AND ANSWERS
After the fourth dose of gentamicin sulfate (Garamycin) IV, the nurse plans to draw blood
samples to determine peak and trough levels. When are the best times to draw these samples?
- ANS 5 minutes before and 30 minutes after the next dose.
The nurse is completing an admission interview and assessment on a client with a history of
Parkinson's disease. Which question provides information relevant to the client's plan of care? -
ANS Have you ever been "frozen" in one spot, unable to move?
To take the vital signs of a 4-month-old child, which order will give the most accurate results? -
ANS Respiratory rate, heart rate, then rectal temperature.
During lung assessment, the nurse places a stethoscope on a client's chest and instructs
him/her to say "99" each time the chest is touched with the stethoscope. What should be the
correct interpretation if the nurse hears the spoken words "99" very clearly through the
stethoscope? - ANS May indicate pneumonia.
The nurse knows that lab values sometimes vary for the older client. Which data would the
nurse expect to find hen reviewing laboratory values of an 80-year-old male? -
ANS Increased protein in the urine, slightly increased serum glucose levels.
A 67-year-old woman who lives alone tripped on a rug in her home and fractured her hip.
Which predisposing factor probably led to the fracture in the proximal end of her femur? -
ANS Osteoporosis resulting from hormonal changes.
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, A 2-year-old child with Down syndrome is brought to the clinic for his regular physical
examination. The nurse knows which problem is frequently associated with Down syndrome? -
ANS Congenital heart disease
A 14-year-old female client tells the nurse that she is concerned about the acne she has
recently developed. Which recommendation should the nurse provide? - ANS Wash the hair
and skin frequently with soap and hot water.
A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells)
as rapidly as possible. Which intervention is most important for the nurse to implement? -
ANS Ensure the accuracy of the blood type match.
A client with multiple sclerosis has experienced an exacerbation of symptoms, including
paresthesias, diplopia, and nystagmus. Which instruction should the nurse provide? -
ANS Schedule extra rest periods.
A nurse working on a mental health unit receives a community call from a person who is tearful
and states, "I just feel so nervous all of the time. I don't know what to do about my problems. I
haven't been able to sleep at night and have hardly eaten for the past 3 or 4 days." The nurse
should initiate a referral based on which assessment? - ANS Moderate levels of anxiety.
When plotting a 20-week-old infant's weight on a standardized growth chart, the nurse
determines that the child's weight is between the 2nd and 3rd percentile. Based on this finding,
which action should the nurse take? - ANS Compare this weight with previous weights
recorded in the child's record.
A female teenager is taking oral tetracycline (Achromycin V) for acne vulgaris. What is the most
important instruction for the nurse to include in this client's teaching plan? - ANS Use
sunscreen when laying by the pool.
A client who was in a motor vehicle collision was admitted to the hospital and the right knee
was placed in skeletal traction. The nurse has documented this nursing diagnosis in the client's
medical record: "Potential for impairment of skin integrity related to immobility from traction."
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