COMPREHENSIVE REVIEW EXAM
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 - ANS-A. Checking the
client's blood pressure
Rationale: 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.
A client is scheduled to undergo an upper gastrointestinal (GI) series, and the licensed practical
nurse reinforces 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." - ANS-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."
Rationale: 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.
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 - ANS-B.
Ask the answering service to contact the on-call physician
Rationale: The nurse has a duty to protect the client from harm. A nurse who believes that a
physician's prescription may be in error is responsible for clarifying the prescription before
carrying it out. Therefore the nurse would not administer the medication; instead, the nurse
would withhold the medication until the dose can be clarified. The nurse would not wait until the
next morning to obtain clarification. It is premature to call the nursing supervisor.
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 - ANS-B. Asking the ED physician to
check the client
Rationale: PVCs are a result of increased irritability of ventricular cells. Peripheral pulses may
be absent or diminished with the PVCs themselves because the decreased stroke volume of the
premature beats may in turn decrease peripheral perfusion. Because other rhythms also cause
widened QRS complexes, it is essential that the nurse determine whether the premature beats
are resulting in perfusion of the extremities. This is done by palpating the carotid, brachial, or
femoral artery while observing the monitor for widened complexes or by auscultating for apical
heart sounds. In the situation of acute MI, PVCs may be considered warning dysrhythmias,
possibly heralding the onset of ventricular tachycardia or ventricular fibrillation. Therefore the
nurse would not tell the client that the PVCs are expected. Although the nurse will continue to
monitor the client and document the findings, these are not the most appropriate actions of
those provided. The most appropriate action would be to ask the ED physician to check the
client.
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 - ANS-A.
Administer the antihypertensive with a small sip of water
,Rationale: General anesthesia is required for ECT, so NPO status is imposed for 6 to 8 hours
before treatment to help prevent aspiration. Exceptions include clients who routinely receive
cardiac medications, antihypertensive agents, or histamine (H2) blockers, which should be
administered several hours before treatment with a small sip of water. Withholding the
antihypertensive and administering it at bedtime and withholding the antihypertensive and
resuming administration on the day after the ECT are incorrect actions, because
antihypertensives must be administered on time; otherwise, the risk for rebound hypertension
exists. The nurse would not administer a medication by way of a route that has not been
prescribed.
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." - ANS-A. "Tell me
more about what you're feeling."
Rationale: When a client expresses feelings of depression, it is extremely important for the
nurse to further explore these feelings with the client. In stating, "This is a normal response after
this type of surgery" the nurse provides false reassurance and avoids addressing the client's
feelings. "It will take time, but, I promise you, you will get over the depression" is also a false
reassurance, and it does not encourage the expression of feelings. "Every client who has this
surgery feels the same way for about a month" is a generalization that avoids the client's
feelings.
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 - ANS-A. Contacting the physician
Rationale: The FHR is assessed for at least 1 minute when the membranes rupture. The nurse
also checks the quantity, color, and odor of the amniotic fluid. The fluid should be clear (often
with bits of vernix) and have a mild odor. Fluid with a foul or strong odor, cloudy appearance, or
yellow coloration suggests chorioamnionitis and warrants notifying the physician. A large
amount of vernix in the fluid suggests that the fetus is preterm. Greenish, meconium-stained
fluid may be seen in cases of postterm gestation or placental insufficiency. Checking the fluid for
protein is not associated with the data in the question. Although the nurse would continue to
, monitor the client and the FHR and would document the findings, contacting the physician is the
priority.
A nurse helps provide an educational session to community members about cancer of the
cervix. The nurse informs the group members that an early sign of this type of cancer is:
A. Dark, foul-smelling vaginal drainage
B. Abdominal pain
C. Constant, profuse bleeding
D. Irregular vaginal bleeding or spotting - ANS-D. Irregular vaginal bleeding or spotting
Rationale: Early cancer of the cervix is usually asymptomatic. The two chief symptoms are
leukorrhea (vaginal discharge) and irregular vaginal bleeding or spotting. The vaginal discharge
increases gradually in amount and becomes watery and finally dark and foul smelling because
of necrosis and infection of the tumor mass. As the disease progresses, the bleeding may
become constant and increase in amount.
A survivor of sexual assault being treated in the emergency department says to the nurse, "I'm
really worried that I've got HIV now." What is the appropriate response by the nurse?
A. "HIV is rarely an issue in survivors of sexual assault."
B. "Every survivor of sexual assault is concerned about HIV."
C. "You're more likely to get pregnant than to contract HIV."
D. "Let's talk about the information that you need to determine your risk of contracting HIV." -
ANS-D. "Let's talk about the information that you need to determine your risk of contracting
HIV."
Rationale: HIV is a concern of survivors of sexual assault. Such concern should always be
addressed, and the survivor should be given the information needed to evaluate his or her risk.
Pregnancy may occur as a result of sexual assault, and pregnancy prophylaxis can be offered in
the emergency department or during follow-up, once the results of a pregnancy test have been
obtained. However, stating, "You're more likely to get pregnant than to contract HIV" avoids the
client's concern. Similarly, "HIV is rarely an issue in survivors of sexual assault" and "Every
survivor of sexual assault is concerned about HIV" are generalized responses that avoid the
client's concern.
A client is taking prescribed ibuprofen (Motrin), 300 mg orally four times daily, to relieve joint
pain resulting from rheumatoid arthritis. The client tells the nurse that the medication is causing
nausea and indigestion. The nurse should tell the client to:
A. Contact the physician
B. Stop taking the medication
C. Take the medication with food
D. Take the medication twice a day instead of four times - ANS-C. Take the medication with food
Rationale: Ibuprofen is a nonsteroidal antiinflammatory medication. Side effects include nausea
(with or without vomiting) and dyspepsia (heartburn, indigestion, or epigastric pain). If
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 - ANS-A. Checking the
client's blood pressure
Rationale: 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.
A client is scheduled to undergo an upper gastrointestinal (GI) series, and the licensed practical
nurse reinforces 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." - ANS-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."
Rationale: 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.
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 - ANS-B.
Ask the answering service to contact the on-call physician
Rationale: The nurse has a duty to protect the client from harm. A nurse who believes that a
physician's prescription may be in error is responsible for clarifying the prescription before
carrying it out. Therefore the nurse would not administer the medication; instead, the nurse
would withhold the medication until the dose can be clarified. The nurse would not wait until the
next morning to obtain clarification. It is premature to call the nursing supervisor.
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 - ANS-B. Asking the ED physician to
check the client
Rationale: PVCs are a result of increased irritability of ventricular cells. Peripheral pulses may
be absent or diminished with the PVCs themselves because the decreased stroke volume of the
premature beats may in turn decrease peripheral perfusion. Because other rhythms also cause
widened QRS complexes, it is essential that the nurse determine whether the premature beats
are resulting in perfusion of the extremities. This is done by palpating the carotid, brachial, or
femoral artery while observing the monitor for widened complexes or by auscultating for apical
heart sounds. In the situation of acute MI, PVCs may be considered warning dysrhythmias,
possibly heralding the onset of ventricular tachycardia or ventricular fibrillation. Therefore the
nurse would not tell the client that the PVCs are expected. Although the nurse will continue to
monitor the client and document the findings, these are not the most appropriate actions of
those provided. The most appropriate action would be to ask the ED physician to check the
client.
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 - ANS-A.
Administer the antihypertensive with a small sip of water
,Rationale: General anesthesia is required for ECT, so NPO status is imposed for 6 to 8 hours
before treatment to help prevent aspiration. Exceptions include clients who routinely receive
cardiac medications, antihypertensive agents, or histamine (H2) blockers, which should be
administered several hours before treatment with a small sip of water. Withholding the
antihypertensive and administering it at bedtime and withholding the antihypertensive and
resuming administration on the day after the ECT are incorrect actions, because
antihypertensives must be administered on time; otherwise, the risk for rebound hypertension
exists. The nurse would not administer a medication by way of a route that has not been
prescribed.
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." - ANS-A. "Tell me
more about what you're feeling."
Rationale: When a client expresses feelings of depression, it is extremely important for the
nurse to further explore these feelings with the client. In stating, "This is a normal response after
this type of surgery" the nurse provides false reassurance and avoids addressing the client's
feelings. "It will take time, but, I promise you, you will get over the depression" is also a false
reassurance, and it does not encourage the expression of feelings. "Every client who has this
surgery feels the same way for about a month" is a generalization that avoids the client's
feelings.
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 - ANS-A. Contacting the physician
Rationale: The FHR is assessed for at least 1 minute when the membranes rupture. The nurse
also checks the quantity, color, and odor of the amniotic fluid. The fluid should be clear (often
with bits of vernix) and have a mild odor. Fluid with a foul or strong odor, cloudy appearance, or
yellow coloration suggests chorioamnionitis and warrants notifying the physician. A large
amount of vernix in the fluid suggests that the fetus is preterm. Greenish, meconium-stained
fluid may be seen in cases of postterm gestation or placental insufficiency. Checking the fluid for
protein is not associated with the data in the question. Although the nurse would continue to
, monitor the client and the FHR and would document the findings, contacting the physician is the
priority.
A nurse helps provide an educational session to community members about cancer of the
cervix. The nurse informs the group members that an early sign of this type of cancer is:
A. Dark, foul-smelling vaginal drainage
B. Abdominal pain
C. Constant, profuse bleeding
D. Irregular vaginal bleeding or spotting - ANS-D. Irregular vaginal bleeding or spotting
Rationale: Early cancer of the cervix is usually asymptomatic. The two chief symptoms are
leukorrhea (vaginal discharge) and irregular vaginal bleeding or spotting. The vaginal discharge
increases gradually in amount and becomes watery and finally dark and foul smelling because
of necrosis and infection of the tumor mass. As the disease progresses, the bleeding may
become constant and increase in amount.
A survivor of sexual assault being treated in the emergency department says to the nurse, "I'm
really worried that I've got HIV now." What is the appropriate response by the nurse?
A. "HIV is rarely an issue in survivors of sexual assault."
B. "Every survivor of sexual assault is concerned about HIV."
C. "You're more likely to get pregnant than to contract HIV."
D. "Let's talk about the information that you need to determine your risk of contracting HIV." -
ANS-D. "Let's talk about the information that you need to determine your risk of contracting
HIV."
Rationale: HIV is a concern of survivors of sexual assault. Such concern should always be
addressed, and the survivor should be given the information needed to evaluate his or her risk.
Pregnancy may occur as a result of sexual assault, and pregnancy prophylaxis can be offered in
the emergency department or during follow-up, once the results of a pregnancy test have been
obtained. However, stating, "You're more likely to get pregnant than to contract HIV" avoids the
client's concern. Similarly, "HIV is rarely an issue in survivors of sexual assault" and "Every
survivor of sexual assault is concerned about HIV" are generalized responses that avoid the
client's concern.
A client is taking prescribed ibuprofen (Motrin), 300 mg orally four times daily, to relieve joint
pain resulting from rheumatoid arthritis. The client tells the nurse that the medication is causing
nausea and indigestion. The nurse should tell the client to:
A. Contact the physician
B. Stop taking the medication
C. Take the medication with food
D. Take the medication twice a day instead of four times - ANS-C. Take the medication with food
Rationale: Ibuprofen is a nonsteroidal antiinflammatory medication. Side effects include nausea
(with or without vomiting) and dyspepsia (heartburn, indigestion, or epigastric pain). If
