COMPREHENSIVE REVIEW EXAM Questions and Correct Answers the Latest Update and Recommended Version
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Course
COMPREHENSIVE
Institution
COMPREHENSIVE
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....
COMPREHENSIVE REVIEW EXAM
Questions and Correct Answers the Latest
Update and Recommended Version
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
→ A. Checking the client's blood pressure
→ Rationale: 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.
A client is scheduled to undergo an upper gastrointestinal (GI) series, and the licensed
practical nurse reinforces 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
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."
→ 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."
→ Rationale: 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.
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 available
→ B. Ask the answering service to contact the on-call physician
→ Rationale: The nurse has a duty to protect the client from harm. A nurse who believes
that a physician's prescription may be in error is responsible for clarifying the
prescription before carrying it out. Therefore the nurse would not administer the
medication; instead, the nurse would withhold the medication until the dose can be
clarified. The nurse would not wait until the next morning to obtain clarification. It is
premature to call the nursing supervisor.
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 MI
→ B. Asking the ED physician to check the client
→ Rationale: PVCs are a result of increased irritability of ventricular cells. Peripheral
pulses may be absent or diminished with the PVCs themselves because the decreased
stroke volume of the premature beats may in turn decrease peripheral perfusion.
Because other rhythms also cause widened QRS complexes, it is essential that the nurse
determine whether the premature beats are resulting in perfusion of the extremities.
This is done by palpating the carotid, brachial, or femoral artery while observing the
monitor for widened complexes or by auscultating for apical heart sounds. In the
situation of acute MI, PVCs may be considered warning dysrhythmias, possibly
heralding the onset of ventricular tachycardia or ventricular fibrillation. Therefore the
nurse would not tell the client that the PVCs are expected. Although the nurse will
continue to monitor the client and document the findings, these are not the most
appropriate actions of those provided. The most appropriate action would be to ask
the ED physician to check the client.
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
→ A. Administer the antihypertensive with a small sip of water
→ Rationale: General anesthesia is required for ECT, so NPO status is imposed for 6 to 8
hours before treatment to help prevent aspiration. Exceptions include clients who
routinely receive cardiac medications, antihypertensive agents, or histamine (H2)
blockers, which should be administered several hours before treatment with a small sip
of water. Withholding the antihypertensive and administering it at bedtime and
withholding the antihypertensive and resuming administration on the day after the ECT
are incorrect actions, because antihypertensives must be administered on time;
otherwise, the risk for rebound hypertension exists. The nurse would not administer a
medication by way of a route that has not been prescribed.
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."
→ A. "Tell me more about what you're feeling."
→ Rationale: When a client expresses feelings of depression, it is extremely important for
the nurse to further explore these feelings with the client. In stating, "This is a normal
response after this type of surgery" the nurse provides false reassurance and avoids
addressing the client's feelings. "It will take time, but, I promise you, you will get over
the depression" is also a false reassurance, and it does not encourage the expression
of feelings. "Every client who has this surgery feels the same way for about a month" is
a generalization that avoids the client's feelings.
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
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