1-Enalapril maleate (Vasotec) is prescribed for a hospitalized
client. Which assessment does the nurse perform as a priority
before administering the medication?
A. Checking the client's blood pressure
B. Checking the client's peripheral pulses
C. Checking the most recent potassium level
D. Checking the client's intake-and-output record for the last 24
hours Correct Answers A. Checking the client's blood pressure
Checking the client's blood pressure
Enalapril maleate is an angiotensin-converting enzyme (ACE)
inhibitor used to treat hypertension. One common side effect is
postural hypotension. Therefore the nurse would check the
client's blood pressure immediately before administering each
dose. Checking the client's peripheral pulses, the results of the
most recent potassium level, and the intake and output for the
previous 24 hours are not specifically associated with this
mediation.
2-A client is scheduled to undergo an upper gastrointestinal (GI)
series, and the nurse provides instructions to the client about the
test. Which statement by the client indicates a need for further
instruction?
A. "The test will take about 30 minutes."
B. "I need to fast for 8 hours before the test."
C. "I need to drink citrate of magnesia the night before the test
and give myself a Fleet enema on the morning of the test."
,D. "I need to take a laxative after the test is completed, because
the liquid that I'll have to drink for the test can be constipating."
Correct Answers C. "I need to drink citrate of magnesia the
night before the test and give myself a Fleet enema on the
morning of the test."
An upper GI series involves visualization of the esophagus,
duodenum, and upper jejunum by means of the use of a contrast
medium. It involves swallowing a contrast medium (usually
barium), which is administered in a flavored milkshake. Films
are taken at intervals during the test, which takes about 30
minutes. No special preparation is necessary before a GI series,
except that NPO status must be maintained for 8 hours before
the test. After an upper GI series, the client is prescribed a
laxative to hasten elimination of the barium. Barium that
remains in the colon may become hard and difficult to expel,
leading to fecal impaction.
3-A nurse on the evening shift checks a physician's prescriptions
and notes that the dose of a prescribed medication is higher than
the normal dose. The nurse calls the physician's answering
service and is told that the physician is off for the night and will
be available in the morning. The nurse should:
A. Call the nursing supervisor
B. Ask the answering service to contact the on-call physician
C. Withhold the medication until the physician can be reached in
the morning
D. Administer the medication but consult the physician when he
becomes available Correct Answers B. Ask the answering
service to contact the on-call physician
,4.An emergency department (ED) nurse is monitoring a client
with suspected acute myocardial infarction (MI) who is awaiting
transfer to the coronary intensive care unit. The nurse notes the
sudden onset of premature ventricular contractions (PVCs) on
the monitor, checks the client's carotid pulse, and determines
that the PVCs are not resulting in perfusion. The appropriate
action by the nurse is:
A. Documenting the findings
B. Asking the ED physician to check the client
C. Continuing to monitor the client's cardiac status
D. Informing the client that PVCs are expected after an MI
Correct Answers B. Asking the ED physician to check the client
5.NPO status is imposed 8 hours before the procedure on a client
scheduled to undergo electroconvulsive therapy (ECT) at 1 p.m.
On the morning of the procedure, the nurse checks the client's
record and notes that the client routinely takes an oral
antihypertensive medication each morning. The nurse should:
A. Administer the antihypertensive with a small sip of water
B. Withhold the antihypertensive and administer it at bedtime
C. Administer the medication by way of the intravenous (IV)
route
D. Hold the antihypertensive and resume its administration on
the day after the ECT Correct Answers A. Administer the
antihypertensive with a small sip of water
6 A client who recently underwent coronary artery bypass graft
surgery comes to the physician's office for a follow-up visit. On
, assessment, the client tells the nurse that he is feeling depressed.
Which response by the nurse is therapeutic?
A. "Tell me more about what you're feeling."
B. "That's a normal response after this type of surgery."
C. "It will take time, but, I promise you, you will get over this
depression."
D. "Every client who has this surgery feels the same way for
about a month." Correct Answers A. "Tell me more about what
you're feeling."
7 A client in labor experiences spontaneous rupture of the
membranes. The nurse immediately counts the fetal heart rate
(FHR) for 1 full minute and then checks the amniotic fluid. The
nurse notes that the fluid is yellow and has a strong odor. Which
of the following actions should be the nurse's priority?
A. Contacting the physician
B. Documenting the findings
C. Checking the fluid for protein
D. Continuing to monitor the client and the FHR Correct
Answers A. Contacting the physician Correct
8 A nurse has assisted a physician in inserting a central venous
access device into a client with a diagnosis of severe
malnutrition who will be receiving parenteral nutrition (PN).
After insertion of the catheter, the nurse immediately plans to:
A. Call the radiography department to obtain a chest x-ray
B. Check the client's blood glucose level to serve as a baseline
measurement