitted diseases, 419–421
testicular disorders, 418–419
uterine disorders, 413–414
Respiratory compromise, 246
Respiratory disorders
acute respiratory distress syndrome, 207–208
cancer of larynx, 202–203
chest trauma, 205–207
chronic obstructive pulmonary disease, 195–197
comprehensive examination, 235–243
keywords/abbreviations, 191–192
lower respiratory infection, 193–195
lung cancer, 199–202
pulmonary embolus, 204–205
reactive airway disease (asthma), 197–198
upper respiratory infections, 192–193
Respiratory distress, 195
Restraints, 708
Retinal detachment, 572, 581
Retrobulbar hemorrhage, 575
Retroviruses, 553
Rhabdomyolysis, 739
Rheumatic fever, 82, 99–100
Rheumatic heart disease, 94
Rheumatoid arthritis, 536, 540–541, 563–564, 668, 762
Rhinitis, 20, 539, 556
Rib fractures, 620
Rifampin, 723
Right femoral cardiac catherization, 77
Right-sided cerebrovascular accident, 8
Right-sided paralysis, 8
Right to Know law, 236
Riluzole (Rilutek), 22
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INDEX
Ringworm, 517
Rule-out tuberculosis, 195
Runaways, 617
Ruptured aneurysm, 9
Ruptured appendix, 301
S
Salmonella bacteria, 296, 319
Salmonella food poisoning, 310
Salmonellosis, 267
Scabies, 500–501, 516, 518
Scleroderma, 562
Sclerotherapy, 142
Scoliosis, 485
Scrotal edema, 439
Seafood allergy, 485
Seborrheic dermatitis, 520
Sedatives, 30, 746
Seizures, 13–14, 34–36, 58, 64
Self-hypnosis, 664
Senile dementia, 600
Sensorineural hearing loss, 586
Sensory deficits
comprehensive examination, 581–584
ear disorders, 573–574
eye disorders, 572–573
keywords/abbreviations, 571
Sensory isolation, 585
Sentinel node biopsy, 423
Sepsis, 592, 602
Septic meningitis, 16–17, 40
Septic shock, 592–593, 604
Septicemia, 592, 593, 684, 761
Serum amylase, 343
Severe acute respiratory syndrome (SARS), 235
Sexual aggression, 600
Sexually transmitted diseases, 419–421, 749
Shared governance systems, 222
Shaving, 527
Shaving bumps, 497
Shingles, 513
Shock, 592–593
Short leg cast, 482
Shortness of breath, 22, 237
Shoulder replacement, 463
Shuffling gait, 45
Sickle cell anemia, 160–161, 181
Sickle cell crisis, 160–161, 181
Sickle cell disease, 755
Sickle Cell Foundation, 161
Sigmoid colon, 320
Sigmoid colostomy, 278, 313, 314
Sigmoid resection, 259
Sigmoidoscopy, 284
Sinus bradycardia, 80
Sinus tachycardia, 81, 98, 620
Sinusitis, 192–193
Sitz bath, 391
Sjögren’s syndrome, 561, 566
Skin cancer, 495–496
Skin check, 507
Skin infection
bacterial, 496–498
fungal/parasitic, 499–501
viral, 498–499
Sleep apnea, 236–237
Sleep deprivation, 559
Sleep difficulties, 703
Slurred speech, 8
Small bowel resection, 762
Small cell carcinoma of the lung, 199
Smallpox, 594
Smoking, 109, 117, 220, 222, 344, 396, 648
Snake bites, 599
Sneezing, 192
Soaps, 524
Social workers, 38, 139
Sodium, 385, 578
Sodium polystyrene sulfonate (Kayexalate), 726
Solu-Medrol, 519, 716
Speech therapy, 63, 548
Sperm banking, 436
Spherocytosis, 181
Spinal anesthesia, 642, 644
Spinal cord injury, 11–13, 31, 752
Spinal headache, 52
Spinal screenings, 480
Spinal shock, 31
Spiral fractures, 489, 762
Spiritual care, 679, 690
Spiritual distress, 680
Sponge recounts, 640
Spontaneous pneumothorax, 207
Spousal abuse, 600–601
Sputum production, 217, 247
Squamous cell carcinoma, 496, 509
Squamous cell skin cancer, 495
St. John’s Wort, 720
St. Louis encephalitis, 60
Stable ventricular tachycardia, 110
Stapedectomy, 582
Staphylococcal food poisoning, 267
Statin medications, 131
Status epilepticus, 14
Steatorrhea, 344
Stem cells, 699
Stereognosis, 584, 588
Steroids, 219, 535–536, 543, 551, 552, 557, 731, 738
Stevens-Johnson syndrome, 520, 525
Stomach lavaging, 282
Stool color, 168, 266, 288, 292
Stool softeners, 425
Stress, chronic, 669, 673
Stroke, 7–8, 71, 494, 762
Subarachnoid hemorrhage, 9
Subclavian steal syndrome, 141, 143, 146, 149
Subcutaneous emphysema, 231
Subdermal levonorgestrel implants, 675
Substance abuse, 19–21, 761
Suction equipment, 596
Suicide, 543
Sulfamylon, 502
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INDEX
Sulfasalazine (Azulfidine), 256
Sumatriptan, 69
Sunscreen products, 509
Supraventricular tachycardia, 726
Surfactant therapy, 233
Surgical asepsis, 632
Surgical checklist, 653
Surgical client interviews, 630
Surgical incisions, 299
Surgical informed consent, 630
Surgical pain, 635
Surgical permission forms, 683
Surgical positioning, 632
Swallowing problems, 548
Swan-Ganz mean pulmonary artery pressure, 237
Swan-neck fingers, 540
Sweating, 87
Swim aerobics, 458
Syndrome of inappropriate antidiuretic hormone (SIADH),
67–68, 334–336, 351, 360
Synthroid, 718
Syphilis, 420, 439–440, 444, 450–451
Systemic lupus erythematosus (SLE), 535–536, 563–564,
569, 756
Systemic sclerosis, 562
Systolic bruit, 132
T
Tachycardia, 633
Tachypnea, 246
Talcum powder, 432
Taste bud acuity, 585, 589
Teas, 668
Teeth, loose, 637
Telemetry, 80–81, 106, 371, 745
Tensilon test, 533, 549
Tension pneumothorax, 208, 230
Tension states, 37
Test taking
anxiety and, 4
cognitive levels and, 5–6
day of exam, 4
examination preparation, 3–4
hints for, 4–5
lecture preparation, 2–3
multiple-choice questions, 5
night before exam, 3–4
practice tests and, 3
RACE model and, 6
understanding question types, 5–6
Testicular cancer, 418–419, 749
Testicular disorders, 418–419
Tetanus injection, 489, 627, 742
Tetracycline, 675
Thalassemia, 181
Theophylline, 240
Therapeutic touch, 665
Thiamine, 47
Thoracic outlet syndrome, 141, 146
Thoracotomy, 238
Thromboangiitis obliterans, 141, 143
Thrombocytopenia, 188
Thrombolytic therapy, 204, 721, 725
Thrush, 316, 553
Thymectomy, 547
Thyroid disorders, 336–337
Thyroid hormone, 363
Thyroid storm, 337
Thyroidectomy, 358, 363, 372
Tibia fracture, 460, 751
Tinea cruris, 500, 516
Tinea pedis, 500
Tinea unguium, 500
Tinnitus (ringing in the ears), 568, 578, 737
Tissue donation, 684–685, 759
Tobacco use, 68, 130, 131. See also Smoking
Tonic-clonic seizures, 13. See also Seizures
Tonsillitis, 192
Total hip replacement, 159, 461–462, 482, 631, 750, 751
Total knee replacement, 462–463
Total laryngectomy, 236
Total parenteral nutrition, 256, 260, 372, 759
Touch, therapeutic, 665
Tourniquets, 472
Tracheostomy, 203
TRAM flap procedure, 423
Transcutaneous electrical nerve stimulation (TENS), 682, 694
Transdermal nitroglycerin, 103
Transesophageal hypophysectomy, 15–16, 334
Transient ischemic attack (TIA), 9, 752
Transurethral prostatectomy, 417
Transurethral resection of the prostate (TURP), 374–375
Transvaginal ultrasound, 432
Traumatic brain injury, 11, 58, 59
Traveler’s diarrhea, 296
Trendelenburg position, 383
Triage/disasters, 596–598
Trichomonas, 421, 440, 724
Trigeminal neuralgia, 55, 63
Trimethoprim-sulfamethoxazole (Bactrim), 374, 727
Trust, 778
Tuberculin tests, 194, 723
Tuberculosis, 194–195, 212, 214, 239, 240, 405, 704, 723
Tubular necrosis, 699
Tumor markers, 438
Tuning fork, 586
Turning bedfast clients, 505
Tympanic membrane, 578, 580
U
Ulcerative colitis, 255–257, 308, 312
Ulcers, 280
Ulna fracture, 461, 483
Ultraviolet skin damage, 508
Unconscious patients, 31, 766
Unequal arm length, 485
Uniform Determination of Brain Death Act, 698
Unresponsive patients, 623
Upper gastrointestinal series, 262
Upper gastrointestinal (UGI) series, 313
Upper respiratory infections, 192–193
Uremic frost, 384
Ureteral calculi, 376
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