1-Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication?
A. Checking the client's blood pressure
B. Checking the client's peripheral pulses
C. Checking the most recent potassium level
D. C...
1-Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which
assessment does the nurse perform as a priority before administering the
medication?
A. Checking the client's blood pressure
B. Checking the client's peripheral pulses
C. Checking the most recent potassium level
D. Checking the client's intake-and-output record for the last 24 hours
Checking the client's blood pressure
Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used
to treat hypertension. One common side effect is postural hypotension.
Therefore the nurse would check the client's blood pressure immediately
before administering each dose. Checking the client's peripheral pulses, the
results of the most recent potassium level, and the intake and output for the
previous 24 hours are not specifically associated with this mediation.
2-A client is scheduled to undergo an upper gastrointestinal (GI) series, and
the nurse provides instructions to the client about the test. Which statement
by the client indicates a need for further instruction?
A. "The test will take about 30 minutes."
B. "I need to fast for 8 hours before the test."
C. "I need to drink citrate of magnesia the night before the test and give
myself a Fleet enema on the morning of the test."
D. "I need to take a laxative after the test is completed, because the liquid
that I'll have to drink for the test can be constipating."
An upper GI series involves visualization of the esophagus, duodenum, and
upper jejunum by means of the use of a contrast medium. It involves
swallowing a contrast medium (usually barium), which is administered in a
flavored milkshake. Films are taken at intervals during the test, which takes
about 30 minutes. No special preparation is necessary before a GI series,
except that NPO status must be maintained for 8 hours before the test. After
an upper GI series, the client is prescribed a laxative to hasten elimination of
the barium. Barium that remains in the colon may become hard and difficult
to expel, leading to fecal impaction.
3-A nurse on the evening shift checks a physician's prescriptions and notes
that the dose of a prescribed medication is higher than the normal dose. The
,nurse calls the physician's answering service and is told that the physician is
off for the night and will be available in the morning. The nurse should:
A. Call the nursing supervisor
B. Ask the answering service to contact the on-call physician
C. Withhold the medication until the physician can be reached in the morning
D. Administer the medication but consult the physician when he becomes
4.An emergency department (ED) nurse is monitoring a client with suspected
acute myocardial infarction (MI) who is awaiting transfer to the coronary
intensive care unit. The nurse notes the sudden onset of premature
ventricular contractions (PVCs) on the monitor, checks the client's carotid
pulse, and determines that the PVCs are not resulting in perfusion. The
appropriate action by the nurse is:
A. Documenting the findings
B. Asking the ED physician to check the client
C. Continuing to monitor the client's cardiac status
D. Informing the client that PVCs are expected after an
5.NPO status is imposed 8 hours before the procedure on a client scheduled
to undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the
procedure, the nurse checks the client's record and notes that the client
routinely takes an oral antihypertensive medication each morning. The nurse
should:
A. Administer the antihypertensive with a small sip of water
B. Withhold the antihypertensive and administer it at bedtime
C. Administer the medication by way of the intravenous (IV) route
D. Hold the antihypertensive and resume its administration on the day after
the ECT
6 A client who recently underwent coronary artery bypass graft surgery
comes to the physician's office for a follow-up visit. On assessment, the
client tells the nurse that he is feeling depressed. Which response by the
nurse is therapeutic?
A. "Tell me more about what you're feeling."
B. "That's a normal response after this type of surgery."
C. "It will take time, but, I promise you, you will get over this depression."
D. "Every client who has this surgery feels the same way for about a month."
7 A client in labor experiences spontaneous rupture of the membranes. The
nurse immediately counts the fetal heart rate (FHR) for 1 full minute and
then checks the amniotic fluid. The nurse notes that the fluid is yellow and
,has a strong odor. Which of the following actions should be the nurse's
priority?
A. Contacting the physician
B. Documenting the findings
C. Checking the fluid for protein
D. Continuing to monitor the client and the
8 A nurse has assisted a physician in inserting a central venous access
device into a client with a diagnosis of severe malnutrition who will be
receiving parenteral nutrition (PN). After insertion of the catheter, the nurse
immediately plans to:
A. Call the radiography department to obtain a chest x-ray
B. Check the client's blood glucose level to serve as a baseline measurement
C. Hang the prescribed bag of PN and start the infusion at the prescribed
rate
D. Infuse normal saline solution through the catheter at a rate of 100 mL/hr
to maintain patency
9 A rape victim being treated in the emergency department says to the
nurse, "I'm really worried that I've got HIV now." What is the appropriate
response by the nurse?
A. "HIV is rarely an issue in rape victims."
B. "Every rape victim is concerned about HIV."
C. "You're more likely to get pregnant than to contract HIV."
D. "Let's talk about the information that you need to determine your risk of
contracting HIV."
10 A client is taking prescribed ibuprofen (Motrin), 300 mg orally four times
daily, to relieve joint pain resulting from rheumatoid arthritis. The client tells
the nurse that the medication is causing nausea and indigestion. The nurse
should tell the client to:
A. Contact the physician
B. Stop taking the medication
C. Take the medication with food
D. Take the medication twice a day instead of four times
11 A client's oral intake of liquids includes 120 mL on the night shift, 800 mL
on the day shift, and 650 mL on the evening shift. The client is receiving an
intravenous (IV) antibiotic every 12 hours, diluted in 50 mL of normal saline
solution. The nurse empties 700 mL of urine from the client's Foley catheter
at the end of the day shift. Thereafter, 500 mL of urine is emptied at the end
of the evening shift and 325 mL at the end of the night shift. Nasogastric
, tube drainage totals 155 mL for the 24-hour period, and the total drainage
from the Jackson-Pratt device is 175 mL. What is the client's total intake
during the 24-hour period? Type your answer in the space provided.
Answer: ________mLAns- Correct Responses: "1670"
12 Lorazepam (Ativan) 1 mg by way of intravenous (IV) injection (IV push) is
prescribed for a client for the management of anxiety. The nurse prepares
the medication as prescribed and administers the medication over a period
of:
A. 3 minutes
B. 10 seconds
C. 15 seconds
D. 30 minutes
13 A nurse, conducting an assessment of a client being seen in the clinic for
symptoms of a sinus infection, asks the client about medications that he is
taking. The client tells the nurse that he is taking nefazodone hydrochloride
(Serzone). On the basis of this information, the nurse determines that the
client most likely has a history of:
A. Depression
B. Diabetes mellitus
C. Hyperthyroidism
D. Coronary artery disease
14 Phenelzine sulfate (Nardil) is prescribed for a client with depression. The
nurse provides information to the client about the adverse effects of the
medication and tells the client to contact the physician immediately if she
experiences:
A. Dry mouth
B. Restlessness
C. Feelings of depression
D. Neck stiffness or soreness
15 Risperidone (Risperdal) is prescribed for a client hospitalized in the
mental health unit for the treatment of a psychotic disorder. Which finding in
the client's medical record would prompt the nurse to contact the prescribing
physician before administering the medication?
A. The client has a history of cataracts.
B. The client has a history of hypothyroidism.
C. The client takes a prescribed antihypertensive.
D. The client is allergic to acetylsalicylic acid (aspirin).
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