Hurst Readiness Exam 3 || 100% Verified Solutions.
Which menu selection by the client diagnosed with nephrotic syndrome indicates that
teaching of proper diet was understood? You answered this question Correctly 1. Pancakes
with whipped butter, syrup, bacon, apple juice 2. Scrambled eggs, sliced turkey, biscuit,
whole milk 3. Grits, fresh fruit, toast, coffee 4. Bagel with jelly, hash browns, tea correct
answers Rationale
2. Correct: Client needs low sodium and increased proteins. 1. Incorrect: This selection is too
high in sodium and fats. 3. Incorrect: This selection has no protein. Remember, nephrotic
syndrome is the exception to the rule of limiting protein. These clients need increased protein
to compensate for the large loss of protein in the urine. 4. Incorrect: This selection has no
protein. Remember, nephrotic syndrome is the exception to the rule of limiting protein. These
clients need increased protein to compensate for the large loss of protein in the urine.
Following a total hip replacement, the nurse provides discharge teaching to the client. The
nurse knows that teaching was effective when the client states which activities are safe to
perform? You answered this question Correctly 1. Using an abduction pillow while sleeping
2. Crossing the legs 3. Using a toilet extender 4. Showering rather than taking a bath 5. Tying
shoes correct answers RationaleStrategies 1., 3., & 4. Correct: The client should use an
abduction pillow to keep hip in proper alignment and prevent hip dislocation. A toilet
extender keeps the hip in proper alignment and prevents hip dislocation. Showering rather
than sitting in a tub will prevent flexion of the hip. 2. Incorrect: Crossing the leg can pop the
hip out of place and prevent total healing and success with the replacement. 5. Incorrect: To
tie shoes, the client has to bend over which can pop the hip out of place. The client would
need to have shoes that do not require tying or have someone do it for them.
What risk factors should the nurse include when conducting a class about type 2 diabetes
mellitus? You answered this question Correctly 1. Fat distribution greater in abdomen than in
hips. 2. Being underweight. 3. Having type 1 diabetes as a child increases risk for type 2
diabetes. 4. Caucasians are more likely to develop type 2 diabetes than Hispanics. 5.
Polycystic ovary syndrome. correct answers RationaleStrategies 1., & 5. Correct: If the body
stores fat primarily in the abdomen, risk of type 2 diabetes is greater than if body stores fat
elsewhere, such as hips and thighs. Women with polycystic ovary syndrome have increased
risk of diabetes. 2. Incorrect: Being overweight is a primary risk factor for type 2 diabetes.
The more fatty tissue, the more resistant cells become to insulin. 3. Incorrect: A type 1
diabetic will remain a type 1 diabetic. 4. Incorrect: African Americans, Hispanics, American
Indians, and Asian Americans are more likely to develop type 2 diabetes than Caucasians are.
The nurse is caring for a client following spinal surgery. The client is placed on
methylprednisolone. What additional drug therapy would the nurse expect to be prescribed
with methylprednisolone? You answered this question Correctly 1. Pantoprazole 2. Phenytoin
3. Imipramine HCI 4. Aminocaproic acid correct answers RationaleStrategies 1. Correct: A
potential side effect of methylprednisolone is a peptic ulcer. The primary healthcare provider
will prescribe a proton pump inhibitor or H2 blocker to prevent this side effect. 2. Incorrect:
Phenytoin is an anticonvulsant. Seizures are not a side effect of methylprednisolone. 3.
Incorrect: Imipramine HCI is an antidepressant which is not routinely given with
methylprednisolone (Although mood changes can occur with steroid administration, anti-
depressants are not routinely given). 4. Incorrect: Aminocaproic acid is given when clients
are bleeding. Bleeding is not a side effect of methylprednisolone.
,In what order, after initially washing hands, should the nurse change a dressing on an infected
abdominal surgical wound that has a Penrose drain and a large amount of purulent drainage?
Place in priority order from first to last. You answered this question CorrectlyThe Correct
Order Apply clean gloves. Remove soiled dressings. Discard soiled dressings and clean
gloves in red bag. Don sterile gloves. Clean surgical wound with moistened sterile 4x4's.
Clean around Penrose drain using a circular pattern inside to outside. Place dry, sterile 4x4's
over surgical wound and Penrose drain. Apply abdominal dressing pad. Your Selected Order
Apply clean gloves. Remove soiled dressings. Discard soiled dressings and clean gloves in
red bag. Don sterile gloves. Clean surgical wound with moistened sterile 4x4's. Clean around
Penrose drain using a circular pattern inside to outside. Place dry, sterile 4x4's over surgical
wound and correct answers RationaleStrategies First, apply clean gloves. Second, remove
soiled dressings. Third, discard soiled dressings and clean gloves in red bag. Fourth, don
sterile gloves. Fifth, clean surgical wound with moistened sterile 4x4's. Sixth, clean around
Penrose drain using circular pattern inside to outside. Seventh, place dry, sterile 4x4's over
surgical wound and Penrose drain. Eighth, apply abdominal dressing pad.
A client diagnosed with schizophrenia who is taking monthly haloperidol injections develops
slurred speech, shuffling gait and drooling. Which prescribed PRN medication would the
nurse administer? You answered this question Incorrectly 1. Lorazepam 2. Atropine 3.
Benztropine 4. Chlorpromazine correct answers RationaleStrategies 3. Correct: These signs
and symptoms are reflective of pseudoparkinsonism, a form of extrapyramidal side effects
which are side effects of the haloperidol. An anticholinergic agent maybe used for treatment.
This is an anticholinergic agent that may be used for extrapyramidal side effects. 1. Incorrect:
This is a sedative/hypnotic or antianxiety agent. It is not used for treatment of extrapyramidal
side effects. 2. Incorrect: This is an anticholinergic agent, but not one commonly used to treat
pseudoparkinsonism, a form of extrapyramidal side effects. It is commonly used to treat
arrhythmias and preoperatively to decrease secretions. 4. Incorrect: This is another
antipsychotic medication.
A nurse is caring for a client who reports fatigue, weight loss, afternoon fevers, night sweats,
cough, and hemoptysis. What interventions should the nurse initiate? You answered this
question Correctly 1. Wear an N95 respirator when caring for client. 2. Restrict fluid intake to
500 mL per day. 3. Position client in semi-Fowler's position. 4. Place client in a negative
pressure airflow room. 5. Do not allow visitors for 48 hours. correct answers
RationaleStrategies 1., 3. & 4. Correct: The nurse should suspect that the client is suffering
from tuberculosis. Early pulmonary TB is asymptomatic. When the bacterial load increases,
nonspecific symptoms of fatigue, weight loss, afternoon fevers, and night sweats may set in.
As disease advances, cough, sputum production, and hemoptysis may appear. This client has
the classic symptoms of TB and should be placed on airborne precautions. N95 respirator
ensures that the nurse does not inhale the TB organism. Placing in a semi-Fowler's position
reduces the work of breathing. 2. Incorrect: Unless contraindicated, 3-4 liters of fluid is
needed per day to liquefy secretions. 5. Incorrect: Visitors are allowed if standard and
airborne precautions are followed.
Which task should the nurse perform first? You answered this question Correctly 1.
Suctioning the tracheostomy. 2. Changing a colostomy bag that is leaking. 3. Performing an
admission assessment on a client. 4. Administering pain medication to a postoperative client.
correct answers RationaleStrategies 1. Correct: The tracheostomy tube must be suctioned to
keep the client's airway open. Suctioning the tracheostomy should take priority. Remember,
airway first. 2. Incorrect: The client may be uncomfortable from the colostomy bag leaking.
,This task can be delegated. The suctioning of the client does not have priority over airway. 3.
Incorrect: Important, but not priority over airway. There is no indication from the question
that the new client is in distress. The priority intervention is to maintain the airway. 4.
Incorrect: Important, but it does not take priority over airway.
A nurse is caring for a client hospitalized with Guillain-Barre syndrome. Which is the most
important nursing measure to include in the nursing care plan for this client? You answered
this question Correctly 1. Observation and support of ventilation 2. Insertion of indwelling
urinary catheter 3. Nasogastric suctioning 4. Frequent assessments of level of consciousness
correct answers RationaleStrategies 1. Correct: Guillain-Barre syndrome is an acquired
inflammatory disease that results in demyelinization of the peripheral nerves. It is usually
ascending in nature and can lead to respiratory paresis or paralysis. 2. Incorrect: Insertion of
an indwelling urinary catheter may in fact be necessary but does not prioritize higher than
support of ventilation. 3. Incorrect: Nasogastric suctioning is not a need identified with
Guillain-Barre syndrome. Guillain-Barre does not affect the LOC. 4. Incorrect: The client's
cognitive function remains intact, and there is no data in the stem of the question that
indicates otherwise; therefore, ventilation is the priority.
The nurse recognizes that treatment has been successful in resolving fluid volume excess
based on which assessment findings? You answered this question Correctly 1. Continued
lethargy 2. Heart rate 112/min 3. Decreasing shortness of breath 4. BP 114/78 5. Increased
thirst correct answers RationaleStrategies 3. & 4. Correct: Urinary output should increase
with decreasing shortness of breath as hydration is corrected, and BP should be normal. 1.
Incorrect: Level of consciousness (LOC) should improve with perfusion to the brain. 2.
Incorrect: Heart rate should decrease if hydration is corrected. 5. Incorrect: Thirst level
should be decreased if hydration is corrected.
The oncoming nurse has just received report and is preparing to make initial rounds. Which
postpartum client should the nurse see first? You answered this question Correctly 1. A
primipara 6 hours postpartum saturating one peripad every two hours 2. A multigravida 1
hour postpartum and reporting intense perineal pain 3. A primigravida 12 hours postpartum
with the uterine fundus at the umbilicus 4. A multigravida 72 hours postpartum with a
brownish pink lochia discharge. correct answers RationaleStrategies 2. Correct: Intense
perineal pain is a symptom of a perineal hematoma which is a medical emergency. 1.
Incorrect: Expected findings for the postpartum period are described here. This is a normal
peripad saturation and does not indicate a problem. 3. Incorrect: Expected findings for the
postpartum period are described here. This is the proper position of the fundus 12 hours
postpartum. 4. Incorrect: Expected findings for the postpartum period are described here also.
A client postpartal 72 hours should have a brownish pink lochia discharge.
The primary healthcare provider prescribes glycopyrrolate 0.2 mg IM thirty minutes prior to
electroconvulsive therapy (ECT). What should be the nurse's response when the client asks
why this drug is being given? You answered this question Incorrectly 1. "The action of the
medication is complex." 2. "This drug will prevent you from having a seizure." 3. "This
medication will relax your muscles so that you do not break a bone." 4. "Glycopyrrolate will
decrease stomach secretions." correct answers RationaleStrategies 4. Correct: Glycopyrrolate
is an anticholinergic. Glycopyrrolate blocks the activity of acetylcholine which reduces
secretions in the mouth, throat, airway, and stomach. It is used prior to procedures to decrease
the risk of aspiration. 1. Incorrect: The client has a right to be told the reason the drug is
given. This is a nontherapeutic communication response. The nurse should not refuse the
, client's desire to understand their medications. 2. Incorrect: Glycopyrrolate blocks the
secretions in the mouth, throat, airway and stomach. The medication does not prevent the
client having a seizure. The ECT will induce a seizure, which is the desire. 3. Incorrect: This
is not the drug's purpose so this would be incorrect information to give to the client.
The nurse is searching for information about the nursing care of a client receiving an
experimental drug for the treatment of obesity. Which database is most likely to address this
issue? You answered this question Correctly 1. Cumulative Index for Nursing and Allied
Health Literature (CINAHL) 2. Cochrane Library 3. Health and Wellness Resource Center 4.
MEDLINE correct answers RationaleStrategies 1. Correct: The Cumulative Index for
Nursing and Allied Health Literature (CINAHL) is a source for reviewing nursing and allied
health information. It is also located in other healthcare data bases. 2. Incorrect: Cochrane
Library includes evidence based medicine databases. 3. Incorrect: The Health and Wellness
Resource Center provides access to a variety of journal articles, magazines, and pamphlets. 4.
Incorrect: MEDLINE is one of the major sources for biomedical information.
A client comes to the clinic reporting palpitations, as well as nausea and vomiting while
taking metronidazole. The nurse notes that the client is flushed and has a heart rate of 118
bpm. Based on this information, what is the most important question for the nurse to ask the
client? You answered this question Correctly 1. "Do you take metronidazole on an empty
stomach?" 2. "Are you using any products that contain alcohol?" 3. "How long have you had
these symptoms?" 4. "What other medications are you currently taking?" correct answers
RationaleStrategies 2. Correct: Flushing, nausea and vomiting, palpitations, tachycardia,
psychosis are signs of disulfiram-type reaction seen when using products containing alcohol
(cologne, after shave lotion, or path splashes) or ingesting alcohol products while taking
metronidazole. 1. Incorrect: Although it is preferable to take metronidazole on an empty
stomach, this is not the most important question to ask at this time. 3. Incorrect: How long the
client has had these symptoms is not as important as whether the client is using any alcohol
containing products. 4. Incorrect: Although the nurse needs to know what other medications
the client is taking, it is not as important as knowing if the client is using any alcohol
containing products.
A case manager is evaluating a client diagnosed with hemiplegia due to a cerebral vascular
accident who will need assistive devices upon discharge. Which devices should the case
manager include for this client? You answered this question Correctly 1. Dinner plate food
guards 2. Transfer belt 3. Raised toilet seat 4. Long handled shoe horn 5. Wide grip eating
utensils 6. Button closures on clothes correct answers RationaleStrategies 1., 2., 3., 4., & 5.
Correct: The goal is to promote self-care by the client as much as possible. The case manager
should evaluate the need for assistive devices to help with eating, bathing, dressing, and
ambulating. The dinner plate food guard will prevent food from being pushed off the plate.
The transfer belt will provide safety for the client to get into a chair or back in bed. A raised
toilet seat makes it easier for the client to sit on the toilet without falling. The long-handled
shoe horn allows the client to put on shoes without assistance. Wide grip utensils
accommodate a weak grip. 6. Incorrect: It is hard for someone with hemiplegia to use
buttons. Velcro fasteners are best.
The nurse is caring for a Native American client who has returned to the surgical floor
following abdominal surgery. The nurse is concerned about the level of discomfort that the
client is experiencing. Which comment is the nurse likely to hear upon assessment? You
answered this question Correctly 1. "The pain is getting worse. I can't stand it." 2. "I need
Which menu selection by the client diagnosed with nephrotic syndrome indicates that
teaching of proper diet was understood? You answered this question Correctly 1. Pancakes
with whipped butter, syrup, bacon, apple juice 2. Scrambled eggs, sliced turkey, biscuit,
whole milk 3. Grits, fresh fruit, toast, coffee 4. Bagel with jelly, hash browns, tea correct
answers Rationale
2. Correct: Client needs low sodium and increased proteins. 1. Incorrect: This selection is too
high in sodium and fats. 3. Incorrect: This selection has no protein. Remember, nephrotic
syndrome is the exception to the rule of limiting protein. These clients need increased protein
to compensate for the large loss of protein in the urine. 4. Incorrect: This selection has no
protein. Remember, nephrotic syndrome is the exception to the rule of limiting protein. These
clients need increased protein to compensate for the large loss of protein in the urine.
Following a total hip replacement, the nurse provides discharge teaching to the client. The
nurse knows that teaching was effective when the client states which activities are safe to
perform? You answered this question Correctly 1. Using an abduction pillow while sleeping
2. Crossing the legs 3. Using a toilet extender 4. Showering rather than taking a bath 5. Tying
shoes correct answers RationaleStrategies 1., 3., & 4. Correct: The client should use an
abduction pillow to keep hip in proper alignment and prevent hip dislocation. A toilet
extender keeps the hip in proper alignment and prevents hip dislocation. Showering rather
than sitting in a tub will prevent flexion of the hip. 2. Incorrect: Crossing the leg can pop the
hip out of place and prevent total healing and success with the replacement. 5. Incorrect: To
tie shoes, the client has to bend over which can pop the hip out of place. The client would
need to have shoes that do not require tying or have someone do it for them.
What risk factors should the nurse include when conducting a class about type 2 diabetes
mellitus? You answered this question Correctly 1. Fat distribution greater in abdomen than in
hips. 2. Being underweight. 3. Having type 1 diabetes as a child increases risk for type 2
diabetes. 4. Caucasians are more likely to develop type 2 diabetes than Hispanics. 5.
Polycystic ovary syndrome. correct answers RationaleStrategies 1., & 5. Correct: If the body
stores fat primarily in the abdomen, risk of type 2 diabetes is greater than if body stores fat
elsewhere, such as hips and thighs. Women with polycystic ovary syndrome have increased
risk of diabetes. 2. Incorrect: Being overweight is a primary risk factor for type 2 diabetes.
The more fatty tissue, the more resistant cells become to insulin. 3. Incorrect: A type 1
diabetic will remain a type 1 diabetic. 4. Incorrect: African Americans, Hispanics, American
Indians, and Asian Americans are more likely to develop type 2 diabetes than Caucasians are.
The nurse is caring for a client following spinal surgery. The client is placed on
methylprednisolone. What additional drug therapy would the nurse expect to be prescribed
with methylprednisolone? You answered this question Correctly 1. Pantoprazole 2. Phenytoin
3. Imipramine HCI 4. Aminocaproic acid correct answers RationaleStrategies 1. Correct: A
potential side effect of methylprednisolone is a peptic ulcer. The primary healthcare provider
will prescribe a proton pump inhibitor or H2 blocker to prevent this side effect. 2. Incorrect:
Phenytoin is an anticonvulsant. Seizures are not a side effect of methylprednisolone. 3.
Incorrect: Imipramine HCI is an antidepressant which is not routinely given with
methylprednisolone (Although mood changes can occur with steroid administration, anti-
depressants are not routinely given). 4. Incorrect: Aminocaproic acid is given when clients
are bleeding. Bleeding is not a side effect of methylprednisolone.
,In what order, after initially washing hands, should the nurse change a dressing on an infected
abdominal surgical wound that has a Penrose drain and a large amount of purulent drainage?
Place in priority order from first to last. You answered this question CorrectlyThe Correct
Order Apply clean gloves. Remove soiled dressings. Discard soiled dressings and clean
gloves in red bag. Don sterile gloves. Clean surgical wound with moistened sterile 4x4's.
Clean around Penrose drain using a circular pattern inside to outside. Place dry, sterile 4x4's
over surgical wound and Penrose drain. Apply abdominal dressing pad. Your Selected Order
Apply clean gloves. Remove soiled dressings. Discard soiled dressings and clean gloves in
red bag. Don sterile gloves. Clean surgical wound with moistened sterile 4x4's. Clean around
Penrose drain using a circular pattern inside to outside. Place dry, sterile 4x4's over surgical
wound and correct answers RationaleStrategies First, apply clean gloves. Second, remove
soiled dressings. Third, discard soiled dressings and clean gloves in red bag. Fourth, don
sterile gloves. Fifth, clean surgical wound with moistened sterile 4x4's. Sixth, clean around
Penrose drain using circular pattern inside to outside. Seventh, place dry, sterile 4x4's over
surgical wound and Penrose drain. Eighth, apply abdominal dressing pad.
A client diagnosed with schizophrenia who is taking monthly haloperidol injections develops
slurred speech, shuffling gait and drooling. Which prescribed PRN medication would the
nurse administer? You answered this question Incorrectly 1. Lorazepam 2. Atropine 3.
Benztropine 4. Chlorpromazine correct answers RationaleStrategies 3. Correct: These signs
and symptoms are reflective of pseudoparkinsonism, a form of extrapyramidal side effects
which are side effects of the haloperidol. An anticholinergic agent maybe used for treatment.
This is an anticholinergic agent that may be used for extrapyramidal side effects. 1. Incorrect:
This is a sedative/hypnotic or antianxiety agent. It is not used for treatment of extrapyramidal
side effects. 2. Incorrect: This is an anticholinergic agent, but not one commonly used to treat
pseudoparkinsonism, a form of extrapyramidal side effects. It is commonly used to treat
arrhythmias and preoperatively to decrease secretions. 4. Incorrect: This is another
antipsychotic medication.
A nurse is caring for a client who reports fatigue, weight loss, afternoon fevers, night sweats,
cough, and hemoptysis. What interventions should the nurse initiate? You answered this
question Correctly 1. Wear an N95 respirator when caring for client. 2. Restrict fluid intake to
500 mL per day. 3. Position client in semi-Fowler's position. 4. Place client in a negative
pressure airflow room. 5. Do not allow visitors for 48 hours. correct answers
RationaleStrategies 1., 3. & 4. Correct: The nurse should suspect that the client is suffering
from tuberculosis. Early pulmonary TB is asymptomatic. When the bacterial load increases,
nonspecific symptoms of fatigue, weight loss, afternoon fevers, and night sweats may set in.
As disease advances, cough, sputum production, and hemoptysis may appear. This client has
the classic symptoms of TB and should be placed on airborne precautions. N95 respirator
ensures that the nurse does not inhale the TB organism. Placing in a semi-Fowler's position
reduces the work of breathing. 2. Incorrect: Unless contraindicated, 3-4 liters of fluid is
needed per day to liquefy secretions. 5. Incorrect: Visitors are allowed if standard and
airborne precautions are followed.
Which task should the nurse perform first? You answered this question Correctly 1.
Suctioning the tracheostomy. 2. Changing a colostomy bag that is leaking. 3. Performing an
admission assessment on a client. 4. Administering pain medication to a postoperative client.
correct answers RationaleStrategies 1. Correct: The tracheostomy tube must be suctioned to
keep the client's airway open. Suctioning the tracheostomy should take priority. Remember,
airway first. 2. Incorrect: The client may be uncomfortable from the colostomy bag leaking.
,This task can be delegated. The suctioning of the client does not have priority over airway. 3.
Incorrect: Important, but not priority over airway. There is no indication from the question
that the new client is in distress. The priority intervention is to maintain the airway. 4.
Incorrect: Important, but it does not take priority over airway.
A nurse is caring for a client hospitalized with Guillain-Barre syndrome. Which is the most
important nursing measure to include in the nursing care plan for this client? You answered
this question Correctly 1. Observation and support of ventilation 2. Insertion of indwelling
urinary catheter 3. Nasogastric suctioning 4. Frequent assessments of level of consciousness
correct answers RationaleStrategies 1. Correct: Guillain-Barre syndrome is an acquired
inflammatory disease that results in demyelinization of the peripheral nerves. It is usually
ascending in nature and can lead to respiratory paresis or paralysis. 2. Incorrect: Insertion of
an indwelling urinary catheter may in fact be necessary but does not prioritize higher than
support of ventilation. 3. Incorrect: Nasogastric suctioning is not a need identified with
Guillain-Barre syndrome. Guillain-Barre does not affect the LOC. 4. Incorrect: The client's
cognitive function remains intact, and there is no data in the stem of the question that
indicates otherwise; therefore, ventilation is the priority.
The nurse recognizes that treatment has been successful in resolving fluid volume excess
based on which assessment findings? You answered this question Correctly 1. Continued
lethargy 2. Heart rate 112/min 3. Decreasing shortness of breath 4. BP 114/78 5. Increased
thirst correct answers RationaleStrategies 3. & 4. Correct: Urinary output should increase
with decreasing shortness of breath as hydration is corrected, and BP should be normal. 1.
Incorrect: Level of consciousness (LOC) should improve with perfusion to the brain. 2.
Incorrect: Heart rate should decrease if hydration is corrected. 5. Incorrect: Thirst level
should be decreased if hydration is corrected.
The oncoming nurse has just received report and is preparing to make initial rounds. Which
postpartum client should the nurse see first? You answered this question Correctly 1. A
primipara 6 hours postpartum saturating one peripad every two hours 2. A multigravida 1
hour postpartum and reporting intense perineal pain 3. A primigravida 12 hours postpartum
with the uterine fundus at the umbilicus 4. A multigravida 72 hours postpartum with a
brownish pink lochia discharge. correct answers RationaleStrategies 2. Correct: Intense
perineal pain is a symptom of a perineal hematoma which is a medical emergency. 1.
Incorrect: Expected findings for the postpartum period are described here. This is a normal
peripad saturation and does not indicate a problem. 3. Incorrect: Expected findings for the
postpartum period are described here. This is the proper position of the fundus 12 hours
postpartum. 4. Incorrect: Expected findings for the postpartum period are described here also.
A client postpartal 72 hours should have a brownish pink lochia discharge.
The primary healthcare provider prescribes glycopyrrolate 0.2 mg IM thirty minutes prior to
electroconvulsive therapy (ECT). What should be the nurse's response when the client asks
why this drug is being given? You answered this question Incorrectly 1. "The action of the
medication is complex." 2. "This drug will prevent you from having a seizure." 3. "This
medication will relax your muscles so that you do not break a bone." 4. "Glycopyrrolate will
decrease stomach secretions." correct answers RationaleStrategies 4. Correct: Glycopyrrolate
is an anticholinergic. Glycopyrrolate blocks the activity of acetylcholine which reduces
secretions in the mouth, throat, airway, and stomach. It is used prior to procedures to decrease
the risk of aspiration. 1. Incorrect: The client has a right to be told the reason the drug is
given. This is a nontherapeutic communication response. The nurse should not refuse the
, client's desire to understand their medications. 2. Incorrect: Glycopyrrolate blocks the
secretions in the mouth, throat, airway and stomach. The medication does not prevent the
client having a seizure. The ECT will induce a seizure, which is the desire. 3. Incorrect: This
is not the drug's purpose so this would be incorrect information to give to the client.
The nurse is searching for information about the nursing care of a client receiving an
experimental drug for the treatment of obesity. Which database is most likely to address this
issue? You answered this question Correctly 1. Cumulative Index for Nursing and Allied
Health Literature (CINAHL) 2. Cochrane Library 3. Health and Wellness Resource Center 4.
MEDLINE correct answers RationaleStrategies 1. Correct: The Cumulative Index for
Nursing and Allied Health Literature (CINAHL) is a source for reviewing nursing and allied
health information. It is also located in other healthcare data bases. 2. Incorrect: Cochrane
Library includes evidence based medicine databases. 3. Incorrect: The Health and Wellness
Resource Center provides access to a variety of journal articles, magazines, and pamphlets. 4.
Incorrect: MEDLINE is one of the major sources for biomedical information.
A client comes to the clinic reporting palpitations, as well as nausea and vomiting while
taking metronidazole. The nurse notes that the client is flushed and has a heart rate of 118
bpm. Based on this information, what is the most important question for the nurse to ask the
client? You answered this question Correctly 1. "Do you take metronidazole on an empty
stomach?" 2. "Are you using any products that contain alcohol?" 3. "How long have you had
these symptoms?" 4. "What other medications are you currently taking?" correct answers
RationaleStrategies 2. Correct: Flushing, nausea and vomiting, palpitations, tachycardia,
psychosis are signs of disulfiram-type reaction seen when using products containing alcohol
(cologne, after shave lotion, or path splashes) or ingesting alcohol products while taking
metronidazole. 1. Incorrect: Although it is preferable to take metronidazole on an empty
stomach, this is not the most important question to ask at this time. 3. Incorrect: How long the
client has had these symptoms is not as important as whether the client is using any alcohol
containing products. 4. Incorrect: Although the nurse needs to know what other medications
the client is taking, it is not as important as knowing if the client is using any alcohol
containing products.
A case manager is evaluating a client diagnosed with hemiplegia due to a cerebral vascular
accident who will need assistive devices upon discharge. Which devices should the case
manager include for this client? You answered this question Correctly 1. Dinner plate food
guards 2. Transfer belt 3. Raised toilet seat 4. Long handled shoe horn 5. Wide grip eating
utensils 6. Button closures on clothes correct answers RationaleStrategies 1., 2., 3., 4., & 5.
Correct: The goal is to promote self-care by the client as much as possible. The case manager
should evaluate the need for assistive devices to help with eating, bathing, dressing, and
ambulating. The dinner plate food guard will prevent food from being pushed off the plate.
The transfer belt will provide safety for the client to get into a chair or back in bed. A raised
toilet seat makes it easier for the client to sit on the toilet without falling. The long-handled
shoe horn allows the client to put on shoes without assistance. Wide grip utensils
accommodate a weak grip. 6. Incorrect: It is hard for someone with hemiplegia to use
buttons. Velcro fasteners are best.
The nurse is caring for a Native American client who has returned to the surgical floor
following abdominal surgery. The nurse is concerned about the level of discomfort that the
client is experiencing. Which comment is the nurse likely to hear upon assessment? You
answered this question Correctly 1. "The pain is getting worse. I can't stand it." 2. "I need
