PRACTICE EXAM TEST BANK WITH ACCURATE AND VERIFIED
QUESTIONS AND ANSWERS FOR GUARANTED PASS
1 .A client diagnosed with major depression has been taking a selective serotonin
reuptake inhibitor for the past 6 weeks. When visiting the mental health center,
the nurse discusses the medication and response with the client. The nurse's
assessment reveals that the client is confused about the date and about the
prescribed dosage of the medication. Which question would be most important
for the nurse to ask to further assess the situation?
1. Are you having trouble sleeping at night?
2. Do you have periods of muscle jerking?
3. Are you having any sexual dysfunction?
4. Is your mood improving?
2. Correct: Myoclonus, high body temperature, shaking, chills, and mental
confusion are some of the symptoms of serotonin syndrome. This client may be
having symptoms of this adverse reaction which, if severe, can be fatal.
1. Incorrect: Sleep disturbances are common with depression. Selective
serotonin reuptake inhibitors (SSRIs) may cause insomnia; however, there is a
more pertinent question needed for assessment of this client. You should be
concerned with the more serious or life-threatening issue.
3. Incorrect: Sexual dysfunction may occur with the SSRIs; however, the client is
exhibiting significant symptoms of an adverse reaction which would take priority.
4. Incorrect: The response to the SSRI medications is important; however, there
is a more significant issue in this case. The possible serotonin syndrome is a
serious situation that would be the priority for the nurse to address.
2.What information should a nurse include when educating a client regarding
buccal administration of a medication?
1. This route allows the medication to get into the bloodstream faster than the
oral route.
2. Stinging may occur after placing the medication in the cheek.
3. If swallowed, the medication may be inactivated by gastric secretions.
4. The buccal dose of medication will need to be increased from the oral dose.
5. Remove the tablet from buccal area after 15 seconds.
1., 2., & 3. Correct: These are correct statements about buccal administration of
medication. Buccal administration involves the medication being placed between
,the gums and cheek, where it dissolves and becomes absorbed into the
bloodstream. The cheek area has many capillaries that allow the medication to be
absorbed quickly without having to pass through the digestive system. The
degree of stinging experienced depends on the medication being administered.
Some effects of certain medications can be lessened by digestive processes.
4. Incorrect: When given by the buccal route, the medication does not go through
the digestive system. This means that the medication is not metabolized through
the liver, and thus a lower dose can be used.
5. Incorrect: Placement should be maintained until the tablet is dissolved in order
to get the dosage and effects desired
.
3. The nurse is working with a committee at the local school to develop an emergency
preparedness plan for tornados. What should be included in the plan?
1. Identification of safe zones.
2. Methods for accounting for all people present in the building.
3. Warning system activation.
4. Identification of the gymnasium as the routine safe place.
5. Regular practice protocols.
1., 2., 3. & 5. Correct: Everyone should be aware of safe zones within the school.
Personnel should be given this information and signs posted in safe zones. There
must be systems in place to accurately determine the number of people in the
building at any given time. There also must be a system in place to alert
personnel and students of tornado warnings. Regular practice prepares everyone
for an actual event.
4. Incorrect: Gymnasiums are not considered safe places due to wide expanse of
roof. Safe zones should be on interior walls, no windows, and a strong concrete
floor if possible.
4
What should a nurse teach family members prior to them entering the room of a
client who has agranulocytosis?
1. Meticulous hand washing is needed.
2. Do not visit if you have any infection.
3. The client must wear a mask.
4. Children under 12 may not visit.
5. Flowers are not allowed in the room.
1., 2., 4., & 5. Correct: Protective isolation is needed for this client because of the
presence of a low white blood cell count. We are protecting the client from
acquiring an infection. So any visitors will need to have meticulous hand washing
, prior to entering. The visitor should not enter if he or she has any type of
infection. To decrease the risk of infection, small children should not visit. Even
the mildest symptom of infection could be detrimental to the client. Flowers have
bacteria and should not be brought into the room.
3. Incorrect: A mask must be worn by the visitor, not the client. The mask is worn
by visitors to prevent a possible spread of an airborne infection to the
immunocompromised client.
5. The primary healthcare provider has prescribed phenytoin 100 mg intravenous push
(IVP) stat for an adult client. What is the least amount of time that the nurse can safely
administer this medication?
1. 1 minute
2. 2 minutes
3. 5 minutes
4. 10 minutes
2. Correct: The rate of IV administration should not exceed 50 mg/min. for adults
and 1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients
because of the risk of severe hypotension and cardiac arrhythmias. So 100 mg
can safely be delivered over a period of at least 2 minutes.
1. Incorrect: The rate of IV administration should not exceed 50 mg/min. for adults
and 1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients
because of the risk of severe hypotension and cardiac arrhythmias. So 100 mg
can safely be delivered over a period of at least 2 minutes. Giving this dose over
only one minute could lead to these or other potential harmful effects.
3. Incorrect: The rate of IV administration should not exceed 50 mg/min. for adults
and 1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients
because of the risk of severe hypotension and cardiac arrhythmias. So 100 mg
can safely be delivered over a period of at least 2 minutes. Five minutes would be
longer than required to be able to safely administer the medication.
4. Incorrect: The rate of IV administration should not exceed 50 mg/min. for adults
and 1-3 mg/kg/min (or 50 mg/min, whichever is slower) in pediatric clients
because of the risk of severe hypotension and cardiac arrhythmias. So 100 mg
can safely be delivered over a period of at least 2 minutes. Ten minutes is much
longer than required to be able to safely administer the medication