Evolve: Comprehensive Exam 2 Questions With 100% Correct Answers

Evolve: Comprehensive Exam 2 Questions With 100% Correct Answers 1. A parent whose 12-year-old child has been inhaling paint fumes asks the nurse, "Can he become addicted to paint fumes?" What is the best response for the nurse to provide? A. Any time you use an illegal substance, you are abusing drugs. B. Tell me what you think may have caused him to start inhaling paint fumes. C. Only hard drugs like cocaine and heroin can cause problems with addiction. D. Abuse of any of the inhalants can eventually lead to addiction. - ANSWER- D. Abuse of any of the inhalants can eventually lead to addiction. EXPLANATION. Any inhalant can become addictive. Any substance that is used to alter perception can be addictive and is not limited to the common street drugs. 2. A young adult female is brought to the emergency room by family members who report that she ingested a large quantity of acetaminophen (Tylenol). The nurse should prepare for which treatment to be implemented? A. Gastric lavage with normal saline. B. IV administration of Narcan. C. Syrup of ipecac per nasogastric tube. D. Acetylcysteine (Microcyst) 140 mg/kg. - ANSWER- D. Acetylcysteine (Microcyst) 140 mg/kg. EXPLANATION. Microcyst (D) is the antidote for acute acetaminophen (Tylenol) poisoning and is the treatment of choice for an overdose. (B) is used for an overdose of narcotics. (C) is used for ingestion of non-corrosive products such as iron tablets. (A) might also be implemented, depending on the number of drugs ingested and the time elapsed since ingestion. 3. An 8-year-old male client with nephrotic syndrome is in remission following treatment with prednisone (Deltasone). The nurse should teach the child to check his urine for which finding? A. Ketones. B. Protein. C. White blood cells. D. Glucose. - ANSWER- B. Protein. EXPLANATION. Children should be taught to check for protein (albumin) (B) in the urine daily, because a positive reading for protein in the urine is often the only indicator of a relapse of nephrotic syndrome. (C) is an indication of infection. (A and D) should be assessed while the child is receiving corticosteroid therapy, since corticosteroids increase blood glucose. 4. When making a home visit to a family with a teething 4-month-old, what information is most important for the nurse to provide the parents? A. No action is required for the common symptoms associated with teething, which include drooling, irritability, and poor sleeping. B. A slight fever is often associated with teething, but a fever lasting more than three days requires medical attention. C. Though child development is characterized by individual differences, first teeth usually erupt during the seventh month. D. Providing cooled teething toys can help decrease the discomfort associated with tooth eruption. - ANSWER- B. A slight fever is often associated with teething, but a fever lasting more than three days requires medical attention. EXPLANATION. A slight fever that persists longer than three days is likely to be associated with a pathological process, not teething, and the parents should seek the attention of their healthcare provider if it occurs (B). (A, C, and D) provide useful information about teething, but do not have the priority of (B). 5. To treat cystitis, a 14-day course of treatment with cephalexin (Cecola) is prescribed for a client residing in a long-term care facility. Which action is most important for the nurse to take prior to administering the first dose of this medication? A. Take the client's vital signs prior to the first dose and once daily for 14 days. B. Determine if the client has ever had a hypersensitivity reaction to penicillin. C. Review the client's fasting blood glucose levels for a hyperglycemic trend. D. Restrict the use of dairy products in the client's diet for the next 3 weeks. - ANSWER- B. Determine if the client has ever had a hypersensitivity reaction to penicillin. EXPLANATION. Most individuals who have an allergy to penicillin (B) are at risk of hypersensitivity to cephalosporins. To prevent a potential hypersensitivity reaction that could cause a life-threatening episode of anaphylactic shock, the nurse must determine if the client has a known penicillin allergy before giving the client a cephalexin (Cecola) dose. (A, C, and D) are not required interventions for the administration of cephalexin (Cecola). 6. A staff member tells the charge nurse that a float nurse assigned to work on the unit has made several medication errors in the past, but is currently working with the education department to improve this skill. What action is best for the charge nurse to take? A. Arrange for someone to be available to assess and assist the float nurse. B. Assign the float nurse to function as a UAP for the day. C. Dismiss the staff nurse's report about the float nurse because it may be just gossip. D. Call the nursing supervisor and request a different employee be sent to the unit. - ANSWER- A. Arrange for someone to be available to assess and assist the float nurse. EXPLANATION. The float nurse is receiving education, but careful assessment of her or his skills and assistance, as needed, is still warranted, so (A) is the best choice. Though the staff member's report may indeed be gossip, failure to pay attention to the information could constitute negligence on the part of the charge nurse (C). (D) is not the best way to manage the unit. (B) is not the best use of a licensed person and would also eliminate the float nurse's opportunity to improve medication administration skills. 7. The blood pressure readings obtained by unlicensed assistive personnel (UAP) are consistently different from those obtained by other staff members. What action should the charge nurse take first? A. Ask the education department to provide additional training for the UAP. B. Observe the UAP performing blood pressure measurements. C. Make staff members aware of the possible errors in blood pressure readings. D. Counsel the UAP about the inaccurate blood pressure readings. - ANSWER- B. Observe the UAP performing blood pressure measurements. EXPLANATION. The charge nurse should first observe the UAP's performance (B), then take appropriate action, which might include (A, C and D).