Exam (elaborations)
NURSING NU1426
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Exam of 22 pages for the course NURSING at NURSING (NURSING NU1426)
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NURSING NU14261. A nurse is caring for a client with histoplasmosis who is receiving intravenous amphotericin B
(Fungizone). What should the nurse do while the medication is being administered?
A Monitor the client’s urine output Correct
B Monitor the client for hypothermia
C Check the client’s neurological status Incorrect
D Check the client’s blood glucose level
Rationale: Amphotericin B can produce medication toxicity during administration and exhibit symptoms
such as chills, fever, headache, vomiting, and impairment of renal function. The medication is also irritating
to the IV site, commonly causing thrombophlebitis.
2. A nurse is assessing a peripheral intravenous (IV) site and notes blanching, coolness, and edema at
the insertion site. What should the nurse do first?
E Remove the IV Correct
F Apply a warm compress
G Check for blood return
H Measure the area of infiltration
Rationale: Blanching, coolness, and edema of the IV site are all signs of infiltration. Because infiltration
may result in damage to the surrounding tissue, the nurse must first remove the IV cannula to prevent any
further damage. The nurse should not depend solely on the blood return for assurance that the cannula is in
the vein, because blood return may be present even if the cannula is only partially in the vein. Compresses
may be used, but the compress (warm or cool) depends on the type of solution infusing and physician
preference. The nurse should measure the area of infiltration after the IV has been removed so that further
tissue damage is prevented.
3. A nurse provides instructions to a client who will be taking furosemide (Lasix). Which of the
following statements by the client indicates to the nurse that the client needs additional instruction?
I “I need to sit or stand up slowly.”
J “I should expect to have ringing in my ears.” Correct
K “I need to maintain my fluid intake.” Incorrect
L “This medication will make me urinate.”
Rationale: Furosemide is a loop diuretic. Adverse effects of furosemide therapy include orthostatic
hypotension and ototoxicity. Therefore the client should change positions slowly to help prevent
lightheadedness. The client must also contact the physician if signs of ototoxicity, such as hearing loss or
ringing in the ears, occur. Fluid intake should be maintained to prevent dehydration.
4. Fluoxetine hydrochloride (Prozac) is prescribed for a client, and the nurse provides instruction
regarding the use of the medication. The nurse tells the client that it is best to take the medication:
M At lunchtime
N In the morning Correct
O With the evening meal
P Midafternoon, with an antacid
Rationale: Fluoxetine hydrochloride (Prozac) is a selective serotonin reuptake inhibitor that elicits an
antidepressant response. It is best administered in the early morning, and there is no need to coordinate the
dose with a meal. (If the medication causes lightheadedness or dizziness, the healthcare provider may
advise the client to take it at bedtime.) The other options are incorrect.
5. A nurse is changing the central line dressing of a client receiving parenteral nutrition (PN). The
nurse notes moisture under the dressing covering the catheter insertion site. What does the nurse assess
next?
Q Temperature
R Time of the last dressing change
S Expiration date on the infusion bag
T Tightness of the tubing connections Correct
Rationale: A loose tubing connection — the most obvious cause of the moisture that could be readily
detected and fixed by the nurse — is the first thing the nurse should look for. The client’s temperature
would be assessed if the nurse were looking for signs of infection. The expiration date on the infusion bag
and the time of the last dressing change are routine observations but have nothing to do with the subject of
the question.
6. A client receiving parenteral nutrition (PN) requires fat emulsion (lipids), which will be
, NURSING NU1426
piggybacked to the PN solution. On obtaining a bottle of fat emulsion, the nurse notes that fat globules are
, NURSING NU1426
floating at the top of the solution. Which of these actions should the nurse take?
U Shaking the bottle vigorously
V Requesting a new bottle from the pharmacy Correct
W Rotating the bottle gently back and forth to mix the globules
X Running the bottle under warm water until the globules disappear Incorrect
Rationale: The nurse should not hang a fat emulsion that contains visible fat globules. Another bottle of
solution should be obtained and used in its place. When PN is combined with fat emulsion, the solution
should not be used if there is a visible “ring” noted in the container of solution. The actions in the other
options are incorrect.
7. A home health nurse provides instructions to a client who is taking allopurinol (Zyloprim) for the
treatment of gout. The nurse should tell the client to:
A Place an ice pack on the lips if they swell
B Drink at least 8 glasses of fluid every day Correct
C Take the medication on an empty stomach 2 hours before meals
D Use an over-the-counter (OTC) antihistamine lotion if a rash develops
Rationale: Clients taking allopurinol are encouraged to drink 3000 mL/day of fluid. Allopurinol is to be
given with or immediately after meals or milk. If a rash, irritation of the eyes, or swelling of the lips or
mouth develops, the client should contact the physician, because this development may indicate
hypersensitivity.
8. Cyclophosphamide has been prescribed for a client with a diagnosis of breast cancer, and the nurse
is providing instructions to the client. The nurse should tell the client:
A To avoid salt while taking this medication
B That it is best to take the medication with food
C To drink at least 2 glasses of orange juice every day
D To increase fluid intake to 2000 mL to 3000 mL/day Correct
Rationale: Hemorrhagic cystitis is a toxic effect of cyclophosphamide. The client must be instructed to
drink copious amounts of fluid during administration of this medication. The client should also monitor her
urine for hematuria. The medication should be taken on an empty stomach, unless gastrointestinal upset
occurs. Hyperkalemia may also result from the use of the medication; therefore the client would not be
encouraged to increase potassium intake (i.e., bananas and orange juice). The client also would not be
instructed to alter her sodium intake.
9. A client taking hydrochlorothiazide reports to the clinic for follow-up blood tests. For which side
effect of the medication does the nurse monitor the client’s laboratory results?
Y Hypokalemia Correct
Z HypocalcemiaAA
Hypernatremia
AB Hypermagnesemia
Rationale: The client taking a potassium-wasting diuretic such as hydrochlorothiazide must be monitored
for reductions in the potassium level. Other fluid and electrolyte imbalances that may occur with use of this
medication are hyponatremia, hypercalcemia, hypomagnesemia, and hypophosphatemia. The nurse should
also educate the client about foods that are rich in potassium.
10. A physician prescribes 1000 mL of 5% dextrose in water, to be infused over 24 hours. The drop
factor is 60 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round your answer to
the nearest whole number).
400Incorrect
Correct Responses: "42"
11. A nurse is caring for a group of adult clients on an acute care nursing unit. Which of the following
clients does the nurse recognize as the least likely candidate for parenteral nutrition (PN)?
AC 61-year-old client with pancreatitis
AD 52-year-old client with severe sepsis Incorrect
AE 45-year-old client who has undergone repair of a hiatal hernia Correct
AF 24-year-old client with a severe exacerbation of ulcerative colitis
Rationale: PN is indicated in the client whose gastrointestinal tract is not functional or who cannot tolerate
an enteral diet for extended periods. The client with sepsis is very ill and may require PN. Other candidates
include clients who have undergone extensive surgery, sustained multiple fractures, or have advanced
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