Which of the following is the drug of
choice for Anthrax?
1. Furosemide Lasix…a diuretic
2. Aminophyllin respiratory medication
3. Cipro or doxycycline or penicillin
4. Tamoxifen used for estrogen receptorpositive breast tumors
Which of the following is the most
appropriate type of isolation precaution for a
patient diagnosed with Botulism?
1. Contact
2. Universal Precautions
3. Respiratory
4. Reverse
Which of the following is the most
appropriate type of isolation precaution for a
patient diagnosed with Botulism?
1. Contact
2. Universal Precautions not
spread from person to
person…use standard
precautions.
3. Respiratory
4. Reverse
Practice Question 41
A nurse is preparing to assist the physician
in performing a liver biopsy. The nurse would
assist the client to which position for this
test?
1. Right lateral side-lying
2. Left lateral side-lying
3. Prone with the hands crossed under the head
4. Supine with the right hand under the head.
Practice Question 41
A nurse is preparing to assist the physician in
performing a liver biopsy. The nurse would
assist the client to which position for this test?
1. Right lateral side-lying anatomical location of the
liver makes this choice incorrect
2. Left lateral side-lying anatomical location of the
liver makes this choice incorrect
3. Prone with the hands crossed under the head
anatomical location of the liver makes this choice
incorrect
4. Supine with the right hand under the head.
Client is also instructed to remain as still as
possible during the procedure.
Practice Question 42
The nurse is providing instructions to the
client with a gastric ulcer regarding the
administration of sucralfate (Carafate).The
nurse instructs the client to
1. take the medication after meals & at bedtime
with a snack.
2. take the medication with meals & at bedtime
with a glass of milk.
3. to space the medication around the clock,
taking it very 6 hours.
4. to take the medication 1 hour before meals
and at bedtime.
The nurse is providing instructions to the client with a gastric
ulcer regarding the administration of sucralfate
(Carafate).The nurse instructs the client to
1. take the medication after meals & at bedtime with a
snack.
2. take the medication with meals & at bedtime with a glass
of milk.
3. to space the medication around the clock, taking it very 6
hours.
4. to take the medication 1 hour before meals and at
bedtime.
•sucralfate forms a protective coating over the gastric
ulcer – food intake will stimulate gastric acid production
and mechanical irritation
•Take at bedtime to provide protective coating during
night time hours.
Practice Question 43
A client who has returned from a
percutaneous liver biopsy should be
placed in what position?
1. Left side.
2. Right side.
3. Semi-Fowler’s
4. Supine
Practice Question 43
A client who has returned from a
percutaneous liver biopsy should be
placed in what position?
1. Left side.
2. Right side.
3. Semi-Fowler’s
4. Supine
•Client placed on operative side (right side)
•Pillow placed under the costal margin to compress the
liver
•Wt of client’s body will apply pressure to the liver and
decr incidence of bleeding
Respiratory
Causes of Ventilator Alarms
High Pressure Alarm:
Increased secretions in the airway
Wheezing or bronchospasm (causing
decreased airway size)
Endotracheal tube displaced
Ventilator tubing obstructed
Water in tubing (condensation)
Kink in tubing (under pt, caught in siderail)
Client coughs, gags, bites endotracheal tube
Client anxious and ‘fights” ventilator
Causes of Ventilator Alarms
Low Pressure Alarm:
Disconnection of ventilator tubing
Leak in the ventilator tubing
Leak in the Endotracheal tube airway cuff
Client stops spontaneous breathing
Practice Question 44
A nurse is caring for a client with a
tracheostomy tube attached to a
ventilator. The high-pressure alarm
sounds on the ventilator. The nurse
plans to
1. assess for a disconnection.
2. evaluate the cuff for a leak.
3. notify the respiratory therapist.
4. suction secretions from the client.
A nurse is caring for a client with a tracheostomy
tube attached to a ventilator. The high-pressure
alarm sounds on the ventilator. The nurse plans
to
1. assess for a disconnection. This would not cause the
high pressure alarm to go off.
2. evaluate the cuff for a leak. This would not cause the
high pressure alarm to go off.
3. notify the respiratory therapist. Delays necessary tx.
4. suction secretions from the client. High
pressure alarm suggests an obstruction. Empty
water from tubing…sx pt…check
equipment…check pt (could be waking up and
fighting the ventilator).
Practice Question 45
A client has a chest tube attached to a Pleur-evac
drainage system. The nurse would ensure that
1.the connection between the chest tube and the drainage
system is taped and that an occlusive dressing is maintained
at the insertion site.
2. the amount of drainage into the chest tube is noted &
recorded every 24 hours in the client’s record.
3. the suction control chamber has sterile water added every
shift & that the system is kept below waist level.
4. the water seal chamber has continuous bubbling and that
assessment for crepitus is done once a shift.
A client has a chest tube attached to a Pleur-evac
drainage system. The nurse would ensure that
1. the connection between the chest tube and the
drainage system is taped and that an occlusive
dressing is maintained at the insertion site.
2. the amount of drainage into the chest tube is noted &
recorded every 24 hours in the client’s record. Drainage
noted and recorded qhr in the 1st 24 hrs then q8 and prn.
3. the suction control chamber has sterile water added every
shift & that the system is kept below waist level. Sterile
water is added at initial set up and then only as needed
(which is rare)
4. the water seal chamber has continuous bubbling and that
assessment for crepitus is done once a shift. Continuous
bubbling in the sx chamber. Bubbling in the water seal is a
sign of an air leak. Assess for Crepitus q8hrs.
Practice Question 46
The nurse caring for a client with a
closed chest drainage system notes
that the tidaling in the water seal
compartment has stopped. Based on
this finding, the nurse would suspect
that
1. the chest tubes are obstructed.
2. suction needs to be increased.
3. the system needs changing.
4. suction needs to be decreased.
Practice Question 46
The nurse caring for a client with a closed chest
drainage system notes that the tidaling in the water
seal compartment has stopped. Based on this
finding, the nurse would suspect that
1. the chest tubes are obstructed. Or the
pneumothorax is resolved…fluctuation continues until
the thorax is resolved.
2. suction needs to be increased. Amt of sx is
irrelevant…controlled via sx control chamber ;usu set at
20.
3. the system needs changing. Only change when
drainage collection device is full or the device is
damaged in some way.
4. suction needs to be decreased. Sx is often discontinued
once drainage stops – waterseal is adequate for the
resolution of the pneumothorax.
Practice Question 47
The client with tuberculosis asks the
nurse when it is permissible to return
to work. The nurse replies that the
client may resume employment when
1. 3 sputum cultures are negative.
2. 5 sputum cultures are negative.
3. a sputum culture & a chest x-ray film
are negative.
4. a sputum culture & a Mantoux test are
negative.
Practice Question 47
The client with tuberculosis asks the nurse when it
is permissible to return to work. The nurse replies
that the client may resume employment when
1. 3 sputum cultures are negative.
2. 5 sputum cultures are negative.
3. a sputum culture & a chest x-ray film are
negative.
4. a sputum culture & a Mantoux test are
negative. Mantoux will always be positive once
it becomes positive. Do not repeat once the pt
has a positive.
Practice Question 48
Which of the following should be
performed prior to drawing arterial blood
gases from the radial artery?
1. Allen’s test
2. Babinski’s reflex
3. Brudzinski’s sign.
4. Homans’ sigh
Practice Question 48
Which of the following should be performed
prior to drawing arterial blood gases from the
radial artery?
1. Allen’s
test assesses for the adequ of
ulnar circulation.
2. Babinski’s reflex performed on the sole of the foot
– unrelated to a procedure performed on the radial
artery.
3. Brudzinski’s sign. Assessment for nuchal rigidity
by bending the head down toward the chest.
4. Homans’ sign sharp dorsiflexion of the feet – used
to assess for thrombophlebitis.
Practice Question 49
A client with tuberculosis is to be started on
rifampin (Rifadin). The nurse provides
instructions to the client and tells the client
1. that yellow-colored skin is common.
2. to wear glasses instead of soft contact
lens.
3. always to take the medication on an empty
stomach.
4. that as soon as the cultures come back
negative, the medication may be stopped.
A client with tuberculosis is to be started on rifampin (Rifadin).
The nurse provides instructions to the client and tells the
client
1. that yellow-colored skin is common. Indication of
jaundice. Should report jaundice to MD.
2. to wear glasses instead of soft contact lens. Soft
contacts may be damaged permanently by the
orange discoloration that rifampin causes in body
fluids.
3. always to take the medication on an empty
stomach. Eliminate because of the word “always”may take with food if client is unable to tolerate on
an empty stomach.
4. that as soon as the cultures come back negative,
the medication may be stopped. Client will be on
the meds a LONG time – as much as 12 months
even if the cultures come back negative.
Practice Question 50
A client with an acute respiratory infection is
admitted to the hospital with a diagnosis of
sinus tachycardia. The nurse develops a
plan of care for the client and includes which
of the following?
1. Providing the client with short, frequent walks.
2. Measuring the client’s pulse each shift.
3. Eliminating sources of caffeine from meal trays.
4. Limiting fluids given orally and IV.
A client with an acute respiratory infection is admitted to the
hospital with a diagnosis of sinus tachycardia. The nurse
develops a plan of care for the client and includes which of
the following?
1. Providing the client with short, frequent walks.
Exercise will not alleviate tachycardia.
2. Measuring the client’s pulse each shift. Will not
alleviate s/s and HR should be measured more
freq. than qshift.
3. Eliminating sources of caffeine from meal trays.
Cause exacerbation of the s/s. Caffeine is a
stimulate.
4. Limiting fluids given orally and IV. Exercise will
not alleviate tachycardia.
Practice Question 51
A client is experiencing an acute
asthmatic attack. Which nursing action
would improve the respiratory status of
the client?
1. Help the client to attain a slow, prolonged
expiration.
2. Have client forcefully exhale.
3. Provide rest by leaving client alone and in
supine position.
4. Assist the client to breathe into a paper bag.
A client is experiencing an acute asthmatic attack.
Which nursing action would improve the respiratory
status of the client?
1. Help the client to attain a slow, prolonged
expiration. This allows the client to exhale a
greater volume and facilitates incr oxygenation.
2. Have client forcefully exhale. Used to measure
peak airflow.
3. Provide rest by leaving client alone and in supine
position. Client should be sitting or in highFowler’s position. Do not leave alone.
4. Assist the client to breathe into a paper bag. This
will incr PCO2 and not improve the pt’s overall
condition.
Practice Question 52
A client with a pneumothorax has a chest
tube inserted & connected to gravity
drainage. When assessing the drainage
system for proper function, what will the
nurse expect to observe?
1. Continuous bubbling in the water-seal
chamber.
2. Slight fluctuation of the water in the water-seal
chamber.
3. Increased bloody drainage in the collection
chamber.
4. Constant bubbling in the collection chamber.
A client with a pneumothorax has a chest tube
inserted & connected to gravity drainage. When
assessing the drainage system for proper function,
what will the nurse expect to observe?
1. Continuous bubbling in the water-seal chamber.
In the sx control chamber OK – in water seal
suggests an air leak.
2. Slight fluctuation of the water in the water-seal
chamber. Should fluctuate with breathing.
3. Increased bloody drainage in the collection
chamber. Incr bloody drainage is never normal.
4. Constant bubbling in the collection chamber.
Bubbling in the sx control chamber OK –
collection chamber should not have bubbling.
Water seal chamber
B
C
Suction control chamber
A
Fluid/drainage collection
chamber
Practice Question 53
The nurse would anticipate which nursing
observation in the client with symptoms of
early laryngotracheobronchitis?
1. Elevated temperature & prostration.
2. Flushed face & labored expirations.
3. Kussmaul respirations & bradycardia.
4. Tachypnea & inspiratory stridor.
Practice Question 53
The nurse would anticipate which nursing
observation in the client with symptoms of
early laryngotracheobronchitis?
1. Elevated temperature & prostration.
Temperature not charactoristic
2. Flushed face & labored expirations. Could
occur – but are not charactoristic – esp. early.
3. Kussmaul respirations & bradycardia. Deep
rapid resp but are not noisy
4. Tachypnea & inspiratory stridor. Rapid,
noisy resp. Occurs as air is drawn
through a narrowed airway.
Practice Question 54
What are the nursing precautions during a tubing
change of a central venous pressure (CVP) line?
1. Flush catheter with 3 ml of NS & then heparin before
disconnecting the line.
2. Position client on right side & then have him take a deep
breath.
3. Elevate HOB & disconnect tubing from fluid container
before disconnecting from client.
4. Position client flat & have him take a deep breath & hold it
while the line is disconnected & a new one connected.
Practice Question 54
What are the nursing precautions during a tubing change of a
central venous pressure (CVP) line?
1. Flush catheter with 3 ml of NS & then heparin before
disconnecting the line. Not necessarily.
2. Position client on right side & then have him take a deep
breath. Position flat.
3. Elevate HOB & disconnect tubing from fluid container
before disconnecting from client. Position flat.
4. Position client flat & have him take a deep breath & hold it
while the line is disconnected & a new one connected.
Increases intrathoracic pressure and so decr possibility
that the client will experience an air embolus during the
tubing change.
Practice Question 55
A client has thick pulmonary secretions. The
nurse would anticipate which classification
of medication to be ordered?
1. Antihistamine
2. Bronchodilator.
3. Decongestant.
4. Expectorant.
Practice Question 55
A client has thick pulmonary secretions. The nurse
would anticipate which classification of
medication to be ordered?
1. Antihistamine block the release of histamine – used
to tx mild allergic disorders.
2. Bronchodilator. Indicated when airways are inflamed
and narrowed.
3. Decongestant. Produce vasoconstriction of dilated
arterioles – leads to reduction in congestions.
4. Expectorant.
Stimulate secr and reduce
the viscosity of the mucus.
Practice Question 56
The nurse is monitoring a client who is receiving IV
theophylline (aminophylline) for control of an acute
episode of his chronic respiratory condition.What
nursing observations would cause the nurse the
most concern?
1.Blurred vision, halos around lights and diplopia.
2. HypoKalemia, diarrhea, and bradycardia.
3. Restlessness, tachycardia, nausea, and vomiting.
4. Tachycardia, pulse oximetry of 90%, irregular
respirations.
The nurse is monitoring a client who is receiving IV
theophylline (aminophylline) for control of an acute episode
of his chronic respiratory condition.What nursing
observations would cause the nurse the most concern?
1.Blurred vision, halos around lights and diplopia.
Does not relate to theophylline use.
2. Hypokalemia, diarrhea, and bradycardia. Does not
relate to theophylline use.
3. Restlessness, tachycardia, nausea, and vomiting.
Indicates toxic levels of theophylline. Lab work
must be done to monitor the theophylline levels.
Normal range is 10-20 mcg/ml.
4. Tachycardia, pulse oximetry of 90%, irregular
respirations. Does not relate to theophylline use.
Practice Question 57
A nurse has an order to remove the
NG tube from a first postoperative day
surgery client. The nurse would
question the order if which of the
following was noted on assessment of
the client?
1. Abdomen is slightly distended.
2. Bowel sounds are absent.
3. NG tube drainage is Hematest negative.
4. The client is drowsy.
A nurse has an order to remove the NG tube from a first
postoperative day surgery client. The nurse would question
the order if which of the following was noted on assessment
of the client?
1. Abdomen is slightly distended. Cause for
concern – but if active BS the distention should be
resolved soon.
2. Bowel sounds are absent. GI system will
continue to produce secretions even if pt is NPO
– if no BS present they will remain in abdomen
and present as an aspiration risk.
3. NG tube drainage is Hematest negative. This
indicates a normal finding.
4. The client is drowsy. Drowsiness is not an
indication for an NG tube
Adult Health II
Developed by
Dare Domico, RN, DSN
Revised by: Jill Ray
Cardiovascular
Practice Question 1
A nurse is preparing to defibrillate a client in
ventricular fibrillation. After placing the
paddles on the client's chest and before
discharging them, which of the following
should be done?
1. Ensure that the client has been intubated
2. Set the defibrillator to the “synchronize” mode
3. Administer lidocaine hydrochloride (Xylocaine).
4. Confirm that the rhythm is actually ventricular
fibrillation.
Practice Question 1
A nurse is preparing to defibrillate a client in
ventricular fibrillation. After placing the
paddles on the client's chest and before
discharging them, which of the following
should be done?
1. Ensure that the client has been intubated does
not have to be intubated to defibrillate
2. Set the defibrillator to the “synchronize” mode
synchronize mode used with cardioversion
3. Administer lidocaine hydrochloride (Xylocaine).
Can be administered after defibrillation
4. Confirm that the rhythm is actually
ventricular fibrillation.
Practice Question 2
Which of the
following best
describes the
rhythm
represented on
the EKG strip?
1. Normal sinus rhythm
2. Ventricular tachycardia
3. Atrial fibrillation
4. Ventricular fibrillation
Practice Question 2
Which of the
following best
describes the
rhythm
represented on
the EKG strip?
1. Normal sinus rhythm note the
presence of a P wave before ea qrs
2. Ventricular tachycardia
3. Atrial fibrillation
4. Ventricular fibrillation
Practice Question 3
A nurse is administering a dose of
hydralazine (Apresoline) IV to a client. The
nurse ensured that which of the following
items is in place before injecting the
medication?
1. Central line.
2. Foley catheter
3. Pulse oximeter
4. Blood pressure cuff.
Practice Question 3
A nurse is administering a dose of hydralazine
(Apresoline) IV to a client. The nurse ensured that
which of the following items is in place before
injecting the medication?
1. Central line. Administration via a peripheral IV
is OK
2. Foley catheter not necessary to monitor u/o.
3. Pulse oximeter not necessary to monitor
oxygen sat post adm.
4. Blood pressure cuff. Medication used to
lower the BP. Monitor BP and pulse after
administration of hydralazine.
Practice Question 4
Which of the following items would the
nurse assess to gain the best information
about a client’s left ventricular function?
1. Breath sounds.
2. Hepatojugular reflux
3. Jugular vein distention
4. Peripheral edema
Practice Question 4
Which of the following items would the
nurse assess to gain the best information
about a client’s left ventricular function?
1. Breath
sounds. Left and lungs.
2. Hepatojugular reflux sign of right sided heart
failure.
3. Jugular vein distention sign of right sided
heart failure.
4. Peripheral edema sign of right sided heart
failure.
Practice Question 5
Which statement by the client indicates that
he understands how to take sublingual
nitroglycerin?
1.“If I have a chest pain, I’ll immediately stop
what I am doing, sit down, & take the
medication.”
2.“I’ll chew 1 tablet then let it dissolve in my
mouth if the chest pain last more than 5
minutes.
3.“Ill take only 1 dose, & stop what I am doing. If
the pain doesn’t stop, I’ll call the doctor.”
4.“If I have chest pain, I’ll call the doctor & put 2
tablets under my tongue.
Practice Question 5
Which statement by the client indicates that he
understands how to take sublingual nitroglycerin?
1.“If I have a chest pain, I’ll immediately stop what I
am doing, sit down, & take the medication.”
2.“I’ll chew 1 tablet then let it dissolve in my mouth if the
chest pain last more than 5 minutes. Don’t chew…
3.“I’ll take only 1 dose, & stop what I am doing. If the pain
doesn’t stop, I’ll call the doctor.” Take the medication
immediately – don’t wait to see if the pain goes away;
must also sit or lie down…causes orthostatic
hypotension
4.“If I have chest pain, I’ll call the doctor & put 2 tablets
under my tongue. Take one tablet, must sit or lie down.
Practice Question 6
The nurse teaches dietary restrictions to a
client with new onset congestive heart
failure. Which statement by the client
indicates that further teaching is needed?
1.“I’m going to have a ham & cheese sandwich
with potato chips for lunch.”
2.”I’m going to weigh myself daily to be sure I don’t
gain too much fluid.”
3.”I can have most fresh fruits and fresh
vegetables.”
4. “I’m not supposed to eat cold cuts.”
Practice Question 6
The nurse teaches dietary restrictions to a client
with new onset congestive heart failure. Which
statement by the client indicates that further
teaching is needed?
1.“I’m going to have a ham & cheese sandwich
with potato chips for lunch.” need to reduce
Na intake – ham, cheese, & chips are high in
Na.
2.”I’m going to weigh myself daily to be sure I don’t gain too
much fluid.” true
3.”I can have most fresh fruits and fresh vegetables.” true
4. “I’m not supposed to eat cold cuts.” true, high in Na
Practice Question 7
Which of the cardiac changes if noted on
the cardiac monitor would indicate the
presence of hypokalemia?
1. Tall, peaked T wave
2. ST segment depression
3. Widening of the QRS complex
4. Prolonged PR interval
Practice Question 7
Which of the cardiac changes if noted on
the cardiac monitor would indicate the
presence of hypokalemia?
1. Tall, peaked T wave - Flat T wave with
hypokalemia. findings noted with
hyperkalemia.
2. ST segment depression
3. Widening of the QRS complex findings noted
with hyperkalemia.
4. Prolonged PR interval findings noted with
hyperkalemia.
Practice Question 8
A nurse notes bilateral 2+ edema in the lower
extremities of a client with myocardial infarction
who was admitted 2 days ago. The nurse would
plan to do which of the following next?
1.Review the intake and output records for the
last 2 days.
2. Change the time of diuretic administration from
morning to evening.
3.Request a sodium restriction of 1 g/day from
the physician
4. Order daily weights starting on the following
morning.
Practice Question 8
A nurse notes bilateral 2+ edema in the
lower extremities of a client with myocardial
infarction who was admitted 2 days ago.
The nurse would plan to do which of the
following next?
1.Review the intake and output records for
the last 2 days.
2. Change the time of diuretic administration from
morning to evening. Must complete assessment
before beginning interventions…also diuretic adm
at night not recommended unless a f/c is in place.
3.Request a sodium restriction of 1 g/day from the
physician Must complete assessment before
beginning interventions…also
4. Order daily weights starting on the following morning.
This is an assessment but #1 would be performed
first.
Practice Question 9
A client with deep vein thrombosis is
receiving a continuous IV infusion of
heparin sodium. The client’s aPPT is 65
seconds; the baseline aPTT before
initiation of therapy was 30 seconds. A
nurse anticipates which action is needed?
1. Shutting off the heparin infusion.
2.Decreasing the rate of the heparin infusion.
3.Leaving the rate of the heparin infusion as is.
4. Increasing the rate of the heparin infusion.
Practice Question 9
A client with deep vein thrombosis is receiving
a continuous IV infusion of heparin sodium. The
client’s aPPT is 65 seconds; the baseline aPTT
before initiation of therapy was 30 seconds. A
nurse anticipates which action is needed?
1. Shutting off the heparin infusion.
2.Decreasing the rate of the heparin infusion.
3.Leaving the rate of the heparin infusion
as is. Activated partial thromboplastin
time. 20-36 seconds nml WNL. 1.5-2.5
times normal is therapeutic level.
4. Increasing the rate of the heparin infusion.
Practice Question 10
The nurse is reviewing the EKG rhythm
strip on a client with a myocardial
infarction. The nurse notes the PR
interval is 0.20 seconds. The nurse
determines that this is
1. a normal finding.
2. indicative of atrial flutter.
3. indicative of impending reinfarction.
4. indicative of atrial fibrillation.
Practice Question 10
The nurse is reviewing the EKG rhythm strip
on a client with a myocardial infarction. The
nurse notes the PR interval is 0.20 seconds.
The nurse determines that this is
1. a normal finding. Time it takes for the
cardiac impulse to spread from atria to
the ventricles. 0.12-0.2 WNL
2. indicative of atrial flutter.
3. indicative of impending reinfarction.
4. indicative of atrial fibrillation.
Practice Question 11
The nurse is providing instructions to a client
who will be taking captopril (Capoten). Which
statement by the client indicates a need for
further instructions?
1.”I need to drink increased amounts of water.”
2.”I need to change positions slowly.”
3.“I need to avoid taking hot baths or showers.”
4.“I need to sit down and rest if dizziness or lightheadedness occurs.
Practice Question 11
The nurse is providing instructions to a client who
will be taking captopril (Capoten). Which statement
by the client indicates a need for further
instructions?
1.”I need to drink increased amounts of water.”
2.”I need to change positions slowly.” can cause orthostatic
hypotension
3.“I need to avoid taking hot baths or showers.”
vasodilatation can precipitate orthostatic hypotension
4.“I need to sit down and rest if dizziness or lightheadedness occurs. can cause orthostatic hypotension
Practice Question 12
A nurse is caring for a client with acute
pulmonary edema. The physician tells the
nurse that medication will be prescribed to
help reduce preload and afterload. The
nurse anticipates that the physician will
prescribe which medication?
1. Digoxin (Lanoxin)
2. Nitroprisside sodium (Nipride)
3. Morphine sulfate
4. Furosemide (Lasix)
Practice Question 12
A nurse is caring for a client with acute pulmonary edema.
The physician tells the nurse that medication will be
prescribed to help reduce preload and afterload. The
nurse anticipates that the physician will prescribe which
medication?
1. Digoxin (Lanoxin) cardiac glycoside – incr cardiac
contractility.
2. Nitroprisside sodium (Nipride) potent vasodilator
that reduces preload and afterload.
3. Morphine sulfate narcotic analgesic, used post MI
because it reduces preload and afterload.
4. Furosemide (Lasix) loop diuretic that can reduce
preload by enhancing renal excretion of Na and
water.
Practice Question 13
A nurse is assisting to position the client for
pericardiocentesis to treat cardiac
tamponade. The nurse positions the client
1. lying on left side with a pillow under the chest
wall.
2. lying on right side with a pillow under the head.
3. supine with the head of bed elevated in a 45 to
60 degree angle.
4. supine with slight Trendelenburg position.
Practice Question 13
A nurse is assisting to position the client for
pericardiocentesis to treat cardiac tamponade.
The nurse positions the client
1. lying on left side with a pillow under the chest
wall.
2. lying on right side with a pillow under the head.
3. supine with the head of bed elevated in
a 45 to 60 degree angle. Places the heart in
close proximity to the chest wall for easier
insertion of the needle into the pericardial sac.
4. supine with slight Trendelenburg position.
Practice Question 14
A nurse has given the client with atrial fibrillation
instructions to take one aspirin daily. Which
explanation by the nurse is most correct? “This will
1. help prevent clot formation in your heart as a result of
your heart rhythm.”
2. prevent any inflammation from occurring on the walls of
your heart.”
3. most likely keep you from ever having a heart attack.”
4. keep you from experiencing chest pain.”
Practice Question 14
A nurse has given the client with atrial fibrillation
instructions to take one aspirin daily.Which
explanation by the nurse is most correct? “This will
1. help prevent clot formation in your heart as a
result of your heart rhythm.” atrial fib puts the
client at risk for mural thrombi because of the
sluggish blood flow through the atria that occurs as a
result of loss of the effective contraction of the atria.
2. prevent any inflammation from occurring on the walls of
your heart.” “any” in the answer eliminates this as a
choice. ASA does have anti-inflammatory properties it
cannot prevent “any inflammation”.
3. most likely keep you from ever having a heart attack.” not
rationale for this therapy.
4. keep you from experiencing chest pain.” low dose ASA
does not have analgesic impact.
Practice Question 15
A nurse is preparing to ambulate a client on
the third day after cardiac surgery. The nurse
would plan to do which of the following to
enable the client to best tolerate the
ambulation?
1. Encourage the client to cough and deep breathe.
2. Premedicate the client with prescribed analgesic.
3. Provide the client with a walker.
4. Remove telemetry equipment.
Practice Question 15
A nurse is preparing to ambulate a client on the third day
after cardiac surgery. The nurse would plan to do which of
the following to enable the client to best tolerate the
ambulation?
1. Encourage the client to cough and deep breathe. will not
actively help with endurance.
2. Premedicate the client with prescribed analgesic.
Encourage regular use of prn med for 48-72 hrs post
surgery because analgesia will promote rest, decr
myocardial oxygen consumption resulting from pain,
and allow better participation in post op activities .
3. Provide the client with a walker. Will not aid in tolerance
of ambulation…do not make dependent on asst
device.
4. Remove telemetry equipment. Contraindicated and
cannot remove unless ordered by MD
Practice Question 16
A client with cardiac disease turns on his call
light and tells the nurse he is experiencing
chest pain. What is the first nursing action?
1. Begin oxygen administration at a rate of 4 L/min
via a nasal cannula.
2. Listen to heart sounds for ectopic beats.
3. Ausculate breath sounds and maintain airway.
4. Determine what the client was doing before
onset of pain.
Practice Question 16
A client with cardiac disease turns on his call light
and tells the nurse he is experiencing chest pain.
What is the first nursing action?
1. Begin oxygen administration at a rate of 4
L/min via a nasal cannula. Angina is the result
of an imbalance betw oxygen supply and
demand…
2. Listen to heart sounds for ectopic beats. Not indicated
3. Ausculate breath sounds and maintain airway. Not
indicated
4. Determine what the client was doing before onset of pain.
Could provided significant info – but pt has hx of
cardiac disease – angina indicates the need for an
intervention to prevent cardiac damage. This
intervention is appro after the acute episode has been
resolved.
Practice Question 17
The client who is receiving digoxin (Lanoxin)
and furosemide (Lasix) is at risk for developing
digitalis toxicity. Which of the following serum
lab values would the nurse correlate with this
problem?
1. Sodium level of 135 mEq/L
2. BUN of 35 mg/dl
3. Calcium level of 6 mg/dl
4. Potassium level of 3.0 mEq/L
Practice Question 17
The client who is receiving digoxin (Lanoxin) and furosemide
(Lasix) is at risk for developing digitalis toxicity. Which of the
following serum lab values would the nurse correlate with
this problem?
1. Sodium level of 135 mEq/L (135-145 mEq/L)
2. BUN of 35 mg/dL (9-25 mg/dL). Elevated
levels indicate a slowing of the glomerular
filtration rate)
3. Calcium level of 6 mg/dL (8.6-10 mg/dL) decr
level.
4. Potassium level of 3.0 mEq/L (3.5-4.1 mEq/L)
pt on Digoxin is very sensitive to serum levels
of potassium
Practice Question 18
A client has developed pulmonary edema secondary
to hypertension & CHF. He was experiencing
peripheral edema & paroxysmal nocturnal dyspnea
prior to admission.The nurse administers Lasix 40
mg IV push. What would the nurse observe as the
desired response?
1. Decrease in respiratory rate & in difficulty
breathing.
2. BP goes from 160/100 to 150/94.
3. Urine output increases to 100 cc per hour for 3
hours.
4. Peripheral edema begins to decrease in 24
hours.
Practice Question 18
A client has developed pulmonary edema secondary to
hypertension & CHF. He was experiencing peripheral edema
& paroxysmal nocturnal dyspnea prior to admission.The nurse
administers Lasix 40 mg IV push. What would the nurse
observe as the desired response?
1. Decrease in respiratory rate & in difficulty
breathing. Secondary to a decrease in the fluid
collecting in the lungs.
2. BP goes from 160/100 to 150/94. Decrease in BP is also
a desired response…not the primary desired
response.
3. Urine output increases to 100 cc per hour for 3 hours.
Increase in u/o desired response also – but the
improvement in breathing pattern is the best choice.
4. Peripheral edema begins to decrease in 24 hours. Could
also see a decrease in peripheral edema as the
circulating blood volume decrease.
Practice Question 19
A nurse has given instructions to the client with
Raynaud’s disease about self-management of
the disease process. The nurse determines
that the client needs further reinforcement if
the client states that:
1. Smoking cessation is important
2. Sources of caffeine should be eliminated from
the diet
3. Taking nifedipine (Procardia) as prescribed will
decrease vessel spasm
4. Moving to a warmer climate is needed.
Practice Question 19
A nurse has given instructions to the client with Raynaud’s
disease about self-management of the disease
process. The nurse determines that the client needs
further reinforcement if the client states that:
1. Smoking cessation is important advised to stop
smoking
2.
Sources of caffeine should be eliminated from the diet
advised to eliminate caffeine from the diet.
3.
Taking nifedipine (Procardia) as prescribed will
decrease vessel spasm inhibits vessel spasms
4. Moving to a warmer climate is needed.
Least desirable option. Can avoid
exposure to cold via a variety of means.
Symptoms could still occur with the use of
air conditioning and ruing periods of cooler
weather.
Renal
Practice Question 20
A client has just had a Foley catheter removed and
is to be started on a bladder retraining
program. Which intervention will provide the
most useful information about the client’s
ability to empty the bladder?
1. Calculating total fluid intake for the shift.
2. Measuring post void residual using a bladder
scan.
3. Assisting the client to the bathroom every 2
hours
4. Recording the amount of the client’s voiding.
Practice Question 20
A client has just had a Foley catheter removed and is to be
started on a bladder retraining program. Which
intervention will provide the most useful information
about the client’s ability to empty the bladder?
1. Calculating total fluid intake for the shift. Does not
provide specific info re: the emptying of the bladder.
2. Measuring post void residual using a
bladder scan. “most useful” and “ability to
empty the bladder”.
3.
4.
Assisting the client to the bathroom every 2 hours
assisting the client to the bathroom and recording
intake and output are general interventions that
provide estimates of the ability to empty the
bladder, but not specific information.
Recording the amount of the client’s voiding. Provides
an estimate, but Does not provide specific info re:
the emptying of the bladder.
Practice Question 21
The nurse is caring for a client in the immediate
postoperative period after a kidney transplant. What
would the nurse anticipate regarding the
administration of IV fluid therapy?
1. Infused at a rate of 100 ml/hr to maintain renal perfusion.
2. Fluid administered at a rate to keep blood pressure within
a normal range.
3.Amount to be infused would be determined hourly based
on urinary output.
4. Adequate fluids to maintain clear urine without evidence
of blood clots.
Practice Question 21
The nurse is caring for a client in the immediate
postoperative period after a kidney transplant. What
would the nurse anticipate regarding the
administration of IV fluid therapy?
1. Infused at a rate of 100 ml/hr to maintain renal perfusion.
Based on u/o for first 12-24 hrs.
2. Fluid administered at a rate to keep blood pressure within
a normal range. Based on u/o for first 12-24 hrs.
3.Amount to be infused would be determined
hourly based on urinary output. For the 1st 1224 hrs.
4. Adequate fluids to maintain clear urine without evidence
of blood clots. Notify MD if gross hematuria and clots
are noted in the urine…urine may be pink/bloody
initially but gradually returns to normal after several
days to weeks.
Practice Question 22
The nurse is assisting the client with
cystitis with diet selection of an acid-ash
diet. The nurse encourages the client to
select which of the following foods.?
1. Low-fat milk
2. Baked haddock
3. Garden peas
4. Apples
Practice Question 22
The nurse is assisting the client with cystitis with diet
selection of an acid-ash diet. The nurse encourages the
client to select which of the following foods.?
1. Low-fat milk alkaline ash: Reduces the acidity of the
urine. Include: fruits (exclude cranberries, plums,
prunes), milk, most veges, rhubarb, small amts of
beef, halibut, veal, trout, salmon
2. Baked haddock acid-ash: incr acidity of urine. With
cystitis want urine pH (5.5) Include bread, cereal,
whole grains, cheese, eggs, fish, meat, corn and
legumes, meat, fish, oysters, poultry, pastries,
cranberries, prunes, plums, tomatoes…
3. Garden peas alkaline ash
4. Apples alkaline ash
Renal Stones/prescribed diet
• Acid Ash Diet:
Ca Phospate Stones
Ca oxalate stones
Stuvite stones
• Alkaline Ash Diet:
Uric acid stones:
• Reduce urinary purine content.
• Decrease intake of high- purine fds: organ meats,
gravies, red wines, sardines
Cystine stones: alkaline ash foods
Practice Question 23
The nurse develops a plan of care for a client
who had a renal transplant. The plan includes
monitoring the client for signs of acute graft
rejection. Which are the signs of acute graft
rejection?
1. Hypotension, graft tenderness, and hypothermia.
2. Hypertension, polyuria, and thirst.
3. Fever, hypotension, and polyuria.
4. Fever, hypertension, and graft tenderness.
Practice Question 23
The nurse develops a plan of care for a client who had
a renal transplant. The plan includes monitoring the
client for signs of acute graft rejection. Which are the
signs of acute graft rejection?
1. Hypotension, graft tenderness, and hypothermia.
Pt would be hyperthermic with rejection.
2. Hypertension, polyuria, and thirst. Polyuria and
thirst could be s/s of high output renal failure –
not graft rejection.
3. Fever, hypotension, and polyuria. Hypertension is
seen with graft refection.
4. Fever, hypertension, and graft tenderness.
Practice Question 24
Which of the following statements made by a patient
about continuous ambulatory peritoneal dialysis
indicates an accurate understanding?
“A portable hemodialysis machine is used so that I will be
able to ambulate during the treatment.”
2. “A cycling machine is used so the risk for infection is
minimized.”
3. “No machinery is involved, and I can pursue my usual
activities.”
4. “The drainage system can be used once during the day
and a cycling machine for three cycles at night.”
1.
Practice Question 24
Which of the following statements made by a patient
about continuous ambulatory peritoneal dialysis
indicates an accurate understanding?
“A portable hemodialysis machine is used so that I will be
able to ambulate during the treatment.” no machinery
involved
2. “A cycling machine is used so the risk for infection is
minimized.” no machinery involved
1.
3. “No machinery is involved, and I can pursue
my usual activities.”
4. “The drainage system can be used once during the day
and a cycling machine for three cycles at night.” no
machinery involved
Eye & Ear
• Review administration
of eye drops
• Review administration
of ear drops
Practice Question 25
The nurse is performing a voice test to assess
hearing. Which of the following describes the
accurate procedure for performing this test?
1. Whisper a statement while the client blocks
both ears
2. Whisper a statement with the examiner’s back
facing the client
3. Whisper a statement and ask the client to
repeat it while blocking one ear.
4. Stand 4 feet away form the client to ensure
that the client can hear at this distance.
Practice Question 25
The nurse is performing a voice test to assess hearing.
Which of the following describes the accurate
procedure for performing this test?
1. Whisper a statement while the client blocks both ears
not assessing hearing if both ears are blocked.
2. Whisper a statement with the examiner’s back facing
the client
3. Whisper a statement and ask the client to
repeat it while blocking one ear.
4.
Stand 4 feet away form the client to ensure that the
client can hear at this distance. Not assessing
distance hearing
Practice Question 26
A client with Meniere’s disease is
experiencing severe vertigo. Which
instruction should the nurse give to the
client to assist in controlling the vertigo?
1. Increase sodium in the diet
2. Avoid sudden head movements
3. Lie still and watch the television
4. Increase fluid intake to 3000 ml/day.
Practice Question 26
A client with Meniere’s disease is experiencing severe
vertigo. Which instruction should the nurse give to the
client to assist in controlling the vertigo?
1. Increase sodium in the diet reduce Na in the diet
2. Avoid sudden head movements
3.
4.
Lie still and watch the television option could work
but would limit mobility/independence…
Increase fluid intake to 3000 ml/day. Fluid restriction
is indicated.
Practice Question 27
Which of the following will facilitate communication
with a client who is hearing impaired?
1. Stand beside the client’s good ear and talk
loudly.
2. Stand behind the client and yell into his good
ear.
3. Face the client and talk loudly.
4. Face the client and talk in a lowered voice.
Practice Question 27
Which of the following will facilitate communication
with a client who is hearing impaired?
1. Stand beside the client’s good ear and talk
loudly.
2. Stand behind the client and yell into his good
ear.
3. Face the client and talk loudly.
4. Face the client and talk in a lowered
voice. The client will be better able to
hear lower tones – yelling and talking
loudly often raises the pitch of the
voice and makes it harder to hear.
Practice Question 28
A client who sustained an eye injury arrives
at the ER. The initial nursing action would
be to
1. flush the eye with sterile saline solution.
2. obtain a history regarding the cause of the
injury.
3. place an ice pack on the eye.
4. instill an antibiotic solution.
Practice Question 28
A client who sustained an eye injury arrives at
the ER. The initial nursing action would be to
1. flush the eye with sterile saline solution. Chemical
burn
2. obtain a history regarding the cause of the injury.
Must finish the assessment before implemented
intervention. Tx of the injury will be dependent on the
cause of the injury.
3. place an ice pack on the eye. contusion
4. instill an antibiotic solution. Must be prescribed by
MD – not usu indicated with an eye injury.
Practice Question 29
A nurse is caring for a client who had
surgery for glaucoma. The nurse tells the
client to avoid
1. bending at the waist.
2. reading books with small type.
3. reading books with larger type.
4. watching television.
Practice Question 29
A nurse is caring for a client who had
surgery for glaucoma. The nurse tells the
client to avoid
1. bending at the waist. Increases
intraocular pressure.
2. reading books with small type.
3. reading books with larger type.
4. watching television.
Avoid activities that increase IOP (intraocular
pressure). Reading and watching TV have no
impact on IOP.
Practice Question 30
The nurse is developing a teaching plan for
the client with chronic glaucoma. Which of
the following instructions would the nurse
include in the plan?
1. Avoid overuse of the eyes.
2. Decrease fluid intake to control the intraocular
pressure.
3. Decrease the amount of salt in the diet.
4. Eye medications will need to be administered
lifelong.
Practice Question 30
The nurse is developing a teaching plan for
the client with chronic glaucoma. Which of
the following instructions would the nurse
include in the plan?
1. Avoid overuse of the eyes.
2. Decrease fluid intake to control the intraocular
pressure. Minimal impact on the fluid levels in
the eye.
3. Decrease the amount of salt in the diet. Minimal
impact on the fluid levels in the eye.
4. Eye medications will need to be
administered lifelong.
Practice Question 31
The home care nurse is reviewing the record of a
client newly diagnosed with glaucoma who is
scheduled for a home visit. The nurse notes that
the physician has prescribed atropine sulfate
(Isopto-Atropine) and pilocarpine hydrochloride
(Isopto-Carpine) eye drops for a client diagnosed
with glaucoma. The nurse contacts the physician
before the home visit to
1. clarify the order for the atropine sulfate.
2. clarify the order for the pilocarpine hydrochloride.
3. determine the date of the follow-up physician visit.
4. determine the extent of the intraocular pressure.
Practice Question 31
The home care nurse is reviewing the record of a cline newly diagnosed
with glaucoma who is scheduled for a home visit. The nurse notes that
the physician has prescribed atropine sulfate (Isopto-Atropine) and
pilocarpine hydrochloride (Isopto-Carpine) eye drops for a client
diagnosed with glaucoma. The nurse contacts the physician before the
home visit to
1. clarify the order for the atropine sulfate.
Contraindicated: anticholinergic. Causes
vasodilation
2. clarify the order for the pilocarpine hydrochloride. Miotic: reduce
intraocular pressure by constricting the pupil and contracting
the ciliary muscle.
3. determine the date of the follow-up physician visit. Not necessary
unless the pt has need for clarification of this. The nurse can
contact MD during/after the visit if needed.
4. determine the extent of the intraocular pressure. Extent of the
Intraocular pressure increase is not needed to plan
for this pt’s care.
Peripheral iridectomy
• Allows aqueous humor to flow from the
posterior to the anterior chamber.
Chronic glaucoma
• Miotics: constrict the pupil
• Carbonic anhydrase inhibitors: decr the
production of aqueous humor
• Beta blockers: decr the production of aqueous
humor
• Medication use will be lifelong
• Avoid anticholinergic medications: Atropine,
Cyclopentolate, Homatropine, Scopolamine,
Tropicamide. Cause vasodilation…
Practice Question 32
The nurse is caring for a client following
enoculation. The nurse notes the presence
of bright red drainage on the dressing.
Which nursing action is appropriate?
1. Continue to monitor the drainage.
2. Document the finding.
3. Mark the drainage on the dressing and monitor
for any increase in bleeding.
4. Notify the physician.
Practice Question 32
The nurse is caring for a client following
enoculation. The nurse notes the presence of
bright red drainage on the dressing. Which
nursing action is appropriate?
1. Continue to monitor the drainage. true
2. Document the finding. true
3. Mark the drainage on the dressing and monitor for any
increase in bleeding. No pressure over the eye area.
4. Notify the physician. Postop eye surgery
always report
1 and 2 are also true – but 4 is best
response.
Neurological
Practice Question 33
A nurse performing a neurological examination is
assessing eye movement. The nurse would
perform which of the following to obtain this
assessment data?
1. Turn a flashlight on directly in front of the eye and watch
for a response.
2. Ask the client to alternate looking straight ahead and then
at the examiner’s finger.
3. Instruct the client to look straight ahead and then shine a
flashlight into the eye.
4. Ask the client to follow the examiner’s finger through the six cardinal
positions of gaze.
Practice Question 33
A nurse performing a neurological examination is
assessing eye movement. The nurse would
perform which of the following to obtain this
assessment data?
1. Turn a flashlight on directly in front of the eye and watch
for a response. Pupil response: reaction to light
2. Ask the client to alternate looking straight ahead and then
at the examiner’s finger. Pupil response:
accommodation
3. Instruct the client to look straight ahead and then shine a
flashlight into the eye. Pupil response: reaction to light
4. Ask the client to follow the examiner’s finger
through the six cardinal positions of gaze.
Practice Question 34
A client with Parkinson’s disease is taking
benztropine mesylate (Cogentin) daily.
The nurse tells the spouse to report which
side effect of the medication if it occurs?
1. Decreased appetite
2. Inability to urinate.
3. Irregular bowel movements.
4. Shuffling gait.
Practice Question 34
A client with Parkinson’s disease is taking
benztropine mesylate (Cogentin) daily. The nurse
tells the spouse to report which side effect of the
medication if it occurs?
1. Decreased appetite
2. Inability to urinate. s/e of med that would
need to be addressed by the MD
3. Irregular bowel movements. Can cause constipation
4. Shuffling gait. Sign of Parkinson’s disease
Most common s/e are constipation and urinary retention.
Important to initiate preventive measures when the client
begins the drug. Med tends to have cumulative effects and
the s/e may occur early or after it has been taken for some
time. Cogentin enhances mobility by decr tremors.
Practice Question 35
A client with myasthenia gravis is taking
neostigmine (Prostigmin). The client has
frequent exacerbations of myasthenic crisis &
cholinergic crisis. The nurse teaches the client
that it is important that this medication be
1. double dosed if one dose is missed.
2. taken on an empty stomach.
3. taken on time.
4. titrated for dosage depending on the symptoms.
Practice Question 35
A client with myasthenia gravis is taking neostigmine
(Prostigmin). The client has frequent exacerbations
of myasthenic crisis & cholinergic crisis. The nurse
teaches the client that it is important that this
medication be
1. double dosed if one dose is missed. Excessive doses
can lead to cholinergic crisis
2. taken on an empty stomach. Adm 30 min before meals
with milk and crackers to reduce GI upset.
3. taken on time. Crisis can be caused by
inadequ med, fatigue, stress, infection
4. titrated for dosage depending on the symptoms. Not true.
Tensilon Test (med used to tx
myasthenia gravis)
• Used to dx
myasthenia gravis
– Adm tensilon
– Improvement in
muscle strength
positive for
myasthenia gravis
– No Improvement in
muscle strength
negative for
myasthenia gravis
• Differentiate between
myasthenia crisis and
cholinergic crisis
– myasthenia crisis:
• Adm tensilon
• Strength improves pt
needs more med for s/s
MG
– cholinergic crisis
• Adm tensilon
• Weakness more severe
too much med for
myasthenia gravis
Practice Question 36
A client has an order to receive valproic acid
(Depakene) 250 mg once daily. To
maximize the client’s safety, the nurse
schedules administration of the medication
1. after breakfast.
2. at bedtime.
3. before breakfast.
4. with lunch.
Practice Question 36
A client has an order to receive valproic acid
(Depakene) 250 mg once daily. To
maximize the client’s safety, the nurse
schedules administration of the medication
1. after breakfast.
2. at bedtime. Safety…
3. before breakfast.
4. with lunch.
Anticonvulsant that causes CNS depression.
S/e sedation , drowsiness, dizziness. Single
daily dose at hs negates risk of injury.
Practice Question 37
The nurse is planning care for the client with a
left hemisphere stroke. The nurse would
incorporate in the care plan to place objects
1. within the client’s reach on the right side.
2. within the client’s reach on the left side.
3. just out of the client’s reach on the right side.
4. just out of the client’s reach on the left side
Practice Question 38
The nurse is planning care for the client with a
left hemisphere stroke. The nurse would
incorporate in the care plan to place objects
1. within the client’s reach on the right side.
2. within the client’s reach on the left side.
3. just out of the client’s reach on the right side.
4. just out of the client’s reach on the left side
Left brain CVA affects motor fx on right side.
Place on left side to maintain the pt’s optimal
level of independence
Left-brain damage
• Hemiplegia right side
• Impaired speech/language (impacts
language center as well as motor speech)
• Impaired right/left discrimination
• Slow performance, cautious
• Aware of deficits: depression, anxiety
• Impaired comprehension r/t language,
math
Practice Question 39
The nurse is providing dietary instructions
to a client about the food items that are
high in niacin. Which food item is highest
in niacin?
1. Milk
2. Potatoes
3. Strawberroes
4. Tomatoes
Practice Question 39
The nurse is providing dietary instrutions
to a client about the food items that are
high in niacin. Which food item is highest
in niacin?
1. Milk dairy, meat, eggs
2. Potatoes
3. Strawberroes
4. Tomatoes
Tomatoes, potatoes, strawberries are high in
ascorbic acid (vitamin C)
Practice Question 40
Acetazolamide (diamox) is prescribed for a
client with a diagnosis of a supratentorial
lesion. A nurse monitors the client for
effectiveness of this medication, knowing
that the primary action of the medication
is to
1. Decrease cerebrospinial fluid production
2. Maintain an adequate blood pressure for
cerebral perfusion
3. Prevent hyperthermia
4. Prevent hypertension
Practice Question 40
Acetazolamide (diamox) is prescribed for a client with
a diagnosis of a supratentorial lesion. A nurse
monitors the client for effectiveness of this
medication, knowing that the primary action of the
medication is to
1. Decrease cerebrospinial fluid production
carbonic anhydrase inhibitor that is used
to decr CSF production.
2. Maintain an adequate blood pressure for cerebral
perfusion
3. Prevent hyperthermia
4. Prevent hypertension
Note that supratentorial lesion clues the test taker that
this is a problem with the brain…preventing incr of ICP
is a primary goal for most….
Practice Question 41
A nurse is caring for a client with trigeminal
neuralgia. The client asks for a snack. The
nurse determines that the most appropriate
choice to meet nutritional needs is
1. Cocoa with honey and toast.
2. Hot herbal tea with graham crackers.
3. Iced coffee and peanut butter crackers.
4. Vanilla wafers and room temperature water.
Practice Question 41
A nurse is caring for a client with trigeminal neuralgia.
The client asks for a snack. The nurse determines that
the most appropriate choice to meet nutritional needs
is
1. Cocoa with honey and toast. Honey is “thick” and could
make chewing more difficult.
2. Hot herbal tea with graham crackers. “hot” tea
3. Iced coffee and peanut butter crackers. “iced” coffee and
peanut butter
4. Vanilla wafers and room temperature
water.
Sensory disorder that causes severe facial pain. Mild
tactile stimulation of the face can trigger pain.…avoid
wind, hot/cold liquids, foods that are mechanically
difficult to chew…anything that would cause CNV to
spasm and cause the pain.
Practice Question 42
A client is diagnosed with Bell’s palsy. The
nurse assessing the client expects to note
which of the following?
1. A symmetrical smile.
2. Difficulty closing the eyelid on the affected side.
3. Narrowing of the palpebral fissure on the affected
side.
4 Paroxysms of excruciating pain in the lips and
cheek on the affected side.
Practice Question 42
A client is diagnosed with Bell’s palsy. The nurse
assessing the client expects to note which of the
following?
1. A symmetrical smile. Smile would be
asymmetrical.
2. Difficulty closing the eyelid on the affected side.
Facial drooping/muscle weakness on the
affected side. Affects CN VII
3. Narrowing of the palpebral fissure on the affected
side. Palpebral fissure is the anatomical name
for the space between the upper and lower
eyelids.
4 Paroxysms of excruciating pain in the lips and
cheek on the affected side. Trigeminal neuralgia.
Practice Question 43
A nurse in the neurological unit is caring for a
client with a supratentorial lesion. The nurse
assesses which of the following as the most
critical index of CNS dysfunction?
1. Ability to speak
2. Blood pressure
3. Level of consciousness
4. Temperature
Practice Question 43
A nurse in the neurological unit is caring for a
client with a supratentorial lesion. The nurse
assesses which of the following as the most
critical index of CNS dysfunction?
1. Ability to speak
2. Blood pressure
3. Level of consciousness
4. Temperature
Changes in LOC can indicate clinical improvement or
deterioration. BP, temp, ability to speak are components
so of t his assessment. LOC provides an index of the
overall CNS
Practice Question 44
The nurse is caring for a client who is 24 hours
postoperative for a craniotomy to remove a
brain tumor. In what position would it be
important for the nurse to maintain the client?
1. Flat with blocks under the head of the bed.
2. Lateral with pillows under the arms & knees.
3. On the back with the head of the bed elevated 3540 °.
4. Prone with the head of the bed elevated 35°
Practice Question 44
The nurse is caring for a client who is 24 hours postoperative
for a craniotomy to remove a brain tumor. In what position
would it be important for the nurse to maintain the client?
1. Flat with blocks under the head of the bed.
2. Lateral with pillows under the arms & knees. Infratentorial
surgery…because of concerns re: edema.
3. On the back with the head of the bed elevated 35-40 °.
Choice that most clearly has the HOB higher than 15
degrees. Keep in semi-fowler’s position (on back with
HOB elevated) to enhance venous drainage from the
cranial vault to asst in preventing the development of
incr ICP.
4. Prone with the head of the bed elevated 35°
Practice Question 45
The nurse is caring for a client who has had a
stroke. The nurse has assigned a nursing aide
to assist the client with eating. What
observation of the aide’s activities would cause
the nurse the most concern? The aide
1. Places the client in high-Flower’s position.
2. Is placing the food on the affected side of the
mouth.
3. Is talking with the client as she is feeding him.
4. Provides liquids that have been thickened.
Practice Question 45
The nurse is caring for a client who has had a
stroke. The nurse has assigned a nursing aide
to assist the client with eating. What
observation of the aide’s activities would cause
the nurse the most concern? The aide
1. Places the client in high-Flower’s position.
2. Is placing the food on the affected side of
the mouth. Place on unaffected side of
mouth
3. Is talking with the client as she is feeding him.
4. Provides liquids that have been thickened.
Musculoskeletal System
Practice Question 46
After fitting a client with crutches the nurse is
assessing to determine if they fit properly.
What observation would cause the nurse the
most concern?
1. When the client is standing, with the hands placed
on the hand supports, the arms are straight.
2.There is space of about 1 1/2 to 2 inches between
the axillary fold and the top of the crutch.
3. The client can place crutches about 6-8 inches
lateral to the to the foot when walking.
4. The arms are flexed about 30° and resting on the
hand supports when the client is standing.
Practice Question 46
After fitting a client with crutches the nurse is
assessing to determine if they fit properly. What
observation would cause the nurse the most concern?
1. When the client is standing, with the hands placed on
the hand supports, the arms are straight. Elbows should
be slightly flexed.
2.There is space of about 1 1/2 to 2 inches between the
axillary fold and the top of the crutch. 2 finger breadth
3. The client can place crutches about 6-8 inches lateral to the
to the foot when walking. correct
4. The arms are flexed about 30° and resting on the hand
supports when the client is standing. Allows for wt bearing
on the hand supports and not under the arm when the
client begins to walk.
Practice Question 47
Postoperatively, following a lumbar
laminectomy, the client complains of the same
low back pain as before surgery. The nurse
knows that this is caused by what problem?
1. Failure of the surgery to remove the herniated disk.
2. Limitation of movement from spinal fusion.
3. Swelling of the operative area that compresses
adjacent structures.
4. Twisting of the spine when turning side to side.
Practice Question 47
Postoperatively, following a lumbar laminectomy, the
client complains of the same low back pain as before
surgery. The nurse knows that this is caused by what
problem?
1. Failure of the surgery to remove the herniated disk.
2. Limitation of movement from spinal fusion. Limitation of
movement will decr pain.
3. Swelling of the operative area that compresses
adjacent structures. After surgery edema may cause
compression of structure in the operative area. This results
in similar pain as experienced by pt preop.
4. Twisting of the spine when turning side to side. Twisting will
cause pain – but it is usu a different pain than the pain
preop.
Practice Question 48
A client has a long leg plaster cast applied.
What nursing actions are implemented while
the cast is still wet?
1. Keep the client and cast covered with blankets.
2. Place a heat lamp directly over the cast.
3. Support the cast on plastic-covered pillows.
4. Use only the fingertips when moving the cast.
Practice Question 48
A client has a long leg plaster cast applied.
What nursing actions are implemented while
the cast is still wet?
1. Keep the client and cast covered with blankets.
Covering the cast with blankets will not
promote drying.
2. Place a heat lamp directly over the cast. Do not
apply heat to damp cast.
3. Support the cast on plastic-covered pillows.
Support the cast on a pillow that will not
absorb the moisture.
4. Use only the fingertips when moving the cast.
Palms of hands used to turn client.
Practice Question 49
A client has a fractured hip and is
currently in Buck’s traction awaiting
surgery. How is the countertraction
achieved in Buck’s traction for a fractured
hip?
1. Applying a 10-pound counterweight at the knee.
2. Elevating the foot of the bed frame and allowing
the weights to hang freely.
3. Elevating the knee gatch and elevating the head of
the bed about 30°.
4. Placing shock blocks under the head of the bed.
Practice Question 49
A client has a fractured hip and is currently in Buck’s
traction awaiting surgery. How is the countertraction
achieved in Buck’s traction for a fractured hip?
1. Applying a 10-pound counterweight at the knee.
2. Elevating the foot of the bed frame and
allowing the weights to hang freely.
3. Elevating the knee gatch and elevating the head of
the bed about 30°.
4. Placing shock blocks under the head of the bed.
For any client in traction, a nsg priority is
to determine the correct amt of wt and
to assess for effectiveness of
countertraction. Wts must hang freely
for countertraction to be effective. In
Buck’s traction the entire foot of the
bed is elevated to prevent the client
from moving toward the end of the bed.
Buck’s Traction
Practice Question 50
The nursing care plan for a postoperative client
who has had a right leg amputation includes
what measures to decrease edema?
1. Administer anti-inflammatory medications as
ordered.
2. Apply ice packs to the stump for 72 hours.
3. Elevate the stump by raising the foot of the bed for
24 to 48 hours.
4. Wrap the stump with Ace bandages from proximal
to distal area.
Practice Question 50
The nursing care plan for a postoperative client who has had a
right leg amputation includes what measures to decrease
edema?
1. Administer anti-inflammatory medications as ordered. Used
for pain relief, not to prevent edema.
2. Apply ice packs to the stump for 72 hours. Ice packs are
not used postop amputation.
3. Elevate the stump by raising the foot of the bed for 24 to 48
hours. Elevation indicated to prevent edema – some
texts recommend using blocks to elevate the FOB.
4. Wrap the stump with Ace bandages from proximal to distal
area. Wrap distal to proximal
Practice Question 51
What is important assessment information to
obtain from a client who is being admitted with
a tentative diagnosis of a fractured hip?
1. Amount of pain that the fracture is causing.
2. Amount of swelling around the fracture site.
3. Circulation and sensation distal to the fracture.
4. Status of the range of motion in the extremity.
Practice Question 51
What is important assessment information to obtain
from a client who is being admitted with a tentative
diagnosis of a fractured hip?
1. Amount of pain that the fracture is causing. Also a correct
response…use ABC’s to select “3”.
2. Amount of swelling around the fracture site. Important, but
the primary concern re: swelling is impact on circulation
and neurosensory deficits.
3. Circulation and sensation distal to the fracture.
4. Status of the range of motion in the extremity. ROM should
not be attempted/assessed on this pt.
Practice Question 52
The nursing care plan for a 2-month-old infant
in a left hip spica cast includes what nursing
measures?
1. Blanch the skin of areas proximal to the casted left
leg.
2. Check cast for tightness by inserting fingers
between skin and cast.
3. Maintain constant traction on the affected left leg.
4. Palpate the left brachial artery and compare it with
the right.
Practice Question 52
The nursing care plan for a 2-month-old infant in a left
hip spica cast includes what nursing measures?
1. Blanch the skin of areas proximal to the casted left leg.
Circulation is checked distal to the cast.
2. Check cast for tightness by inserting fingers
between skin and cast. Make sure the cast is
not too tight as this would impair circulation.
3. Maintain constant traction on the affected left leg. Child is
not in traction
4. Palpate the left brachial artery and compare it with the right.
The arms are not being treated
Spica Cast
Practice Question 53
The nursing care for the client in Russell
traction includes what measures?
1. Allowing client to sit in a chair at bedside.
2. Checking distal circulation of affected leg.
3. Maintaining client in semi-Fowler’s position to
promote deep breathing.
4. Turning client every 2 hours to unaffected side.
Practice Question 53
The nursing care for the client in Russell traction
includes what measures?
1. Allowing client to sit in a chair at bedside. client in traction
not generally allowed OOB. Note that traction would not
be moved so that it would be maintained while the pt
was OOB.
2. Checking distal circulation of affected leg. Always
monitor circulation distal to the area of injury in an
orthopedic injury.
3. Maintaining client in semi-Fowler’s position to promote deep
breathing. Could position this client in semi-Fowler’s but
it is not a requirement of the traction.
4. Turning client every 2 hours to unaffected side. Generally
maintained supine to promote straight pull of traction.
Might release traction, turn s/s for hygienic purposes or
skin care, then re-establish the traction.
Russell Traction
Practice Question 54
Which of the statements by the client following
a total hip replacement indicates a lack of
understanding of mobility limitations?
1. “I should not bend down to put on shoes or socks.”
2. “It is OK to cross my legs while sitting in a chair.”
3. “I should put a pillow between my legs when lying
on my side.”
4. “I should not sit in low chairs or low toilet seats.”
Practice Question 54
Which of the statements by the client following a total
hip replacement indicates a lack of understanding of
mobility limitations?
1. “I should not bend down to put on shoes or socks.” true.
2. “It is OK to cross my legs while sitting in a
chair.” Operative leg cannot be brought across
midline. (Abduction of leg is contraindicated)
3. “I should put a pillow between my legs when lying on my
side.” maintains adduction, prevents abduction of the
affected leg.
4. “I should not sit in low chairs or low toilet seats.” usu sent
home with a device that raises the height of the toilet
seat.
Practice Question 55
Which assessment finding would cause the
nurse concern regarding development of
compartment syndrome following a fractured
fibula repaired with an external fixator? Select
all that apply.
1. Decrease in pulse rate on affected leg.
2. Paresthesia distal to area of injury.
3.Toes on affected leg cool to touch and edematous.
4. Complaints that pins are hurting
5. Complaints of pain unrelieved by analgesics.
6. Client angry & calling loudly to the nurse every 10
minutes
Practice Question 55
Which assessment finding would cause the nurse
concern regarding development of compartment
syndrome following a fractured fibula repaired with an
external fixator? Select all that apply.
1. Decrease in pulse rate on affected leg. A decrease in the
quality of the pulse would be cause for alarm.
2. Paresthesia distal to area of injury.
3.Toes on affected leg cool to touch and
edematous.
4. Complaints that pins are hurting pins do cause discomfort.
5. Complaints of pain unrelieved by analgesics.
6. Client angry & calling loudly to the nurse every 10 minutes
many clients are angry re: immobility /do not always use
effective coping mechanisms.
Compartment Syndrome
• Tough fascia surrounds muscle groups forming
compartments from which arteries, veins, nerve
enter and exit
• An increase in pressure in one or more of these
compartments leads to decr blood flow, tissue
ischemia, neurovascular impairment
• Irreversible nerve damage can occur in 4-6 hrs
after the onset of compartment syndrome
• Notify MD immediately…
Immune
Practice Question 56
The nurse would anticipate which laboratory
finding in a client with joint pain, “butterfly
rash,’ photosensitivity, weight loss, and fever?
1. Glycosuria
2. Increased red blood cell and white blood cell
counts.
3. Negative serum complement level.
4. Presence of antinuclear antibodies.
Practice Question 56
The nurse would anticipate which laboratory finding
in a client with joint pain, “butterfly rash,’
photosensitivity, weight loss, and fever?
1. Glycosuria seen with DM
2. Increased red blood cell and white blood cell counts. Not
seen
3. Negative serum complement level. Elevated erythrocyte
sedimentation rate (ESR)
4. Presence of antinuclear antibodies. Positive
ANA. Also see leucopenia, thrombocytopenia,
lymphopenia, and a positive lupus erythematosus
cell prep. Proteinurea with cellular casts if often
noted.
Practice Question 57
The nurse is preparing discharge teaching for a
woman newly diagnosed with systemic lupus
erythematosus (SLE). What will be important for
the nurse to include? Select all that apply.
1. Wear sunscreen & clothing when in sunlight.
2. Avoid NSAIDS to prevent bleeding.
3. Plan activities that use ROM in extremities.
4. Pregnancy is contraindicated.
5. Observe fingertips for changes in circulation
6. Assist to prioritize self-care activities.
Practice Question 57
The nurse is preparing discharge teaching for a woman newly
diagnosed with systemic lupus erythematosus (SLE). What will be
important for the nurse to include? Select all that apply.
1. Wear sunscreen & clothing when in sunlight. Photosensitive: Avoid
exposure to sunlight & ultraviolet light
2. Avoid NSAIDS to prevent bleeding. Use NSAIDS to tx pain and
inflammation
3. Plan activities that use ROM in extremities. Must keep joints
mobilized because of the invasion of the lupus erythematosus cells
into the joints. Pace activities to conserve energy – need to
maintain ROM
4. Pregnancy is contraindicated. Creates extra stress on body but is OK.
Should be advised re: progress of her disease and implications fro
pregnancy – but can carry and deliver healthy infant.
5. Observe fingertips for changes in circulation s/s asso with
Reynaud’s Phenomenon occur. 2nd to circulatory inflammation and
irritation.
6. Assist to prioritize self-care activities. Pace activities to minimize
fatigue – maintain independence as long as possible.
Practice Question 58
The nurse is caring for a client who is
categorized as HIV+, Category A. What would
the nurse anticipate finding on the nursing
assessment?
1. Confusion, disorientation, loss of coordination.
2. Dyspnea, tachycardia on exertion, fever.
3.Fatigue, weight loss, night sweats.
4. Red, raised lesions on neck and face, fever.
Practice Question 58
The nurse is caring for a client who is categorized as
HIV+, Category A. What would the nurse anticipate
finding on the nursing assessment?
1. Confusion, disorientation, loss of coordination. Not asso
with category A
2. Dyspnea, tachycardia on exertion, fever. Not asso with
category A
3. Fatigue, weight loss, night sweats. Category A
is when the primary condition is identified or the
client has recently been infected. May be
asymptomatic or may have symptoms of early
nonspecific changes.
4. Red, raised lesions on neck and face, fever. Not asso with
category A
Practice Question 59
A child has chicken pox. What type
immunity will this child have on his
recovery?
1. Actively acquired immunity
2. Artificially acquired immunity
3. Natural passive immunity
4. Naturally acquired active immunity
Practice Question 59
A child has chicken pox. What type immunity will
this child have on his recovery?
1. Actively acquired immunity injection of human
or animal serum
2. Artificially acquired immunity immunizations
3. Natural passive immunity placental transfer
4. Naturally acquired active immunity a child
who contracts chicken pox for the first time
develops antibodies during the period of
infection. These antibodies cerate a
naturally acquired, lifelong type of active
immunity.
Practice Question 60
The nurse is caring for a client who is experiencing
a severe anaphylactic reaction to penicillin.
After beginning oxygen administration and
determining that vital signs, including
respiration are adequate, the next most
important nursing action would be to:
1. Administer analgesics to reliever the pain
2. Start an IV for fluid administration
3. Insert a catheter to determine urinary output
4. Obtain a history of possible reactions to
penicillin.
Practice Question 60
The nurse is caring for a client who is experiencing a
severe anaphylactic reaction to penicillin. After
beginning oxygen administration and determining that
vital signs, including respiration are adequate, the next
most important nursing action would be to:
1. Administer analgesics to reliever the pain should be
not pain
2. Start an IV for fluid administration Shock is a
common problem in anaphylactic reactions.
Important to establish an IV for fluid and med
administration.
3. Insert a catheter to determine urinary output no reason
client cannot void on his own.
4. Obtain a history of possible reactions to penicillin.
History important but can be addressed later.
Extra Adult Health
Extra Practice Question 1
A nurse is teaching a client with angina
pectoris about disease management. Which
statement by the client indicates a need for
further teaching”
1. “I will take nitroglycerin whenever chest
discomfort begins.”
2. “I will use muscle relaxation to cope with
stressful situations”
3. “It is best to exercise once a week for an hour.
4. “I will avoid using table salt with meals.”
Extra Practice Question 1
A nurse is teaching a client with angina pectoris
about disease management. Which statement by
the client indicates a need for further teaching”
1. “I will take nitroglycerin whenever chest discomfort
begins.” true
2. “I will use muscle relaxation to cope with stressful
situations” good idea to teach stress reduction
techniques
3. “It is best to exercise once a week for an
hour”. Exercise 3 times a week for 20-30 minutes.
4. “I will avoid using table salt with meals.”
true
Extra Practice Question 2
A nurse has provided dietary instructions to
a client with coronary artery disease. Which
statement by the client indicates an
understanding of the dietary instructions?
1. “I need to substitute eggs for meat.”
2. “I should eliminate all cholesterol and fat from
my diet.”
3. “I should use polyunsaturated oils .”
4. “I’ll need to become a strict vegetarian.”
Extra Practice Question 2
A nurse has provided dietary instructions to a client with
coronary artery disease. Which statement by the client
indicates an understanding of the dietary instructions?
1. “I need to substitute eggs for meat.” needs to
avoid foods high in saturated fat and cholesterol
such as eggs, whole milk, and red meat.
2. “I should eliminate all cholesterol and fat from
my diet.” note the use of the word “all”
3. “I should use polyunsaturated oils .”
recommended to control
hypercholesterolemia.
4. “I’ll need to become a strict vegetarian.” not
necessary.
Extra Practice Question 3
A client returning to the unit following cardiac
catheterization has a stat order to receive a
dose of procainamide (Pronestyl). The nurse
uses which equipment to determine most
adequately the client’s response to the
medication?
1. Cardiac monitor
2. Glucometer
3. Noninvasive blood pressure cuff
4. Pulse oximeter
Extra Practice Question 3
A client returning to the unit following cardiac catheterization
has a stat order to receive a dose of Procainamide
(Pronestyl). The nurse uses which equipment to determine
most adequately the client’s response to the medication?
1. Cardiac monitor used to tx ventricular dysrythmias.
Procainamide is an antidysrhythmic.
2. Glucometer not indicated
3. Noninvasive blood pressure cuff good to have as an
improvement in rhythm would improve CO and
BP…not best choice.
4. Pulse oximeter…good to have as this provides general
info about the client’s cardiovascular status…not best
choice.
Extra Practice Question 4
A client with a myocardial infarction calls the
nurse because he is experiencing chest pain.
The nurse administers a sublingual
nitroglycerin.The chest pain is unrelieved.
The next nursing action is which of the
following?
1. Administer another nitroglycerin tablet.
2. Increase the flow rate of the oxygen.
3. Contact the physician.
4. Call the client’s family.
Extra Practice Question 4
A client with a myocardial infarction calls the nurse because
he is experiencing chest pain. The nurse administers a
sublingual nitroglycerin.The chest pain is unrelieved. The
next nursing action is which of the following?
1. Administer another nitroglycerin tablet. Adm one
tablet q5min times three for chest pain if SBP is 100 or
greater.
2. Increase the flow rate of the oxygen. If prescribed by MD
this would be next action
3. Contact the physician. If 3 NTG tablets do not relieve
the pain contact the MD.
4. Call the client’s family.
Extra Practice Question 5
The client is having difficulty coughing and deep
breathing because of pain after a
nephrectomy. Which action by the nurse
would be least helpful in promoting optimal
respiratory function?
1. Administering pain medication only before
ambulation
2. Encouraging use of incentive Spiro meter
hourly
3. Assisting the client to splint the incision during
respiratory exercise
4. Offering prn pain medication every 4 hours
when due.
Extra Practice Question 5
The client is having difficulty coughing and deep breathing
because of pain after a nephrectomy. Which action by
the nurse would be least helpful in promoting optimal
respiratory function?
1. Administering pain medication only before
ambulation Insufficient – needs more often
than before ambulation.
2. Encouraging use of incentive Spiro meter
hourly very helpful in promoting respiratory
function
3. Assisting the client to splint the incision during
respiratory exercise very helpful, asst to
breath deeply and makes the exercises
more efficient.
4. Offering prn pain medication every 4 hours
when due.
Extra Practice Question 6
A child is receiving propylthiouracil (PTU) for
treatment of hyperthyroidism. The
parents and child should be taught to
recognize and report immediately which
of the following symptoms?
1. Ear pain
2. Headache
3. Fever, sore throat
4. Gastrointestinal infection
Extra Practice Question 6
A child is receiving propylthiouracil (PTU) for
treatment of hyperthyroidism. The parents and
child should be taught to recognize and report
immediately which of the following symptoms?
1. Ear pain not necessarily an indication of
primary infection.
2. Headache not necessarily an indication of
primary infection
3. Fever, sore throat earliest indications
of agranulocytosis, which is the most
serious toxic effect of this medication.
Watch for other s/s of URI also.
4. Gastrointestinal infection
Extra Practice Question 7
A nurse will administer phenytoin (Dilantin) IV push
through an IV line of 0.9% sodium chloride. Write
the numbers representing each action in order from
first action to last action.
1. Check the client’s ID bracelet.
2. Pinch off the IV tubing above the injection port.
3. Draw up the medication in a 3 ml syringe.
4. Check the compatibility of phenytoin with the IV solution
5. Inject the medication.
6. Document that the medication was given.
Extra Practice Question 7
A nurse will administer phenytoin (Dilantin) IV push
through an IV line of 0.9% sodium chloride. Write
the numbers representing each action in order from
first action to last action.
1. Check the client’s ID bracelet.
2. Pinch off the IV tubing above the injection port.
3. Draw up the medication in a 3 ml syringe.
4. Check the compatibility of phenytoin with the IV solution
5. Inject the medication.
6. Document that the medication was given.
4,3,1,2,5,6
Extra Practice Question 8
The nurse is providing instructions to a client with a
seizure disorder who will be taking phenytoin
(Diilantin). Which statement make by the client
indicates understanding about this medication? “I
should
1. take my medication before having a blood level drawn.”
2. adjust my dose depending of the severity of the side
effects.”
3. drink alcohol in moderation.”
4. perform good oral hygiene.”
Extra Practice Question 8
The nurse is providing instructions to a client with a
seizure disorder who will be taking phenytoin
(Diilantin). Which statement make by the client
indicates understanding about this medication? “I
should
1. take my medication before having a blood level drawn.”
take med as prescribed by MD.
2. adjust my dose depending of the severity of the side
effects.” Never adjust dose of any med without
consulting MD
3. drink alcohol in moderation.” avoid alcohol
4. perform good oral hygiene.” Can cause
gum problems.
Extra Practice Question 9
A client has systemic lupus erythematosus
(SLE). What statement best describes this
client’s immune response?
1. An immediate reaction to prior exposure.
2. An immune complex that forms with antibody
production.
3. Delayed hypersensitivity that is cell mediated.
4. The immune system no longer recognizes normal
body tissue.
Extra Practice Question 9
A client has systemic lupus erythematosus (SLE).
What statement best describes this client’s immune
response?
1. An immediate reaction to prior exposure. Characteristic of
a transplant rejection or a reaction to TB skin testing.
2. An immune complex that forms with antibody production.
Type I reaction characterized by a prior exposure to the
antigen; as occurs with anaphylaxis.
3. Delayed hypersensitivity that is cell mediated. Type III
response that occurs with acute glomerulonephritis.
4. The immune system no longer recognizes
normal body tissue. Autoimmune disorder. The
body begins to invad and destroy normal tissue.
Extra Practice 10
A client comes into the ER; he states that he
had a kidney transplant a month ago. What
symptoms would cause the nurse the most
concern?
1. Fever, increased blood pressure, and increased
fatigue.
2. Inflamed joints and pitting edema in lower
extremities.
3. Nausea, vomiting and diarrhea for the past 6
hours.
4. Urine dark with a specific gravity of 1.025.
Extra Practice 10
A client comes into the ER; he states that he had a
kidney transplant a month ago. What symptoms would
cause the nurse the most concern?
1. Fever, increased blood pressure, and increased fatigue.
Fever and fatigue are the most freq. early symptom of
acute rejection.
2. Inflamed joints and pitting edema in lower extremities.
Pitting edema is not common – esp in the early stages
of rejection.
3. Nausea, vomiting and diarrhea for the past 6 hours. Not
asso with early stages of rejection
4. Urine dark with a specific gravity of 1.025. Indicates that
the kidneys are able to concentrate urine – normal.
Extra Practice 11
A client with a diagnosis of AID’S has developed
Pneumocystis carnii pneumonia (PCP). What will be
important for the nurse to include in the nursing care
plan?
1. Explain to the client why he cannot go outside his room.
2. Put a mask on the client whenever he has visitors in his
room.
3. Wear a mask and gown when providing direct care to the
client.
4. Wear a gown and gloves when assisting client with personal
hygiene.
Extra Practice 11
A client with a diagnosis of AID’S has developed
Pneumocystis carnii pneumonia (PCP). What will be
important for the nurse to include in the nursing care
plan?
1. Explain to the client why he cannot go outside his room.
2. Put a mask on the client whenever he has visitors in his
room.
3. Wear a mask and gown when providing direct care to the
client.
4. Wear a gown and gloves when assisting client
with personal hygiene. Not transmitted person
to person. Do not need airborne or droplet
precautions but standard precautions must be
strictly adhered to.
Extra Practice Question 12
A client has a problem with severe painful
osteoarthritis. A regimen of heat, massage, and
exercise has been ordered. What is the desired
response to this treatment?
1. Assist the client to effectively cope with pain.
2. Help relax muscles and relieve pain and stiffness.
3.prevent the inflammatory process.
4. Restore range of motion previously lost.
Extra Practice Question 12
A client has a problem with severe painful
osteoarthritis. A regimen of heat, massage, and
exercise has been ordered. What is the desired
response to this treatment?
1. Assist the client to effectively cope with pain. Makes client
more comfortable, does not asst in coping with pain.
2. Help relax muscles and relieve pain and
stiffness.
3.prevent the inflammatory process. Does not prevent
inflammatory process – heat would asst in relieving…
4. Restore range of motion previously lost. Usu does not
restore lost ROM...hope prevents further ROM loss