ADVANCED NURSING.
Which statement by a patient indicates additional teaching is required about the medication
warfarin?
A) "I will increase the intake of green, leafy vegetables for a more healthful diet."
B) "I will restrict the intake of foods high in vitamin C."
C) "I will increase the amount of protein in my diet to protect my kidneys."
D) "I will continue my diabetic diet and restrict sugar."
A
Foods such as green, leafy vegetables have high levels of vitamin K. Warfarin is an
anticoagulant that acts by interfering with vitamin K-dependent clotting factors. If the amount of
vitamin K is increased in the diet, the medication dose may need to be adjusted. A diabetic diet
would be continued as indicated for a patient receiving warfarin. Vitamin C is not related to
warfarin.
Which statement indicates that the client needs more teaching about mucositis?
A) "I will use a soft-bristled toothbrush to prevent trauma."
B) "I will rinse my mouth with water after every meal."
C) "I should use an alcohol-based mouth rinse to kill bacteria."
D) "I cannot use floss because it may irritate my gums."
C
Mouthwashes that contain alcohol are drying and can exacerbate mucosal irritation, leading to
painful mouth sores. Rinsing the mouth with water or normal saline is indicated. Interventions
aimed at decreasing risk for trauma or irritation are matters of priority because of inflammation
associated with mucositis.
Which statement made by a nurse represents the need for further education regarding pain
management in older adult clients?
clients perceive pain any differently than younger clients. The other statements are accurate
regarding older clients and pain.
A client is being treated for dehydration. Which statement made by the client indicates
understanding of this condition?
A). I will use a salt substitute when making and eating my meals.
B) I must drink a quart of water or other liquid each day.
C) I will not drink liquids after 6 PM so I won't have to get up at night.
,D) I will weigh myself each morning before I eat or drink.
D
Because 1 L of water weighs 1 kg, change in body weight is a good measure of excess fluid loss
or fluid retention. Weight loss greater than 0.5 lb daily is indicative of excessive fluid loss. The
other statements are not indicative of practices that will prevent dehydration.
A client is hospitalized with a urinary tract infection (UTI). Which clinical manifestation alerts
the nurse to the possibility of a complication from the UTI?
A) Hematuria
B) Fever and chills
C) Cloudy, dark urine
D) Burning on urination
B
Lower urinary tract infections are rarely associated with systemic symptoms of fever and chills.
A client with a UTI who develops fever and chills should be assessed for the development of
pyelonephritis. The other options can be seen with UTI.
A client is receiving a chemotherapeutic agent intravenously through a peripheral line. What is
the nurse's first action when the client reports burning at the site?
A) Apply a cold compress.
B) Discontinue the infusion.
C) Slow the rate of infusion.
D) Check for a blood return.
B
Both irritants and vesicants can cause tissue damage. If the nurse suspects extravasation, he or
she should immediately stop the infusion. Even if the IV has a good blood return, some of the
chemotherapeutic agent can still be leaking into the tissues. Slowing the rate of infusion is not
sufficient to prevent further leakage and damage. Applying a cold compress may or may not be
the correct action, depending on the specific agent. However, the compress would be applied
only after the infusion has been discontinued.
A client is taking furosemide (Lasix) and becomes confused. Which potassium level does the
nurse correlate with this condition?
A) 2.9 mEq/L
B) 5.0 mEq/L
C) 6.0 mEq/L
D) 3.8 mEq/L
A
,Hypokalemia decreases cerebral function and is manifested by lethargy, confusion, inability to
perform problem-solving tasks, disorientation, and coma. Normal potassium levels are 3.5 to 5.0
mEq/L. At 2.9 mEq/L, potassium is too low, and this could lead to neurologic manifestations.
A client presents to the emergency department after prolonged exposure to the cold. The client is
shivering, has slurred speech, and is slow to respond to questions. Which intervention will the
nurse prepare for this client FIRST?
A) Continuous arteriovenous rewarming
B) Dry clothing and warm blankets
C) Peritoneal lavage with warmed normal saline
D) Administration of warmed IV fluids
B
Mild hypothermia is manifested by shivering, slurred speech, poor muscular coordination, and
impaired cognitive abilities. Mild hypothermia may be treated with dry clothing and warm
blankets. Rewarming should occur slowly by removing wet clothing and providing dry warm
blankets first. Other treatments are secondary and should be used to treat moderate to severe
hypothermia.
A client presents with a pressure ulcer on the ankle. Which is the first intervention that the nurse
implements?
A) Place the client in bed and instruct him or her to elevate the foot.
B) Prepare for and assist with obtaining a wound culture.
C) Assess the affected leg for pulses, skin color, and temperature.
D) Draw blood for albumin, prealbumin, and total protein.
C
A client with an ulcer on the foot should be assessed for interruption in arterial flow to the area.
This begins with assessment of pulses and color and temperature of the skin. The nurse can also
assess for pulses noninvasively with a Doppler if unable to palpate with his or her fingers.
Elevation of the foot would impair the ability of arterial blood to flow to the area. Wound
cultures are done after it has been determined drainage, odor, and other risks for infection are
present. Tests to determine nutritional status and risk assessment would be completed after the
initial assessment is done.
A client presents with an acute exacerbation of multiple sclerosis. Which prescribed medication
does the nurse prepare to administer?
A) Interferon beta-1b (Betaseron)
B) Baclofen (Lioresal)
C) Methylprednisolone (Medrol)
D) Dantrolene sodium (Dantrium)
C
, Methylprednisolone is the drug of choice for acute exacerbations of the disease. The other
medications are not appropriate.
A client receiving intravenous chemotherapy asks the nurse the reason for wearing a mask,
gloves, and gown while administering drugs to the client. What is the nurse's best response?
A) "I am preventing the spread of infection from you to me or any other client here."
B) "The clothing protects me from accidentally absorbing these drugs."
C) "The policy is for any nurse giving these drugs to wear a gown, gloves, and mask."
D) "These coverings protect you from getting an infection from me."
B
Most chemotherapy drugs are absorbed through the skin and mucous membranes. As a result,
health care workers who prepare or give these drugs, especially nurses and pharmacists, are at
risk for absorbing them. Even at low doses, chronic exposure to chemotherapy drugs can affect
health. The Oncology Nursing Society and the Occupational Safety and Health Administration
(OSHA) have specific guidelines for using caution and wearing protective clothing whenever
preparing, giving, or disposing of chemotherapy drugs.
A client who first experienced symptoms related to a confirmed thrombotic stroke 2 hours ago is
brought to the intensive care unit. Which prescribed medication does the nurse prepare to
administer?
A) Tissue plasminogen activator
B) Heparin sodium
C) Warfarin (Coumadin)
D) Gabapentin (Neurontin)
A
The client who has had a thrombotic stroke has a 3-hour time frame from the onset of symptoms
to receive recombinant tissue plasminogen activator (rt-PA) to dissolve the cerebral artery
occlusion and re-establish blood flow. Clients must meet eligibility criteria for administration of
this therapy. The other medications do not assist in the re-establishment of blood flow for a client
with a confirmed thrombotic stroke.
A client who had a stroke is receiving clopidogrel (Plavix). Which adverse effect does the nurse
monitor for in this client?
A) New-onset confusion
B) Repeated syncope
C) Abdominal distention
D) Spontaneous ecchymosis
D
Which statement by a patient indicates additional teaching is required about the medication
warfarin?
A) "I will increase the intake of green, leafy vegetables for a more healthful diet."
B) "I will restrict the intake of foods high in vitamin C."
C) "I will increase the amount of protein in my diet to protect my kidneys."
D) "I will continue my diabetic diet and restrict sugar."
A
Foods such as green, leafy vegetables have high levels of vitamin K. Warfarin is an
anticoagulant that acts by interfering with vitamin K-dependent clotting factors. If the amount of
vitamin K is increased in the diet, the medication dose may need to be adjusted. A diabetic diet
would be continued as indicated for a patient receiving warfarin. Vitamin C is not related to
warfarin.
Which statement indicates that the client needs more teaching about mucositis?
A) "I will use a soft-bristled toothbrush to prevent trauma."
B) "I will rinse my mouth with water after every meal."
C) "I should use an alcohol-based mouth rinse to kill bacteria."
D) "I cannot use floss because it may irritate my gums."
C
Mouthwashes that contain alcohol are drying and can exacerbate mucosal irritation, leading to
painful mouth sores. Rinsing the mouth with water or normal saline is indicated. Interventions
aimed at decreasing risk for trauma or irritation are matters of priority because of inflammation
associated with mucositis.
Which statement made by a nurse represents the need for further education regarding pain
management in older adult clients?
clients perceive pain any differently than younger clients. The other statements are accurate
regarding older clients and pain.
A client is being treated for dehydration. Which statement made by the client indicates
understanding of this condition?
A). I will use a salt substitute when making and eating my meals.
B) I must drink a quart of water or other liquid each day.
C) I will not drink liquids after 6 PM so I won't have to get up at night.
,D) I will weigh myself each morning before I eat or drink.
D
Because 1 L of water weighs 1 kg, change in body weight is a good measure of excess fluid loss
or fluid retention. Weight loss greater than 0.5 lb daily is indicative of excessive fluid loss. The
other statements are not indicative of practices that will prevent dehydration.
A client is hospitalized with a urinary tract infection (UTI). Which clinical manifestation alerts
the nurse to the possibility of a complication from the UTI?
A) Hematuria
B) Fever and chills
C) Cloudy, dark urine
D) Burning on urination
B
Lower urinary tract infections are rarely associated with systemic symptoms of fever and chills.
A client with a UTI who develops fever and chills should be assessed for the development of
pyelonephritis. The other options can be seen with UTI.
A client is receiving a chemotherapeutic agent intravenously through a peripheral line. What is
the nurse's first action when the client reports burning at the site?
A) Apply a cold compress.
B) Discontinue the infusion.
C) Slow the rate of infusion.
D) Check for a blood return.
B
Both irritants and vesicants can cause tissue damage. If the nurse suspects extravasation, he or
she should immediately stop the infusion. Even if the IV has a good blood return, some of the
chemotherapeutic agent can still be leaking into the tissues. Slowing the rate of infusion is not
sufficient to prevent further leakage and damage. Applying a cold compress may or may not be
the correct action, depending on the specific agent. However, the compress would be applied
only after the infusion has been discontinued.
A client is taking furosemide (Lasix) and becomes confused. Which potassium level does the
nurse correlate with this condition?
A) 2.9 mEq/L
B) 5.0 mEq/L
C) 6.0 mEq/L
D) 3.8 mEq/L
A
,Hypokalemia decreases cerebral function and is manifested by lethargy, confusion, inability to
perform problem-solving tasks, disorientation, and coma. Normal potassium levels are 3.5 to 5.0
mEq/L. At 2.9 mEq/L, potassium is too low, and this could lead to neurologic manifestations.
A client presents to the emergency department after prolonged exposure to the cold. The client is
shivering, has slurred speech, and is slow to respond to questions. Which intervention will the
nurse prepare for this client FIRST?
A) Continuous arteriovenous rewarming
B) Dry clothing and warm blankets
C) Peritoneal lavage with warmed normal saline
D) Administration of warmed IV fluids
B
Mild hypothermia is manifested by shivering, slurred speech, poor muscular coordination, and
impaired cognitive abilities. Mild hypothermia may be treated with dry clothing and warm
blankets. Rewarming should occur slowly by removing wet clothing and providing dry warm
blankets first. Other treatments are secondary and should be used to treat moderate to severe
hypothermia.
A client presents with a pressure ulcer on the ankle. Which is the first intervention that the nurse
implements?
A) Place the client in bed and instruct him or her to elevate the foot.
B) Prepare for and assist with obtaining a wound culture.
C) Assess the affected leg for pulses, skin color, and temperature.
D) Draw blood for albumin, prealbumin, and total protein.
C
A client with an ulcer on the foot should be assessed for interruption in arterial flow to the area.
This begins with assessment of pulses and color and temperature of the skin. The nurse can also
assess for pulses noninvasively with a Doppler if unable to palpate with his or her fingers.
Elevation of the foot would impair the ability of arterial blood to flow to the area. Wound
cultures are done after it has been determined drainage, odor, and other risks for infection are
present. Tests to determine nutritional status and risk assessment would be completed after the
initial assessment is done.
A client presents with an acute exacerbation of multiple sclerosis. Which prescribed medication
does the nurse prepare to administer?
A) Interferon beta-1b (Betaseron)
B) Baclofen (Lioresal)
C) Methylprednisolone (Medrol)
D) Dantrolene sodium (Dantrium)
C
, Methylprednisolone is the drug of choice for acute exacerbations of the disease. The other
medications are not appropriate.
A client receiving intravenous chemotherapy asks the nurse the reason for wearing a mask,
gloves, and gown while administering drugs to the client. What is the nurse's best response?
A) "I am preventing the spread of infection from you to me or any other client here."
B) "The clothing protects me from accidentally absorbing these drugs."
C) "The policy is for any nurse giving these drugs to wear a gown, gloves, and mask."
D) "These coverings protect you from getting an infection from me."
B
Most chemotherapy drugs are absorbed through the skin and mucous membranes. As a result,
health care workers who prepare or give these drugs, especially nurses and pharmacists, are at
risk for absorbing them. Even at low doses, chronic exposure to chemotherapy drugs can affect
health. The Oncology Nursing Society and the Occupational Safety and Health Administration
(OSHA) have specific guidelines for using caution and wearing protective clothing whenever
preparing, giving, or disposing of chemotherapy drugs.
A client who first experienced symptoms related to a confirmed thrombotic stroke 2 hours ago is
brought to the intensive care unit. Which prescribed medication does the nurse prepare to
administer?
A) Tissue plasminogen activator
B) Heparin sodium
C) Warfarin (Coumadin)
D) Gabapentin (Neurontin)
A
The client who has had a thrombotic stroke has a 3-hour time frame from the onset of symptoms
to receive recombinant tissue plasminogen activator (rt-PA) to dissolve the cerebral artery
occlusion and re-establish blood flow. Clients must meet eligibility criteria for administration of
this therapy. The other medications do not assist in the re-establishment of blood flow for a client
with a confirmed thrombotic stroke.
A client who had a stroke is receiving clopidogrel (Plavix). Which adverse effect does the nurse
monitor for in this client?
A) New-onset confusion
B) Repeated syncope
C) Abdominal distention
D) Spontaneous ecchymosis
D
