NURSING NCLEX Module 8 Exam Questions and Answers,100% CORRECT

NURSING NCLEX Module 8 Exam Questions and Answers Submission Details • Submission Date: 1/17/2017 • Submission Time: 9:55 PM • Points Awarded: 115 • Points Missed: 10 • Number of Attempts Allowed: 1 • Not Scored ...

NURSING NCLEX Module 8 Exam Questions and Answers Submission Details • Submission Date: 1/17/2017 • Submission Time: 9:55 PM • Points Awarded: 115 • Points Missed: 10 • Number of Attempts Allowed: 1 • Not Scored: 0 • Percentage: 92% 1. Questions 1. 1.ID: 9476967734 A nurse notes that the site of a client’s peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous near the insertion point of the catheter. On the basis of this assessment, the nurse should take which action first? A. Remove the IV catheter Correct B. Slow the rate of infusion C. Notify the health care provider D. Check for loose catheter connections Awarded 1.0 points out of 1.0 possible points. 2. 2.ID: 9476963098 A nurse hangs a 500­mL bag of intravenous (IV) fluid for an assigned client. One hour later the client complains of chest tightness, is dyspneic and apprehensive, and has an irregular pulse. The IV bag has 100 mL remaining. Which action should the nurse take first? A. Remove the IV B. Sit the client up in bed C. Shut off the IV infusion Correct D. Slow the rate of infusion Awarded 1.0 points out of 1.0 possible points. 3. 3.ID: 9476961248 A nurse discontinues an infusion of a unit of packed red blood cells (RBCs) because the client is experiencing a transfusion reaction. After discontinuing the transfusion, which action should the nurse take next? A. Remove the IV catheter B. Contact the health care provider Correct C. Change the solution to 5% dextrose in water D. Obtain a culture of the tip of the catheter device removed from the client Awarded 1.0 points out of 1.0 possible points. 4. 4.ID: 9476963017 The nurse determines that the client is exhibiting signs of a hemolytic transfusion reaction while receiving a blood transfusion. The nurse should perform these actions in which priority order? Arrange the actions in the order that they should be performed. All options must be used. Correct A. Stopping the infusion of blood B. Hanging an IV bag of normal saline solution (NS) at a keep­vein­open (KVO) rate C. Notifying the health care provider D. Obtaining vital signs/oxygen saturation E. Documenting the findings Awarded 1.0 points out of 1.0 possible points. 2. 5.ID: 9476964571 A client with heart failure is being given furosemide and digoxin. The client calls the nurse and complains of anorexia and nausea. Which action should the nurse take first? A. Administer an antiemetic B. Administer the daily dose of digoxin C. Discontinue the morning dose of furosemide D. Checkthe result of laboratory testing for potassium on the sample drawn 3 hours ago Correct Awarded 1.0 points out of 1.0 possible points. 2. 6.ID: 9476961282 The health care provider (HCP)prescribes the administration of totalparenteral nutrition (TPN), to be started at a rate of 50 mL/hr by way of infusion pump through an established subclavian central line. After the first 2 hours of the TPN infusion, the client suddenly complains of difficulty breathing and chest pain. The nurse should take which immediate action? A. Obtain blood for culture B. Clamp the TPN infusion line Correct C. Obtain an electrocardiogram (ECG) D. Obtain a sample for blood glucose testing Rationale: One complication of a subclavian central line is embolism, caused by air or thrombus. Sudden onset of chest pain shortly after the initiation of TPN may mean that this complication has developed. The infusion is clamped (the line should not be discontinued, however), the client turned on the left side with the head down, and the HCP notified immediately. Depending on agency protocol, the rapid response team would also be called. Blood cultures are not necessary in this situation, because infection is not the concern. Likewise, there is no useful reason for checking the blood glucose level. An ECG may be obtained, but this is not the immediate priority. If the client shows signs of an air embolism, the nurse should examine the catheter to determine whether an open port has allowed air into the circulatory system. Test­Taking Strategy: Note the strategic word “immediate.” Focus on the data provided in the question to determine that an embolus has occurred. Eliminate blood cultures and blood glucose testing, which, respectively, relate to infection and hyperglycemia, which is not likely to occur during the first 2 hours of TPN administration. To select from the remaining options, focus on the strategic word “immediate”; this will direct you to the correct option. Review the complications of TPN and the associated nursing interventions Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: TotalParenteral Nutrition Giddens Concepts: Clinical Judgment, Perfusion HESI Concepts: Clinical Decision­Making/Clinical Judgment, Perfusion­Clotting Awarded 1.0 points out of 1.0 possible points. 3. 7.ID: 9476957598 The health care provider prescribes 2000 mL of 5% dextrose and normal saline 0.45% for infusion over 24 hours. The drop factor is 15 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round to the nearest whole number). Correct Correct Responses A. 21 Rationale: Use the IV flow rate formula: Awarded 1.0 points out of 1.0 possible points. 2. 8.ID: 9476963091 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? A. Remove the IV Correct B. Apply a warm compress C. Check for blood return D. Measure the area of infiltration Awarded 1.0 points out of 1.0 possible points. 2. 9.ID: 9476964540 A home care nurse has been assigned a client who has been discharged home with a prescription for total parenteral nutrition (TPN). Which parameters does the nurse plan to check at each visit as a means of identifying complications of the TPN therapy? Select all that apply. A. Weight Correct B. Glucose test Correct C. Temperature Correct D. Peripheral pulses E. Hemoglobin and hematocrit Awarded 3.0 points out of 3.0 possible points. 3. 10.ID: 9476959510 A nurse is caring for a group of adult clients on an acute care nursing unit. Which clients does the nurse recognize as the most likely candidates for total parenteral nutrition (TPN)? Select all that apply. A. A client with pancreatitis Correct B. A client with severe sepsis Correct C. A client with renal calculi D. A client who has undergone repair of a hiatal hernia E. A client with a severe exacerbation of ulcerative colitis Correct Awarded 2.0 points out of 3.0 possible points. 4. 11.ID: 9476957565 A client with a peripheral intravenous (IV) line in place has a new prescription for infusion of total parenteral nutrition (TPN), a solution containing 25% glucose. Which action should be taken by the nurse? A. Hanging the IV solution as prescribed B. Questioning the health care provider about the prescription Correct C. Diluting the solution with sterile water to half­strength D. Hanging the IV solution but setting the infusion at just half the prescribed rate Awarded 1.0 points out of 1.0 possible points. 5. 12.ID: 9476967726 The first bag of total parenteral nutrition (TPN) solution has arrived on the clinical unit for a client beginning this nutritional therapy. The solution is to be infused by way of a central line. Which essential piece of equipment should the nurse obtain before hanging the solution? A. Pulse oximeter B. Blood glucose meter C. Electronic infusion device Correct D. Noninvasive blood pressure monitor Awarded 1.0 points out of 1.0 possible points. 6. 13.ID: 9476972002 A nurse is monitoring a client who is receiving total parenteral nutrition (TPN). Which t signs and symptoms causes the nurse to suspect that the client is experiencing hyperglycemia as a complication? A. Pallor, weak pulse, and anuria B. Nausea, vomiting, and oliguria C. Nausea, thirst, and increased urine output Correct D. Sweating, chills, and decreased urine output Awarded 1.0 points out of 1.0 possible points. 7. 14.ID: 9476957590 At 1600 the nurse checks a client’s total parenteral nutrition (TPN) infusion bag and notes that the solution is running at a rate of 100 mL/hr. The bag was hung the previous day at 1800. The nurse plans to change the infusion bag and tubing this evening at what time? A. 1700 Incorrect B. 1800 Correct C. 2000 D. 2100 Awarded 0.0 points out of 1.0 possible points. 8. 15.ID: 9476970165 A nurse is changing the central line dressing of a client receiving total parenteral nutrition (TPN). The nurse notes moisture under the dressing covering the catheter insertion site. What should the nurse assess next? A. Temperature B. Time of the last dressing change C. Expiration date on the infusion bag D. Tightness of the tubing connections Correct Awarded 1.0 points out of 1.0 possible points. 9. 16.ID: 9476970170 A client receiving total parenteral nutrition (TPN) requires fat emulsion (lipids), which will be piggybacked to the TPN solution. On obtaining a bottle of fat emulsion, the nurse notes that fat globules are floating at the top of the solution. Which action should the nurse take? A. Shake the bottle vigorously B. Request a new bottle from the pharmacy Correct C. Rotate the bottle gently back and forth to mix the globules D. Run the bottle under warm water until the globules disappear Awarded 1.0 points out of 1.0 possible points. 10. 17.ID: 9476963029 A nurse is preparing a client for the insertion of a central intravenous line into the subclavian vein by the health care provider. The nurse gathers the equipment, places it at the bedside, and prepares to assist the health care provider with the procedure. As further preparation for the procedure, the nurse places the client in which position? A. Flat on the left side B. In the prone position C. In the supine position D. In a slight Trendelenburg position Correct Awarded 1.0 points out of 1.0 possible points. 11. 18.ID: 9476959516 A client is receiving total parenteral nutrition (TPN) with fat emulsion (lipids) piggybacked to the TPN solution. For which signs of an adverse reaction to the fat emulsion should the nurse monitor the client? Select all that apply. A. Chills Correct B. Pallor C. Headache Correct D. Chest and back pain Correct E. Nausea and vomiting Correct F. Subnormal temperature Awarded 4.0 points out of 4.0 possible points. 12. 19.ID: 9476959599 The nurse is preparing to change the solution bag and intravenous tubing of a client receiving total parenteral nutrition (TPN) through a left subclavian central venous line. Which essential action does the nurse ask the client to perform just before switching the tubing? A. Turn the head to the left B. Turn the head to the right C. Exhale slowly and evenly D. Take a deep breath and hold it Correct Awarded 1.0 points out of 1.0 possible points. 13. 20.ID: 9476961270 A nurse suspects that a client receiving total parenteral nutrition (TPN) through a central line has an air embolism. The nurse immediately places the client in which position? A. Left side with the head lower than the feet Correct B. Left side with the head higher than the feet C. Right side with the head lower than the feet D. Right side with the head higher than the feet Awarded 1.0 points out of 1.0 possible points. 14. 21.ID: 9476970158 A nurse is making initial rounds on a group of assigned clients. Which client should the nurse see first? A. A client receiving total parenteral nutrition (TPN) at a rate of 50 mL/hr for the last 24 hours B. A client receiving TPN at a rate of 50 mL/hr whose temp was 99° F on the previous shift C. A client receiving TPN at a rate of 100 mL/hr who has complained of needing frequent trips to the bathroom to void D. A client whose TPN solution was decreased to a rate of 25 mL/hr who is now complaining of weakness, headache, and sweating Correct Awarded 1.0 points out of 1.0 possible points. 15. 22.ID: 9476964581 A nurse answers a call bell and finds that the total parenteral nutrition (TPN) solution bag of an assigned client is empty. The new prescription was written for a new bag at the beginning of the shift, but it has not yet arrived from the pharmacy. Which action should the nurse take first? A. Call the health care provider B. Call the pharmacy for further instructions C. Hang a solution of 10% dextrose in water Correct D. Hang a solution of 5% dextrose in 0.9% sodium chloride Awarded 1.0 points out of 1.0 possible points. 16. 23.ID: 9476957513 A young female client with schizophrenia says to the nurse, “Since I started on olanzapine last year, I’m doing well in school and all, but I’ve gained so much weight, and it’s really bothering me. What can I do about this?” Which response by the nurse would be therapeutic? A. “Well, I think you’re overreacting. Today people think they should be skinny­minnies, even though it’s not healthy.” B. “Weight gain can be a side effect of the medication, so you need to watch your diet and exercise. How much weight have you gained?” Correct C. “That medication isn’t any more likely to cause weight gain than the others you’re taking. Perhaps we could go over your diet and exercise habits.” D. “I want you to stop taking this medication immediately, and I’m calling the doctor, because this is a very serious side effect and you may need dialysis.” Awarded 1.0 points out of 1.0 possible points. 17. 24.ID: 9476961262 A client with schizophrenia has been taking an antipsychotic medication for 2 months. For which adverse effect should the nurse monitor the client closely? A. Akathisia Correct B. Pelvic thrusts C. Athetoid limbs D. Protruding tongue Awarded 1.0 points out of 1.0 possible points. 18. 25.ID: 9476957544 A client with schizophrenia who has been taking an antipsychotic medication calls the clinic nurse and says, “I need to cancel my appointment with the psychiatrist again, because I still have this awful sore throat. It’s so bad that my mouth has a sore.” How does the nurse respond to the client? A. “I wouldn’t be upset. It happens when you aren’t drinking enough water.” B. “I think you need to come in for blood work today, because this may be an adverse effect of your medicine.” Correct C. “Do you remember when you started this medication? Your psychiatrist told you how important it is to keep your appointments with him.” D. “You probably have a simple flu, but it might help if you gargle with some antiseptic mouthwash every 2 hours or so and drink plenty of water.” Awarded 1.0 points out of 1.0 possible points. 19. 26.ID: 9476967709 A client rings the call bell and complains of pain at the site of an IV infusion. The nurse assesses the site and determines that phlebitis has developed. Which actions should the nurse take? Select all that apply. A. Removing the IV catheter at that site Correct B. Applying warm, moist compresses to the IV site Correct C. Notifying the health care provider about the finding Correct D. Encouraging the client to scrub the site while in the shower E. Starting a new IV line in a proximal portion of the same vein Awarded 3.0 points out of 3.0 possible points. 20. 27.ID: 9476964536 A nurse notes that the site of a client’s peripheral IV catheter is reddened, warm, painful, and slightly edematous in the area of the insertion site. After taking appropriate steps to care for the client, the nurse documents in the medical record that the client has experienced which problem? A. Phlebitis of the vein Correct B. Infiltration of the IV line C. Hypersensitivity to the IV solution D. An allergic reaction to the IV catheter material Awarded 1.0 points out of 1.0 possible points. 21. 28.ID: 9476957517 A nurse has a written prescription to remove an intravenous (IV) line. Which item should the nurse obtain from the unit supply area for use in applying pressure to the site after removing the IV catheter? A. Alcohol swab B. Adhesive bandage C. Sterile 2 × 2 gauze Correct D. Povidone­iodine (Betadine) swab Awarded 1.0 points out of 1.0 possible points. 22. 29.ID: 9476961274 A client has just undergone insertion of a central venous catheter by the health care provider at the bedside. Which result would the nurse be sure to check before initiating infusion of the IV solution that the health care provider has prescribed? A. Serum osmolality B. Serum electrolytes C. Portable chest x­ray Correct D. Intake and output record Awarded 1.0 points out of 1.0 possible points. 23. 30.ID: 9476970196 A nurse has obtained a unit of blood from the blood bank and properly checked the blood bag with another nurse. Which parameter should the nurse assess just before hanging the transfusion? A. Skin color B. Vital signs Correct C. Latest platelet count D. Urine output over the last 24 hours Awarded 1.0 points out of 1.0 possible points. 24. 31.ID: 9476963068 A nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. For how long does the nurse plan to stay with the client after the unit of blood is hung? A. 5 minutes B. 15 minutes Correct C. 45 minutes D. 60 minutes Awarded 1.0 points out of 1.0 possible points. 25. 32.ID: 9476957575 A client has a prescription for a unit of packed red blood cells (RBCs). Which IV solution should the nurse obtain to hang with the blood product at the client’s bedside? A. 0.9% sodium chloride Correct B. Lactated Ringer’s solution (LR) C. 5% dextrose in 0.9% sodium chloride D. 5% dextrose in water in 0.45% sodium chloride Awarded 1.0 points out of 1.0 possible points. 26. 33.ID: 9476964591 The health care provider prescribes 1000 mL of normal saline 0.45% for infusion over 8 hours. The drop factor is 10 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round to the nearest whole number). Correct Correct Responses A. 21 Awarded 1.0 points out of 1.0 possible points. 2. 34.ID: 9476961213 A nurse discontinues an infusion of a unit of blood after the client experiences a transfusion reaction. Once the incident has been documented appropriately, where does the nurse send the blood transfusion bag? A. Blood bank Correct B. Risk management C. Microbiology laboratory D. Infection­control department Awarded 1.0 points out of 1.0 possible points. 2. 35.ID: 9476963006 Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit values. The nurse takes the client’s temperature orally before hanging the blood transfusion and notes that it is 100.0° F (37.7 C). What should the nurse do next? A. Call the health care provider Correct B. Begin the transfusion as prescribed C. Administer an antihistamine and begin the transfusion D. Administer 2 tablets of acetaminophen and begin the transfusion Awarded 1.0 points out of 1.0 possible points. 3. 36.ID: 9476961252 A nurse has just hung a transfusion of packed red blood cells and stayed with the client for the appropriate amount of time. Before leaving the room, the nurse tells the client that it is most important to immediately report which specific signs if it occurs? Select all that apply. A. Rash Correct B. Chills Correct C. Fatigue Incorrect D. Backache Correct E. Tiredness Awarded 1.0 points out of 3.0 possible points. 4. 37.ID: 9476961290 At 1300, the nurse is documenting the receipt of a unit of packed blood cells at the hospital blood bank. The nurse calculates that the transfusion must be started by which time? A. 1315 B. 1330 Correct C. 1345 D. 1400 Awarded 1.0 points out of 1.0 possible points. 5 38.ID: 9476959502 A client who needs to receive a blood transfusion has experienced a pruritic rash during previous transfusions. The client asks the nurse whether it is safe to receive the transfusion. Which medication does the nurse anticipate will most likely be prescribed before the transfusion? A. Ibuprofen B. Acetaminophen C. Diphenhydramine Correct D. Acetylsalicylic acid Awarded 1.0 points out of 1.0 possible points. 6. 39.ID: 9476964586 The health care provider prescribes 1000 mL of 5% dextrose in water to be infused over 8 hours. The drop factor is 15 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round to the nearest whole number). Correct Correct Responses A. 31 Rationale: Use the IV flow rate formula: Awarded 1.0 points out of 1.0 possible points. 2. 40.ID: 9476967788 The health care provider prescribes an intramuscular dose of 200,000 units of penicillin G benzathine for an adult client. The label on the 10­mL ampule sent from the pharmacy reads, “Penicillin G benzathine,300,000 units/mL.” How many milliliters of medication does the nurse prepares to ensure administration of the correct dose? (Round to the nearest tenth.) Correct Correct Responses: "0.7, .7" Awarded 1.0 out of 1.0 possible points. 3. 41.ID: 9476964522 The health care provider’s prescription for an adult client reads, “Potassium chloride 15 mEq by mouth.” The label on the medication bottle reads, “20 mEq potassium chloride/15 mL.” How many milliliters of KCl does the nurse prepare to ensure administration of the correct dose of medication? (Round to the nearest whole number.) Correct Correct Responses A. 11 Rationale: Use the medication formula: Awarded 1.0 points out of 1.0 possible points. 4. 42.ID: 9476961236 The health care provider 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 to the nearest whole number). Correct Correct Responses A. 42 Rationale: Use the IV flow rate formula: Awarded 1.0 points out of 1.0 possible points. 5. 43.ID: 9476959549 The health care provider’s prescription reads, “Clindamycin phosphate 0.3 g in 50 mL NS, to be administered IV over 30 minutes.” The medication label reads, “Clindamycin phosphate 150 mg/mL.” How many milliliters of medication does the nurse prepare to ensure that the correct dose is administered? Correct Correct Responses A. 2 Awarded 1.0 points out of 1.0 possible points. 6. 44.ID: 9476970182 The health care provider’s prescription reads, “Phenytoin 0.1 g by mouth twice daily.” The medication label indicates that the bottle contains 100­mg capsules. How many capsules does the nurse prepare for administration of one dose? Correct Correct Responses A. 1 Awarded 1.0 points out of 1.0 possible points. 7. 45.ID: 9476959572 A nurse is preparing a plan of care for a client who will be receiving meperidine hydrochloride. Which side/adverse effects does the nurse make a note of needing to be alert to in the plan of care? Select all that apply. A. Hypotension Correct B. Constipation Correct C. Bradycardia D. Urine retention Correct E. Respiratory depression Correct Awarded 4.0 points out of 4.0 possible points. 2. 46.ID: 9476957583 A nurse is preparing a plan of care for a client with a diagnosis of cancer who is receiving morphine sulfate for pain. Which action does the nurse identify as a priority in the plan of care for this client? A. Monitoring urine output B. Encouraging increased fluids C. Monitoring the client’s temperature D. Monitoring the client’s respiratory rate Correct Awarded 1.0 points out of 1.0 possible points. 3. 47.ID: 9476964563 A client who has been taking lisinopril complains to the nurse of a persistent dry cough. What should the nurse tell the client? A. This is a side effect of therapy Correct B. He probably has an upper respiratory infection C. He needs to have his blood counts checked D. A chest x­ray is required because the cough is a sign of heart failure Awarded 1.0 points out of 1.0 possible points. 4. 48.ID: 9476961266 A client has been given a prescription to begin using nitroglycerin transdermal patches for the management of angina pectoris. What should the nurse tell the client about the medication? A. Place the patch in the area of a skin fold to promote adherence B. Apply the patch at the same time each day and leave it in place for 12 to 16 hours as directed Correct C. If the patch becomes dislodged, do not reapply and wait until the next day to apply a new patch. D. Alternate daily dose times between the morning and the evening to prevent the development of tolerance to the medication Rationale: Nitroglycerin is a coronary vasodilator used in the management of angina pectoris. The client is generally advised to apply a new patch at the same time each day (usually each morning) and leave in place for 12 to 16 hours as per health care provider directions. This prevents the client from developing tolerance (such as that which happens with 24­hour use). The client should avoid placing patches in skin folds or excoriated areas. The client benefits from removing the patch for sleep as well, because the nitroglycerin may cause a headache, which could disrupt sleep. The client may apply a new patch if the old one is dislodged, because the dose is released continuously in small amounts through the skin. Test­Taking Strategy: Focus on the subject, correct use of a nitroglycerin transdermal patch. Specific information on this type of medication administration system is needed to answer this question correctly. Remember that most nitrate medications contain the letters nitr in their names and that nitrate medications induce vasodilation. Recalling that medication tolerance can develop with this type of medication administration will direct you to the correct option. Review this type of medication administration Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology Giddens Concepts: Caregiving, Patient Education HESI Concepts: Caregiving, Teaching and Learning/Patient Education Reference: Rosenjack Burchum, Rosenthal (2016) p. 592 Awarded 1.0 points out of 1.0 possible points. 5. 49.ID: 9476970178 A client with newly diagnosed angina pectoris has taken 2 sublingual nitroglycerin tablets for chest pain. The chest pain is relieved, but the client complains of a headache. What should the nurse tell the client? A. This is an indication that the medication should not be used again B. Headache indicates medication tolerance, and the dosage must be increased C. This may be an allergic reaction to the nitroglycerin, and the health care provider must be notified D. This is an expected side effect of the nitroglycerin, and the client can relieve it by taking acetaminophen Correct Awarded 1.0 points out of 1.0 possible points. 6. 50.ID: 9476970192 A client has been taking metoprolol. Which finding indicates to the nurse that the medication is effective? A. The client’s ankles are swollen. B. The client’s weight has increased. C. The client’s blood pressure has decreased. Correct D. The client has wheezes in the lower lobes of the lungs. Awarded 1.0 points out of 1.0 possible points. 7. 51.ID: 9476970174 A nurse has taught a client taking a methylxanthine bronchodilator about beverages that must be avoided. Which beverage choices by the client indicate to the nurse that the client needs further education? Select all that apply. A. Cocoa Correct B. Coffee Correct C. Lemonade D. Orange juice E. Chocolate milk Correct Awarded 3.0 points out of 3.0 possible points. 8. 52.ID: 9476972011 A client taking hydrochlorothiazide reports to the clinic for follow­up blood tests. For which side/adverse effect of the medication does the nurse monitor the client’s laboratory results? A. Hypokalemia Correct B. Hypocalcemia C. Hypernatremia D. Hypermagnesemia Awarded 1.0 points out of 1.0 possible points. 9. 53.ID: 9476970145 A nurse has taught a client who is taking lithium carbonate about the medication. The nurse determines that the client needs additional teaching if the client makes which comment to the nurse? A. The medication should be taken with meals B. The lithium blood levels must be monitored very closely C. It is important to decrease fluid intake while taking the medication to avoid nausea Correct D. The health care provider must be called if excessive diarrhea, vomiting, or diaphoresis occurs lithium should be taken with meals. A normal diet and normal salt and fluid intake (1500 to 3000 mL/day of fluid) should be maintained, because lithium decreases sodium reabsorption in the renal tubules, which may result in sodium depletion. Low sodium intake causes an increase in lithium retention and could lead to toxicity. Test­Taking Strategy: Note the strategic words “needs additional teaching” in the question, which indicate a negative event query and the need to select the incorrect client statement. Remember that clients should be taught to maintain adequate fluid intake. This principle will direct you to the correct option. Review client teaching points for the administration of lithium Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology Giddens Concepts: Client Education, Safety HESI Concepts: Teaching and Learning/Patient Education, Safety References: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p. 711) St. Louis: Saunders. Rosenjack Burchum, Rosenthal (2016) pp. 371­372 @ Rationale: Because the therapeutic and toxic dosage ranges are so close, the blood level of lithium in a client taking the medication must be monitored closely; assessments are performed frequently at first and every several months after that. The client should be instructed to stop taking the medication if excessive diarrhea, vomiting, or diaphoresis occurs and to inform the health care provider if any of these problems develops. Lithium is irritating to the gastric mucosa; therefore lithium should be taken with meals. A normal diet and normal salt and fluid intake (1500 to 3000 mL/day of fluid) should be maintained, because lithium decreases sodium reabsorption in the renal tubules, which may result in sodium depletion. Low sodium intake causes an increase in lithium retention and could lead to toxicity. Test­Taking Strategy: Note the strategic words “needs additional teaching” in the question, which indicate a negative event query and the need to select the incorrect client statement. Remember that clients should be taught to maintain adequate fluid intake. This principle will direct you to the correct option. Review client teaching points for the administration of lithium Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology Giddens Concepts: Client Education, Safety HESI Concepts: Teaching and Learning/Patient Education, Safety References: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p. 711) St. Louis: Saunders. Rosenjack Burchum, Rosenthal (2016) pp. 371­372 Awarded 1.0 points out of 1.0 possible points. 10. 54.ID: 9476967714 A nurse is developing a plan of care for a client, hospitalized with heart failure, who has a history of Parkinson disease and is taking benztropine mesylate daily. Which intervention does the nurse identify as a priority in the plan? A. Monitoring intake and output Correct B. Monitoring the client’s pupillary response C. Placing the client in a right side­lying position D. Checking the client’s hemoglobin level daily Awarded 1.0 points out of 1.0 possible points. 11. 55.ID: 9476964528 A nurse is providing instructions to a client regarding quinapril hydrochloride. The nurse should teach the client to implement which measure? A. To take the medication with meals B. To rise slowly from a lying to a sitting position Correct C. To discontinue the medication if nausea occurs D. That a therapeutic effect will be felt immediately Awarded 1.0 points out of 1.0 possible points. 12. 56.ID: 9476959557 Methylergonovine intramuscularly is prescribed for a postpartum client. Before administering the medication, the nurse explains to the client that the medication will promote which effect? A. Reduce lochial drainage B. Prevent postpartum bleeding Correct C. Maintain a normal blood pressure D. Decrease the strength of uterine contractions Awarded 1.0 points out of 1.0 possible points. 13. 57.ID: 9476957528 Carbamazepine is prescribed for a client with trigeminal neuralgia. Which side/adverse effects does the nurse instruct the client to report to the health care provider? Select all that apply. A. Fever Correct B. Nausea C. Headache D. Sore throat Correct E. Mouth sores Correct Awarded 3.0 points out of 3.0 possible points. 14. 58.ID: 9476964506 Disulfiram is prescribed for a client. Which questions does the nurse make a priority of asking the client before administering this medication? Select all that apply. A. “When did you have your last full meal?” B. “Do you have a history of diabetes insipidus?” C. “When was your last drink of alcohol?” Correct D. “Do you have a history of thyroid problems?” Correct E. “Do you have a history of cancer in your family?” Awarded 2.0 points out of 2.0 possible points. 15. 59.ID: 9476964558 A nurse is assessing a client who is being hospitalized with a diagnosis of pneumonia. The client’s husband tells the nurse that the client is taking donepezil hydrochloride. The nurse should ask the husband about the client’s history of which disorder? A. Dementia Correct B. Seizure disorder C. Diabetes mellitus D. Posttraumatic stress disorder Awarded 1.0 points out of 1.0 possible points. 16. 60.ID: 9476967730 Fluoxetine hydrochloride 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 at what time? A. At lunchtime B. In the morning Correct C. With the evening meal D. Midafternoon, with an antacid Awarded 1.0 points out of 1.0 possible points. 17. 61.ID: 9476964511 A nurse is teaching a client how to mix regular and NPH insulin in the same syringe. The nurse should provide the client with which information about the insulin? A. Keep insulin refrigerated at all times B. Draw the regular insulin into the syringe first Correct C. Shake the NPH insulin bottle before mixing the two types D. Remove all of the air from the bottle before mixing the two types Awarded 1.0 points out of 1.0 possible points. 18. 62.ID: 9476964518 A nurse provides instructions to a client who will be taking furosemide. Which statement by the client indicates to the nurse that the client needs additional instruction? A. “I need to sit or stand up slowly.” B. “I need to maintain my fluid intake.” C. “This medication will make me urinate.” D. “I should expect to have ringing in my ears.” Correct Awarded 1.0 points out of 1.0 possible points. 19. 63.ID: 9476957539 A client is receiving heparin sodium by way of continuous IV infusion. For which adverse effects of the therapy does the nurse assess the client? Select all that apply. A. Tinnitus B. Tarry stools Correct C. Slowed pulse D. Bleeding from the gums Correct E. Increased blood pressure Rationale: Heparin is an anticoagulant, and the client who receives continuous IV heparin is at risk for bleeding. The nurse must be alert for signs of bleeding: bleeding from the gums, ecchymoses on the skin, cloudy or pink­tinged urine, tarry stools, and body fluids that test positive for occult blood. Test­Taking Strategy: Focus on the subject, the adverse effects of heparin sodium. Recalling that this medication is an anticoagulant will direct you to the correct options. Review the adverse effects of heparin sodium. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Pharmacology Giddens Concepts: Clinical Judgment, Clotting HESI Concepts: Clinical Decision­Making/Clinical Judgment, Perfusion­Clotting Reference: Gahart, B., & Nazareno, A. (2015). 2015 Intravenous medications (31st ed., p. 626). St. Louis: Mosby. @ Rationale: Heparin is an anticoagulant, and the client who receives continuous IV heparin is at risk for bleeding. The nurse must be alert for signs of bleeding: bleeding from the gums, ecchymoses on the skin, cloudy or pink­tinged urine, tarry stools, and body fluids that test positive for occult blood. Test­Taking Strategy: Focus on the subject, the adverse effects of heparin sodium. Recalling that this medication is an anticoagulant will direct you to the correct options. Review the adverse effects of heparin sodium. Level of Cognitive Ability: Analyzing Awarded 2.0 points out of 2.0 possible points. 20. 64.ID: 9476967737 A client has a prescription for short­term therapy with enoxaparin . The nurse explains to the client that this medication is being prescribed for which purpose? A. Prevent pain B. Relieve back spasms C. Increase the client’s energy level D. Reduce the risk of deep vein thrombosis Correct Awarded 1.0 points out of 1.0 possible points. 21. 65.ID: 9476963055 Metoprolol has been prescribed for a client with hypertension. For which common side effects of the medication does the nurse monitor the client? Select all that apply. A. Fatigue Correct B. Dry eyes C. Weakness Correct D. Impotence Correct E. Nightmares Awarded 3.0 points out of 3.0 possible points. 22. 66.ID: 9476964597 A client with HIV infection has been started on therapy with zidovudine. The nurse tells the client to report to the laboratory in 3 months for testing to detect adverse effects of the therapy. Which laboratory test is most important to monitor for this client? A. Creatinine B. Serum potassium C. Blood urea nitrogen (BUN) D. Complete blood count (CBC) Correct Awarded 1.0 points out of 1.0 possible points. 23. 67.ID: 9476959537 A nurse is reading the medical record of a client receiving haloperidol. The nurse notes that the health care provider has documented that the client is experiencing signs of akathisia. On the basis of the health care provider’s note, which clinical manifestation would the nurse expect to find during assessment of the client? A. Motor restlessness Correct B. Puffing of the cheeks C. Puckering of the mouth D. Protrusion of the tongue Rationale: Akathisia —motor restlessness, or the desire to keep moving —may appear within 6 hours of administration of the first dose of haloperidol. It may be difficult to distinguish from psychotic agitation. Tardive dyskinesia is uncontrolled rhythmic movements of the mouth, face, and extremities, including lip smacking or puckering, puffing of the cheeks, uncontrolled chewing, and rapid or wormlike movements of the tongue. The health care provider should be notified if any of these symptoms occurs. Test­Taking Strategy: Focus on the subject, akathisia. Eliminate the options that are comparable or alike in that they are manifestations involving the face. Review the signs of akathisia Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Pharmacology Giddens Concepts: Cellular Regulation, Clinical Judgment HESI Concepts: Cellular Regulation, Clinical Decision­Making/Clinical Judgment Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p. 567) St. Louis: Saunders. @ Rationale: Akathisia —motor restlessness, or the desire to keep moving —may appear within 6 hours of administration of the first dose of haloperidol. It may be difficult to distinguish from psychotic agitation. Tardive dyskinesia is uncontrolled rhythmic movements of the mouth, face, and extremities, including lip smacking or puckering, puffing of the cheeks, uncontrolled chewing, and rapid or wormlike movements of the tongue. The health care provider should be notified if any of these symptoms occurs. Test­Taking Strategy: Focus on the subject, akathisia. Eliminate the options that are comparable or alike in that they are manifestations involving the face. Review the signs of akathisia Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Pharmacology Giddens Concepts: Cellular Regulation, Clinical Judgment HESI Concepts: Cellular Regulation, Clinical Decision­Making/Clinical Judgment Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p. 567) St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 24. 68.ID: 9476964554 Phenelzine sulfate is being administered to a client with depression. The client suddenly complains of a severe frontally radiating occipital headache, neck stiffness and soreness, and vomiting. On further assessment, the client exhibits signs of hypertensive crisis. Which medication should the nurse prepare to administer, anticipating that it will be prescribed as the antidote to treat phenelzine­ induced hypertensive crisis? A. Phentolamine Correct B. Acetylcysteine C. Protamine sulfate D. Calcium gluconate Awarded 1.0 points out of 1.0 possible points. 25. 69.ID: 9476964515 Risperidone is prescribed for a client with a diagnosis of schizophrenia. Which laboratory study does the nurse expect to see among the health care provider’s prescriptions? A. Platelet count Incorrect B. Creatinine level Correct C. Sedimentation rate D. Red blood cell count Awarded 0.0 points out of 1.0 possible points. 26. 70.ID: 9476963078 Betaxolol eye drops have been prescribed for the treatment of a client’s glaucoma. The nurse tells the client to return to the clinic for follow­up for which purpose? A. To have weight checked B. To give a sample for urinalysis C. To have the blood glucose level checked D. For measurement of blood pressure and apical pulse Correct Awarded 1.0 points out of 1.0 possible points. 27. 71.ID: 9476963042 Intravenous tobramycin sulfate is prescribed for a client with a respiratory tract infection. For which of the following symptoms, indicative of an adverse effect, does the nurse monitor the client? A. Nausea B. Vertigo Correct C. Vomiting D. Hypotension Awarded 1.0 points out of 1.0 possible points. 28. 72.ID: 9476957560 A client who is taking bupropion in an attempt to stop smoking tells a nurse that he has been doubling the daily dose to make it easier to resist smoking. The nurse warns the client that doubling the daily dosage is dangerous. Of which adverse effect of the medication does the nurse warn the client? A. Insomnia B. Seizures Correct C. Weight gain D. Orthostatic hypotension Awarded 1.0 points out of 1.0 possible points. 29. 73.ID: 9476970154 A nurse is caring for a client with histoplasmosis who is receiving intravenous amphotericin B . 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 D. Check the client’s blood glucose level Awarded 1.0 points out of 1.0 possible points. 30. 74.ID: 9476961244 A client with rheumatoid arthritis is taking high doses of acetylsalicylic acid. While assessing the client for aspirin toxicity, which question should the nurse ask the client? A. “Are you constipated?” B. “Are you having any diarrhea?” C. “Do you have any double vision?” D. “Do you have any ringing in the ears?” Correct Awarded 1.0 points out of 1.0 possible points. 31. 75.ID: 9476970120 A nurse is reviewing the laboratory results of a client receiving intravenous chemotherapy. Which laboratory finding prompts the nurse to initiate neutropenic precautions? A. A clotting time of 10 minutes B. An ammonia level of 20 mcg N/dL (14.6 μmol N/L) C. A platelet count of 100 × 103/μL (100× 109/L). D. A white blood cell (WBC) count of 2.0 × 103/μL (2.0 × 109/L). Correct Awarded 1.0 points out of 1.0 possible points. 32. 76.ID: 9476964575 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 provide which information to the client? A. To avoid salt while taking this medication B. That it is best to take the medication with food C. To increase fluid intake to 2000 mL to 3000 mL/day Correct D. To drink at least 2 glasses of orange juice every day Awarded 1.0 points out of 1.0 possible points. 33. 77.ID: 9476964567 A client is receiving intravenous bleomycin sulfate. During administration of the chemotherapy, nursing assessment is the priority? A. Heart rate B. Lung sounds Correct C. Peripheral pulses D. Level of consciousness Awarded 1.0 points out of 1.0 possible points. 34. 78.ID: 9476961294 The serum theophylline level of a client who is taking the medication (Theo­24) is 16 mcg/mL. On the basis of this result, the nurse should take which action initially? A. Document the normal value on the chart Correct B. Call the health care provider immediately C. Call the rapid response team to help with the emergency D. Call the pharmacy to alert the pharmacist regarding the client’s theophylline level Awarded 1.0 points out of 1.0 possible points. 35. 79.ID: 9476970188 A client with tuberculosis is being started on isoniazid and the nurse stresses the importance of returning to the clinic for follow­up blood testing. Which blood test will be performed? A. Liver enzymes Correct B. Serum creatinine C. Blood urea nitrogen D. Red blood cell count Awarded 1.0 points out of 1.0 possible points. 36. 80.ID: 9476961298 Baclofen is prescribed for a client with a spinal cord injury who is experiencing muscle spasms. While providing instructions to the client, which side effect does the nurse tell the client is possible? A. Photosensitivity B. Nasal congestion Correct C. Increased appetite D. Increased salivation Awarded 1.0 points out of 1.0 possible points. 37. 81.ID: 9476967717 A nurse is caring for a client with myasthenia gravis who is exhibiting signs of cholinergic crisis. Which medication does the nurse ensure is available to treat this crisis? A. Acetylcysteine B. Atropine sulfate Correct C. Protamine sulfate D. Pyridostigmine bromide Awarded 1.0 points out of 1.0 possible points. 38. 82.ID: 9476964532 A nurse is providing instruction to a client who is taking codeine sulfate for severe back pain. Which instruction should the nurse provide to the client? A. Decrease fluid intake B. Maintain a high­fiber diet Correct C. Avoid all exercise to help prevent lightheadedness D. Avoid the use of stool softeners to help prevent diarrhea Awarded 1.0 points out of 1.0 possible points. 39. 83.ID: 9476967721 A nurse is preparing a plan of care for a pregnant client who will be given oxytocin to induce labor. Which occurrence does the nurse include in the plan of care as a reason for immediate discontinuation of the oxytocin infusion? A. Uterine atony B. Severe drowsiness C. Uterine hyperstimulation Correct D. Early decelerations of the fetal heart rate Awarded 1.0 points out of 1.0 possible points. 40. 84.ID: 9476970141 A home health nurse provides instructions to a client who is taking allopurinol for the treatment of gout. Which instruction should the nurse provide to the client? 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 over­the­counter (OTC) antihistamine lotion if a rash develops Awarded 1.0 points out of 1.0 possible points. 41. 85.ID: 9476961278 A client taking metronidazole for the treatment of trichomoniasis vaginalis calls the clinic nurse to express concern because her urine has turned dark in color. The nurse should provide which information to the client? A. To increase her fluid intake B. To discontinue the medication C. That darkening of the urine is a harmless side effect Correct D. To report to the clinic to see the health care provider Awarded 1.0 points out of 1.0 possible points. 42. 86.ID: 9476964502 Erythromycin is prescribed for a client with a respiratory tract infection. The nurse provides instructions to the client regarding the administration of the oral medication and tells the client that it is best to take the medication in which way? A. With juice B. With a meal C. On an empty stomach Correct D. At bedtime, with a snack Awarded 1.0 points out of 1.0 possible points. 43. 87.ID: 9476964550 A nurse is monitoring a client who is receiving a continuous intravenous infusion of morphine sulfate. Which finding should cause the nurse to contact the health care provider? A. Temperature of 97.6° F B. Urine output of 30 mL/hr C. Blood pressure of 100/60 mm Hg D. Respiratory rate of 10 breaths/min Correct Awarded 1.0 points out of 1.0 possible points. 44. 88.ID: 9476964544 A nurse is providing dietary instructions to a client taking spironolactone. Which foods does the nurse instruct the client are acceptable to consume? Select all that apply. A. Rice Correct B. Cereal Correct C. Carrots Correct D. Bananas Incorrect E. Citrus fruits Incorrect Awarded ­2.0 points out of 3.0 possible points. 45. 89.ID: 9476967701 A nurse is caring for a client with a diagnosis of chronic kidney disease who is receiving dialysis. Epoetin alfa, to be administered subcutaneously, has been prescribed, and the nurse is drawing the medication from a single­use vial. What should the nurse do to prepare the medication? A. Shake the vial before drawing up the medication B. Draw up the medication and discard the unused portion Correct C. Obtain the medication from the medication freezer and allow it to thaw D. Mix the medication with 0.1 mL of heparin before administration to prevent clotting Awarded 1.0 points out of 1.0 possible points. 46. 90.ID: 9476961257 Zidovudine (is prescribed for an adult client with HIV infection. The nurse should provide which instruction to the client about the medication? A. That the medication must be taken with milk B. That aspirin can be taken to treat headache C. To discontinue the medication if nausea occurs D. To space the doses evenly around the clock Correct Awarded 1.0 points out of 1.0 possible points. 47. 91.ID: 9476961223 A nurse is to administer a dose of digoxin to a client with atrial fibrillation and notes that the client has a potassium level of 4.6 mEq/L (4.6 mmol/L). The nurse determines which about the administration of the dose? A. Should be withheld that day B. Should be administered as prescribed Correct C. Should be preceded with a dose of potassium D. Should be withheld and the health care provider notified Awarded 1.0 points out of 1.0 possible points. 48. 92.ID: 9476970133 A client with heart failure being discharged home will be taking furosemide. Which statement by the client indicates to the nurse that the teaching has been effective? A. “I’ll weigh myself every day.” Correct B. “I’ll take my pulse every day.” C. “I’ll measure my urine output.” D. “I’ll check my ankles every day for swelling.” Awarded 1.0 points out of 1.0 possible points. 49. 93.ID: 9476967705 A client who has undergone adrenalectomy is prescribed prednisone. Which finding indicates that the client is experiencing an adverse effect of the medication? A. Dry mouth B. Tarry stools Correct C. Hypotension D. Hypoglycemia Awarded 1.0 points out of 1.0 possible points. 50. 94.ID: 9476964578 A pregnant client is receiving magnesium sulfate for the management of preeclampsia. Which assessment finding indicates to the nurse that the client is experiencing magnesium toxicity? A. Proteinuria of +3 B. Sudden drop in fetal heart rate Correct C. Presence of deep tendon reflexes D. Serum magnesium level of 2.5 mEq/L (1.25 mmol/L) Awarded 1.0 points out of 1.0 possible points. 51. 95.ID: 9476970149 A client with a thoracic spinal cord injury is receiving dantrolene sodium. Which statement by the client indicates to the nurse that the client is experiencing an adverse effect of the medication? A. “I’m feeling really drowsy.” Correct B. “My legs are very relaxed.” C. “I can’t seem to get enough to eat.” D. “I urinate about the same amount as I always did.” Awarded 1.0 points out of 1.0 possible points. 52. 96.ID: 9476957554 The emergency department staff prepares for the arrival of a child who has ingested a bottle of acetaminophen. Which medication does the nurse ensure is available? A. Pancreatin B. Phytonadione C. Acetylcysteine Correct D. Protamine sulfate Awarded 1.0 points out of 1.0 possible points. 53. 97.ID: 9476957571 A nurse is caring for a client who has been taking acetazolamide for glaucoma. Which, if documented in the assessment data, indicates to the nurse that the client may be experiencing an adverse effect of the medication? A. Tinnitus B. Jaundice Correct C. No change in peripheral vision D. Pupillary constriction in response to light Awarded 1.0 points out of 1.0 possible points. 54. 98.ID: 9476963002 A nurse instructs a client with hypothyroidism about the dosage, method of administration, and side effects of levothyroxine sodium. Which statement by the client indicates an understanding of the nurse’s instructions? A. “I should take the medication in the evening.” B. “I can expect diarrhea, insomnia, and excessive sweating.” C. “If I feel nervous or have tremors, I should only take half the dose.” D. “I need to report any episodes of palpitations, chest pain, or dyspnea.” Correct Awarded 1.0 points out of 1.0 possible points. 55. 99.ID: 9476959589 Warfarin sodium has been prescribed, and the nurse teaches the client about the medication. Which statement by the client indicates that further teaching is necessary? A. “I won’t play football anymore.” B. “I won’t take any over­the­counter medications except aspirin.” Correct C. “I’ll use an electric shaver until the doctor stops the Coumadin prescription.” D. “I’ll buy one of those medication alert tags that tells people I’m taking an anticoagulant.” Awarded 1.0 points out of 1.0 possible points. 56. 100.ID: 9476961286 A client is taking a folic acid supplement. Which laboratory parameter does the nurse use to evaluate the effectiveness of this therapy? Select all that apply. A. Magnesium B. Hemoglobin Correct C. Blood glucose D. Hematocrit Correct E. Alkaline phosphatase Awarded 2.0 points out of 2.0 possible points.