EVOLVE ACTUAL TEST WITH
VERIFIED SOLUTIONS
◉ While assessing a client with recurring chest pain, the unit
secretary notifies the nurse that the client's health care provider is
on the telephone. What action should the nurse instruct the unit
secretary to implement?
A.Transfer the call into the room of the client.
B.Instruct the secretary to explain reason for the call.
C.Ask another nurse to take the phone call.
D.Ask the health care provider to see the client on the unit.. Answer:
C
Rationale:
Another nurse should be asked to take the phone call (C), which
allows the nurse to stay at the bedside to complete the assessment
of the client's chest pain. (A and B) should not be done during an
acute change in the client's condition. Requesting the health care
provider (D) to come to the unit is premature until the nurse
completes assessment of the client's status.
◉ Which instruction(s) should the nurse include in the discharge
teaching plan of a male client who has had a myocardial infarction
,and who has a new prescription for nitroglycerin (NTG)? (Select all
that apply.)
A.Keep the medication in your pocket so that it can be accessed
quickly.
B.Call 911 if chest pain is not relieved after one nitroglycerin.
C.Store the medication in its original container and protect it from
light.
D.Activate the emergency medical system after three doses of
medication.
E.Do not use within 1 hour of taking sildenafil citrate (Viagra)..
Answer: B,C
Rationale:
Emergency action should be taken if chest pain is not relieved after
one nitroglycerin tablet (B). The medication should be kept in the
original container to protect from light (C). Keeping the medication
in the shirt pocket provides an environment that is too warm (A).
The newest guidelines recommend calling 911 after one
nitroglycerin tablet if chest pain is not relieved (D). Nitroglycerin
and other nitrates should never be taken with Viagra (E).
◉ The nurse prepares to administer 3 units of regular insulin and 20
units of NPH insulin subcutaneously to a client with an elevated
blood glucose level. Which procedure is correct?
A.Using one syringe, first insert air into the regular vial and then
insert air into the NPH vial.
,B.Using one syringe, add the regular insulin into the syringe and
then add the NPH insulin.
C.Avoid combining the two insulins because incompatibility could
cause an adverse reaction.
D.Administer the regular insulin subcutaneously and then give the
NPH IV to prevent a separate stick.. Answer: B
Rationale:
The regular or "clear" insulin should be withdrawn into the syringe
first, followed by the NPH (B). Air should first be injected into the
NPH vial and then air should be inserted into the regular vial (A).
NPH and regular insulin are compatible, and combining will reduce
the number of injections (C). The insulin is ordered subcutaneously
and NPH cannot be given IV (D).
◉ An 8-year-old child is receiving digoxin (Lanoxin) for congestive
heart failure (CHF). In assessing the child, the nurse finds that her
apical heart rate is 80 beats/min, she complains of being slightly
nauseated, and her serum digoxin level is 1.2 ng/mL. What action
should the nurse take?
A.Because the child's heart rate and digoxin level are within normal
range, assess for the cause of the nausea.
B.Hold the next dose of digoxin until the health care provider can be
notified because the serum digoxin level is elevated.
C.Administer the next dose of digoxin and notify the health care
provider that the child is showing signs of toxicity.
, D.Notify the health care provider that the child's pulse rate is below
normal for her age group.. Answer: A
Rationale:
Nausea and vomiting are early signs of digoxin toxicity. However, the
normal resting heart rate for a child 8 to 10 years of age is 70 to 110
beats/min and the therapeutic range of serum digoxin levels is 0.5 to
2 ng/mL. Based on the objective data, (A) is the best of the choices
provided because the serum digoxin level is within normal levels.
(B) is not warranted by the data presented. The digoxin level is
within the therapeutic range and the child is not showing signs of
toxicity (C). The child's pulse rate is within normal range for her age
group (D).
◉ The nurse prepares to administer acetaminophen oral suspension
to a child who weighs 66 pounds. The prescription reads:
Administer 15 mg/kg every 6 hours by mouth. The Tylenol is
available 150 mg/5 ml. Which is the correct dosage indicated on the
image?
A.30ml
B.15ml
C.10ml
D.5ml. Answer: B
Rationale:
66 lb/(2.2 kg/lb) = 30 kg
30 kg × (15 mg/kg) = 450 mg
VERIFIED SOLUTIONS
◉ While assessing a client with recurring chest pain, the unit
secretary notifies the nurse that the client's health care provider is
on the telephone. What action should the nurse instruct the unit
secretary to implement?
A.Transfer the call into the room of the client.
B.Instruct the secretary to explain reason for the call.
C.Ask another nurse to take the phone call.
D.Ask the health care provider to see the client on the unit.. Answer:
C
Rationale:
Another nurse should be asked to take the phone call (C), which
allows the nurse to stay at the bedside to complete the assessment
of the client's chest pain. (A and B) should not be done during an
acute change in the client's condition. Requesting the health care
provider (D) to come to the unit is premature until the nurse
completes assessment of the client's status.
◉ Which instruction(s) should the nurse include in the discharge
teaching plan of a male client who has had a myocardial infarction
,and who has a new prescription for nitroglycerin (NTG)? (Select all
that apply.)
A.Keep the medication in your pocket so that it can be accessed
quickly.
B.Call 911 if chest pain is not relieved after one nitroglycerin.
C.Store the medication in its original container and protect it from
light.
D.Activate the emergency medical system after three doses of
medication.
E.Do not use within 1 hour of taking sildenafil citrate (Viagra)..
Answer: B,C
Rationale:
Emergency action should be taken if chest pain is not relieved after
one nitroglycerin tablet (B). The medication should be kept in the
original container to protect from light (C). Keeping the medication
in the shirt pocket provides an environment that is too warm (A).
The newest guidelines recommend calling 911 after one
nitroglycerin tablet if chest pain is not relieved (D). Nitroglycerin
and other nitrates should never be taken with Viagra (E).
◉ The nurse prepares to administer 3 units of regular insulin and 20
units of NPH insulin subcutaneously to a client with an elevated
blood glucose level. Which procedure is correct?
A.Using one syringe, first insert air into the regular vial and then
insert air into the NPH vial.
,B.Using one syringe, add the regular insulin into the syringe and
then add the NPH insulin.
C.Avoid combining the two insulins because incompatibility could
cause an adverse reaction.
D.Administer the regular insulin subcutaneously and then give the
NPH IV to prevent a separate stick.. Answer: B
Rationale:
The regular or "clear" insulin should be withdrawn into the syringe
first, followed by the NPH (B). Air should first be injected into the
NPH vial and then air should be inserted into the regular vial (A).
NPH and regular insulin are compatible, and combining will reduce
the number of injections (C). The insulin is ordered subcutaneously
and NPH cannot be given IV (D).
◉ An 8-year-old child is receiving digoxin (Lanoxin) for congestive
heart failure (CHF). In assessing the child, the nurse finds that her
apical heart rate is 80 beats/min, she complains of being slightly
nauseated, and her serum digoxin level is 1.2 ng/mL. What action
should the nurse take?
A.Because the child's heart rate and digoxin level are within normal
range, assess for the cause of the nausea.
B.Hold the next dose of digoxin until the health care provider can be
notified because the serum digoxin level is elevated.
C.Administer the next dose of digoxin and notify the health care
provider that the child is showing signs of toxicity.
, D.Notify the health care provider that the child's pulse rate is below
normal for her age group.. Answer: A
Rationale:
Nausea and vomiting are early signs of digoxin toxicity. However, the
normal resting heart rate for a child 8 to 10 years of age is 70 to 110
beats/min and the therapeutic range of serum digoxin levels is 0.5 to
2 ng/mL. Based on the objective data, (A) is the best of the choices
provided because the serum digoxin level is within normal levels.
(B) is not warranted by the data presented. The digoxin level is
within the therapeutic range and the child is not showing signs of
toxicity (C). The child's pulse rate is within normal range for her age
group (D).
◉ The nurse prepares to administer acetaminophen oral suspension
to a child who weighs 66 pounds. The prescription reads:
Administer 15 mg/kg every 6 hours by mouth. The Tylenol is
available 150 mg/5 ml. Which is the correct dosage indicated on the
image?
A.30ml
B.15ml
C.10ml
D.5ml. Answer: B
Rationale:
66 lb/(2.2 kg/lb) = 30 kg
30 kg × (15 mg/kg) = 450 mg
