HESI PATIENT REVIEW MODULE EXAMS QUESTIONS AND ANSWERS

HESI PATIENT REVIEW MODULE EXAMS QUESTIONS AND ANSWERS 1. A nurse notes that the site of a client’s peripheral intravenous (IV) catheter is reddened, warm, ID: 73 painful, and slightly edematous near the insertion point of the catheter. On the basis of this assessment, the nurse performs which action first? A. Removes the IV catheter Correct Rationale: Phlebitis is an inflammatory process in the vein. Phlebitis at an IV site may be indicated by client discomfort at the site or by redness, warmth, and swelling in the area of the catheter. The IV catheter should be removed and a new IV line inserted at a different site. Slowing the rate of infusion and checking for loose catheter connections are not correct responses. The health care provider would be notified if phlebitis were to occur, but this is not the initial action. Test-Taking Strategy: Use the process of elimination, focusing on the data in the question. Eliminate slowing the rate of infusion and checking the connection because they are comparable or alike options in that they indicate continuation of IV therapy. Although the health care provider would be notified of this occurrence, the word “first” should direct you to select the option of removing the IV catheter. Review the signs of phlebitis and the actions to be taken when it occurs if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Intravenous Therapy B. Slows the rate of infusion C. Notifies the health care provider D. Checks for loose catheter connections 2. A 500-mL bag of intravenous (IV) fluid is hung for an assigned client. One hour later, the client ID: 97 complains of chest tightness, is dyspneic and apprehensive, and has an irregular pulse. The IV bag has 100 mL remaining. Which of the following actions should the nurse take first? A. Removing the IV B. Sitting the client up in bed C. Shutting off the IV infusion Correct Rationale: The client’s symptoms are indicative of speed shock, which results from the rapid infusion of drugs or a bolus infusion. In this case, the nurse would note that 400 mL has infused over 60 minutes. The first action on the part of the nurse is shutting off the IV infusion. Other actions may follow in rapid sequence: The nurse may elevate the head of the bed to aid the client’s breathing and then immediately notify the health care provider. Slowing the infusion rate is inappropriate because the client will continue to receive fluid. The IV does not need to be removed. It may be needed to manage the complication. Test-Taking Strategy: Use the process of elimination, focusing on the data in the question. Note the question contains the strategic word “first.” Recognizing the signs of speed shock and recalling the appropriate interventions should also direct you to the option of shutting off the IV infusion. Review the initial nursing actions for speed shock if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Intravenous Therapy D. Slowing the rate of infusion 3. A nurse discontinues infusion of a unit of packed red blood cells (RBCs) because the client is ID: 63 experiencing a transfusion reaction. After discontinuing the transfusion, which of the following actions does the nurse take next? A. Removing the IV catheter B. Notifying the registered nurse Correct C. Changing the solution to 5% dextrose in water D. Obtaining a culture of the tip of the catheter device removed from the client 4. A client with heart failure is being given furosemide (Lasix) and digoxin (Lanoxin). The client calls the nurse and complains of anorexia and nausea. Which action should the nurse take first? ID: 48 A. Administering an antiemetic B. Administering the daily dose of digoxin C. Discontinuing the morning dose of furosemide D. Checking the result of laboratory testing for potassium on the sample drawn 3 hours ago Correct 5. A client is receiving parenteral nutrition (PN), which was started by the registered nurse at a ID: 17 prescribed rate of 50 mL/hr by way of an infusion pump through an established subclavian central line. After the first 2 hours of the PN infusion, the client suddenly complains of difficulty breathing and chest pain. The nurse should immediately take which action? A. Obtain blood for culture. B. Clamp the PN infusion line. Correct Rationale: One complication of a subclavian central line is embolism, caused by air or thrombus. Sudden onset of chest pain shortly after the initiation of PN may mean that this complication has developed. The infusion is clamped (the line should not be discontinued, however), the client turned on the left side with the head down, and the registered nurse notified immediately. Depending on agency protocol, the rapid response team would also be called. Blood cultures are not necessary in this situation because infection is not the concern. Likewise, there is no useful reason to check the blood glucose level. An ECG may be obtained, but this is not the immediate priority. If the client shows signs of an air embolism, the nurse should examine the catheter to determine whether an open port has allowed air into the circulatory system. Test-Taking Strategy: Note the strategic words “after the first 2 hours” and “immediately.” Focus on the data provided in the question to determine that an embolus has occurred. Eliminate blood cultures and blood glucose testing, which, respectively, relate to infection and hyperglycemia, which is not likely to occur during the first 2 hours of PN administration. To select from the remaining options, focus on the strategic word “immediately”; this will direct you to the correct option. Review the complications of PN and the associated nursing interventions if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Parenteral Nutrition C. Obtain a sample for blood glucose testing. D. Obtain an electrocardiogram (ECG). 6. A nurse is monitoring a peripheral intravenous (IV) site and notes blanching, coolness, and edema at the insertion site. What should the nurse do first? A. Remove the IV. Correct ID: 73 Rationale: Blanching, coolness, and edema of the IV site are all signs of infiltration. Because infiltration may result in damage to the surrounding tissue, the nurse must first remove the IV cannula to prevent any further damage. The nurse should not depend solely on the blood return for assurance that the cannula is in the vein because blood return may be present even if the cannula is only partially in the vein. Compresses may be used, but the compress (warm or cool) depends on the type of solution infusing and health care provider preference. The nurse should measure the area of infiltration after the IV has been removed so that further tissue damage is prevented. Test-Taking Strategy: Note the strategic word “first.” Although each of these options is appropriate, it is necessary to prioritize them. The signs presented in the question point to infiltration. Infiltration indicates that the IV must be removed. Review the signs of infiltration and the appropriate initial interventions if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Intravenous Therapy B. Apply a warm compress. C. Check for blood return. D. Measure the area of infiltration. 7. A home care nurse has been assigned a client who has been discharged home with a ID: 40 prescription for parenteral nutrition (PN). Which of the following parameters does the nurse plan to check at each visit as a means of identifying complications of the PN therapy? Select all that apply. A. Weight Correct B. Glucose test Correct C. Temperature Correct D. Peripheral pulses E. Hemoglobin and hematocrit Rationale: When a client is receiving PN therapy, the nurse monitors the client’s weight to determine the effectiveness of the therapy. The nurse should weigh the client at each visit to make sure that the client has not gained or lost an excessive amount of weight. Because the formula contains a large amount of dextrose, the health care provider should check the client’s glucose level frequently. The nurse caring for a client receiving PN at home should also monitor the temperature to detect infection, which is a potential complication of this therapy. An infection in the intravenous line could result in sepsis because the catheter is in a blood vessel. The peripheral pulses and hemoglobin and hematocrit readings may provide data but are unrelated to complications associated with PN therapy. Test-Taking Strategy: Focus on the subject, complications associated with PN therapy. Think about the procedures involved with the administration of PN and the associated complications to answer correctly. Review the priority assessments in the client receiving PN if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Parenteral Nutrition Awarded 3.0 points out of 3.0 possible points. 8. A nurse is caring for a group of adult clients on an acute care nursing unit. Which client does the nurse recognize as the least likely candidate for parenteral nutrition (PN)? A. A 61-year-old client with pancreatitis B. A 52-year-old client with severe sepsis C. A 45-year-old client who has undergone repair of a hiatal hernia Correct ID: 95 D. A 24-year-old client with a severe exacerbation of ulcerative colitis 9. A client with a peripheral intravenous (IV) line in place has a new prescription for infusion of ID: 09 parenteral nutrition (PN), a solution containing 25% glucose. Which of the following actions should be taken by the nurse? A. Hanging the IV solution as prescribed B. Diluting the solution with sterile water to half-strength C. Questioning the registered nurse about the appropriateness of the order Correct D. Hanging the IV solution but setting the infusion at just half the prescribed rate 10. The first bag of parenteral nutrition (PN) solution has arrived on the clinical unit for a client ID: 77 beginning this nutritional therapy. The solution is to be infused by way of a central line. Which essential piece of equipment does the practical nurse obtain for the registered nurse to use when hanging the solution? A. Pulse oximeter B. Blood glucose meter C. Electronic infusion device Correct Rationale: The nurse obtains an electronic infusion device before hanging a PN solution. Because of the high glucose load, it is necessary to use an infusion device to ensure that the solution does not infuse too rapidly or fall too far behind. Because the client’s blood glucose is checked every 6 to 8 hours during administration of PN, a blood glucose meter will also be needed, but it is not essential before the solution is hung. A noninvasive blood pressure cuff is unnecessary for this procedure. Although oxygen saturation is important, in this situation, it is not the most important equipment to use at this time. Test-Taking Strategy: Note that the question contains the strategic words “essential” and “before hanging.” This tells you that the correct option identifies the item that is needed to start the infusion. Use your knowledge of the procedures for PN administration to eliminate each of the incorrect options. Review technique for administration of PN if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Parenteral Nutrition D. Noninvasive blood pressure monitor 11. A nurse is monitoring a client who is receiving parenteral nutrition (PN). Which signs or ID: 10 symptoms causes the nurse to suspect that the client is experiencing hyperglycemia as a complication? A. Pallor, weak pulse, and anuria B. Nausea, vomiting, and oliguria C. Nausea, thirst, and increased urine output Correct D. Sweating, chills, and decreased urine output 12. At 1600 the nurse checks a client’s parenteral nutrition (PN) infusion bag and finds 1100 mL ID: 31 remaining in the 3000-mL bag. The solution is running at a rate of 100 mL/hr. The bag was hung the previous day at 1800. The nurse plans to change the infusion bag and tubing this evening at which time? A. 1700 B. 1800 Correct C. 2000 D. 2100 13. The licensed practical nurse is assisting the RN who is changing the central line dressing of a ID: 62 client receiving parenteral nutrition (PN). The nurse notes moisture under the dressing covering the catheter insertion site. What does the nurse determine next? A. Temperature B. Time of the last dressing change C. Expiration date on the infusion bag D. Tightness of the tubing connections Correct 14. A client receiving parenteral nutrition (PN) requires fat emulsion (lipids), which will be ID: 85 piggybacked to the PN solution. On obtaining a bottle of fat emulsion, the nurse notes that fat globules are floating at the top of the solution. Which action should the nurse take? A. Shaking the bottle vigorously B. Requesting a new bottle from the pharmacy Correct Rationale: The nurse should not hang a fat emulsion that contains visible fat globules. Another bottle of solution should be obtained and used in its place. When PN is combined with fat emulsion, the solution should not be used if there is a visible “ring” noted in the container of solution. The actions in the other options are incorrect. Test-Taking Strategy: Remember that comparable or alike options are not likely to be correct. With this in mind, eliminate rotating the bag and shaking the bottle first. To select from the remaining options, think about the significance of seeing fat globules in the solution and imagine the potential adverse effect of fat globules in the client’s bloodstream. This will direct you to the correct option. Review the procedures for administration of fat emulsion if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Parenteral Nutrition C. Rotating the bottle gently back and forth to mix the globules D. Running the bottle under warm water until the globules disappear 15. A nurse is preparing a client for the insertion of a central intravenous line into the subclavian ID: 37 vein by the health care provider. The nurse gathers the equipment, places it at the bedside, and prepares to assist the health care provider with the procedure. As further preparation for the procedure, the nurse places the client in which manner? A. Flat on the left side B. In the prone position C. In the supine position D. In a slight Trendelenburg position Correct 16. A client is receiving parenteral nutrition (PN) with fat emulsion (lipids) piggybacked to the PN ID: 34 solution. For which signs of an adverse reaction to the fat emulsion should the nurse monitor the client? Select all that apply. A. Chills Correct B. Pallor C. Headache Correct D. Chest and back pain Correct E. Nausea and vomiting Correct F. Subnormal temperature 17. The licensed practical nurse is assisting the registered nurse who is preparing to change the ID: 91 solution bag and intravenous tubing of a client receiving parenteral nutrition (PN) through a left subclavian central venous line. Which essential action does the nurse ask the client to perform just before switching the tubing? A. Turn the head to the left. B. Turn the head to the right. C. Exhale slowly and evenly. D. Take a deep breath and hold it. Correct 18. A nurse suspects that a client receiving parenteral nutrition (PN) through a central line has an air embolism. The nurse immediately positions the client in which way? A. Left side with the head lower than the feet Correct ID: 40 B. Left side with the head higher than the feet C. Right side with the head lower than the feet D. Right side with the head higher than the feet 19. A nurse is making initials rounds on a group of assigned clients. Which client should the nurse see first? ID: 07 A. A client receiving parenteral nutrition (PN) at a rate of 50 mL/hr for the past 24 hours B. A client receiving PN at a rate of 50 mL/hr whose temp was 99° F on the previous shift C. A client receiving PN at a rate of 100 mL/hr who has complained of needing frequent trips to the bathroom to void D. A client whose PN solution was decreased to a rate of 25 mL/hr who is now complaining of weakness, headache, and sweating Correct Rationale: The nurse should see the client complaining of weakness, headache, and sweating first because these are signs of hypoglycemia, which could be caused by the decrease in the PN rate. The client who has been receiving PN at a rate of 50 mL/hr for the past 24 hours should be seen but does not need to be seen first. The client who complains of frequent trips to the bathroom should be monitored for hyperglycemia, one of the side effects of PN, but should not take precedence over the client showing signs of hypoglycemia. A client with an increased temperature should be monitored closely but does not take precedence over the client exhibiting signs of hypoglycemia. Test-Taking Strategy: Read each client description carefully. Think about the subject, complications of PN. Noting the words “decreased to a rate of 25 mL/hr who is now complaining of weakness, headache, and sweating” will direct you to this option as the priority client. Review the complications of PN and the associated signs and symptoms if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection 20. A nurse answers a call bell and finds that the parenteral nutrition (PN) solution bag of an ID: 06 assigned client is empty. The new prescription was written for a new bag at the beginning of the shift, but it has not yet arrived from the pharmacy. Which action should the nurse take first? A. Calling the health care provider B. Notifying the registered nurse so that a solution of 10% dextrose in water can be hung C. Hanging a solution of 10% dextrose in water Correct Rationale: The solution containing the highest amount of dextrose should be hung until the new bag of PN becomes available. Because PN solutions contain high-glucose concentrations, the 10% dextrose solution is the best solution to infuse because it will minimize the risk of hypoglycemia. The pharmacy and health care provider should also be called, but care of the client is the immediate priority of the nurse. Test-Taking Strategy: Note the strategic word “first” in the query of the question and focus on the data in the question. Eliminate calling the pharmacy or health care provider first because these options do not directly address the client. To select from the remaining options, recall the concentration of a PN solution and remember that this client is at risk for hypoglycemia; this will direct you to the correct option. Review care of the client receiving PN if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Parenteral Nutrition D. Hanging a solution of 5% dextrose in 0.9% sodium chloride 21. A young female client with schizophrenia says to the nurse, “Since I started on Zyprexa ID: 67 [olanzapine] last year, I’m doing well in school and all, but I’ve gained so much weight, and it’s really bothering me. What can I do about this?” Which response by the nurse would be therapeutic? A. “Well, I think you’re overreacting. Today people think they should be skinny-minnies, even though it’s not healthy.” B. “Weight gain can be a side effect of the medication, so you need to watch your diet and exercise. How much weight have you gained?” Correct Rationale: Olanzapine (Zyprexa) is an antipsychotic agent that causes weight gain, a disadvantage of the medication. Weight gain, especially in a young woman, for whom it may be an especially serious blow to self-image, may lead to noncompliance with the medication regimen. “That medication isn’t any more likely to cause weight gain than the others you’re taking” offers incorrect information. “I think you’re overreacting” minimizes the client’s complaints. “I want you to stop taking this medication immediately” gives incorrect information and is presented in an unprofessional style. Test Taking Strategy: Use knowledge of the subject, the adverse effects of olanzapine. Eliminate the option that states the client’s medication does not cause weight gain any more than others do first because this medication can cause weight gain. Next eliminate the option in which the nurse tells the client to stop taking this medication immediately because it is also inaccurate and could cause anxiety for the client. To select from the remaining options, eliminate the one in which the nurse states the client is overreacting, because this minimizes the client’s complaints. Review the effects of olanzapine if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Communication and Documentation Content Area: Pharmacology C. “That medication isn’t any more likely to cause weight gain than the others you’re taking. Perhaps we could go over your diet and exercise habits.” D. “I want you to stop taking this medication immediately, and I’m calling the doctor, because this is a very serious side effect and you may need dialysis.” 22. A client with schizophrenia has been taking an antipsychotic medication for 2 months. For which adverse effect should the nurse monitor the client closely? A. Akathisia Correct ID: 71 B. Pelvic thrusts C. Athetoid limbs D. Protruding tongue 23. A client with schizophrenia who has been taking an antipsychotic medication calls the clinic ID: 13 nurse and says, “I need to cancel my appointment with the psychiatrist again because I still have this awful sore throat. It’s so bad that my mouth has a sore.” How does the nurse respond to the client? A. “I wouldn’t be upset. It happens when you aren’t drinking enough water.” B. “I think you need to come in for blood work today because this may be a side effect of your medicine.” Correct C. “Do you remember when you started this medication? Your psychiatrist told you how important it is to keep your appointments with him.” D. “You probably have a simple flu, but it might help if you gargle with some antiseptic mouthwash every 2 hours or so and drink plenty of water.” 24. A client rings the call bell and complains of pain at the site of an IV infusion. The nurse ID: 49 assesses the site and determines that phlebitis has developed. Which actions should the nurse take? Select all that apply. A. Removing the IV catheter at that site Correct B. Applying warm, moist compresses to the IV site Correct C. Notifying the registered nurse about the finding Correct D. Encouraging the client to scrub the site while in the shower E. Starting a new IV line in a proximal portion of the same vein Rationale: The nurse should remove the IV from the phlebitic site and apply warm, moist compresses to the area to speed resolution of the inflammation. The nurse also notifies the registered nurse of this complication. The nurse should restart the IV line in a vein other than the one in which phlebitis has developed. The nurse should discourage the client from rubbing the site while in the shower because this could cause sloughing of the tissue. Test-Taking Strategy: Focus on the subject, interventions for phlebitis. Think about the pathophysiology of phlebitis to find the correct interventions. Review nursing interventions for phlebitis if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Intravenous Therapy Awarded 3.0 points out of 3.0 possible points. 25. A nurse notes that the site of a client’s peripheral IV catheter is reddened, warm, painful, and ID: 33 slightly edematous in the area of the insertion site. After taking appropriate steps to care for the client, the nurse documents in the medical record that the client has experienced which event? A. Phlebitis of the vein Correct Rationale: Phlebitis at an IV site can be identified by client discomfort at the site, as well as by redness, warmth, and swelling in the area of the catheter. The IV should be removed and a new one inserted at a different site. The remaining options are incorrect. Coolness and swelling would be noted if infiltration had occurred. The symptoms of hypersensitivity and allergic reaction depend on whether these complications are local or systemic. Test-Taking Strategy: Use the process of elimination. Remember that comparable or alike options (here, hypersensitivity and allergic reaction) are not likely to be correct. Choose phlebitis of the vein over infiltration of the IV line after recalling that warmth is noted at an IV site in which phlebitis has developed. Coolness would be noted if infiltration had occurred. Review the signs of phlebitis if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Communication and Documentation Content Area: Intravenous Therapy B. Infiltration of the IV line C. Hypersensitivity to the IV solution D. An allergic reaction to the IV catheter material 26. A nurse has a written prescription to remove an intravenous (IV) line. Which item should the ID: 08 nurse obtain from the unit supply area for use in applying pressure to the site after removing the IV catheter? A. Adhesive bandage B. Alcohol swab C. Povidone-iodine (Betadine) swab D. Sterile 2 × 2 gauze Correct 27. A client has just undergone insertion of a central venous catheter by the health care provider at ID: 99 the bedside. Which results would the licensed practical nurse be sure to bring to the attention of the registered nurse before the infusion of the IV solution is initiated? A. Serum osmolality B. Serum electrolytes C. Portable chest x-ray Correct D. Intake and output record 28. A licensed practical nurse is assisting the registered nurse who is administering a blood ID: 44 transfusion of whole blood. The RN has checked the blood bag with another nurse. Which parameter needs to be monitored before the transfusion? A. Skin color B. Vital signs Correct C. Latest platelet count D. Urine output over the past 24 hours 29. A licensed practical nurse will be monitoring a client who is to receive a transfusion of packed ID: 32 red blood cells. How long does the nurse plan to stay with the client after the unit of blood is hung? A. 5 minutes B. 15 minutes Correct C. 45 minutes D. 60 minutes 30. A client has a prescription for a unit of packed red blood cells (RBCs). Which IV solution should the nurse bring to the registered nurse to be hung with the blood product at the client’s bedside? A. 0.9% sodium chloride Correct ID: 42 B. Lactated Ringer’s solution (LR) C. 5% dextrose in 0.9% sodium chloride D. 5% dextrose in water in 0.45% sodium chloride 31. 32. A client has received a partial amount of the unit of blood hung 3½ hours ago. He experienced a transfusion reaction. Where does the nurse send the blood transfusion bag? A. Blood bank Correct B. Risk management C. Microbiology laboratory D. Infection-control department Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit ID: 87 ID: 58 values. The nurse takes the client’s temperature orally before hanging the blood transfusion and notes that it is 100.0°F. What should the nurse do next? A. Notify the registered nurse. Correct B. Begin the transfusion as prescribed. C. Administer an antihistamine and begin the transfusion. D. Administer 2 tablets of acetaminophen (Tylenol) and begin the transfusion. 33. A nurse has just hung a transfusion of packed red blood cells and stayed with the client for the ID: 67 appropriate amount of time. Before leaving the room, the nurse tells the client that it is most important to immediately report which specific signs? Select all that apply. A. Rash Correct B. Chills Correct C. Fatigue D. Backache Correct E. Tiredness 34. 35. At 1300, the nurse is documenting the receipt of a unit of packed blood cells from the hospital blood bank. The nurse calculates that the transfusion must be started by what time? A. 1315 B. 1330 Correct C. 1345 D. 1400 A client who needs to receive a blood transfusion has experienced a pruritic rash during ID: 91 ID: 61 previous transfusions. The client asks the nurse whether it is safe to receive the transfusion. Which medication does the nurse explain will likely be prescribed before the transfusion? A. Ibuprofen B. Acetaminophen C. Diphenhydramine Correct D. Acetylsalicylic acid 36. A licensed practical nurse is following a plan of care for a client with renal colic who is receiving ID: 29 meperidine hydrochloride for pain. Which side effects does the nurse make a note of needing to be alert to in the plan of care? Select all that apply. A. Hypotension Correct B. Constipation Correct C. Bradycardia D. Urine retention Correct E. Respiratory depression Correct 37. A licensed practical nurse is following a plan of care for a client with a diagnosis of cancer who ID: 47 is receiving morphine sulfate for pain. Which action does the nurse identify as a priority in the plan of care for this client? A. Monitoring urine output B. Encouraging increased fluids C. Monitoring the client’s temperature D. Monitoring the client’s respiratory rate Correct 38. A client who has been taking lisinopril complains to the nurse of a persistent dry cough. The licensed practical nurse reinforces which instruction? A. This is a side effect of therapy. Correct ID: 57 B. He probably has an upper respiratory infection. C. He needs to have his blood counts checked. D. A chest x-ray is required because the cough is a sign of heart failure. 39. A client has been given a prescription to begin using nitroglycerin transdermal patches for the management of angina pectoris. The licensed practical nurse reinforces which instruction? A. Place the patch in the area of a skin fold to promote adherence. B. Apply the patch at the same time each day and leave it in place for 12 to 16 hours as directed. Correct ID: 15 C. If the patch becomes dislodged, do not reapply and wait until the next day to apply a new patch. D. Alternate daily dose times between the morning and the evening to prevent the development of tolerance to the medication. 40. A client with newly diagnosed angina pectoris has taken two sublingual nitroglycerin tablets for ID: 95 chest pain. The chest pain is relieved, but the client complains of a headache. The licensed practical nurse reinforces which instruction? A. This is an indication that the medication should not be used again. B. Headache indicates medication tolerance, and the dosage must be increased. C. This may be an allergic reaction to the nitroglycerin, and the health care provider must be notified. D. This is an expected side effect of the nitroglycerin, and the client can relieve it by taking acetaminophen (Tylenol). Correct 41. 42. A client has been taking metoprolol (Lopressor, Toprol-XL). Which finding indicates to the nurse that the medication is effective? A. The client’s ankles are swollen. B. The client’s weight has increased. C. The client’s blood pressure has decreased. Correct D. The client has wheezes in the lower lobes of the lungs. A nurse has taught a client taking a methylxanthine bronchodilator about beverages that must ID: 89 ID: 01 be avoided. Which beverage choices by the client indicate to the nurse that the client needs further education? Select all that apply. A. Cocoa Correct B. Coffee Correct C. Lemonade D. Orange juice E. Chocolate milk Correct 43. A client taking hydrochlorothiazide reports to the clinic for follow-up blood tests. For which side effect of the medication does the nurse monitor the client’s laboratory results? A. Hypokalemia Correct B. Hypocalcemia C. Hypernatremia D. Hypermagnesemia ID: 45 44. A nurse has taught a client who is taking lithium carbonate about the medication. The nurse determines that the client needs additional teaching if the client makes which statement? ID: 04 A. The medication should be taken with meals. B. The lithium blood levels must be monitored very closely. C. It is important to decrease fluid intake while taking the medication to avoid nausea. Correct Rationale: Because the therapeutic and toxic dosage ranges are so close, the blood level of lithium in a client taking the medication must be monitored closely; assessments are performed frequently at first and every several months thereafter. The client should be instructed to stop taking the medication if excessive diarrhea, vomiting, or diaphoresis occurs and to inform the health care provider if any of these problems develops. Lithium is irritating to the gastric mucosa; therefore lithium should be taken with meals. A normal diet and normal salt and fluid intake (1500–3000 mL/day of fluid) should be maintained because lithium decreases sodium reabsorption in the renal tubules, which may result in sodium depletion. Low sodium intake causes an increase in lithium retention and could lead to toxicity. Test-Taking Strategy: Note the strategic words “needs additional teaching” in the query of the question, which indicate a negative event query and the need to select the incorrect client statement. Remember that clients should be taught to maintain adequate fluid intake. This principle will direct you to the correct option. Review client teaching points for the administration of lithium if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology D. The health care provider must be called if excessive diarrhea, vomiting, or diaphoresis occurs. 45. A licensed practical nurse is following a plan of care for a client, hospitalized with heart failure, ID: 38 who has a history of Parkinson disease and is taking benztropine mesylate daily. Which intervention does the nurse identify as a priority in the plan? A. Monitoring intake and output Correct B. Monitoring the client’s pupillary response C. Placing the client in a right side-lying position D. Checking the client’s hemoglobin level daily 46. A licensed practical nurse is reinforcing instructions to a client regarding quinapril hydrochloride. The nurse reinforces which client instructions? A. To take the medication with meals B. To rise slowly from a lying to a sitting position Correct ID: 12 C. To discontinue the medication if nausea occurs D. That a therapeutic effect will be felt immediately 47. Methylergonovine intramuscularly is prescribed for a postpartum client. Before administering the medication, the licensed practical nurse reinforces which instructions to the client? A. Reduce lochial drainage. B. Prevent postpartum bleeding. Correct ID: 77 Rationale: Methylergonovine, an ergot alkaloid/oxytocic agent, is used to prevent or control postpartum hemorrhage by inducing uterine contraction and enhancing myometrial tone. The immediate dose is usually administered intramuscularly, and then, if needed, the drug is given again by mouth. Methylergonovine increases the strength and frequency of contractions and may increase blood pressure. One priority before the administration of methylergonovine is assessment of the client’s blood pressure. There is no relationship between the action of this medication and lochial drainage. Test-Taking Strategy: Use the process of elimination and focus on the subject, methylergonovine. Recalling the classification of the medication and remembering that this medication is an oxytocic agent will direct you to the correct option. If you had difficulty with this question, review methylergonovine and its effects. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology C. Maintain a normal blood pressure. D. Decrease the strength of uterine contractions. 48. 49. Carbamazepine is prescribed for a client with trigeminal neuralgia. Which side effects does the nurse reinforce to the client to report to the health care provider? Select all that apply. A. Fever Correct B. Nausea C. Headache D. Sore throat Correct E. Mouth sores Correct Disulfiram is prescribed for a client. Which questions does the nurse make a priority of asking the client before administering this medication? Select all that apply. A. “When did you have your last full meal?” B. “Do you have a history of diabetes insipidus?” C. “When was your last drink of alcohol?” Correct D. “Do you have a history of thyroid problems?” Correct E. “Do you have a history of cancer in your family?” ID: 79 ID: 51 50. A nurse is monitoring a client who is being hospitalized with a diagnosis of pneumonia. The ID: 97 client’s husband tells the nurse that the client is taking donepezil hydrochloride). The nurse should ask the husband about the client’s history of which disorder? A. Dementia Correct B. Seizure disorder C. Diabetes mellitus D. Posttraumatic stress disorder 51. Fluoxetine hydrochloride is prescribed for a client, and the nurse reinforces instruction ID: 43 regarding the use of the medication. The nurse tells the client that it is best to take the medication at what time? A. At lunchtime B. In the morning Correct C. With the evening meal D. Midafternoon, with an antacid 52. A nurse is reinforcing instructions to a client how to mix regular and NPH insulin in the same syringe. The nurse provides which client instruction? A. Shake the NPH insulin bottle before mixing the two types. B. Draw the regular insulin into the syringe first. Correct ID: 27 C. Remove all of the air from the bottle before mixing the two types. D. Keep insulin refrigerated at all times. 53. A nurse reinforces instructions to a client who will be taking furosemide. Which statement by the client indicates to the nurse that the client needs additional instruction? A. “I need to sit or stand up slowly.” B. “I should expect to have ringing in my ears.” Correct ID: 93 C. “I need to maintain my fluid intake.” D. “This medication will make me urinate.” 54. 55. A client is receiving heparin sodium by way of continuous intravenous (IV) infusion. For which adverse effects of the therapy does the nurse monitor the client? Select all that apply. A. Tinnitus B. Tarry stools Correct C. Slowed pulse D. Bleeding from the gums Correct E. Increased blood pressure A client has a prescription for short-term therapy with enoxaparin. The nurse reinforces to the client that this medication is being prescribed for which reason? A. Prevent pain. B. Relieve back spasms. C. ID: 59 ID: 65 Increase the client’s energy level. D. Reduce the risk of deep vein thrombosis. Correct 56. Metoprolol has been prescribed for a client with hypertension. For which common side effects of the medication does the nurse monitor the client? Select all that apply. A. Fatigue Correct B. Dry eyes C. Weakness Correct D. Erectile dysfunction Correct E. Nightmares ID: 21 57. A client with HIV infection has been started on therapy with zidovudine. The nurse tells the ID: 75 client to report to the laboratory in 3 months for testing to detect adverse effects of the therapy. Which laboratory test is most important in light of the therapy that has been prescribed for this client? A. Creatinine B. Serum potassium C. Blood urea nitrogen (BUN) D. Complete blood count (CBC) Correct Rationale: Agranulocytopenia and anemia are common side effects of zidovudine. In some cases lactic acidosis develops. The nurse carefully monitors CBC results for these changes. With early HIV infection or in the client who is asymptomatic, a CBC is performed monthly for 3 months, then every 3 months thereafter. In clients with advanced disease, a CBC is performed every 2 weeks for the first 2 months and then once a month if the medication is tolerated well. The other options are incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that both involve kidney function. To select from the remaining options, recall that agranulocytopenia and anemia are common side effects of this medication; this will direct you to the correct option. Review the side effects of zidovudine if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology 58. A nurse is reading the medical record of a client receiving haloperidol. The nurse notes that the ID: 71 health care provider has documented that the client is experiencing signs of akathisia. On the basis of the health care provider’s note, which clinical manifestation would the nurse expect to find during assessment of the client? A. Motor restlessness Correct B. Puffing of the cheeks C. Puckering of the mouth D. Protrusion of the tongue 59. Phenelzine sulfate is being administered to a client with depression. The client suddenly ID: 02 complains of a severe frontally radiating occipital headache, neck stiffness and soreness, and vomiting. On further assessment, the client exhibits signs of hypertensive crisis. Which medications should the nurse prepare to administer, anticipating that it will be prescribed as the antidote to treat phenelzine-induced hypertensive crisis? A. Phentolamine Correct B. Protamine sulfate C. Calcium gluconate D. Acetylcysteine 60. Risperidone is prescribed for a client with a diagnosis of schizophrenia. Which laboratory study does the nurse expect to see among the health care provider’s prescriptions? A. Platelet count Incorrect B. Creatinine level Correct C. Sedimentation rate D. Red blood cell count ID: 35 61. 62. Betaxolol eye drops have been prescribed for the treatment of a client’s glaucoma. The nurse reinforces instructions to the client to return to the clinic for which reason? A. To have her weight checked B. To give a sample for urinalysis C. To have the blood glucose level checked D. For measurement of blood pressure and apical pulse Correct Intravenous tobramycin sulfate is prescribed for a client with a respiratory tract infection. For which symptom, indicative of an adverse effect, does the nurse monitor the client? A. Nausea B. Vertigo Correct ID: 79 ID: 87 C. Vomiting D. Hypotension 63. A client who is taking bupropion in an attempt to stop smoking tells a nurse that he has been ID: 99 doubling the daily dose to make it easier to resist smoking. The nurse warns the client that doubling the daily dosage is dangerous. Of which adverse effect of the medication does the nurse warn the client? A. Insomnia B. Seizures Correct C. Weight gain D. Orthostatic hypotension 64. A nurse is caring for a client with histoplasmosis who is receiving intravenous (IV) amphotericin B. What should the nurse do while the medication is being administered? A. Monitor the client’s urine output. Correct ID: 60 Rationale: Amphotericin B can produce medication toxicity during administration and exhibit symptoms such as chills, fever, headache, vomiting, and impairment of renal function. The medication is also irritating to the IV site, commonly causing thrombophlebitis. The nurse administering this medication watches for all of these problems. The other options are not specifically related to the administration of this medication. Test-Taking Strategy: Use your knowledge of the subject, this potent medication, to answer this question. Recalling that fever and chills may occur will help you eliminate monitoring of the client for hypothermia. To select from the remaining options, recall that the medication can be toxic to the kidneys, which should direct you to the correct option. Review nursing care in regard to the administration of amphotericin B if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology B. Monitor the client for hypothermia. C. Check the client’s neurological status. D. Check the client’s blood glucose level. 65. A client with rheumatoid arthritis is taking high doses of aspirin. While assessing the client for aspirin toxicity, which question should the nurse ask the client? A. “Are you constipated?” B. “Are you having any diarrhea?” C. “Do you have any double vision?” D. “Do you have any ringing in the ears?” Correct ID: 05 66. A nurse is reviewing the laboratory results of a client receiving intravenous chemotherapy. Which laboratory findings prompts the nurse to initiate neutropenic precautions? ID: 69 A. A clotting time of 10 minutes B. An ammonia level of 20 mcg/dL C. A platelet count of 100,000 cells/mm3 D. A white blood cell (WBC) count of 2000 cells/mm3 Correct 67. Cyclophosphamide, a chemotherapy agent known to cause hemorrhagic cystitis, has been prescribed for a client with breast cancer. The nurse should reinforce which instructions? A. To avoid salt while taking this medication B. That it is best to take the medication with food C. To drink at least two glasses of orange juice every day D. To increase fluid intake to 2000 mL to 3000 mL/day Correct ID: 28 Rationale: Hemorrhagic cystitis is a toxic effect of cyclophosphamide. The client must be instructed to drink copious amounts of fluid during administration of this medication. The client should also monitor her urine for hematuria. The medication should be taken on an empty stomach, unless gastrointestinal upset occurs. Hyperkalemia may also result from the use of the medication; therefore the client would not be encouraged to increase potassium intake (i.e., bananas and orange juice). The client also would not be instructed to alter her sodium intake. Test-Taking Strategy: Knowledge regarding the subject, the toxic effects of cyclophosphamide, will assist you in answering this question correctly. Correlate cyclophosphamide with hemorrhagic cystitis to direct you to the correct option. If you had difficulty with this question, review the toxic effects associated with cyclophosphamide. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology 68. A client is receiving intravenous bleomycin sulfate, an agent known to cause interstitial ID: 83 pneumonitis. During administration of the chemotherapy, which of the following is the highest priority for the nurse to monitor? A. Heart rate B. Lung sounds Correct C. Peripheral pulses D. Level of consciousness 69. The serum theophylline level of a client who is taking the medication (Theo-24) is 16 mcg/mL. On the basis of this result, the nurse will take which initial action? A. Document the normal value on the chart. Correct ID: 30 B. Call the health care provider immediately. C. Call the rapid response team to help with the emergency. D. Call the pharmacy to alert the pharmacist regarding the client’s theophylline level. 70. A client with tuberculosis is being started on isoniazid (INH), and the nurse stresses the ID: 50 importance of returning to the clinic for follow-up blood testing. Which blood test will be performed? A. Liver enzymes Correct B. Serum creatinine C. Blood urea nitrogen D. Red blood cell count 71. Baclofen is prescribed for a client with a spinal cord injury who is experiencing muscle spasms. ID: 65 While reinforcing instructions to the client, which side effect does the nurse tell the client is possible? A. Photosensitivity B. Nasal congestion Correct Rationale: Common side effects of baclofen include drowsiness, dizziness, weakness, and nausea. Occasional side effects include headache, paresthesia of the hands and feet, constipation or diarrhea, anorexia, hypotension, confusion, and nasal congestion. Paradoxical central nervous system excitement and restlessness may occur, along with slurred speech, tremor, dry mouth, nocturia, and impotence. Photosensitivity is not a side effect of this medication. Test-Taking Strategy: Knowledge regarding the subject, the side effects of baclofen, is needed to answer this question. Eliminate increased appetite and increased salivation because they are comparable or alike options. To select from the remaining options, it is necessary to know that nasal congestion can occur. Review the side effects of baclofen if you had difficulty with this question.. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology C. Increased appetite D. Increased salivation 72. A nurse is caring for a client with myasthenia gravis who is exhibiting signs of cholinergic crisis. Which medication does the nurse ensure is available to treat this crisis? A. Atropine sulfate Correct ID: 52 B. Protamine sulfate C. Acetylcysteine (Mucomyst) D. Pyridostigmine bromide (Mestinon) 73. A nurse is reinforcing instruction to a client who is taking codeine sulfate for severe back pain. The nurse should provide which instruction? A. Decrease fluid intake. B. Maintain a high-fiber diet. Correct C. Avoid all exercise to help prevent lightheadedness. D. Avoid the use of stool softeners to help prevent diarrhea. ID: 69 74. A nurse is monitoring a pregnant client who is being given oxytocin to induce labor. Which ID: 25 occurrence should the nurse recognize requires the registered nurse to be notified immediately so the oxytocin infusion can be discontinued? A. Uterine atony B. Severe drowsiness C. Uterine hyperstimulation Correct Rationale: Oxytocin, a synthetic hormone that stimulates uterine contractions, is a commonly used pharmacological means of inducing labor. One major concern associated with oxytocin is hyperstimulation of uterine contractions. Hyperstimulation of the uterus, which may result in diminished placental perfusion, may cause fetal distress. Therefore an oxytocin infusion must be stopped if there are any signs of uterine hyperstimulation. Early decelerations of the fetal heart rate are a reassuring sign and do not indicate fetal distress. Uterine atony and severe drowsiness are not indications of the need to discontinue the infusion. Test-Taking Strategy: Use data in the question regarding induction of labor. Knowing that induction of labor involves the stimulation of uterine contractions will help you answer this question. Using your knowledge of the effect of uterine contractions on uteroplacental circulation should help you recognize that hyperstimulation of contractions would compromise fetal oxygenation, a primary physiological need. Review the nursing implications associated with the administration of oxytocin if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology D. Early decelerations of the fetal heart rate 75. A home health nurse reinforces instructions to a client who is taking allopurinol for the treatment of gout. The nurse provide which client instructions? A. Place an ice pack on the lips if they swell. B. Drink at least 8 glasses of fluid every day. Correct ID: 83 C. Take the medication on an empty stomach 2 hours before meals. D. Use an over-the-counter (OTC) antihistamine lotion if a rash develops. 76. A client taking metronidazole for the treatment of trichomoniasis vaginalis calls the clinic nurse ID: 23 to express concern because her urine has turned dark. The nurse should reinforce which client information? A. To increase her fluid intake B. To discontinue the medication C. To report to the clinic to see the health care provider D. That darkening of the urine is a harmless side effect Correct 77. Erythromycin is prescribed for a client with a respiratory tract infection. The nurse reinforces ID: 53 instructions to the client regarding the administration of the oral medication and tells the client to take the medication in which manner? A. With juice B. With a meal C. On an empty stomach Correct D. At bedtime, with a snack 78. The licensed practical nurse (LPN) is monitoring a client who is receiving a continuous ID: 56 intravenous infusion of morphine sulfate. Which finding should cause the LPN to notify the registered nurse? A. Temperature of 97.6°F B. Urine output of 30 mL/hr C. Blood pressure of 100/60 mm Hg D. Respiratory rate of 10 breaths/min Correct Rationale: Before an opioid is administered, respiratory rate, blood pressure, and pulse rate should be measured. The medication should be withheld and the health care provider notified if the respiratory rate is 12 breaths/min or slower, if the blood pressure is significantly below the pretreatment value, or if the pulse rate is significantly above or below the pretreatment value. A urine output of 30 mL/hr is normal. A temperature of 97.6°F is below normal, but it is not necessary to notify the health care provider of this reading. Test-Taking Strategy: Use the process of elimination. Recall the subject, the effects of morphine sulfate. Knowing that morphine sulfate primarily affects respiration will help direct you to the correct option. If you are unfamiliar with the adverse effects of morphine sulfate, review this content. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology 79. A nurse is reinforcing dietary instructions to a client taking spironolactone. Which foods does the nurse instruct the client to avoid? Select all that apply. A. Rice B. Cereal C. Carrots D. Bananas Correct E. Citrus fruits Correct ID: 81 80. A nurse is caring for a client with a diagnosis of chronic renal failure who is receiving dialysis. ID: 85 Epoetin alfa, to be administered subcutaneously, has been prescribed, and the nurse is drawing the medication from a single-use vial. The nurse should prepare the medication in which manner? A. Shaking the vial before drawing up the medication B. Drawing up the medication and discarding the unused portion Correct C. Obtaining the medication from the medication freezer and allowing it to thaw D. Mixing the medication with 0.1 mL of heparin before administration to prevent clotting 81. Zidovudine is prescribed for an adult client with HIV infection. The nurse, while reinforcing instructions to the client, should provide which information? A. That the medication must be taken with milk B. That aspirin can be taken to treat headache C. To discontinue the medication if nausea occurs ID: 36 D. To space the doses evenly around the clock Correct Rationale: The adult dosage of zidovudine is usually 200 mg every 8 hours or 300 mg every 12 hours. The client is instructed to space doses of the medication evenly around the clock. Food or milk does not affect the gastrointestinal absorption of the medication. The client is instructed to continue therapy for the full prescribed duration of treatment. The client is also instructed not to take any medication, including aspirin, without the health care provider’s approval. Test-Taking Strategy: Knowledge of the subject, administration of zidovudine, and basic principles of medication administration will assist you in eliminating the option referring to discontinuation of the medication. To select from the remaining options, recall that this medication is an antiviral, which will direct you to the correct option. Remember that evenly spaced doses are necessary to maintain virustatic concentrations of the medication. Review client teaching points for zidovudine if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology 82. A nurse is to administer a dose of digoxin to a client with atrial fibrillation. The client has a potassium level of 4.6 mEq/L. The nurse makes which determination regarding the dose? A. The dose should be withheld that day. B. The dose should be administered as prescribed. Correct ID: 75 C. The dose should be withheld and the health care provider notified. D. The dose should be preceded with a dose of potassium. 83. A client with heart failure being discharged home will be taking furosemide (Lasix). Which statements by the client indicates to the nurse that the teaching has been effective? A. “I’ll weigh myself every day.” Correct ID: 03 Rationale: A client taking furosemide must be able to monitor fluid status throughout therapy. Weighing oneself each day is the easiest and most accurate way to accomplish this. Checking the ankles for swelling and measuring urine output are incorrect because of the difficulty of assessing fluid status accurately in these ways. Taking daily pulse is not necessary and unrelated to the administration of furosemide. Test-Taking Strategy: Use the process of elimination. Use knowledge of the subject, effective client teaching. In client teaching questions, try to select the option that would be the easiest and most effective for a nurse to teach and for the client to understand. Remember, if you teach a client to do something that is too complicated, compliance will be poor. Having the client weigh himself every day is the easiest and most accurate way to measure fluid status. If you had difficulty with this question, review the measures with which to effectively identify a therapeutic response to furosemide. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology B. “I’ll take my pulse every day.” C. “I’ll measure my urine output.” D. “I’ll check my ankles every day for swelling.” 84. 85. A client who has undergone adrenalectomy is prescribed prednisone. Which finding indicates that the client is experiencing an adverse effect of the medication? A. Dry mouth B. Tarry stools Correct C. Hypotension D. Hypoglycemia A pregnant client is receiving magnesium sulfate for the management of preeclampsia. Which finding indicates to the nurse that the client is experiencing magnesium toxicity? A. Proteinuria of +3 B. Sudden drop in fetal heart rate Correct ID: 54 ID: 81 C. Presence of deep tendon reflexes D. Serum magnesium level of 6 mEq/L 86. A client with a thoracic spinal cord injury is receiving dantrolene sodium. Which statement by ID: 46 the client indicates to the nurse that the client is experiencing an undesired effect of the medication? A. “I’m feeling really drowsy.” Correct B. “My legs are very relaxed.” C. “I can’t seem to get enough to eat.” D. “I urinate about the same amount as I always did.” 87. 88. The emergency department staff prepares for the arrival of a child who has ingested a bottle of acetaminophen. Which medication does the nurse ensure is available? A. Pancreatin B. Protamine sulfate C. Phytonadione (vitamin K) D. Acetylcysteine Correct A nurse is caring for a client who has been taking acetazolamide for glaucoma. Which ID: 55 ID: 89 information, documented in the assessmen