CAT 2 Review
______ has cross reactivity with penicillins - ANS-cefazolin (cephalosporins)
A client who is 16 years old goes to the community health clinic. The client tells the nurse, "I
think I got an infection from having sex with my boyfriend. I can't tell my parents. They will
kill me!" Which is the best response by the nurse?
1. "Since you are a minor, I will have to notify your parents."
2. "Your parents will appreciate your maturity in seeking help."
3. "Does your boyfriend understand that he will need treatment?"
4. "Your parents do not need to know, but will you give me consent for treatment?" - ANS-4.
"Your parents do not need to know, but will you give me consent for treatment?"
The nurse needs to obtain informed consent for treatment from the unemancipated minor.
The nurse is not obligated to notify the parents.
A client asks for an explanation about advance directives. Which entity should the nurse
include in the response to this client? (Select all that apply.)
1. Living will.
2. Health care proxy.
3. Organ donor card.
4. Hospice benefit guide.
5. Do-not-resuscitate prescription. - ANS-1, 2, 5
A client diagnosed with thrombocytopenia calls the clinic nurse. The client states, "I just cut
my skin while shaving; the bleeding won't stop even though I placed a bandage over the
cut." Which response by the nurse is best? - ANS-hold the pressure to the wound for 10 min
and call back
A client relieves severe abdominal pain that radiates to the back by sitting forward with the
knees bent. Which laboratory test will the nurse expect to be prescribed for this client?
1. Creatinine.
2. Serum amylase.
3. Creatinine kinase.
4. Blood urea nitrogen. - ANS-2. Amylase in the blood. amylase is a digestive enzyme
secreted by the pancreas. since the client is demonstrating signs of acute pancreatitis
A client takes a statin as prescribed. Which action does the nurse implement to identify if
the client is experiencing any side effects of the medication?
1. Find out your height and weight. 2. Check recent cholesterol level.
3. Inquire about the consistency of stool.
4. Assess for muscle tenderness. - ANS-assess for muscle tenderness
myalgia or muscle tenderness may indicate development of rhabdomyolysis, which is an
adverse reaction to statin meds
monitoring cholesterol evaluates the effectiveness of the med. not the side effects
A client who is pregnant is prescribed a medication that is pregnancy category D. Which
statement does the nurse make to the client when explaining this drug category? -
ANS-"Studies indicate that a possible fetal risk in humans has been reported."
, A client who is pregnant is prescribed a medication that is pregnancy category X. Which
statement does the nurse make to the client when explaining this drug category? -
ANS-reports indicate fetal abnormalities occur
Metoprolol XL 50 mg, taken orally twice daily, is prescribed to a patient who uses a gastric
feeding tube. Which action will the nurse take when providing this medication?
1. Use a nasogastric tube to administer the medication after crushing it. 2. Have the client
swallow the pill with a sip of water.
3. Call the health care provider.
4. Call the pharmacy to ask for a different form of metoprolol. - ANS-call HCP
A prescription cannot be changed at the pharmacy. A client's IV alarm sounds. A nurse
states, "I'll get it! That alarm has been beeping all shift. It might be broken. During client
rounds, the charge nurse finds the IV pump alarm button covered with a heavy layer of tape.
Which immediate action by the charge nurse is appropriate?
1. Report evidence of "alarm fatigue" among staff to the unit manager.
2. Replace the pump, label the current pump, and send it for repairs.
3. Fill out an incident report, citing the behavior that endangered a client.
4. Approach the nurse and discuss how to handle broken equipment. - ANS-2. Send the
current pump to be repaired, label it, and replace the pump. Focus the immediate action on
the client and the safe use of equipment. Make arrangements to have the pump fixed or
replaced if it keeps sounding alarming. A mother brings her 1-week-old newborn to the clinic
for a wellness checkup. She verbalizes frustration with breastfeeding because of nipple
soreness. Which nurse's advice might help ease nipple soreness? - ANS-apply ice to the
nipples after feeding due to its numbing effect allowing breast milk to dry on nipples helps
relieve soreness
a yellow brown coating on the clients tongue indicates? - ANS-client smokes cigarettes
absence of plantar creases? - ANS-Full- and post-term neonates have deep plantar
creases. A preterm newborn has few creases on the foot.
alendronate should be taken with a full glass of water to prevent? - ANS-acid reflex
can an LPN help a client with a colostomy who requires assistance with colostomy
irrigation? - ANS-yes
can an NAP add up intake and output for each client? - ANS-yes
can an NAP administer a tap water enema for a colonscopy in 2 hours? - ANS-no
client has insomnia, do you tell them to keep alarm clock out of room to help? - ANS-no, not
having an alarm clock in the room may increase anxiety. but the alarm clock should not be
facing the client
contractions occuring 2-3 min intervals lasting 2 minutes seen with ____ phase -
ANS-transition
The ANS-active phase of labor is characterized by contractions lasting 50-60 seconds and
occurring every 2-4 minutes. contractions occuring at regular intervals lasting 1-2 min seen
at _____ phase - ANS-transition
creatinine kinase is used to evaluate? - ANS-muscle function
do you want clients with bleeding disorders to be on stool softeners and why? - ANS-yes
because it prevents rectal bleeding from straining
dry skin, poor wound healing, and fatigue indicate? - ANS-malnutrition
during the initial home care visit the nurse should? - ANS--evaluate safety of clients
neighborhood
-arrange the visit at at time when it is safe to be in area
-collect info about the clients diagnosis/treatment
______ has cross reactivity with penicillins - ANS-cefazolin (cephalosporins)
A client who is 16 years old goes to the community health clinic. The client tells the nurse, "I
think I got an infection from having sex with my boyfriend. I can't tell my parents. They will
kill me!" Which is the best response by the nurse?
1. "Since you are a minor, I will have to notify your parents."
2. "Your parents will appreciate your maturity in seeking help."
3. "Does your boyfriend understand that he will need treatment?"
4. "Your parents do not need to know, but will you give me consent for treatment?" - ANS-4.
"Your parents do not need to know, but will you give me consent for treatment?"
The nurse needs to obtain informed consent for treatment from the unemancipated minor.
The nurse is not obligated to notify the parents.
A client asks for an explanation about advance directives. Which entity should the nurse
include in the response to this client? (Select all that apply.)
1. Living will.
2. Health care proxy.
3. Organ donor card.
4. Hospice benefit guide.
5. Do-not-resuscitate prescription. - ANS-1, 2, 5
A client diagnosed with thrombocytopenia calls the clinic nurse. The client states, "I just cut
my skin while shaving; the bleeding won't stop even though I placed a bandage over the
cut." Which response by the nurse is best? - ANS-hold the pressure to the wound for 10 min
and call back
A client relieves severe abdominal pain that radiates to the back by sitting forward with the
knees bent. Which laboratory test will the nurse expect to be prescribed for this client?
1. Creatinine.
2. Serum amylase.
3. Creatinine kinase.
4. Blood urea nitrogen. - ANS-2. Amylase in the blood. amylase is a digestive enzyme
secreted by the pancreas. since the client is demonstrating signs of acute pancreatitis
A client takes a statin as prescribed. Which action does the nurse implement to identify if
the client is experiencing any side effects of the medication?
1. Find out your height and weight. 2. Check recent cholesterol level.
3. Inquire about the consistency of stool.
4. Assess for muscle tenderness. - ANS-assess for muscle tenderness
myalgia or muscle tenderness may indicate development of rhabdomyolysis, which is an
adverse reaction to statin meds
monitoring cholesterol evaluates the effectiveness of the med. not the side effects
A client who is pregnant is prescribed a medication that is pregnancy category D. Which
statement does the nurse make to the client when explaining this drug category? -
ANS-"Studies indicate that a possible fetal risk in humans has been reported."
, A client who is pregnant is prescribed a medication that is pregnancy category X. Which
statement does the nurse make to the client when explaining this drug category? -
ANS-reports indicate fetal abnormalities occur
Metoprolol XL 50 mg, taken orally twice daily, is prescribed to a patient who uses a gastric
feeding tube. Which action will the nurse take when providing this medication?
1. Use a nasogastric tube to administer the medication after crushing it. 2. Have the client
swallow the pill with a sip of water.
3. Call the health care provider.
4. Call the pharmacy to ask for a different form of metoprolol. - ANS-call HCP
A prescription cannot be changed at the pharmacy. A client's IV alarm sounds. A nurse
states, "I'll get it! That alarm has been beeping all shift. It might be broken. During client
rounds, the charge nurse finds the IV pump alarm button covered with a heavy layer of tape.
Which immediate action by the charge nurse is appropriate?
1. Report evidence of "alarm fatigue" among staff to the unit manager.
2. Replace the pump, label the current pump, and send it for repairs.
3. Fill out an incident report, citing the behavior that endangered a client.
4. Approach the nurse and discuss how to handle broken equipment. - ANS-2. Send the
current pump to be repaired, label it, and replace the pump. Focus the immediate action on
the client and the safe use of equipment. Make arrangements to have the pump fixed or
replaced if it keeps sounding alarming. A mother brings her 1-week-old newborn to the clinic
for a wellness checkup. She verbalizes frustration with breastfeeding because of nipple
soreness. Which nurse's advice might help ease nipple soreness? - ANS-apply ice to the
nipples after feeding due to its numbing effect allowing breast milk to dry on nipples helps
relieve soreness
a yellow brown coating on the clients tongue indicates? - ANS-client smokes cigarettes
absence of plantar creases? - ANS-Full- and post-term neonates have deep plantar
creases. A preterm newborn has few creases on the foot.
alendronate should be taken with a full glass of water to prevent? - ANS-acid reflex
can an LPN help a client with a colostomy who requires assistance with colostomy
irrigation? - ANS-yes
can an NAP add up intake and output for each client? - ANS-yes
can an NAP administer a tap water enema for a colonscopy in 2 hours? - ANS-no
client has insomnia, do you tell them to keep alarm clock out of room to help? - ANS-no, not
having an alarm clock in the room may increase anxiety. but the alarm clock should not be
facing the client
contractions occuring 2-3 min intervals lasting 2 minutes seen with ____ phase -
ANS-transition
The ANS-active phase of labor is characterized by contractions lasting 50-60 seconds and
occurring every 2-4 minutes. contractions occuring at regular intervals lasting 1-2 min seen
at _____ phase - ANS-transition
creatinine kinase is used to evaluate? - ANS-muscle function
do you want clients with bleeding disorders to be on stool softeners and why? - ANS-yes
because it prevents rectal bleeding from straining
dry skin, poor wound healing, and fatigue indicate? - ANS-malnutrition
during the initial home care visit the nurse should? - ANS--evaluate safety of clients
neighborhood
-arrange the visit at at time when it is safe to be in area
-collect info about the clients diagnosis/treatment
