and Answers
A nurse is caring for a client who has been off
the unit for physical therapy for the past hour
notes that the infusion pump for the clients TPN A nurse is reinforcing teaching to a client who is
is turned off. The client tells the nurse that the newly diagnosed with hypertension and has been
battery went dead while she was in physical prescribed captopril (Capoten). The nurse should
therapy. The nurse should monitor the client for reinforce that which of the following medications
which of the following manifestations? - - has the potential to reduce the antihypertensive
Shakiness and diaphoresis effect of captopril? - - Aspirin (Bayer)
These are manifestations of hypoglycemia, which
can occur if there is a sudden interruption in the Aspirin and other NSAIDS can reduce the
delivery of TPN, resulting in the client receiving antihypertensive effects of captopril, which is an
below the prescribed amount. ACE inhibitor. The nurse should reinforce to the
client that aspirin has the potential to reduce the
antihypertensive effect of captopril and should be
A nurse is reinforcing teaching to parents of a avoided.
child who is admitted with rheumatic fever. Which
of the following statements by the parent
indicates a need for further teaching? - - A nurse is caring for a client who is prescribed
"This illness will not recur because my child has lithium (Eskalith). Which of the following clinical
now had it" findings should be immediately reported to the
provider? - - Slurred speech
It is possible for rheumatic fever to recur, so
prophylactic treatment with monthly IM injections lurred speech is an early clinical finding
of benzathine penicillin G, or daily oral doses of associated with lithium toxicity and can
penicillin or sulfadiazine, will be needed. precipitate the onset of seizures or coma. Using
the safety and risk reduction priority setting
framework, this finding jeopardizes the immediate
A nurse is assisting with the care of a client who physiological safety of the client and should be
is in labor. Following spontaneous rupture of reported to the provider immediately.
membranes, the nurse visualizes the umbilical
cord protruding from the vagina and the fetal
heart rate is 50/min. After calling for assistance A nurse is reviewing the electronic fetal heart rate
and notifying the provider, which of the following tracing of a client who is in labor. Which of the
is the priority action by the nurse? - - Place following images exhibits variable decelerations?
the client in a knee-chest position - - *Variable decelerations are caused from
cord compression.
Placing the client in a knee-chest position will aid
in keeping the pressure of the presenting part of Late decelerations are caused from
the fetus off the cord. Using the ABC priority uteroplacental insufficiency.
setting framework, the greatest risk is the
cessation of circulation to the fetus; therefore, Prolonged decelerations are a decrease in the
this is the priority action the nurse should take. fetal heart rate of 15/min below baseline.
BUT wrapping the umbilical cord in the 0.9% Prolonged decelerations last more than 2 min but
sodium chloride solution is also CORRECT but less than 10 min. This can result from maternal
not priority i guess.. hypotension, umbilical cord prolapsed, placental
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, Nurse Logic Testing and Remediation Advanced Test Questions
and Answers
rupture, placental hemorrhage, and tetanic multi-medication resistant organisms, breeches in
contraction. infection control practices, and invasive
procedures. The urinary tract is a common site
Early decelerations are caused from head for health care associated infections. ***(UTIs
compression. and CAUTIs from caths)
Surgical wound is correct. ***(any open wound
A nurse is reinforcing teaching about methods to can contract bacteria if not properly
decrease nausea to a client who is receiving cleaned/maintained)
chemotherapy. Which of the following statements
by the client indicates a need for further Musculoskeletal system is INCORRECT. While
teaching? - - "I should eat low injuries can occur in the health care setting that
carbohydrate foods" is correct. Clients who are affect the musculoskeletal system, this is not a
experiencing nausea should eat foods high in common site for health care associated
carbohydrates, such as crackers, yogurt, toast, infections.
bananas, and sherbet. This is not an appropriate
statement by the client and indicates a need for Respiratory tract is correct. ***( droplet and
further teaching airborne precautions are a must, TB, pertussis,
rubella etc..)
A nurse is reinforcing teaching regarding foods Blood stream is correct. ***(any open wound
containing complete protein to a client. Which of again, any time an IV is placed or injected etc.
the following should be included in the teaching? hard line to the blood stream and cause for
- - Soybeans sepsis)
Food sources of complete proteins contain
sufficient quantities of all nine essential amino A nurse is caring for an infant who has been
acids to support body growth and maintenance. prescribed a one-time dose of ceftriaxone
Soybeans are a source of complete protein and (Rocephin) 50 mg/kg IM. The infant weighs 17.6
should be included in the teaching. lb. Available is 500 mg/mL. How many mL should
the nurse administer? - - 0.8mL
A nurse in a long-term care facility is assisting STEP 1: Determine the infant's weight in kg: 2.2
with an educational program regarding common lb / x kg = weight in lb / 1 kg; 2.2 lb / x kg = 17.6
sites of health care associated infections for a lb / 1 kg. Cross multiply and x = 8 kg
group of newly hired assistive personnel. Which
of the following sites should be included in the STEP 2: Find total of one-time dose: Amount
teaching? (Select all that apply.) - - Urinary prescribed x kg weight (mg x kg) = total daily
Tract, Surgical Wounds, Respiratory Tract, an dose; 50 mg x 8 kg = 400 mg
Blood Stream are all correct
STEP 3: What is the dose needed? Dose needed
Urinary tract is correct. Health care associated = Desired; Desired = 400 mg
infections are caused from health care delivery in
a health care facility. These result from STEP 4: What is the dose available? Dose
prescribed antibiotic administration, presence of available = Have; Have = 500 mg
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