Medical Surgical Nursing I (SCR 210)Detailed Answer Key Final Exam Version Spring 2023 for passing 2024 exam.
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Course
Medical Surgical Nursing I
Institution
Medical Surgical Nursing I
Medical Surgical Nursing I (SCR 210)
Detailed Answer Key
Final Exam Version Spring 20231. A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation
with haloperidol. The nurse should assess the client for which of the following adverse effec...
Medical Surgical Nursing I (LaGuardia Community College)
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Detailed Answer Key
Final Exam Version Spring 2023
1. A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation
with haloperidol. The nurse should assess the client for which of the following adverse effects?
A. Dysrhythmias
Rationale: Cardiac dysrhythmias are a risk for clients taking haloperidol and other conventional
antipsychotic medications. The client should be monitored for changes in vital signs,
tachycardia, and ECG changes, including prolonged QT interval, while taking haloperidol. There
is a risk for cardiac arrest due to torsades de pointes.
B. Cataracts
Rationale: The client who takes haloperidol is at risk for glaucoma, but cataracts are not an adverse effect.
C. Pancreatitis
Rationale: The client who takes haloperidol is at risk for hepatitis, but pancreatitis is not an adverse effect.
D. Bleeding
Rationale: The client who takes haloperidol does not have an increased risk for bleeding.
2. A nurse is caring for a client who has bipolar disorder and has been taking lithium for 1 year. Before administering
the medication, the nurse should check to see that which of the following tests have been completed?
A. Thyroid hormone assay
Rationale: Thyroid testing is important because long-term use of lithium may lead to thyroid dysfunction.
B. Liver function tests
Rationale: LFTs must be monitored before and during valproic acid therapy, not lithium therapy.
C. Erythrocyte sedimentation rate
Rationale: This is not a necessary test related to lithium therapy.
D. Brain natriuretic peptide
Rationale: Brain natriuretic peptide (BNP) is not a necessary test related to lithium therapy. The BNP is
used to monitor heart failure.
3. A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5
days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both
anticoagulants are necessary. Which of the following statements should the nurse make?
A. "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic
level."
Rationale:
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Detailed Answer Key
Final Exam Version Spring 2023
Heparin and warfarin are both anticoagulants that decrease the clotting ability of the blood and
help prevent thrombosis formation in the blood vessels. However, these medications work in
different ways to achieve therapeutic coagulation and must be given together until therapeutic
levels of anticoagulation can be achieved by warfarin alone, which is usually within 1 to 5 days.
When the client's PT and INR are within therapeutic range, the heparin can be discontinued.
B. "I will call the provider to get a prescription for discontinuing the IV heparin today."
Rationale: Discontinuing the IV heparin is not indicated at this time.
C. "Both heparin and warfarin work together to dissolve the clots."
Rationale: Neither medication dissolves clots that have already formed.
D. "The IV heparin increases the effects of the warfarin and decreases the length of your hospital stay."
Rationale: Neither medication increases the effects of the other.
4. A nurse is providing teaching to a client who has asthma and a new prescription for inhaled beclomethasone.
Which of the following instructions should the nurse provide?
A. Check the pulse after medication administration.
Rationale: Beclomethasone, an inhaled glucocorticoid, does not cause cardiac side effects.
B. Take the medication with meals.
Rationale: Oral, not inhaled, glucocorticoids should be administered with food.
C. Rinse the mouth after administration.
Rationale: Use of glucocorticoids by metered dose inhaler can allow a fungal overgrowth in the mouth.
Rinsing the mouth after administration can lessen the likelihood of this complication.
D. Limit caffeine intake.
Rationale: Caffeine does not interact with beclomethasone and is not contraindicated.
5. A nurse is teaching a client who has a urinary tract infection (UTI) and is taking ciprofloxacin. Which of the following
instructions should the nurse give to the client?
A. "If the medicine causes an upset stomach, take an antacid at the same time."
Rationale: Ciprofloxacin is best absorbed on an empty stomach with a full glass of water. Antacids
containing either magnesium or aluminum can decrease the absorption of ciprofloxacin. If an
antacid is taken, the nurse should instruct the client to wait at least 2 hr after administering the
ciprofloxacin.
B. "Limit your daily fluid intake while taking this medication."
Rationale: The nurse should instruct the client that ciprofloxacin is a fluoroquinolone antibiotic used in the
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Detailed Answer Key
Final Exam Version Spring 2023
treatment of mild to severe infections. It is excreted primarily via the kidneys, and drinking extra
fluids will reduce the risk of crystallization in the kidneys.
C. "This medication can cause photophobia, so be sure to wear sunglasses outdoors."
Rationale: Ciprofloxacin can cause phototoxicity, putting the client at risk for extreme sunburn from minimal
sun exposure. The client should wear protective clothing when out in the sun. Photophobia is
eye sensitivity to light.
D. "You should report any tendon discomfort you experience while taking this medication."
Rationale: The nurse should instruct the client to report any tendon discomfort as well as swelling or
inflammation of the tendons due to the risk of tendon rupture.
6. A nurse is assessing a client who is taking levothyroxine. The nurse should recognize that which of the following
findings is a manifestation of levothyroxine overdose?
A. tachycardia
B. constipation
C. insomnia
D. absent deep-tendon reflexes
7. A nurse is teaching a client who has been taking prednisone to treat asthma and has a new prescription to
discontinue the medication. The nurse should explain to the client to reduce the dose gradually to prevent which of
the following adverse effects?
A. Hyperglycemia
Rationale: Hyperglycemia is an adverse effect of prednisone, especially for clients who have a history of
diabetes mellitus. Once the medication is discontinued, however, this adverse effect should not
occur.
B. Addisonian crisis
Rationale: Prednisone, a corticosteroid, is similar to cortisol, the glucocorticoid hormone produced by the
adrenal glands. It relieves inflammation and is used to treat certain forms of arthritis, severe
allergies, autoimmune disorders, and asthma. Administration of glucocorticoids can suppress
production of glucocorticoids, and an abrupt withdrawal of the drug can lead to a syndrome of
adrenal insufficiency.
C. Severe dehydration
Rationale: Fluid retention is an adverse effect of prednisone. Once the medication is discontinued,
however, this adverse effect should not occur.
D. Rebound pulmonary congestion
Rationale: Fluid retention is an adverse effect of prednisone. Rebound pulmonary congestion should not
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