Labels: antidote, drug action, Drug Toxicities, normal range, nursing management, sign and symptoms, toxic levels

Digoxin 2 Lithium 2 Aminophylline 20 Dilantin 20 Acetaminophen 200 Digoxin Brand Name: Lanoxin Toxicity: 2 Normal Range: 0.5-1.5 meq/L Indication: Congestive Heart Failure Classification: Cardiac Glycoside Mechanism of Action: Increase force of Myocardial Contraction Increase force of Cardiac Contraction Increase Cardiac Output Nursing Management: Check Apical Pulse Rate HR < 60bpm- Notify the Physician S/S: Anorexia Nausea and Vomiting Diarrhea Confusion Photophobia Xantopsia Antidote: DIGIBIND Lithium Brand Name: Lithane Toxicity: 2 Normal Range: 0.6-1.2 meq/L Indication: Bipolar Disorder (Anti-Manic) Mechanism of Action: Decrease ACTH Decrease Norepinephrine Decrease Serotonin Nursing Management: Force Fluid (2-3 L) Increase Sodium Intake (4-10 g/daily to prevent dehydration) S/S: Anorexia Diarrhea Dehydration Hypothyroidism Fine Tremors Aminophylline/Theophylline Brand Names: Elixophyllin Toxicity: 20 Normal Range: 10-19meq/100ml Indication: COPD Classification: Bronchodilator Mechanism of Action: Bronchodilator- dilates the bronchial tree thereby allowing more air to enter the lungs. Nursing Management: Avoid Caffeine S/S:

 Tachycardia CNS excitability Irritability and Agitation Restlessness Tremors Dilantin/Phenytoin Toxicity: 20 Normal Range: 10-19 meq/L Classification: Anti-Convulsant Mechanism of Action: Suppresses the paroxysmal electrical activity that makes up focal lesions. Blocks post-tetanic potentiation (PTT). PTT is an important mechanism in the development of high frequency trains of impulses in excitatory brain circuits; the spread of this activity to adjacent neurons and propagation to distant neuronal aggregates results in uncontrolled spread of excitation of the whole brain leading to a tonic-clonic seizure. Nursing Management: It is only mixed with 0.9 plain NSS or NaCl to prevent crystals or precipitate. Given via: Sandwich Method Instruct client to avoid alcohol- CNS depression, may lead to seizure. S/S: Gingival Hyperplasia Instruct client to massage his gums Hairy Tongue Ataxia (+) Rhombergs Test Nystagmus Acetaminophen Brand Name: Tylenol Toxicity: 200 Indication: Osteoarthritis Classification: Anti- Narcotic Analgesic Mechanism of Action: Acetaminophen is used for the relief of fever as well as aches and pains associated with many conditions. Relieves pain in mild arthritis but has no effect on the underlying inflammation, redness, and swelling of the joint. S/S: Jaundice Abdominal Pain Vomiting Antidote: Acetylceisteine Nursing Management: Prepare suction apparatus.

NCLEX Questions: 1. The nurse knows that which statement by the mother indicates that the mother understands safety precautions with her four monthold infant and her 4 year-old child? A) "I strap the infant car seat on the front seat to face backwards." B) "I place my infant in the middle of the living room floor on a blanket to play with my 4 year old while I make supper in the kitchen." C) "My sleeping baby lies so cute in the crib with the little buttocks stuck up in the air while the four year old naps on the sofa." D) "I have the 4 year-old hold and help feed the four month-old a bottle in the kitchen while I make supper." 2. Upon completing the admission documents, the nurse learns that the 87 year-old client does not have an advance directive. What action should the nurse take? A) Record the information on the chart B) Give information about advance directives C) Assume that this client wishes a full code D) Refer this issue to the unit secretary 3. A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to A) Maintain the airway B) Administer epinephrine 1:1000 as ordered C) Monitor for hypotension with shock D) Administer diphenhydramine as ordered 4. Which of these children at the site of a disaster at a child day care center would the triage nurse put in the "treat last" category? A) An infant with intermittent buldging anterior fontonel between crying episodes B) A toddler with severe deep abrasions over 98% of the body C) A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture D) A school-age child with singed eyebrows and hair on the arms 5. When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurses best action is to A) change whichever item is incorrect to the correct information B) use the bracelet and admission form until a replacement is supplied C) notify the admissions office and wait to apply the bracelet D) make a corrected identification bracelet for the client 6. The nurse is having difficulty reading the health care provider's written order that was written right before the shift change. What action should be taken? A) Leave the order for the oncoming staff to follow-up B) Contact the charge nurse for an interpretation C) Ask the pharmacy for assistance in the interpretation D) Call the provider for clarification 7. An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to: A) check the cartoid pulse B) deliver 5 abdominal thrusts C) give 2 rescue breaths D) open the client's airway 8. A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing action? A) Ask the client if there are any breathing problems B) Have the client void as much as possible C) Check the vital signs D) Ausculate the lungs 9. Following change-of-shift report on an orthopedic unit, which client should the nurse see first? A) 16 year-old who had an open reduction of a fractured wrist 10 hours ago B) 20 year-old in skeletal traction for 2 weeks since a motor cycle accident C) 72 year-old recovering from surgery after a hip replacement 2 hours ago

D) 75 year-old who is in skin traction prior to planned hip pinning surgery. 10. A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make? A) Why dont we now have the client turn back to the left side. B) That was done correctly. Did you have any problems with the insertion? C) Lets check to see if the suppository is in far enough. D) Did you feel any stool in the intestinal tract 11. A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is the appropriate type to use when performing postmortem care? A) airborne precautions B) droplet precautions C) contact precautions D) compromised host precautions 12. The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is appropriate teaching? A) Void a little, clean the meatus, then collect specimen B) clean the meatus, begin voiding, then catch urine stream C) Clean the meatus, then urinate into container D) Void continuously and catch some of the urine 13. The provider orders Lanoxin (digoxin) 0.125 mg po and furosomide 40 mg every day. Which of these foods would the nurse reinforce for the client to eat at least daily? A) spaghetti B) watermelon C) chicken D) tomatoes 14. A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse take? A) Look up the policy on needle sticks B) Contact employee health services C) Immediately wash the hands with vigor D) Notify the supervisor and risk management 15. As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to give the medication without first aspirating. What should the nurse do? A) Ask the student: "What did you forget to do? B) Stop. Tell me why aspiration is needed. C) Loudly state: You forgot to aspirate. D) Walk up and whisper in the students ear Stop. Aspirate. Then inject. 16. A client with Guillain Barre is in a nonresponsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition? A) Comatose, breathing unlabored B) Glascow Coma Scale 8, respirations regular C) Appears to be sleeping, vital signs stable D) Glascow Coma Scale 13, no ventilator required 17. A client enters the emergency department unconscious via ambulance from the clients work place. What document should be given priority to guide the direction of care for this client? A) The statement of client rights and the client self determination act B) Orders written by the health care provider C) A notarized original of advance directives brought in by the partner D) The clinical pathway protocol of the agency and the emergency department 18. The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel (UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse manager? A) An admission at the change of shifts with atrial fibrillation and heart failure - PN B) Client who had a major stroke 6 days ago - PN nursing student C) A child with burns who has packed cells and albumin IV running - charge nurse D) An elderly client who had a myocardial infarction a week ago - UAP

19. A mother brings her 3 month-old into the clinic, complaining that the child seems to be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical assessment? A) Increased temperature and lethargy B) Restlessness and increased mucus production C) Increased sleeping and listlessness D) Diarrhea and poor skin turgor 20. As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis? A) "The child has been listless and has lost weight." B) "The urine is dark yellow and small in amounts." C) "Clothes are becoming tighter across her abdomen." D) "We notice muscle weakness and some unsteadiness." Answers: 1. D 2. B 3. B 4. B 5. C 6. D 7. D 8. D 9. C 10. B 11. C 12. B 13. B 14. C 15. D 16. B 17. C 18. A 19. B 20. C

Ginkgo Biloba Uses: Asthma Bronchitis Fatigue Tinnitus (ringing or roaring sounds in the ears) Memory improvement Alzheimers disease and other types of dementia Sexual dysfunction Multiple sclerosis Contraindications: Taking blood thinning drugs Diagnosed with bleeding disorders Scheduled for surgery Side Effects and Cautions Headache Nausea Diarrhea Dizziness Allergic skin reactions Increase bleeding Risk for Seizures Some promising results have been seen for Alzheimers disease/dementia and intermittent claudication, among others, but larger, welldesigned research studies are needed. Some smaller studies for memory enhancement have had promising results, but a trial sponsored by the National Institute on Aging of more than 200 healthy adults over age 60 found that ginkgo taken for 6 weeks did not improve memory. St. Johns Worth Uses: Depression Anxiety Sleep disorders Malaria Nerve pain Sedative Contraindications: Pregnant and Lactating Women Severely Depressed Patients Individuals already taking antidepressants Oral Contraceptives Preoperative or Postoperative Patients Epileptics Anemics Patients with HIV Transplant Patients Side Effects: Increased sensitivity to sunlight Anxiety Dry mouth Dizziness Gastrointestinal symptoms Fatigue Headache Sexual dysfunction Interferes with Absorption of Iron Drug Interactions: Research shows that St. Johns wort interacts with some drugs. The herb affects the way the body processes or breaks down many drugs; in some cases, it may speed or slow a drugs breakdown. Drugs that can be affected include: Antidepressants Birth control pills Cyclosporine, which prevents the body from rejecting transplanted organs Digoxin, which strengthens heart muscle contractions Indinavir and possibly other drugs used to control HIV infection

 Irinotecan and possibly other drugs used to treat cancer Warfarin and related anticoagulants When combined with certain antidepressants, St. Johns wort may increase side effects such as nausea, anxiety, headache, and confusion. Asian Ginseng Uses: Increasing Immune System Recovering from illness Increasing energy & stamina Improving mental & physical performance Erectile dysfunction Hepatitis C Menopausal symptoms Lowering blood sugar Controlling blood pressure Contraindications: Diabetics Patients with Hypertension Patients taking opiates for pain relief Pregnant Women Side Effects: Headaches Sleep problems Gastrointestinal problems Allergic reactions Breast tenderness, Menstrual irregularities High blood pressure ( Low blood sugar Some studies have shown that Asian ginseng may lower blood glucose. Other studies indicate possible beneficial effects on immune function. Research results on Asian ginseng are not conclusive enough to prove health claims associated with the herb. Only a handful of large clinical trials on Asian ginseng have been conducted. Most studies have been small or have had flaws in design and reporting. Some claims for health benefits have been based only on studies conducted in animals. Echinacea Uses: Colds, flu, and other infections. Stimulating the immune system Infections Wounds and skin problems, such as acne or boils Contraindications: Pregnant women Patients with autoimmune disorders Patients with tuburculosis Young children Side Effects Incresed side effects if taken beyond 8 weeks Stomach problems Allergic reactions, including rashes, asthma, and anaphylaxis (a life-threatening allergic reaction), people with Allergies to other plants may be more susceptible Study results are mixed on whether echinacea effectively treats colds or flu. For example, two NCCAM-funded studies did not find a benefit from echinacea, either as Echinacea purpurea fresh-pressed juice for treating colds in children, or as an unrefined mixture of Echinacea angustifolia root and Echinacea purpurea root and herb in adults. However, other studies have shown that echinacea may be beneficial in treating upper respiratory infections. Black Cohash Uses: Rheumatism (arthritis and muscle pain)

Menopausal symptoms Menstrual irregularities and premenstrual syndrome Labor induction Blackcohosh Contraindications: Pregnant Women Children Side Effects: Headaches and stomach discomfort Heaviness in the legs Weight problems Interactions & Cautions No interactions have been reported between black cohosh and prescription medicines. It is not clear if black cohosh is safe for women who have had breast cancer or for pregnant women. Study results are mixed on whether black cohosh effectively relieves menopausal symptoms. Studies to date have been less than 6 months long, so long-term safety data are not currently available. Kava Uses: Anxiety Insomnia Menopausal symptoms Fatigue Asthma Urinary tract infections Contraindications: Pregnant & nursing women People being treated for depression People with Parkinsons disease People with liver problems People with high blood pressure Side Effects Liver damage, including hepatitis and liver failure Dystonia (abnormal muscle spasm or involuntary muscle movements) Hypertension Scaly, yellowed skin (associated with long-term use) Drowsiness Drug Interactions: Kava may interact with several drugs, including drugs used for Parkinsons disease. What the Science Says Although scientific studies provide some evidence that kava may be beneficial for the management of anxiety, the U.S. Food and Drug Administration (FDA) has issued a warning that using kava supplements has been linked to a risk of severe liver damage. Evening Primrose Uses: Eczema (a condition in which the skin becomes inflamed, itchy, or scaly because of allergies or other irritation) Inflammation Rheumatoid arthritis Menstrual & menopausal symptoms Contraindications: Pregnant women Epileptics Schizophrenics Side Effects and Cautions: Stomach upset Headache May lower seizure threshold

Evening primrose oil may have modest benefits for eczema, and it may be useful for rheumatoid arthritis and breast pain. However, study results are mixed, and most studies have been small and not well designed. Evening primrose oil does not appear to affect menopausal symptoms. Although some clinical trials have shown a benefit of evening primrose oil for premenstrual syndrome, the best-designed trials found no effect. Saw Palmetto Uses: Urinary symptoms associated with an enlarged prostate gland Chronic pelvic pain Bladder disorders Decreased sex drive Hair loss Hormone imbalances Contraindications: Pregnant Women Children Side Effects and Cautions: Stomach discomfort. Some men have reported side effects such as tender breasts and a decline in sexual desire Several small studies suggest that saw palmetto may be effective for treating BPH symptoms. In 2006, a large study of 225 men with moderate-to-severe BPH found no improvement with 320 mg saw palmetto daily for 1 year versus placebo. NCCAM cofunded the study with the National Institute of Diabetes and Digestive and Kidney Diseases. There is not enough scientific evidence to support the use of saw palmetto for reducing the size of an enlarged prostate or for any other conditions. Banned Herbal Medicine : Ephedra (aka Ma-Huang) Ephedra is a naturally occurring substance that comes from botanicals. The principal active ingredient ephedrine is an amphetaminelike compound that can powerfully stimulate the nervous system and heart. In recent years, ephedra products have been marketed as dietary supplements to promote weight loss, increase energy, and enhance athletic performance. After a careful review of the available evidence about the risks and benefits of ephedra in supplements, the FDA found that these supplements present an unreasonable risk of illness or injury to consumers. The data showed little evidence of ephedras effectiveness, except for short-term weight loss, while confirming that the substance raises blood pressure and stresses the heart. The increased risk of heart problems and strokes negates any benefits of weight loss.

1. Which statement describes how elderly clients react to medication? a. At increased risk for adverse reactions b. Tolerate medication better because theyre less active c. Metabolize medications quickly d. All of the above 2. Nursing interventions for a male client taking central nervous system (CNS) stimulants include monitoring the client for which condition? a. Hyperpyrexia, slow pulse, and weight gain b. Tachycardia, weight loss, and mood swings c. Hypotension, weight gain, and listlessness d. All of the above 3. The charge nurse in an acute care setting assigns to a male client, whos on one-to-one suicide precautions, to a psychiatric aide. This assignment is considered: a. Poor nursing practice because a registered nurse should work with this client b. Reasonable nursing practice because one-to-one supervision requires the total attention of a staff member

c. Outside the responsibility of an aide d. Illegal to delegate to an aide 4. Whats a nurse most important role in caring for an adult client with a mental disorder? a. To offer advice b. To know how to solve the clients problem c. To establish trust and rapport d. To set limits with the client 5. Unhealthy personal boundaries are a product of dysfunctional families and a lack of positive role models. Unhealthy boundaries may also be a result of: a. Structured limit setting b. A supportive environment c. Abuse and neglect d. Direction and attention 6. The nurse in-charge is displaying assertive behavior when she: a. Says whats on her mind at the expense of others b. Expresses an air of superiority c. Avoids unpleasant situations and circumstances d. Stands up for her rights while respecting the rights of others. 7. In a group therapy setting, one male member is very demanding, repeatedly interrupting others and taking most of the group time. The nurses best response would be: a. Will you briefly summarize your point because others need time also? b. Your behavior is obnoxious and drains the group. c. To ignore the behavior and allow him vent d. Im so frustrated with your behavior 8. The nurse is aware that the primary indication for the use of electroconvulsive therapy (ECT) is: a. Severe agitation b. Antisocial behavior c. Noncompliance with treatment d. Major depression with psychotic features 9. Two nurses are discussing a female clients condition in the elevator. The employer of the mentioned client overhears the conversation and fires the client. The nurses may be liable for which act? a. Assault b. Battery c. Neglect d. Breach of confidentiality 10. A nurse at a substance abuse center answers the phone. A probation officer asks if the male client is in treatment. The nurse responds, No, the client youre looking for isnt here. Which statement best describes the nurses response? a. Correct because she didnt give out information about the client b. A violation of confidentiality because she informed the officer that the client wasnt there c. A breach of the principle of veracity because the nurse is misleading the officer d. Illegal because shes withholding information from law enforcement agents. 11. The employer of a female client on the psychiatric unit calls the nursing station inquiring about the clients progress. The nurse doesnt know if consent has been given by the client to allow the staff to give information out to caller on the phone. Which

response by the nurse would be best? a. Im not permitted to discuss her progress. b. Ill give you the name and telephone number of her physician. c. Ill have her call you. d. I cant confirm whether your employee is a client here. 12. A voluntary male client in a health care facility decided to leave the unit before treatment is complete. To detain the client, the nurse refuses to return his personal effects. This is an example of: a. False imprisonment b. Limit setting c. Slander d. Violation of confidentiality 13. Which statement is guideline to help nurses avoid liability? a. Follow every physicians order b. Do what the client desires even though you may disagree c. Practice within the scope of the Nurse Practice Act d. Obtain malpractice insurance 14. A nurse places a male client in full leather restraints. How often must the nurse check the clients circulation? a. Once per hour b. Once per 8-hour shift c. Every 15 minutes d. Every 2 hours 15. Which clinical condition meets the criteria for involuntary commitment? a. A single parent who leaves her minor children unattended and stays out all night drinking b. A person who lives alone and has schizophrenia with delusions of persecution c. A man who threatens to kill his wife d. A person with depression who says hes tired of living but doesnt have a suicide plan 16. An adult client in an acute care mental health program refuses his morning dose of an oral antipsychotic medication and believes hes being poisoned. The nurse should respond by taking which action? a. Administering the medication by injection b. Omitting the dose and trying again the next day c. Crushing the medication and putting it in his food d. Consulting with the physician about a care plan 17. A nurse is working with a female dying client and his family. Which communication technique is most important to use? a. Reflection b. Interpretation c. Clarification d. Active listening 18. A male client receiving morphine for long-term pain management develops tolerance. Tolerance is defined as: a. An increased response to a medication b. A diminished response to a drug so that more is required to achieve the same effect c. An allergic reaction to a medication

d. An ability to take the same drug for extended periods of time. 19. The nurse is aware that the goal of crisis intervention is: a. To solve the clients problems for him b. Psychological resolution of the immediate crisis c. To establish a means for long-term therapy d. To provide a means for admission to an acute care facility 20. A male client in a group therapy is restless. His face is flushed and he makes sarcastic remarks to group members. The nurse responds by saying, You look angry. The nurse is using which technique? a. A broad opening statement b. Reassurance c. Clarifying d. Making observations 21. A male patient with antisocial personality disorder smokes where it is prohibited and refuses to follow other unit and hospital rules. The patient gets others to do the laundry and other personal chores, splits the staff, and will work only with certain nurses. The plan of care for this patient should focus primarily on: a. A consistently enforcing unit rules and hospital policy b. Isolating the patient to decrease contact with easily manipulated patients c. Engaging in power struggles with the patient to minimize manipulative behavior d. Using behavior modification to decrease negative behavior by using negative reinforcement 22. The nurse knows that the doctor in charge has ordered the liquid form of the drug chlorpromazine rather than the tablet form because the liquid? a. Has a more predictable onset of action b. Produces fewer anticholinergic effects c. Produces fewer drug infections d. Has a longer duration of action 23. A male patient receiving fluphenazine (Prolixen) therapy develops pseudoparkinsonism. The doctor is likely to prescribe which drug to control this extrapyramidal effect? a. Phenytoin (Dilantin) b. Amantadine (Symmetrel) c. Benztropine (Cogentin) d. Diphenhydramine 24. During a panic attack, a male patient runs to the nurse and reports breathing difficulty, chest pain, and palpitations. The patient is pale, with the mouth wide open and eyebrows raised. What should the nurse do first? a. Assist the patient to breath deeply into a paper bag b. Orient the patient to person, place and time c. Set limits for acting out delusional behaviors d. Administer an I.M. anxiolytic agent 25. A husband and wife seek emergency crisis intervention because he slapped her repeatedly the night before. The husband says he grew up in a household where his father frequently abused both his mother and him. When interviewing with this couple, the nurse in charge knows they are at risk for repeated violence because the husband: a. Has only moderate impulse control b. Denies feelings of jealousy or possessiveness c. Has learned violence as an acceptable behavior d. Feels secure in his relationship with his wife

26. What occurs during the working phase of the nurse-patient relationship? a. The nurse assesses the patients needs and develops a plan of care b. The nurse and patient together evaluate and modify the goals of the relationship c. The nurse and patient discuss their feelings about terminating the relationship d. The nurse and patient explore each others expectations of the relationship 27. When caring for a male adolescent patient diagnosed with depression, the nurse should remember that depression manifests differently in adolescents and adult. In an adolescent, signs and symptoms of depression are likely to include: a. Helplessness, hopelessness, hypersomnolence, and anorexia b. Truancy, a change of friends, social withdrawal, and oppositional behavior c. Curfew breaking, stealing from family members, truancy, and oppositional behavior d. Hypersomnolence, obsession with body image, and valuing of peers opinion. 28. During the admission assessment, a male patient with a panic disorder begins to hyperventilate and says, Im going to die if I dont get out of here right now! What is the nurses best response? a. Just calm down. Youre getting overly anxious. b. What do you think is causing your panic attack? c. You can rest alone in your room until you feel better. d. Youre having panic attack. Ill stay here with you. 29. In a female patient with a conversion disorder who reports blindness, ophthalmologic examinations reveal that no organic disorder is causing progressive vision loss. The most likely source of this patients blindness is: a. A family history of major depression b. Having been forced to watch a loved ones torture c. Noncompliance with a psychotropic medication regimen d. Daily use of antianxiety agents and alcoholic beverages 30. A busy attorney with a successful law practice is admitted to an acute care facility with epigastric pain. Since admission, the patient has called the nurse 15 minutes with one request or another. This patient is exhibiting: a. Repression b. Somatization c. Regression d. Conversion Answers and Rationale Answer A. As individuals become older, their livers metabolize drugs at a slower rate. Cumulative effects can occur and increase the risk of adverse reactions. Level of activity typically doesnt affect a persons reaction to medication. Elderly clients typically need lower doses, not higher. 1. 2. Answer B. Stimulants produce mood swings, weight loss, and tachycardia. The other symptoms indicate CNS depression. Answer B. A psychiatric aide can sit with the client and provide safety. The nurse is still responsible for assessing the client and ensuring that one-to-one supervision occurs. Aides are capable of providing one-to-one observation. It isnt illegal to delegate observation to an aide. Answer C. Its extremely important that the nurse establish trust and rapport. The nurse shouldnt offer advice. Instead, she should help the client develop the coping mechanisms necessary to solve his own problems. Setting limits is also important as developing trust and rapport. Answer C. Abuse and neglect lead to poor self-concept and role confusion, which are the basis for unhealthy personal boundaries. Healthy boundaries are established in childhood when parents provide consistent, supportive environment, and direction and attention. Answer C. The basic element of assertive behavior includes the ability to express feelings and thoughts while respecting the

3.

4.

5.

rights of others. Doing so at the expense of others and expressing superiority are aggressive behaviors, and avoiding unpleasant situation is a form of passive behavior. 6. Answer A. Asking the client to summarize his point redirects the clients to focus his comments and allows him to make his point. Telling the client that his behavior is obnoxious is judgmental, and ignoring the behavior doesnt help facilitate communication. Expressing frustration focuses more on the nurse than on the clients need. Answer D. ECT is indicated for major depression. ECT isnt indicated severe agitation, antisocial behavior, or treatment noncompliance. Answer D. Breach of confidentiality occurs when a nurse shares information that can cause harm to an individual. Assault is an act that results in fear that one will be touched without consent. Battery involves unconsented touching of another person. Neglect is the failure to do whats deemed reasonable in a situation. Answer B. The nurse violated confidentiality by informing the officer that the client wasnt in treatment. Even with law enforcement agents, the nurse must be a client advocate and protect the clients confidentiality. Because its unknown in this question whether the client is actually in treatment, it cant be concluded that the nurse is misleading the officer because her statement may be truthful. Information can be legally withheld when a court order isnt in place.

7. 8.

9.

10. Answer D. The nurses release of information to the clients employer without the clients consent is a breach of confidentiality. The stigma associated with psychiatric illness may affect the clients employment; therefore, its better to maintain confidentiality and refrain from disclosing any information about the client, including whether shes a client in the hospital. 11. Answer A. Confining a voluntary client against his will be considered false imprisonment. Limit setting is a therapeutic technique used to achieve a desired behavior, and wouldnt involve confining a voluntary client. Slander is oral defamation of character. The nurse hasnt given out any information about the client, so confidentiality hasnt been violated. 12. Answer C. The Nurse Practice Act outlines acceptable standards for nursing. Practicing within those guidelines will protect the nurse from liability. Physicians may not be aware of guidelines for nurses and may inadvertently delegate inappropriate treatment of practice for the nurse. The client doesnt know standards of care and isnt responsible for the nurses actions. Insurance wont prevent a liability suit, but only assist the nurse if a suit would be filed. 13. Answer C. Circulatory as well as skin and nerve damage can occur within 15 minutes. Checking every hour, 2 hours, or 8 hours isnt often enough and could result is permanent damage to the clients extremities. 14. Answer C. One of the criteria for involuntary commitment is an emergency in which the client is a threat to himself or others, such as a man who threatens to kill his wife. A parent might have a child removed from the home because of neglect, but that doesnt meet the criteria for involuntary commitment. Many individuals with schizophrenia can learn to live with hallucinations and delusions and dont require hospitalization. To meet criteria for involuntary commitment, a depressed individual must have a suicide plan and be a direct threat to himself. 15. Answer D. To determine care plan for clients who are noncompliant with medications, the nurse should consult with the physician. Unless the client presents a danger to himself of others, medications cant be forced on a client. A dose shouldnt be omitted without first checking with the physician. Intentionally deceiving of misleading a client violates the therapeutic relationship. 16. Answer D. When working with a dying patient and his family, the nurse uses active listening to assess their feelings, coping skills, and immediate and long-term needs. It also helps the nurse select other appropriate strategies, such as reflection and clarification. Interpretation should be used sparingly to avoid making false interference or putting the client on the defensive. 17. Answer B. Tolerance occurs when the body requires higher doses of substances, such alcohol, opioids, or benzodiazepines, to achieve desired effect. Increased response indicates a need for less of a drug to achieve the same effects. Allergic reactions are autoimmune response to a particular drug or class of drugs. A client may be able to take, or tolerate, the same drug for an extended period; however this isnt the definition of developing tolerance. 18. Answer B. The goal of crisis intervention is the resolution of an immediate problem. The client must learn to solve his own problems. Although some clients do enter long-term therapy or are admitted to an acute care facility, neither is the goal of crisis intervention. 19. Answer D. The nurse is using observation to give the client feedback about his behavior and attitude. A broad statement doesnt give feedback to the client. The nurse didnt reassure the client or ask him to explain his actions (clarifying). 20. Answer A. Firmness and consistency regarding rules are the hallmarks of a plan of care for a patient with a personality disorder. Isolation is inappropriate and would violate the patients rights. Power struggles should be avoided because the patient may try to manipulate people through them. Behavior modification usually fails because of staff inconsistency and patient manipulation. 21. Answer A. A liquid phenothiazine preparation will produce effects in 2 to 4 hours. The onset with tablet is unpredictable.

22. Answer B. An antiparkinsonian agent, such as amantadine, may be used to control pseudoparkinsonism, diphenhydramine or benztropine may be used to control other extrapyramidal effects. 23. Answer A. Physiological needs, particularly breathing, are the first priorities during a panic attack. Having the patient breathe deeply into a paper bag corrects hyperventilation; restoring a normal breathing pattern should relieve the patients other symptoms. Orientation usually is unnecessary because most patients respond to external control and reduce stimulation. During a panic attack, the patient is not likely to act out but may strike out if feeling threatened. An anxiolytic agent may be effective but is not the first priority. 24. Answer C. Family violence usually is a learned behavior begets violence, putting this couple at risk. Repeated slapping may indicate poor, not moderate, impulse control. Violent people commonly are jealous and possessive and feel insecure in their relationships. 25. Answer B. The therapeutic nurse-patient relationship consists of four phases: preinteraction, introduction or orientation, working and termination. During the working phase, the nurse and patient together evaluate and refine the goals established during the orientation phase, in addition, major therapeutic work takes place and insight is integrated into a plan of action. The orientation phase involves assessing the patient, formulating a contract, exploring feelings, and establishing expectation about relationship. During the termination phase, the nurse prepares the patient for separation and explores feelings about the end of the relationship. 26. Answer B. In adolescents, depression typically manifests as truancy, a change of friends, social withdrawal, and oppositional behavior. In adults, it usually produces helplessness, hopelessness, hypersomnolence, and anorexia. Drug use may lead to curfew breaking, stealing, truancy, and oppositional behavior. Adolescents normally display hypersomnelence, and obsession with body image, and valuing of peers opinions. 27. Answer D. During a panic attack, the nurses best approach is to orient the patient to what is happening and provide reassurance that the patient will not be left alone. The anxiety level is likely to increase and the panic attack is likely to continueif the patient is told to calm down (as in option A), asked the reasons for the attack (as in option B), or left alone (as in option C). 28. Answer B. Conversion disorder, or hysterical neurosis, is characterized by alteration or loss of physical function with no physiological basis; the patients symptoms result from psychological conflict. For example, a patient may report blindness after having observed a distressing act. None of the other opinions causes conversion disorder. 29. Answer C. The patient is exhibiting the defense mechanism of regressiona return to behavior characteristic of an earlier developmental level. Dependent, attentiongetting behavior is an attempt to relieve anxiety. Repression would manifest as ignoring the symptoms. Somatization is the channeling of anxiety into a preoccupation with physical complaints. Conversion involves transfer of a mental conflict into a physical symptom to relieve anxiety. 30.Answer C. The patient is exhibiting the defense mechanism of regressiona return to behavior characteristic of an earlier developmental level. Dependent, attentiongetting behavior is an attempt to relieve anxiety. Repression would manifest as ignoring the symptoms. Somatization is the channeling of anxiety into a preoccupation with physical complaints. Conversion involves transfer of a mental conflict into a physical symptom to relieve anxiety. 1. The Client Self-Determination Act of 1990 requires all hospitals to inform clients of advance directives. What should nurse Byron tell the client about such advance directives as living wills and health care power of attorney? a. They guide the clients treatment in certain health care situations b. They cant provide do-not-resuscitate (DNR) orders for clients with terminal illnesses c. They allow physicians to make decisions about treatment d. They permit physicians to give verbal DNR orders 2. Nurse Calvin receives a medication order over the telephone. How should the nurse handle this situation? a. Tell the physician that the nurse practice act prohibits taking medication orders over the telephone b. Verify the order by repeating it over the phone c. Request that a second physician repeat the order to the nurse over the telephone d. Insist that the physician sign the medication order within 1 hour 3. A client who agreed to become an organ donor is pronounced dead. What is the most important factor in selecting a transplant recipient? a. Blood relationship b. Sex and size c. Compatible blood and tissue types d. Need 4. Emergency restraints or seclusion may be implemented without a physicians order under which of the following conditions? a. When a written order will be obtained from the primary physician within 8 hours

b. Never c. If a voluntary client wants to leave against medical advice d. When a minor child is out of control 5. The basis for building a strong therapeutic nurse-client relationship begins with the nurses: a. sincere desire to help others b. acceptance of others c. self-awareness and understanding d. sound knowledge of psychiatric nursing 6. Nurse Carl is concerned about another nurses relationship with the members of a family and their ill preschooler. Which of the following behaviors would be most worrisome and should be brought to the attention of the nurse-manager? a. The nurse keeps communication channels open among herself, the family, physicians, and other health care providers. b. The nurse attempts to influence the familys decisions by presenting her own thoughts and opinions. c. The nurse works with the family members to find ways to decrease their dependence on health care providers. d. The nurse has developed teaching skills to instruct the family members so they can accomplish tasks independently. 7. A man found wandering in a local park is unable to state who or where he is or where he lives. He is brought to the emergency department, where his identification is eventually discovered. The clients wife states that he was diagnosed with Alzheimers disease 3 years ago and has had increasing memory loss. She tells the nurse she is worried about how shell continue to care for him. Which response by the nurse would be most helpful? a. Because of the nature of your husbands disease, you should start looking into nursing homes for him b. What aspect of caring for your husband is causing you the greatest concern? c. You may benefit from a support group called Mates of Alzheimers Disease Clients d. Do you have any children or friends who could give you a break from his care every now and then? 8. Nurse Carrol works on a general medical-surgical unit where nurses work on 12-client pods. Each pod is staffed by two registered nurses. When one of the nurses leaves the unit for any reason, the remaining nurse cares for all 12 clients. If she needs help, she can call the agencys in-house resource nurse. One evening when a coworker nurse left the unit, the remaining nurse, who was making rounds on the departed nurses clients, found medications left at bedsides and a client with a blood-draw tourniquet remaining on his arm. In addressing the problems, the nurse should: a. inform the nurse-supervisor right away b. correct the problems and submit a written report c. speak to the coworker when she returns to the unit d. ask for a meeting with the coworker and a manager 9. Nurse Carter at a substance abuse center answers the phone. A probation officer asks if a client is in treatment. The nurse responds, No, the client youre looking for isnt here. Which of the following statements best describes the nurses response? a. Correct because she didnt give out information about the client b. A violation of confidentiality because she informed the officer that the client wasnt there c. A breech of the principle of veracity because the nurse is misleading the officer d. Illegal because shes withholding information from law enforcement agents 10. Nurse Carey is caring for a client with hyperemesis gravidarum who will need close monitoring at home. When should the nurse begin discharge planning? a. On the day of discharge b. When the client expresses readiness to learn c. When the clients vomiting has stopped d. On admission to the facility 11. A client is being discharged after undergoing abdominal surgery and colostomy formation to treat colon cancer. Which nursing action is most likely to promote continuity of care? a. Notifying the American Cancer Society of the clients diagnosis b. Requesting Meals On Wheels to provide adequate nutritional intake c. Referring the client to a home health nurse for follow-up visits to provide colostomy care d. Asking an occupational therapist to evaluate the client at home 12. In planning a presentation that advocates a decrease in the client-to-nurse ratio from 8:1 to 6:1, a nurse should emphasize its effect on: a. institutional resources b. standards of practice c. client-care quality d. nursing recruitment 13. A client requests his medication at 9 p.m. instead of 10 p.m. so that he can go to sleep earlier. Which type of nursing intervention is required?

a. Intradependent b. Interdependent c. Dependent d. Independent 14. A family member visiting on an acute care psychiatric unit approaches the nurses station and reports that an elderly client is walking in the hall without her clothing. Nurse Casper doesnt assist the client and suggests that the family member inform the nurse assigned to that client. Which of the following terms describes the nurses action? a. Negligent b. Sensitive c. Compassionate d. Organized 15. a. b. c. d. The clients rights to information, informed consent, and treatment refusal are addressed in the: standards of nursing practice clients bill of rights nurse practice act code for nurses

16. An agitated client demands to see her chart so she can read what has been written about her. Which of the following statements is nurse Cedric best response to the client? a. Im sorry the chart is the property of the facility. We dont permit clients to read them b. You have the right to see your chart. Please discuss this with your primary care provider c. You may see your chart after youre discharged d. Please discuss this matter with your attorney 17. Nurse Chadwick is caring for a school-age child with cerebral palsy. The child has difficulty eating using regular utensils and requires a lot of assistance. Which of the following referrals is most appropriate? a. Registered dietitian b. Physical therapist c. Occupational therapist d. Nursing assistant 18. a. b. c. d. When prioritizing a clients plan of care based on Maslows hierarchy of needs, nurse Charles first priority would be: allowing the family to see a newly admitted client ambulating the client in the hallway administering pain medication placing wrist restraints on the client

19. Nurse Chester manages a unit that has four full-time vacant positions, and nurses volunteer to work extra shifts to cover the staffing shortages. One of the staff nurses hasnt volunteered and states, Forty hours a week of nursing is all I can manage to do. I wont volunteer for overtime. The nurse-manager says to an attending physician on the unit, Ill adjust her schedule to make her wish shed volunteered. The physician to whom she commented should: a. choose to ignore the comment because it isnt the physicians domain b. report the nurse-manager to the labor relations board c. ensure that the nurse-manager receives counseling about her comment d. tell the staff nurse what the manager said about her 20. A client with mitral valve prolapse is advised to have elective mitral valve replacement. Because the client is a Jehovahs Witness, she declares in her advance directive that no blood products are to be administered. As a result, the consulting cardiac surgeon refuses to care for the client. It would be most appropriate for nurse Christian whos caring for the client to: a. realize the surgeon has the right to refuse to care for the client b. advise the surgeon to arrange for an alternate cardiac surgeon c. tell the client that she can donate her own blood for the procedure d. inform the client that her decision could shorten her life 21. A newly hired charge nurse assesses the staff nurses as competent individually but ineffective and nonproductive as a team. In addressing her concern, the charge nurse should understand that the usual reason for such a situation is: a. unhappiness about the change in leadership b. unexpressed feelings and emotions among the staff c. fatigue from overwork and understaffing d. failure to incorporate staff in decision making 22. Which of the following options serves as a framework for nursing education and clinical practice? a. Scientific breakthroughs b. Technological advances

c. Theoretical models d. Medical practices 23. Nurse Chrisopher is caring for an infant with congenital clubfoot. After the final cast has been removed, which member of the health care team will most likely help the infant with leg and ankle exercises and provide his parents with a home exercise regimen? a. Occupational therapist b. Physical therapist c. Recreational therapist d. Speech therapist 24. a. b. c. d. 25. a. b. c. d. Which statement reflects appropriate documentation in the medical record of a hospitalized client? Small pressure ulcer noted on left leg Client seems to be mad at the physician Client had a good day Clients skin is moist and cool Critical pathways of care refer to: a plan of care that provides outcome-based guidelines with a designated length of stay a plan of care designed for physicians to prescribe medications a design of treatment that includes approved therapies a technique in therapy to care for the client holistically

Answers and Rational 1. Answer A. Advance directives are signed, witnessed documents that provide specific instructions for treatment if a client cant give those instructions personally when required. Depending on the clients wishes, they may or may not include DNR orders. 2. Answer B. When taking a medication order over the telephone, standard practice requires verbal verification of the order and the physicians written signature within 24 hours. The nurse practice act doesnt prohibit taking medication orders over the telephone 3. Answer C. The donor and recipient must have compatible blood and tissue types. They should be fairly close in size and age. When a living donor is considered, its preferable to have a relative donate the organ. Need is important but it cant be the critical factor if a compatible donor isnt available. 4. Answer A. The primary physician in charge of a clients care must write an order for the restraint within 8 hours. In an emergency, a client who is a threat to himself or others may be restrained without an order. Voluntary clients have the right to leave against medical advice. A minor is treated the same as an adult regarding restraints. 5. Answer C. Although all of the options are desirable, knowledge of self is the basis for building a strong, therapeutic nurse-client relationship. Being aware of and understanding personal feelings and behavior are prerequisites for understanding and helping clients. 6. Answer B. When a nurse attempts to influence a familys decision with her own opinions and values, the situation becomes one of overinvolvement on the nurses part and a nontherapeutic relationship. When a nurse keeps communication channels open, works with family members to decrease their dependence on health care providers, and instructs family members so they can accomplish tasks independently, she has developed an appropriate therapeutic relationship. 7. Answer B. The nurse should determine the specific concerns of the clients wife. Jumping to conclusions regarding the clients need for a nursing home or other care placement options would be inappropriate. The nurse must tailor care to the client and family, focusing on their needs. 8. Answer C. When a nurse discovers substandard practice by another nurse, its always appropriate to address the situation before conveying the information to a manager or supervisor. Informing the nurse-supervisor first doesnt promote goodwill between nurses and can affect nursing care. 9. Answer B. The nurse violated confidentiality by informing the officer that the client wasnt in treatment. Even with law enforcement agents, the nurse must be a client advocate and protect the clients confidentiality. Information can be legally withheld when a court order isnt in place. 10. Answer D. Discharge planning should begin when a client is first admitted to the facility. Initially, discharge planning requires collecting information about the clients home environment, support systems, functional abilities, and finances. 11. Answer C. Many clients are discharged from acute care settings so quickly that they dont receive complete instructions. Therefore, the first priority is to arrange for colostomy care. The American Cancer Society often sponsors support groups, which are helpful when the person is ready, but contacting this organization doesnt take precedence over ensuring proper colostomy care. Requesting Meals on Wheels and asking for an occupational therapy evaluation are important but can occur later in rehabilitation. 12. Answer C. Client-care quality should always be the first consideration when proposing a change in care provision. Institutional

resources, standards of practice, and nursing recruitment will all influence the decision but none as much as client-care quality should. 13. Answer D. Nursing interventions are classified as independent, interdependent, or dependent. Altering the drug schedule to coincide with the clients daily routine represents an independent intervention, whereas consulting with the physician and pharmacist to change a clients medication because of adverse reactions represents an interdependent intervention. Administering an alreadyprescribed drug on time is a dependent intervention. An intradependent nursing intervention doesnt exist. 14. Answer A. The nurse has failed to respond immediately to the safety and privacy of a vulnerable client. Negligence is defined as an omission to do something a reasonable person would do. This nurses behavior is anything but sensitive, caring, or compassionate. Organization isnt addressed in this situation. 15. Answer B. The clients bill of rights addresses the clients rights to information, informed consent, timely responses to requests for services, and treatment refusal. Its a legal document and serves as a guideline for decision making by the nurse. Standards of nursing practice, the nurse practice act, and the code for nurses contain nursing practice parameters and primarily describe use of the nursing process in providing care. 16. Answer B. The Bill of Rights for Psychiatric Clients includes the right for clients to access their medical records unless doing so would be detrimental to their health. To determine if information might to be detrimental to the client, the primary care provider should be informed of the clients request. The client doesnt need an attorney to view her chart. She also doesnt need to wait until after discharge to view it. 17. Answer C. An occupational therapist helps physically disabled clients adapt to physical limitations and is most qualified to help a child with cerebral palsy eat and perform other activities of daily living. A registered dietitian manages and plans for the nutritional needs of children with cerebral palsy but isnt trained in modifying or fitting utensils with assistive devices. A physical therapist is trained to help a child with cerebral palsy gain function and prevent further disability but not to assist the child in performing activities of daily living. A nursing assistant can help a child eat; however, the nursing assistant isnt trained in modifying utensils. 18. Answer C. In Maslows hierarchy of needs, pain relief is on the first layer. Activity (option B) is on the second layer. Safety (option D) is on the third layer. Love and belonging (option A) are on the fourth layer. 19. Answer C. Its discriminatory and punitive for the nurse-manager to alter the staff nurses schedule. The remark is inappropriate and unprofessional, and the nurse-manager should receive counseling. The physician could choose to ignore the comment, but any provider who hears of discrimination should deal with it. If the matter can be resolved locally, reporting the nurse-manager to the labor relations board should be avoided. Institutional documentation should exist for such matters. Its inappropriate for the physician to inform the staff nurse about what was said. Such action could create difficult relations on the unit and, thereby, affect nursing care. 20. Answer A. Physicians have an ethical and legal right to refuse to care for any client in a nonemergency situation when standard medical care isnt acceptable to the client. It isnt the responsibility of the surgeon to find an alternate. Jehovahs Witnesses dont believe in any kind of transfusion, homologous or autologous. Informing the client that her decision can shorten her life is inappropriate in that the statement may be inaccurate and it ignores the clients right of autonomy. 21. Answer B. The usual or most prevalent reason for lack of productivity in a group of competent nurses is inadequate communication or a situation where the nurses have unexpressed feelings and emotions. Although the other answers could be contributing to the problematic situation, theyre less likely to be the cause. 22. Answer C. Theoretical models of nursing provide the foundation for all nursing knowledge. They also direct nursing practice based on the concepts of health, person, environment, and nursing. Scientific breakthroughs, technological advances, and medical practices may affect nursing but arent frameworks for nursing education and practice. 23. Answer B. After the final cast has been removed, foot and ankle exercises may be necessary to improve range of motion. A physical therapist should work with the child. A physical therapist is trained to help clients restore function and mobility, which will prevent further disability. 24. Answer D. Documentation should include data that the nurse obtains using only observations that are heard, seen, smelled, or felt. The nurse should record findings or observations precisely and accurately. Documentation of a leg ulcer should include its exact size and location. Documenting observed client behaviors or conversations is appropriate, but drawing conclusions about a clients feelings is not. Stating that the client had a good day doesnt provide precise enough information to be useful. 25. Answer A. Critical pathways are defined as a provision of care in a case management system. The pathways provide outcome-based guidelines for goal achievement within a designated length of stay. Critical pathways are to be used by the treatment team, not just by the physician. Pathways are designated lengths of stay, not therapies.

1. An infection in a central venous access device is not eliminated by giving antibiotics through the catheter. How would bacterial glycocalyx contribute to this? a. It protects the bacteria from antibiotic and immunologic destruction.

b. Glycocalyx neutralizes the antibiotic rendering it ineffective. c. It competes with the antibiotic for binding sites on the microbe. d. Glycocalyx provides nutrients for microbial growth. 2. Central venous access devices are beneficial in pediatric therapy because: a. They dont frighten children. b. Use of the arms is not restricted. c. They cannot be dislodged. d. They are difficult to see. 3. How can central venous access devices (CVADs) be of value in a patient receiving chemotherapy who has stomatitis and severe diarrhea? a. The chemotherapy can be rapidly completed allowing the stomatitis and diarrhea to resolve. b. Crystalloid can be administered to prevent dehydration. c. Concentrated hyperalimentation fluid can be administered through the CVAD. d. The chemotherapy dose can be reduced. 4. Some central venous access devices (CVAD) have more than one lumen. These multi lumen catheters: a. Have an increased risk of infiltration. b. Only work a short while because the small bore clots off. c. Are beneficial to patient care but are prohibitively expensive. d. Allow different medications or solutions to be administered simultaneously. 5. Some institutions will not infuse a fat emulsion, such as Intralipid, into central venous access devices (CVAD) because: a. Lipid residue may accumulate in the CVAD and occlude the catheter. b. If the catheter clogs, there is no treatment other than removal and replacement. c. Lipids are necessary only in the most extreme cases to prevent essential fatty acid (EFA) deficiency. d. Fat emulsions are very caustic. 6. A male patient needs a percutaneously inserted central catheter (PICC) for prolonged IV therapy. He knows it can be inserted without going to the operating room. He mentions that, at least the doctor wont be wearing surgical garb, will he? How will the nurse answer the patient? a. You are correct. It is a minor procedure performed on the unit and does not necessitate surgical attire. b. To decrease the risk of infection, the doctor inserting the PICC will wear a cap, mask, and sterile gown and gloves. c. It depends on the doctors preference. d. Most doctors only wear sterile gloves, not a cap, mask, or sterile gown. 7. A male patient is to receive a percutaneously inserted central catheter (PICC). He asks the nurse whether the insertion will hurt. How will the nurse reply? a. You will have general anesthesia so you wont feel anything. b. It will be inserted rapidly, and any discomfort is fleeting. c. The insertion site will be anesthetized. Threading the catheter through the vein is not painful. d. You will receive sedation prior to the procedure. 8. a. b. c. d. What volume of air can safely be infused into a patient with a central venous access device (CVAD)? It is dependent on the patients weight and height. Air entering the patient through a CVAD will follow circulation to the lungs where it will be absorbed and cause no problems. It is dependent on comorbidities such as asthma or chronic obstructive lung disease. None.

9. Kent a new staff nurse asks her preceptor nurse how to obtain a blood sample from a patient with a portacath device. The preceptor nurse teaches the new staff nurse: a. The sample will be withdrawn into a syringe attached to the portacath needle and then placed into a vacutainer. b. Portacath devices are not used to obtain blood samples because of the risk of clot formation. c. The vacutainer will be attached to the portacath needle to obtain a direct sample. d. Any needle and syringe may be utilized to obtain the sample. 10. What is the purpose of tunneling (inserting the catheter 2-4 inches under the skin) when the surgeon inserts a Hickman central catheter device? Tunneling: a. Increases the patients comfort level. b. Decreases the risk of infection. c. Prevents the patients clothes from having contact with the catheter d. Makes the catheter less visible to other people. 11. The primary complication of a central venous access device (CVAD) is: a. Thrombus formation in the vein. b. Pain and discomfort.

c. Infection. d. Occlusion of the catheter as the result of an intra-lumen clot. 12. Nurse Blessy is doing some patient education related to a patients central venous access device. Which of the following statements will the nurse make to the patient? a. These type of devices are essentially risk free. b. These devices seldom work for more than a week or two necessitating replacement. c. The dressing should only the changed by your doctor. d. Heparin in instilled into the lumen of the catheter to decrease the risk of clotting. 13. a. b. c. d. 14. a. b. c. d. The chemotherapeutic DNA alkylating agents such as nitrogen mustards are effective because they: Cross-link DNA strands with covalent bonds between alkyl groups on the drug and guanine bases on DNA. Have few, if any, side effects. Are used to treat multiple types of cancer. Are cell cycle-specific agents. Hormonal agents are used to treat some cancers. An example would be: Thyroxine to treat thyroid cancer. ACTH to treat adrenal carcinoma. Estrogen antagonists to treat breast cancer. Glucagon to treat pancreatic carcinoma.

15. Chemotherapeutic agents often produce a certain degree of myelosuppression including leukopenia. Leukopenia does not present immediately but is delayed several days to weeks because: a. The patients hemoglobin and hematocrit are normal. b. Red blood cells are affected first. c. Folic acid levels are normal. d. The current white cell count is not affected by chemotherapy. 16. Currently, there is no way to prevent myelosuppression. However, there are medications available to elicit a more rapid bone marrow recovery. An example is: a. Epoetin alfa (Epogen, Procrit). b. Glucagon. c. Fenofibrate (Tricor). d. Lamotrigine (Lamictal). 17. Estrogen antagonists are used to treat estrogen hormone-dependent cancer, such as breast carcinoma. Androgen antagonists block testosterone stimulation of androgen-dependent cancers. An example of an androgen-dependent cancer would be: a. Prostate cancer. b. Thyroid cancer. c. Renal carcinoma. d. neuroblastoma. 18. Serotonin release stimulates vomiting following chemotherapy. Therefore, serotonin antagonists are effective in preventing and treating nausea and vomiting related to chemotherapy. An example of an effective serotonin antagonist antiemetic is: a. ondansetron (Zofran). b. fluoxetine (Prozac). c. paroxetine (Paxil). d. sertraline (Zoloft). 19. Methotrexate, the most widely used antimetabolite in cancer chemotherapy does not penetrate the central nervous system (CNS). To treat CNS disease this drug must be administered: a. Intravenously. b. Subcutaneously. c. Intrathecally. d. By inhalation. 20. Methotrexate is a folate antagonist. It inhibits enzymes required for DNA base synthesis. To prevent harm to normal cells, a fully activated form of folic acid known as leucovorin (folinic acid; citrovorum factor) can be administered. Administration of leucovorin is known as: a. Induction therapy. b. Consolidation therapy. c. Pulse therapy. d. Rescue therapy. 21. A male Patient is undergoing chemotherapy may also be given the drug allopurinol (Zyloprim, Aloprim). Allopurinol inhibits the synthesis of uric acid. Concomitant administration of allopurinol prevents:

a. Myelosuppression. b. Gout and hyperuricemia. c. Pancytopenia. d. Cancer cell growth and replication 22. Superficial bladder cancer can be treated by direct instillation of the antineoplastic antibiotic agent mitomycin (Mutamycin). This process is termed: a. Intraventricular administration. b. Intravesical administration. c. Intravascular administration. d. Intrathecal administration. 23. a. b. c. d. 24. a. b. c. d. 25. a. b. c. d. 26. a. b. c. d. 27. a. b. c. d. The most common dose-limiting toxicity of chemotherapy is: Nausea and vomiting. Bloody stools. Myelosuppression. Inability to ingest food orally due to stomatitis and mucositis. Chemotherapy induces vomiting by: Stimulating neuroreceptors in the medulla. Inhibiting the release of catecholamines. Autonomic instability. Irritating the gastric mucosa. Myeloablation using chemotherapeutic agents is useful in cancer treatment because: It destroys the myelocytes (muscle cells). It reduces the size of the cancer tumor. After surgery, it reduces the amount of chemotherapy needed. It destroys the bone marrow prior to transplant. Anticipatory nausea and vomiting associated with chemotherapy occurs: Within the first 24 hours after chemotherapy. 1-5 days after chemotherapy. Before chemotherapy administration. While chemotherapy is being administered. Medications bound to protein have the following effect: Enhancement of drug availability. Rapid distribution of the drug to receptor sites. The more drug bound to protein, the less available for desired effect. Increased metabolism of the drug by the liver.

28. Some drugs are excreted into bile and delivered to the intestines. Prior to elimination from the body, the drug may be absorbed. This process is known as: a. Hepatic clearance. b. Total clearance. c. Enterohepatic cycling. d. First-pass effect. 29. An adult patient has been taking a drug (Drug A) that is highly metabolized by the cytochrome p-450 system. He has been on this medication for 6 months. At this time, he is started on a second medication (Drug B) that is an inducer of the cytochrome p-450 system. You should monitor this patient for: a. Increased therapeutic effects of Drug A. b. Increased adverse effects of Drug B. c. Decreased therapeutic effects of Drug A. d. Decreased therapeutic effects of Drug B. 30. a. b. c. d. Epinephrine is administered to a female patient. The nurse should expect this agent to rapidly affect: Adrenergic receptors. Muscarinic receptors. Cholinergic receptors. Nicotinic receptors.

Answers and Rationale Answer C. Glycocalyx is a viscous polysaccharide or polypeptide slime that covers microbes. It enhances adherence to surfaces, resists phagocytic engulfment by the white blood cells, and prevents antibiotics from contacting the microbe. Glycocalyx does not

have the effects in options B-D. 1. Answer B. The child can move his extremities and function in a normal fashion. This lessens stress associated with position restriction and promotes normal activity. Fear may not be eliminated. All lines can be dislodged. Even small catheters can be readily seen. 2. Answer C. In patients unable to take oral nutrition, parenteral hyperalimentation is an option for providing nutritional support. High concentrations of dextrose, protein, minerals, vitamins, and trace elements can be provided. Dosing is not affected with options a and d. Crystalloid can provide free water but has very little nutritional benefits. Hyperalimentation can provide free water and considerable nutritional benefits. 3. Answer D. A multilumen catheter contains separate ports and means to administer agents. An agent infusing in one port cannot mix with an agent infusing into another port. Thus, agents that would be incompatible if given together can be given in separate ports simultaneously. 4. Answer A. Occlusion occurs with slow infusion rates and concurrent administration of some medications. Lipid occlusions may be treated with 70 percent ethanol or with 0.1 mmol/mL NaOH. Lipids provide essential fatty acids. It is recommended that approximately 4 percent of daily calories be EFAs. A deficiency can quickly develop. Daily essential fatty acids are necessary for constant prostaglandin production. Lipids are almost isotonic with blood. 5. Answer C. Strict aseptic technique including the use of cap, mask, and sterile gown and gloves is require when placing a central venous line including a PICC. Options A, B, and D are incorrect statements. They increase the risk of infection. 6. Answer C. Pain related to PICC insertion occurs with puncture of the skin. When inserting PICC lines, the insertion site is anesthetized so no pain is felt. The patient will not receive general anesthesia or sedation. Statement 2 is false. Unnecessary pain should be prevented. 7. Answer B. Any air entering the right heart can lead to a pulmonary embolus. All air should be purged from central venous lines; none should enter the patient. 8. Answer A. A special portacath needle is used to access the portacath device. A syringe is attached and the sample is obtained. One of the primary reasons for insertion of a portacath device is the need for frequent or long-term blood sampling. A vacutainer will exert too much suction on the central line resulting in collapse of the line. Only special portacath needles should be used to access the portacath device. 9. Answer B. The actual access to the subclavian vein is still just under the clavicle, but by tunneling the distal portion of the catheter several inches under the skin the risk of migratory infection is reduces compared to a catheter that enters the subclavian vein directly and is not tunneled. The catheter is tunneled to prevent infection. 10. Answer C. A foreign body in a blood vessel increases the risk of infection. Catheters that come outside the body have an even higher risk of infection. Most infections are caused by skin bacteria. Other infective organisms include yeasts and fungi. Options 1 and 4 are complications of a CVAD but are not the primary problem. Once placed, these lines do not cause pain and discomfort. 11. Answer D. A solution containing heparin is used to reduce catheter clotting and maintain patency. The concentration of heparin used depends on the patients age, comorbidities, and the frequency of catheter access/flushing. Although patients have few complications, the device is not risk free. Patients may develop infection, catheter clots, vascular obstruction, pneumothorax, hemothorax, or mechanical problems (catheter breakage). Strict adherence to protocol enhances the longevity of central access devices. They routinely last weeks to months and sometimes years. The patient will be taught how to perform dressing changes at home. 12. Answer A. Alkylating agents are highly reactive chemicals that introduce alkyl radicals into biologically active molecules and thereby prevent their proper functioning, replication, and transcription. Alkylating agents have numerous side effects including alopecia, nausea, vomiting, and myelosuppression. Nitrogen mustards have a broad spectrum of activity against chronic lymphocytic leukemia, non-Hodgkins lymphoma, and breast and ovarian cancer, but they are effective chemotherapeutic agents because of DNA cross-linkage. Alkylating agents are noncell cycle-specific agents. 13. Answer C. Estrogen antagonists are used to treat estrogen hormone-dependent cancer, such as breast carcinoma. A wellknown estrogen antagonist used in breast cancer therapy is tamoxifen (Nolvadex). This drug, in combination with surgery and other chemotherapeutic drugs reduces breast cancer recurrence by 30 percent. Estrogen antagonists can also be administered to prevent breast cancer in women who have a strong family history of the disease. Thyroxine is a natural thyroid hormone. It does not treat thyroid cancer. ACTH is an anterior pituitary hormone, which stimulates the adrenal glands to release glucocorticoids. It does not treat adrenal cancer. Glucagon is a pancreatic alpha cell hormone, which stimulates glycogenolysis and gluconeogenesis. It does not treat pancreatic cancer. 14. Answer D. The time required to clear circulating cells before the effect that chemotherapeutic drugs have on precursor cell maturation in the bone marrow becomes evident. Leukopenia is an abnormally low white blood cell count. Answers A-C pertain to red blood cells. 15. Answer A. Epoetin alfa (Epogen, Procrit) is a recombinant form of endogenous erythropoietin, a hematopoietic growth factor normally produced by the kidney that is used to induce red blood cell production in the bone marrow and reduce the need for blood transfusion. Glucagon is a pancreatic alpha cell hormone, which cause glycogenolysis and gluconeogenesis. Fenofibrate (Tricor) is an antihyperlipidemic agent that lowers plasma triglycerides. Lamotrigine (Lamictal) is an anticonvulsant. 16. Answer A. Prostate tissue is stimulated by androgens and suppressed by estrogens. Androgen antagonists will block testosterone stimulation of prostate carcinoma cells. The types of cancer in options 2-4 are not androgen dependent.

17. Answer A. Chemotherapy often induces vomiting centrally by stimulating the chemoreceptor trigger zone (CTZ) and peripherally by stimulating visceral afferent nerves in the GI tract. Ondansetron (Zofran) is a serotonin antagonist that bocks the effects of serotonin and prevents and treats nausea and vomiting. It is especially useful in single-day highly emetogenic cancer chemotherapy (for example, cisplatin). The agents in options 2-4 are selective serotonin reuptake inhibitors. They increase the available levels of serotonin. 18. Answer C. With intrathecal administration chemotherapy is injected through the theca of the spinal cord and into the subarachnoid space entering into the cerebrospinal fluid surrounding the brain and spinal cord. The methods in options A, B, and D are ineffective because the medication cannot enter the CNS. 19. Answer B. Leucovorin is used to save or "rescue" normal cells from the damaging effects of chemotherapy allowing them to survive while the cancer cells die. Therapy to rapidly reduce the number of cancerous cells is the induction phase. Consolidation therapy seeks to complete or extend the initial remission and often uses a different combination of drugs than that used for induction. Chemotherapy is often administered in intermittent courses called pulse therapy. Pulse therapy allows the bone marrow to recover function before another course of chemotherapy is given. 20. Answer B. Prevent uric acid nephropathy, uric acid lithiasis, and gout during cancer therapy since chemotherapy causes the rapid destruction of cancer cells leading to excessive purine catabolism and uric acid formation. Allopurinol can induce myelosuppression and pancytopenia. Allopurinol does not have this function. 21. Answer B. Medications administered intravesically are instilled into the bladder. Intraventricular administration involves the ventricles of the brain. Intravascular administration involves blood vessels. Intrathecal administration involves the fluid surrounding the brain and spinal cord. 22. Answer C. The overall goal of cancer chemotherapy is to give a dose large enough to be lethal to the cancer cells, but small enough to be tolerable for normal cells. Unfortunately, some normal cells are affected including the bone marrow. Myelosuppression limits the bodys ability to prevent and fight infection, produce platelets for clotting, and manufacture red blood cells for oxygen portage. Even though the effects in options a, b, and d are uncomfortable and distressing to the patient, they do not have the potential for lethal outcomes that myelosuppression has. 23. Answer A. Vomiting (emesis) is initiated by a nucleus of cells located in the medulla called the vomiting center. This center coordinates a complex series of events involving pharyngeal, gastrointestinal, and abdominal wall contractions that lead to expulsion of gastric contents. Catecholamine inhibition does not induce vomiting. Chemotherapy does not induce vomiting from autonomic instability. Chemotherapy, especially oral agents, may have an irritating effect on the gastric mucosa, which could result in afferent messages to the solitary tract nucleus, but these pathways do not project to the vomiting center. 24. Answer A. Myelo comes from the Greek word myelos, which means marrow. Ablation comes from the Latin word ablatio, which means removal. Thus, myeloablative chemotherapeurtic agents destroy the bone marrow. This procedure destroys normal bone marrow as well as the cancerous marrow. The patients bone marrow will be replaced with a bone marrow transplant. Myelocytes are not muscle cells Tumors are solid masses typically located in organs. Surgery may be performed to reduce tumor burden and require less chemotherapy afterward. 25. Answer C. Nausea and vomiting (N&V) are common side effects of chemotherapy. Some patients are able to trigger these events prior to actually receiving chemotherapy by anticipating, or expecting, to have these effects. N&V occurring postchemotherapeutic administration is not an anticipatory event but rather an effect of the drug. N&V occurring during the administration of chemotherapy is an effect of the drug. 26. Answer C. Only an unbound drug can be distributed to active receptor sites. Therefore, the more of a drug that is bound to protein, the less it is available for the desired drug effect. Less drug is available if bound to protein. Distribution to receptor sites is irrelevant since the drug bound to protein cannot bind with a receptor site. Metabolism would not be increased. The liver will first have to remove the drug from the protein molecule before metabolism can occur. The protein is then free to return to circulation and be used again. 27. Answer C. Drugs and drug metabolites with molecular weights higher than 300 may be excreted via the bile, stored in the gallbladder, delivered to the intestines by the bile duct, and then reabsorbed into the circulation. This process reduces the elimination of drugs and prolongs their half-life and duration of action in the body. Hepatic clearance is the amount of drug eliminated by the liver. Total clearance is the sum of all types of clearance including renal, hepatic, and respiratory. First-pass effect is the amount of drug absorbed from the GI tract and then metabolized by the liver; thus, reducing the amount of drug making it into circulation. 28. Answer C. Drug B will induce the cytochrome p-450 enzyme system of the liver; thus, increasing the metabolism of Drug A. Therefore, Drug A will be broken down faster and exert decreased therapeutic effects. Drug A will be metabolized faster, thus reducing, not increasing its therapeutic effect. Inducing the cytochrome p-450 system will not increase the adverse effects of Drug B. Drug B induces the cytochrome p-450 system but is not metabolized faster. Thus, the therapeutic effects of Drug B will not be decreased. 29. Answer A. Epinephrine (adrenaline) rapidly affects both alpha and beta adrenergic receptors eliciting a sympathetic (fight or flight) response. Muscarinic receptors are cholinergic receptors and are primarily located at parasympathetic junctions. Cholinergic receptors respond to acetylcholine stimulation. Cholinergic receptors include muscarinic and nicotinic receptors. Nicotinic receptors are cholinergic receptors activated by nicotine and found in autonomic ganglia and somatic neuromuscular junctions.

The nurse is performing her admission assessment of a patient. When grading arterial pulses, a 1+ pulse indicates: a. Above normal perfusion. b. Absent perfusion. c. Normal perfusion. d. Diminished perfusion. 2. Murmurs that indicate heart disease are often accompanied by other symptoms such as: a. Dyspnea on exertion. b. Subcutaneous emphysema. c. Thoracic petechiae. d. Periorbital edema. 3. Which pregnancy-related physiologic change would place the patient with a history of cardiac disease at the greatest risk of developing severe cardiac problems? a. Decrease heart rate b. Decreased cardiac output c. Increased plasma volume d. Increased blood pressure 4. The priority nursing diagnosis for the patient with cardiomyopathy is: a. Anxiety related to risk of declining health status. b. Ineffective individual coping related to fear of debilitating illness c. Fluid volume excess related to altered compensatory mechanisms. d. Decreased cardiac output related to reduced myocardial contractility. 5. A patient with thrombophlebitis reached her expected outcomes of care. Her affected leg appears pink and warm. Her pedal pulse is palpable and there is no edema present. Which step in the nursing process is described above? a. Planning b. Implementation c. Analysis d. Evaluation 6. An elderly patient may have sustained a basilar skull fracture after slipping and falling on an icy sidewalk. The nurse knows that basilar skull factures: a. Are the least significant type of skull fracture. b. May have cause cerebrospinal fluid (CSF) leaks from the nose or ears. c. Have no characteristic findings. d. Are always surgically repaired. 7. Which of the following types of drugs might be given to control increased intracranial pressure (ICP)? a. Barbiturates b. Carbonic anhydrase inhibitors c. Anticholinergics d. Histamine receptor blockers 8. The nurse is teaching family members of a patient with a concussion about the early signs of increased intracranial pressure (ICP). Which of the following would she cite as an early sign of increased ICP? a. Decreased systolic blood pressure b. Headache and vomiting c. Inability to wake the patient with noxious stimuli

d. Dilated pupils that dont react to light

9. Jessie James is diagnosed with retinal detachment. Which intervention is the most important for this patient?
a. Admitting him to the hospital on strict bed rest b. Patching both of his eyes c. Referring him to an ophthalmologist d. Preparing him for surgery 10. Dr. Bruce Owen, a chemist, sustained a chemical burn to one eye. Which intervention takes priority for a patient with a chemical burn of the eye? a. Patch the affected eye and call the ophthalmologist. b. Administer a cycloplegic agent to reduce ciliary spasm. c. Immediately instill a tropical anesthetic, then irrigate the eye with saline solution. d. Administer antibiotics to reduce the risk of infection 11. The nurse is assessing a patient and notes a Brudzinskis sign and Kernigs sign. These are two classic signs of which of the following disorders? a. Cerebrovascular accident (CVA) b. Meningitis

c. Seizure disorder d. Parkinsons disease

12. A patient is admitted to the hospital for a brain biopsy. The nurse knows that the most common type of primary brain tumor is: a. Meningioma. b. Angioma. c. Hemangioblastoma. d. Glioma. 13. The nurse should instruct the patient with Parkinsons disease to avoid which of the following? a. Walking in an indoor shopping mall b. Sitting on the deck on a cool summer evening c. Walking to the car on a cold winter day d. Sitting on the beach in the sun on a summer day 14. Gary Jordan suffered a cerebrovascular accident that left her unable to comprehend speech and unable to speak. This type of aphasia is known as: a. Receptive aphasia b. Expressive aphasia c. Global aphasia d. Conduction aphasia 15. Kelly Smith complains that her headaches are occurring more frequently despite medications. Patients with a history of headaches should be taught to avoid: a. Freshly prepared meats. b. Citrus fruits. c. Skim milk d. Chocolate 16. Immediately following cerebral aneurysm rupture, the patient usually complains of: a. Photophobia b. Explosive headache c. Seizures

d. Hemiparesis 17. Which of the following is a cause of embolic brain injury? a. Persistent hypertension b. Subarachnoid hemorrhage c. Atrial fibrillation d. Skull fracture 18. Although Ms. Priestly has a spinal cord injury, she can still have sexual intercourse. Discharge teaching should make her aware that: a. She must remove indwelling urinary catheter prior to intercourse. b. She can no longer achieve orgasm. c. Positioning may be awkward. d. She can still get pregnant. 19. Ivy Hopkins, age 25, suffered a cervical fracture requiring immobilization with halo traction. When caring for the patient in halo traction, the nurse must: a. Keep a wrench taped to the halo vest for quick removal if cardiopulmonary resuscitation is necessary. b. Remove the brace once a day to allow the patient to rest. c. Encourage the patient to use a pillow under the ring. d. Remove the brace so that the patient can shower. 20. The nurse asks a patients husband if he understands why his wife is receiving nimodipine (Nimotop), since she suffered a cerebral aneurysm rupture. Which response by the husband indicates that he understands the drugs use? a. Nimodipine replaces calcium. b. Nimodipine promotes growth of blood vessels in the brain. c. Nimodipine reduces the brains demand for oxygen. d. Nimodipine reduces vasospasm in the brain.

21.

Many men who suffer spinal injuries continue to be sexually active. The teaching plan for a man with a spinal cord injury should include sexually concerns. Which of the following injuries would most likely prevent erection and ejaculation? a. C5 b. C7 c. T4 d. S4

22. Cathy Bates, age 36, is a homemaker who frequently forgets to take her carbamazepine (Tegretol). As a result, she has been experiencing seizures. How can the nurse best help the patient remember to take her medication? a. Tell her take her medication at bedtime. b. Instruct her to take her medication after one of her favorite television shows. c. Explain that she should take her medication with breakfast. d. Tell her to buy an alarm watch to remind her. 23. Richard Barnes was diagnosed with pneumococcal meningitis. What response by the patient indicates that he understands the precautions necessary with this diagnosis? a. Im so depressed because I cant have any visitors for a week. b. Thank goodness, Ill only be in isolation for 24 hours. c. The nurse told me that my urine and stool are also sources of meningitis bacteria. d. The doctor is a good friend of mine and wont keep me in isolation. 24. An early symptom associated with amyotrophic lateral sclerosis (ALS) includes: a. Fatigue while talking b. Change in mental status c. Numbness of the hands and feet

d. Spontaneous fractures 25. When caring for a patient with esophageal varices, the nurse knows that bleeding in this disorder usually stems from: a. Esophageal perforation b. Pulmonary hypertension c. Portal hypertension d. Peptic ulcers 26. Tiffany Black is diagnosed with type A hepatitis. What special precautions should the nurse take when caring for this patient? a. Put on a mask and gown before entering the patients room. b. Wear gloves and a gown when removing the patients bedpan. c. Prevent the droplet spread of the organism. d. Use caution when bringing food to the patient. 27. Discharge instructions for a patient who has been operated on for colorectal cancer include irrigating the colostomy. The nurse knows her teaching is effective when the patient states hell contact the doctor if: a. He experiences abdominal cramping while the irrigant is infusing b. He has difficulty inserting the irrigation tube into the stoma c. He expels flatus while the return is running out d. Hes unable to complete the procedure in 1 hour 28. The nurse explains to the patient who has an abdominal perineal resection that an indwelling urinary catheter must be kept in place for several days afterward because: a. It prevents urinary tract infection following surgery b. It prevents urine retention and resulting pressure on the perineal wound c. It minimizes the risk of wound contamination by the urine d. It determines whether the surgery caused bladder trauma 29. The first day after, surgery the nurse finds no measurable fecal drainage from a patients colostomy stoma. What is the most appropriate nursing intervention? a. Call the doctor immediately. b. Obtain an order to irrigate the stoma. c. Place the patient on bed rest and call the doctor. d. Continue the current plan of care. 30. If a patients GI tract is functioning but hes unable to take foods by mouth, the preferred method of feeding is: a. Total parenteral nutrition b. Peripheral parenteral nutrition c. Enteral nutrition d. Oral liquid supplements 31. Which type of solution causes water to shift from the cells into the plasma? a. Hypertonic b. Hypotonic c. Isotonic d. Alkaline 32. Particles move from an area of greater osmelarity to one of lesser osmolarity through: a. Active transport b. Osmosis c. Diffusion d. Filtration 33. Which assessment finding indicates dehydration?

a. Tenting of chest skin when pinched b. Rapid filling of hand veins c. A pulse that isnt easily obliterated d. Neck vein distention 34. Which nursing intervention would most likely lead to a hypo-osmolar state? a. Performing nasogastric tube irrigation with normal saline solution b. Weighing the patient daily c. Administering tap water enema until the return is clear d. Encouraging the patient with excessive perspiration to dink broth 35. Which assessment finding would indicate an extracellular fluid volume deficit? a. Bradycardia b. A central venous pressure of 6 mm Hg c. Pitting edema d. An orthostatic blood pressure change 36. A patient with metabolic acidosis has a preexisting problem with the kidneys. Which other organ helps regulate blood pH? a. Liver b. Pancreas c. Lungs d. heart 37. The nurse considers the patient anuric if the patient; a. Voids during the nighttime hours b. Has a urine output of less than 100 ml in 24 hours c. Has a urine output of at least 100 ml in 2 hours d. Has pain and burning on urination 38. Which nursing action is appropriate to prevent infection when obtaining a sterile urine specimen from an indwelling urinary catheter? a. Aspirate urine from the tubing port using a sterile syringe and needle b. Disconnect the catheter from the tubing and obtain urine c. Open the drainage bag and pour out some urine d. Wear sterile gloves when obtaining urine 39. After undergoing a transurethral resection of the prostate to treat benign prostatic hypertrophy, a patient is retuned to the room with continuous bladder irrigation in place. One day later, the patient reports bladder pain. What should the nurse do first? a. Increase the I.V. flow rate b. Notify the doctor immediately c. Assess the irrigation catheter for patency and drainage d. Administer meperidine (Demerol) as prescribed 40. A patient comes to the hospital complaining of sudden onset of sharp, severe pain originating in the lumbar region and radiating around the side and toward the bladder. The patient also reports nausea and vomiting and appears pale, diaphoretic, and anxious. The doctor tentatively diagnoses renal calculi and orders flat-plate abdominal X-rays. Renal calculi can form anywhere in the urinary tract. What is their most common formation site? a. Kidney b. Ureter c. Bladder d. Urethra 41. A patient comes to the hospital complaining of severe pain in the right flank, nausea, and vomiting. The doctor tentatively

diagnoses right ureter-olithiasis (renal calculi). When planning this patients care, the nurse should assign highest priority to which nursing diagnosis? a. Pain b. Risk of infection c. Altered urinary elimination d. Altered nutrition: less than body requirements 42. The nurse is reviewing the report of a patients routine urinalysis. Which of the following values should the nurse consider abnormal? a. Specific gravity of 1.002 b. Urine pH of 3 c. Absence of protein d. Absence of glucose 43. A patient with suspected renal insufficiency is scheduled for a comprehensive diagnostic work-up. After the nurse explains the diagnostic tests, the patient asks which part of the kidney does the work. Which answer is correct? a. The glomerulus b. Bowmans capsule c. The nephron d. The tubular system 44. During a shock state, the renin-angiotensin-aldosterone system exerts which of the following effects on renal function? a. Decreased urine output, increased reabsorption of sodium and water b. Decreased urine output, decreased reabsorption of sodium and water c. Increased urine output, increased reabsorption of sodium and water d. Increased urine output, decreased reabsorption of sodium and water 45. While assessing a patient who complained of lower abdominal pressure, the nurse notes a firm mass extending above the symphysis pubis. The nurse suspects: a. A urinary tract infection b. Renal calculi c. An enlarged kidney d. A distended bladder 46. Gregg Lohan, age 75, is admitted to the medical-surgical floor with weakness and left-sided chest pain. The symptoms have been present for several weeks after a viral illness. Which assessment finding is most symptomatic of pericarditis? a. Pericardial friction rub b. Bilateral crackles auscultated at the lung bases c. Pain unrelieved by a change in position d. Third heart sound (S3) 47. James King is admitted to the hospital with right-side-heart failure. When assessing him for jugular vein distention, the nurse should position him: a. Lying on his side with the head of the bed flat. b. Sitting upright. c. Flat on his back. d. Lying on his back with the head of the bed elevated 30 to 45 degrees. 48. The nurse is interviewing a slightly overweight 43-year-old man with mild emphysema and borderline hypertension. He admits to smoking a pack of cigarettes per day. When developing a teaching plan, which of the following should receive highest priority to help decrease respiratory complications? a. Weight reduction b. Decreasing salt intake

c. Smoking cessation d. Decreasing caffeine intake 49. What is the ratio of chest compressions to ventilations when one rescuer performs cardiopulmonary resuscitation (CPR) on an adult? a. 15:1 b. 15:2 c. 12:1 d. 12:2 50. When assessing a patient for fluid and electrolyte balance, the nurse is aware that the organs most important in maintaining this balance are the: a. Pituitary gland and pancreas b. Liver and gallbladder. c. Brain stem and heart. d. Lungs and kidneys. Answer: D A 1+ pulse indicates weak pulses and is associated with diminished perfusion. A 4+ is bounding perfusion, a 3+ is increased perfusion, a 2+ is normal perfusion, and 0 is absent perfusion.

1. Answer: A
A murmur that indicates heart disease is often accompanied by dyspnea on exertion, which is a hallmark of heart failure. Other indicators are tachycardia, syncope, and chest pain. Subcutaneous emphysema, thoracic petechiae, and perior-bital edema arent associated with murmurs and heart disease. Answer: C Pregnancy increase plasma volume and expands the uterine vascular bed, possibly increasing both the heart rate and cardiac output. These changes may cause cardiac stress, especially during the second trimester. Blood pressure during early pregnancy may decrease, but it gradually returns to prepregnancy levels. Answer: D Decreased cardiac output related to reduced myocardial contractility is the greatest threat to the survival of a patient with cardiomyopathy. The other options can be addressed once cardiac output and myocardial contractility have been restored. Answer: D Evaluation assesses the effectiveness of the treatment plan by determining if the patient has met the expected treatment outcome. Planning refers to designing a plan of action that will help the nurse deliver quality patient care. Implementation refers to all of the nursing interventions directed toward solving the patients nursing problems. Analysis is the process of identifying the patients nursing problems. Answer: B A basilar skull fracture carries the risk of complications of dural tear, causing CSF leakage and damage to cranial nerves I, II, VII, and VIII. Classic findings in this type of fracture may include otorrhea, rhinorrhea, Battles signs, and raccoon eyes. Surgical treatment isnt always required. Answer: A Barbiturates may be used to induce a coma in a patient with increased ICP. This decreases cortical activity and cerebral metabolism, reduces cerebral blood volume, decreases cerebral edema, and reduces the brains need for glucose and oxygen. Carbonic anhydrase inhibitors are used to decrease ocular pressure or to decrease the serum pH in a patient with metabolic alkalosis. Anticholinergics have many uses including reducing GI spasms. Histamine receptor blockers are used to decrease stomach acidity. Answer: B Headache and projectile vomiting are early signs of increased ICP. Decreased systolic blood pressure, unconsciousness, and dilated pupils that dont reac to light are considered late signs. Answer: A Immediate bed rest is necessary to prevent further injury. Both eyes should be patched to avoid consensual eye movement and the patient should receive early referral to an ophthalmologist should treat the condition immediately. Retinal reattachment can be accomplished by surgery only. If the macula is detached or threatened, surgery is urgent; prolonged detachment of the macula results in permanent loss of central vision. Answer: C A chemical burn to the eye requires immediate instillation of a topical anesthetic followed by irrigation with copious amounts of saline solution. Irrigation should be done for 5 to 10 minutes, and then the pH of the eye should be checked. Irrigation

2.

3. 4.

5.

6.

7. 8.

9.

should be continued until the pH of the eye is restored to neutral (pH 7.0): Double eversion of the eyelids should be performed to look for and remove ciliary spasm, and an antibiotic ointment can be administered to reduce the risk of infection. Then the eye should be patched. Parenteral narcotic analgesia is often required for pain relief. An ophthalmologist should also be consulted. 10. Answer: B A positive response to one or both tests indicates meningeal irritation that is present with meningitis. Brudzinskis and Kernigs signs dont occur in CVA, seizure disorder, or Parkinsons disease. 11. Answer: D Gliomas account for approximately 45% of all brain tumors. Meningiomas are the second most common, with 15%. Angiomas and hemangioblastomas are types of cerebral vascular tumors that account for 3% of brain tumors. 12. Answer: D The patient with Parkinsons disease may be hypersensitive to heat, which increases the risk of hyperthermia, and he should be instructed to avoid sun exposure during hot weather. 13. Answer: C Global aphasia occurs when all language functions are affected. Receptive aphasia, also known as Wernickes aphasia, affects the ability to comprehend written or spoken words. Expressive aphasia, also known as Brocas aphasia, affected the patients ability to form language and express thoughts. Conduction aphasia refers to abnormalities in speech repetition. 14. Answer: D Patients with a history of headaches, especially migraines, should be taught to keep a food diary to identify potential food triggers. Typical headache triggers include alcohol, aged cheeses, processed meats, and chocolate and caffeine-containing products. 15. Answer: B An explosive headache or the worst headache Ive ever had is typically the first presenting symptom of a bleeding cerebral aneurysm. Photophobia, seizures, and hemiparesis may occur later. 16. Answer: C An embolic injury, caused by a traveling clot, may result from atrial fibrillation. Blood may pool in the fibrillating atrium and be released to travel up the cerebral artery to the brain. Persistent hypertension may place the patient at risk for a thrombotic injury to the brain. Subarachnoid hemorrhage and skull fractures arent associated with emboli. 17. Answer: D Women with spinal cord injuries who were sexually active may continue having sexual intercourse and must be reminded that they can still become pregnant. She may be fully capable of achieving orgasm. An indwelling urinary catheter may be left in place during sexual intercourse. Positioning will need to be adjusted to fit the patients needs. 18. Answer: A The nurse must have a wrench taped on the vest at all times for quick halo removal in emergent situations. The brace isnt to be removed for any other reason until the cervical fracture is healed. Placing a pillow under the patients head may alter the stability of the brace. 19. Answer: D Nimodipine is a calcium channel blocker that acts on cerebral blood vessels to reduce vasospasm. The drug doesnt increase the amount of calcium, affect cerebral vasculature growth, or reduce cerebral oxygen demand. 20. Answer: D Men with spinal cord injury should be taught that the higher the level of the lesion, the better their sexual function will be. The sacral region is the lowest area on the spinal column and injury to this area will cause more erectile dysfunction. 21. Answer: C Tegretol should be taken with food to minimize GI distress. Taking it at meals will also establish a regular routine, which should help compliance. 22. Answer: B Patient with pneumococcal meningitis require respiratory isolation for the first 24 hours after treatment is initiated. 23. Answer: A Early symptoms of ALS include fatigue while talking, dysphagia, and weakness of the hands and arms. ALS doesnt cause a change in mental status, paresthesia, or fractures. 24. Answer: C Increased pressure within the portal veins causes them to bulge, leading to rupture and bleeding into the lower esophagus. Bleeding associated with esophageal varices doesnt stem from esophageal perforation, pulmonary hypertension, or peptic ulcers. 25. Answer: B The nurse should wear gloves and a gown when removing the patients bedpan because the type A hepatitis virus occurs in stools. It may also occur in blood, nasotracheal secretions, and urine. Type A hepatitis isnt transmitted through the air by way of droplets. Special precautions arent needed when feeding the patient, but disposable utensils should be used. 26. Answer: B

The patient should notify the doctor if he has difficulty inserting the irrigation tube into the stoma. Difficulty with insertion may indicate stenosis of the bowel. Abdominal cramping and expulsion of flatus may normally occur with irrigation. The procedure will often take an hour to complete. 27. Answer: B An indwelling urinary catheter is kept in place several days after this surgery to prevent urine retention that could place pressure on the perineal wound. An indwelling urinary catheter may be a source of postoperative urinary tract infection. Urine wont contaminate the wound. An indwelling urinary catheter wont necessarily show bladder trauma. 28. Answer: D The colostomy may not function for 2 days or more (48 to 72 hours) after surgery. Therefore, the normal plan of care can be followed. Since no fecal drainage is expected for 48 to 72 hours after a colostomy (only mucous and serosanguineous), the doctor doesnt have to be notified and the stoma shouldnt be irrigated at this time. 29. Answer: C If the patients GI tract is functioning, enteral nutrition via a feeding tube is the preferred method. Peripheral and total parenteral nutrition places the patient at risk for infection. If the patient is unable to consume foods by mouth, oral liquid supplements are contraindicated. 30. Answer: A A hypertonic solution causes water to shift from the cells into the plasma because the hypertonic solution has a greater osmotic pressure than the cells. A hypotonic solution has a lower osmotic pressure than that of the cells. It causes fluid to shift into the cells, possibly resulting in rupture. An isotonic solution, which has the same osmotic pressure as the cells, wouldnt cause any shift. A solutions alkalinity is related to the hydrogen ion concentration, not its osmotic effect. 31. Answer: C Particles move from an area of greater osmolarity to one of lesser osmolarity through diffusion. Active transport is the movement of particles though energy expenditure from other sources such as enzymes. Osmosis is the movement of a pure solvent through a semipermeable membrane from an area of greater osmolarity to one of lesser osmolarity until equalization occurs. The membrane is impermeable to the solute but permeable to the solvent. Filtration is the process by which fluid is forced through a membrane by a difference in pressure; small molecules pass through, but large ones dont. 32. Answer: A Tenting of chest skin when pinched indicates decreased skin elasticity due to dehydration. Hand veins fill slowly with dehydration, not rapidly. A pulse that isnt easily obliterated and neck vein distention indicate fluid overload, not dehydration. 33. Answer: C Administering a tap water enema until return is clear would most likely contribute to a hypo-osmolar state. Because tap water is hypotonic, it would be absorbed by the body, diluting the body fluid concentration and lowering osmolarity. Weighing the patient is the easiest, most accurate method to determine fluid changes. Therefore, it helps identify rather than contribute to fluid imbalance. Nasogastric tube irrigation with normal saline solution wouldnt cause a shift in fluid balance. Drinking broth wouldnt contribute to a hypo-osmolar state because it doesnt replace sodium and water lost through excessive perspiration. 34. Answer: D An orthostatic blood pressure indicates an extracellular fluid volume deficit. (The extracellular compartment consists of both the intravascular compartment and interstitial space.) A fluid volume deficit within the intravascular compartment would cause tachycardia, not bradycardia or orthostatic blood pressure change. A central venous pressure of 6 mm Hg is in the high normal range, indicating adequate hydration. Pitting edema indicates fluid volume overload. 35. Answer: C The respiratory and renal systems act as compensatory mechanisms to counteract-base imbalances. The lungs alter the carbon dioxide levels in the blood by increasing or decreasing the rate and depth of respirations, thereby increasing or decreasing carbon dioxide elimination. The liver, pancreas, and heart play no part in compensating for acid-base imbalances. 36. Answer: B Anuria refers to a urine output of less than 100 ml in 24 hours. The baseline for urine output and renal function is 30 ml of urine per hour. A urine output of at least 100 ml in 2 hours is within normal limits. Voiding at night is called nocturia. Pain and burning on urination is called dysuria. 37. Answer: A To obtain urine properly, the nurse should aspirate it from a port, using a sterile syringe after cleaning the port. Opening a closed urine drainage system increases the risk of urinary tract infection. Standard precautions specify the use of gloves during contract with body fluids; however, sterile gloves arent necessary. 38. Answer: C Although postoperative pain is expected, the nurse should ensure that other factors, such as an obstructed irrigation catheter, arent the cause of the pain. After assessing catheter patency, the nurse should administer an analgesic such as meperidine as prescribed. Increasing the I.V. flow rate may worse the pain. Notifying the doctor isnt necessary unless the pain is severe or unrelieved by the prescribed medication. 39. Answer: A

Renal calculi most commonly from in the kidney. They may remain there or become lodged anywhere along the urinary tract. The ureter, bladder, and urethra are less common sites of renal calculi formation. 40. Answer: A Ureterolithiasis typically causes such acute, severe pain that the patient cant rest and becomes increasingly anxious. Therefore, the nursing diagnosis of pain takes highest priority. Risk for infection and altered urinary elimination are appropriate once the patients pain is controlled. Altered nutrition: less than body requirements isnt appropriate at this time. 41. Answer: B Normal urine pH is 4.5 to 8; therefore, a urine pH of 3 is abnormal and may indicate such conditions as renal tuberculosis, pyrexia, phenylketonuria, alkaptonuria, and acidosis. Urine specific gravity normally ranges from 1.002 to 1.032, making the patients value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals. 42. Answer: C The nephron is the kidneys functioning unit. The glomerulus, Bowmans capsule, and tubular system are components of the nephron. 43. Answer: A As a response to shock, the renin-angiotensin-aldosterone system alters renal function by decreasing urine output and increasing reabsorption of sodium and water. Reduced renal perfusion stimulates the renin-angiotensin-aldosterone system in an effort to conserve circulating volume. 44. Answer: D The bladder isnt usually palpable unless it is distended. The feeling of pressure is usually relieved with urination. Reduced bladder tone due to general anesthesia is a common postoperative complication that causes difficulty in voiding. A urinary tract infection and renal calculi arent palpable. The kidneys arent palpable above the symphysis pubis. 45. Answer: A A pericardial friction rub may be present with the pericardial effusion of pericarditis. The lungs are typically clear when auscultated. Sitting up and leaning forward often relieves pericarditis pain. An S3 indicates left-sided heart failure and isnt usually present with pericarditis. 46. Answer: D Assessing jugular vein distention should be done when the patient is in semi-Fowlers position (head of the bed elevated 30 to 45 degrees). If the patient lies flat, the veins will be more distended; if he sits upright, the veins will be flat. 47. Answer: C Smoking should receive highest priority when trying to reduce risk factors for with respiratory complications. Losing weight and decreasing salt and caffeine intake can help to decrease risk factors for hypertension. 48. Answer: B The correct ratio of compressions to ventilations when one rescuer performs CPR is 15:2 49. Answer: D The lungs and kidneys are the bodys regulators of homeostasis. The lungs are responsible for removing fluid and carbon dioxide; the kidneys maintain a balance of fluid and electrolytes. The other organs play secondary roles in maintaining homeostasis.