NURS396 TEST WITH COMPLETE SOLUTIONS
A nurse is caring for a client with pulmonary tuberculosis who is to receive several
antitubercular medications. Which of the first-line antitubercular medications is
associated with damage to the eighth cranial nerve?
1) Isoniazid (INH)
2) Rifampin (Rifadin)
3) Streptomycin
4) Ethambutol (Myambutol) - ANSWER Correct: 3 Streptomycin
Rationale: Streptomycin is ototoxic and can cause damage to the eighth cranial nerve,
resulting in deafness. Assessment for ringing or roaring in the ears, vertigo, and hearing
acuity should be made before, during, and after treatment. Isoniazid does not affect the
ear; however, blurred vision and optic neuritis, as well as peripheral neuropathy, may
occur. Rifampin does not affect hearing; however, visual disturbances may occur.
Ethambutol does not affect hearing; however, visual disturbances may occur.
A client who is to have brain surgery has a signed advance directive in the medical
record. In what situation should this document be used?
1) Discharge planning is not covered by insurance.
2) Client cannot consent to his or her own surgery.
3) Postoperative complications occur that require additional treatment.
4) In case of the client's death, there will be directions about which client's belongings
are to be given to family members. - ANSWER Correct 2
Rationale: Advance directives allow clients to designate another person to consent to
procedures if they are unable to do so. Advance directives are not related to insurance.
No information suggests the client cannot consent to treatment. Directions for
distribution of belongings should be stipulated in a will, not in an advance directive.
What clinical indicators should the nurse expect a client with hyperkalemia to exhibit?
Select all that apply.
1) Tetany
2) Seizures
3) Diarrhea
4) Weakness
, 5) Dysrhythmia - ANSWER Correct, 3.4.5
Rationale: Tetany is caused by hypocalcemia. Seizures caused by electrolyte
imbalances are associated with low calcium or sodium levels. Because of potassium's
role in the sodium/potassium pump, hyperkalemia will cause diarrhea, weakness, and
cardiac dysrhythmias.
A health care provider prescribes transdermal fentanyl (Duragesic) 25 mcg/hr every 72
hours. During the first 24 hours after starting the fentanyl, what is the most important
nursing intervention?
1) Titrate the dose until pain is tolerable.
2) Manage pain with oral pain medication.
3) Assess the client for anticholinergic side effects.
4) Instruct the client to take the medication with food. - ANSWER Correct: 2
Rationale: It takes 24 hours to reach the peak effect of transdermal fentanyl
(Duragesic). Oral pain medication may be necessary to support client comfort until the
fentanyl reaches its peak effect. The nurse needs to administer the dose of transdermal
fentanyl exactly as prescribed by the health care provider. This is associated with
tricyclic antidepressants, not transdermal fentanyl. A transdermal medication is
administered through the skin via a patch applied to the skin, not via the gastrointestinal
tract.
To minimize the side effects of the vincristine (Oncovin) that a client is receiving, what
does the nurse expect the dietary plan to include?
1) Low in fat
2) High in iron
3) High in fluids
4) Low in residue - ANSWER Correct: 3
Rationale: A common side effect of vincristine is a paralytic ileus that results in
constipation. Preventative measures include high-fiber foods and fluids that exceed
minimum requirements. These will keep the stool bulky and soft, thereby promoting
evacuation. Low in fat, high in iron, and low in residue dietary plans will not provide the
roughage and fluids needed to minimize the constipation associated with vincristine.
A plan of care for a client newly diagnosed with type 1 diabetes includes teaching how
to self-administer insulin, adjust insulin dosage, select appropriate food on the
prescribed diet, and test the serum for glucose. The client demonstrates achievement of
these skills and is discharged five days following admission. What is the legal
implication in this situation?
A nurse is caring for a client with pulmonary tuberculosis who is to receive several
antitubercular medications. Which of the first-line antitubercular medications is
associated with damage to the eighth cranial nerve?
1) Isoniazid (INH)
2) Rifampin (Rifadin)
3) Streptomycin
4) Ethambutol (Myambutol) - ANSWER Correct: 3 Streptomycin
Rationale: Streptomycin is ototoxic and can cause damage to the eighth cranial nerve,
resulting in deafness. Assessment for ringing or roaring in the ears, vertigo, and hearing
acuity should be made before, during, and after treatment. Isoniazid does not affect the
ear; however, blurred vision and optic neuritis, as well as peripheral neuropathy, may
occur. Rifampin does not affect hearing; however, visual disturbances may occur.
Ethambutol does not affect hearing; however, visual disturbances may occur.
A client who is to have brain surgery has a signed advance directive in the medical
record. In what situation should this document be used?
1) Discharge planning is not covered by insurance.
2) Client cannot consent to his or her own surgery.
3) Postoperative complications occur that require additional treatment.
4) In case of the client's death, there will be directions about which client's belongings
are to be given to family members. - ANSWER Correct 2
Rationale: Advance directives allow clients to designate another person to consent to
procedures if they are unable to do so. Advance directives are not related to insurance.
No information suggests the client cannot consent to treatment. Directions for
distribution of belongings should be stipulated in a will, not in an advance directive.
What clinical indicators should the nurse expect a client with hyperkalemia to exhibit?
Select all that apply.
1) Tetany
2) Seizures
3) Diarrhea
4) Weakness
, 5) Dysrhythmia - ANSWER Correct, 3.4.5
Rationale: Tetany is caused by hypocalcemia. Seizures caused by electrolyte
imbalances are associated with low calcium or sodium levels. Because of potassium's
role in the sodium/potassium pump, hyperkalemia will cause diarrhea, weakness, and
cardiac dysrhythmias.
A health care provider prescribes transdermal fentanyl (Duragesic) 25 mcg/hr every 72
hours. During the first 24 hours after starting the fentanyl, what is the most important
nursing intervention?
1) Titrate the dose until pain is tolerable.
2) Manage pain with oral pain medication.
3) Assess the client for anticholinergic side effects.
4) Instruct the client to take the medication with food. - ANSWER Correct: 2
Rationale: It takes 24 hours to reach the peak effect of transdermal fentanyl
(Duragesic). Oral pain medication may be necessary to support client comfort until the
fentanyl reaches its peak effect. The nurse needs to administer the dose of transdermal
fentanyl exactly as prescribed by the health care provider. This is associated with
tricyclic antidepressants, not transdermal fentanyl. A transdermal medication is
administered through the skin via a patch applied to the skin, not via the gastrointestinal
tract.
To minimize the side effects of the vincristine (Oncovin) that a client is receiving, what
does the nurse expect the dietary plan to include?
1) Low in fat
2) High in iron
3) High in fluids
4) Low in residue - ANSWER Correct: 3
Rationale: A common side effect of vincristine is a paralytic ileus that results in
constipation. Preventative measures include high-fiber foods and fluids that exceed
minimum requirements. These will keep the stool bulky and soft, thereby promoting
evacuation. Low in fat, high in iron, and low in residue dietary plans will not provide the
roughage and fluids needed to minimize the constipation associated with vincristine.
A plan of care for a client newly diagnosed with type 1 diabetes includes teaching how
to self-administer insulin, adjust insulin dosage, select appropriate food on the
prescribed diet, and test the serum for glucose. The client demonstrates achievement of
these skills and is discharged five days following admission. What is the legal
implication in this situation?
