Nclex 70 question: Week 7

A nurse is providing care based on Maslow's hierarchy of basic human needs. For
which nursing activities is this approach useful?

a. Making accurate nursing diagnoses

b. Establishing priorities of care
c. Communicating concerns more concisely
d. Integrating science into nursing care
b. Maslow's hierarchy of basic human needs is useful for establishing priorities of care.

The nurse is prioritizing nursing care for a patient in a long-term care facility. Which
examples of nursing interventions help meet physiologic needs? Select all that apply.

a. Preventing falls in the facility

b. Changing a patient's oxygen tank
c. Providing materials for a patient who likes to draw
d. Helping a patient eat his dinner
e. Facilitating a visit from a spouse
f. Referring a patient to a cancer support group.
b, d. Physiologic needs—oxygen, water, food, elimination, temperature, sexuality,
physical activity, and rest—must be met at least minimally to maintain life. Providing
food and oxygen are examples of interventions to meet these needs. Preventing falls
helps meet safety and security needs, providing art supplies may help meet self-
actualization needs, facilitating visits from loved ones helps meet self-esteem needs,
and referring a patient to a support group helps meet love and belonging needs.

The nurse caring for patients postoperatively uses careful hand hygiene and sterile
techniques when handling patients. Which of Maslow's basic human needs is being met
by this nurse?

a. Physiologic
b. Safety and security
c. Self-esteem
d. Love and belonging
b. By carrying out careful hand hygiene and using sterile technique, nurses provide
safety from infection. An example of a physiologic need is clearing a patient's airway.
Self-esteem needs may be met by allowing an older adult to talk about a past career. An
example of helping meet a love and belonging need is contacting a hospitalized
patient's family to arrange a visit.
The nurse caring for patients in a long-term care facility knows that the highest level on
Maslow's hierarchy of needs is self-actualization needs. Which statements accurately
describe the achievement of self-actualization? Select all that apply.

a. Humans are born with a fully developed sense of self-actualization.

b. Self-actualization needs are met by depending on others for help.
c. The self-actualization process continues throughout life.
d. Loneliness and isolation occur when self-actualization needs are unmet.
e. A person achieves self-actualization by focusing on problems outside self.
f. Self-actualization needs may be met by creatively solving problems.
c, e, f. Self-actualization, or reaching one's full potential, is a process that continues
throughout life. A person achieves self-actualization by focusing on problems outside
oneself and using creativity as a guideline for solving problems and pursuing interests.
Humans are not born with a fully developed sense of self-actualization, and self-
actualization needs are not met specifically by depending on others for help. Loneliness
and isolation are not always the result of unmet self-actualization needs.

A nurse works with families in crisis at a community mental health care facility. What is
the best broad definition of a family?

a. A father, a mother, and children

b. A group whose members are biologically related
c. A unit that includes aunts, uncles, and cousins
d. A group of people who live together and depend on each other for support
d. Although all the responses may be true, the best definition is a group of people who
live together and depend on each other for physical, emotional, or financial support.

A nurse performs an assessment of a family consisting of a single mother, a

grandmother, and two children. Which interview questions directed to the single mother
could the nurse use to assess the affective and coping family function? Select all that
apply.

a. Who is the person you depend on for emotional support?

b. Who is the breadwinner in your family?
c. Do you plan on having any more children?
d. Who keeps your family together in times of stress?
e. What family traditions do you pass on to your children?
f. Do you live in an environment that you consider safe?
a, d. The five major areas of family function are physical, economic, reproductive,
affective and coping, and socialization. Asking who provides emotional support in times
of stress assesses the affective and coping function. Assessing the breadwinner
focuses on the economic function. Inquiring about having more children assesses the
reproductive function, asking about family traditions assesses the socialization function,
and checking the environment assesses the physical function.

The nurse caring for families in a free health care clinic identifies psychosocial risk
factors for altered family health. Which example describes one of these risk factors?

a. The family does not have dental care insurance or resources to pay for it.
b. Both parents work and leave a 12-year old child to care for his younger brother.
c. Both parents and their children are considerably overweight.
d. The youngest member of the family has cerebral palsy and needs assistance from
community services.
b. Inadequate childcare resources is a psychosocial risk factor. Not having access to
dental care and obese family members are lifestyle risk factors. Having a family
member with birth defects is a biologic risk factor.

Shuba and Raul are a couple in their late seventies. According to Duvall, which
developmental task is appropriate for this older adult family?

a. Maintain a supportive home base

b. Strengthen marital relationships
c. Cope with loss of energy and privacy
d. Adjust to retirement
d. The developmental tasks of the family with older adults are to adjust to retirement
and possibly to adjust to the loss of a spouse and loss of independent living.
Maintaining a supportive home base and strengthening marital relationships are tasks of
the family with adolescents and young adults. Coping with loss of energy and privacy is
a task of the family with children.

A visiting nurse performs a community assessment in an area of the city in which the
nurse will be working. What is one element of a healthy community?

a. Meets all the needs of its inhabitants

b. Has mixed residential and industrial areas
c. Offers access to health care services
d. Has modern housing and condominiums
c.A healthy community offers access to health care services to treat illness and to
promote health. A healthy community does not usually meet all the needs of its
residents, but should be able to help with health issues such as nutrition, education,
recreation, safety, and zoning regulations to separate residential sections from industrial
ones. The age of housing is irrelevant as long as residences are maintained properly
according to code.

A nurse is practicing community-based nursing in a mobile health clinic. What would be

the central focus of this nurse's care?

a. Individual and family health care needs

b. Populations within the community
c. Local health care facilities
d. Families in crisis
a. In contrast to community health nursing, whichfocuses on populations within a
community, community-based nursing is centered on individual and family health care
needs. Community-based nurses may help families in crisis and work in health care
facilities, but these are not the focus of community-based nursing

A nurse is caring for a patient in the ICU who is being monitored for a possible cerebral
aneurysm following a loss of consciousness in the emergency room. The nurse
anticipates preparing the patient for ordered diagnostic tests. This nurse's knowledge of
the diagnostic procedures for this condition reflects which aspect of nursing?

a. The art of nursing

b. The science of nursing
c. The caring aspect of nursing
d. The holistic approach to nursing
b. The science of nursing is the knowledge base for care that is provided. In contrast,
the skilled application of that knowledge is the art of nursing. Providing holistic care to
patients based on the science of nursing is considered the art of nursing.

Which nurse who was influential in the development of nursing in North America is
regarded as the founder of American nursing?

a. Clara Barton
b. Lillian Wald
c. Lavinia Dock
d. Florence Nightingale
d. Florence Nightingale elevated the status of nursing to a respected occupation,
improved the quality of nursing care, and founded modern nursing education. Clara
Barton established the Red Cross in the United States in 1882. Lillian Wald is the
founder of public health nursing. Lavinia Dock was a nursing leader and women's rights
activist instrumental in womens' right to vote.

In early civilizations, the theory of animism attempted to explain the mysterious changes
occurring in bodily functions. Which statement describes a component of the
development of nursing that occurred in this era?

a. Women who committed crimes were recruited into nursing the sick in lieu of serving
jail sentences.
b. Nurses identified the personal needs of the patient and their role in meeting those
needs.
c. Women called deaconesses made the first visits to the sick and male religious orders
cared for the sick and buried the dead.
d. The nurse was the mother who cared for her family during sickness by using herbal
remedies.
d. The theory of animism was based on the belief that everything in nature was alive
with invisible forces and endowed with power. In this era, the nurse usually was the
mother who cared for her family during sickness by providing physical care and herbal
remedies. At the beginning of the 16th century the shortage of nurses led to the
recruitment of women who had committed crimes to provide nursing care instead of
going to jail. In the early Christian period, women called deaconesses made the first
organized visits to sick people, and members of male religious orders gave nursing care
and buried the dead. The influences of Florence Nightingale were apparent from the
middle of the 19th century to the 20th century; one of her accomplishments was
identifying the personal needs of the patient and the nurse's role in meeting those
needs.

World War II had a tremendous effect on the nursing profession. Which development
occurred during this period?

a. The role of the nurse was broadened.

b. There was a decreased emphasis on education.
c. Nursing was practiced mainly in hospital settings.
d. There was an overabundance of nurses.
a. During World War II, large numbers of women worked outside the home. They
became more independent and assertive, which led to an increased emphasis on
education. The war itself created a need for more nurses and resulted in a knowledge
explosion in medicine and technology. This trend broadened the role of nurses to
include practicing in a wide variety of health care settings.

Which phrase describes a purpose of the ANA's Nursing's Social Policy Statement?
Select all that apply.

a. To describe the nurse as a dependent caregiver

b. To provide standards for nursing educational programs
c. To define the scope of nursing practice
d. To establish a knowledge base for nursing practice
e. To describe nursing's social responsibility
f. To regulate nursing research
c, d, e. The ANA Social Policy Statement (2010) describes the social context of nursing,
a definition of nursing, the knowledge base for nursing practice, the scope of nursing
practice, standards of professional nursing practice, and the regulation of professional
nursing.
One of the four broad aims of nursing practice is to restore health. Which examples of
nursing interventions reflect this goal? Select all that apply.

a. A nurse counsels adolescents in a drug rehabilitation program.

b. A nurse performs range-of-motion exercises for a patient on bedrest.
c. A nurse shows a diabetic patient how to inject insulin.
d. A nurse recommends a yoga class for a busy executive.
e. A nurse provides hospice care for a patient with end-stage cancer.
f. A nurse teaches a nutrition class at a local high school.
a, b, c. Activities to restore health focus on the individual with an illness and range from
early detection of a disease to rehabilitation and teaching during recovery. These
activities include drug counseling, teaching patients how to administer their medications,
and performing range-of-motion exercises for bedridden patients. Recommending a
yoga class for stress reduction is a goal of preventing illness, and teaching a nutrition
class is a goal of promoting health. A hospice care nurse helps to facilitate coping with
disability and death.

Nursing is recognized increasingly as a profession based on which defining criteria?

Select all that apply.

a. Well defined body of general knowledge

b. Interventions dependent upon the medical practice
c. Recognized authority by a professional group
d. Regulation by the medical industry
e. Code of ethics
f. Ongoing research
c, e, f. Nursing is recognized increasingly as a profession based on the following
defining criteria: well-defined body of specific and unique knowledge, strong service
orientation, recognized authority by a professional group, code of ethics, professional
organization that sets standards, ongoing research, and autonomy and self-regulation.

A nurse is practicing as a nurse-midwife in a busy OB-GYN office. Which degree in

nursing is necessary to practice at this level?

a. LPN
b. ADN
c. BSN
d. MSN
d. A master's degree (MSN) prepares advanced practice nurses. Many master's
graduates gain national certification in their specialty area, for example, as family nurse
practitioners (FNPs) or nurse midwives.
Nurse practice acts are established in each state of the United States to regulate
nursing practice. What is a commonelement of every state practice act?

a. Defining the legal scope of nursing practice

b. Providing continuing education programs
c. Determining the content covered in the NCLEXexamination
d. Creating institutional policies for health care practices
a. Nurse practice acts are established in each state to regulate the practice of nursing
by defining the legal scope of nursing practice, creating a state board of nursing to
make and enforce rules and regulations, define important terms and activities in
nursing, and establish criteria for the education and licensure of nurses. The acts do not
determine the content covered on the NCLEX, but they do have the legal authority to
allow graduates of approved schools of nursing to take the licensing examination. The
acts also may determine educational requirements for licensure, but do not provide the
education. Institutional policies are created by the institutions themselves.

The National Advisory Council on Nurse Education and Practice identifies critical
challenges to nursing practice in the 21st century. What is a current health care trend
contributing to these challenges?

a. Decreased numbers of hospitalized patients

b. Older and more acutely ill patients
c. Decreasing health care costs due to managed care
d. Slowed advances in medical knowledge and technology
b. The National Advisory Council on Nurse Education and Practice identifies the
following critical challenges to nursing practice in the 21st century: A growing population
of hospitalized patients who are older and more acutely ill, increasing health care costs,
and the need to stay current with rapid advances in medical knowledge and technology.

. A nurse assesses patients in a physician's office who are experiencing different levels
of health and illness. Which statements best define the concepts of health and illness?
Select all that apply.

a. Health and illness are the same for all people.

b. Health and illness are individually defined by each person.
c. People with acute illnesses are actually healthy.
d. People with chronic illnesses have poor health beliefs.
e. Health is more than the absence of illness.
f. Illness is the response of a person to a disease.
b, e, f. Each person defines health and illness individually, based on a number of
factors. Health is more than just the absence of illness; it is an active process in which a
person moves toward one's maximum potential. An illness is the response of the person
to a disease.
The student nurse learns that illnesses are classified as either acute or chronic. Which
are examples of chronic illnesses? Select all that apply.

a. Diabetes mellitus
b. Bronchial pneumonia
c. Rheumatoid arthritis
d. Cystic fibrosis
e. Fractured hip
f. Otitis media
a, c, d. Diabetes, arthritis, and cystic fibrosis are chronic diseases because they are
permanent changes caused by irreversible alterations in normal anatomy and
physiology, and they require patient education along with a long period of care or
support. Pneumonia, fractures, and otitis media are acute illnesses because they have
a rapid onset of symptoms that last a relatively short time.

Despite a national focus on health promotion, nurses working with patients in inner-city
clinics continue to see disparities in health care for vulnerable populations. Which
patients would be considered vulnerable populations? Select all that apply.

a. A White male diagnosed with HIV

b. An African American teenager who is 6 months pregnant
c. A Hispanic male who has type II diabetes
d. A low-income family living in rural America
e. A middle-class teacher living in a large city
f. A White baby who was born with cerebral palsy
b, c, d, f. National trends in the prevention of health disparities are focused on
vulnerable populations, such as racial and ethnic minorities, those living in poverty,
women, children, older adults, rural and inner-city residents, and people with disabilities
and special health care needs.

A nurse has volunteered to give influenza immunizations at a local clinic. What level of
care is the nurse demonstrating?

a. Tertiary
b. Secondary
c. Primary
d. Promotive
c. Giving influenza injections is an example of primary health promotion and illness
prevention.

A nurse's neighbor tells the nurse, "I have a high temperature, feel awful, and I am not
going to work." What stage of illness behavior is the neighbor exhibiting?

a. Experiencing symptoms
b. Assuming the sick role
c. Assuming a dependent role
d. Achieving recovery and rehabilitation
b. When people assume the sick role, they define themselves as ill, seek validation of
this experience from others, and give up normal activities. In stage 1: experiencing
symptoms, the first indication of an illness usually is recognizing one or more symptoms
that are incompatible with one's personal definition of health. The stage of assuming a
dependent role is characterized by the patient's decision to accept the diagnosis and
follow the prescribed treatment plan. In the achieving recovery and rehabilitation role,
the person gives up the dependent role and resumes normal activities and
responsibilities.

Which clinic patient is most likely to have annual breast examinations and
mammograms based on the physical human dimension?

a. Jane, whose her best friend had a benign breast lump removed
b. Sarah, who lives in a low-income neighborhood
c. Tricia, who has a family history of breast cancer
d. Nancy, whose family encourages regular physical examinations
c. The physical dimension includes genetic inheritance, age, developmental level, race,
and gender. These components strongly influence the person's health status and health
practices. A family history of breast cancer is a major risk factor.

Health promotion activities may occur on a primary, secondary, or tertiary level. Which
activities are considered tertiary health promotion? Select all that apply.

a. A nurse runs an immunization clinic in the inner city.

b. A nurse teaches a patient with an amputation how to care for the residual limb.
c. A nurse provides range-of-motion exercises for a paralyzed patient.
d. A nurse teaches parents of toddlers how to childproof their homes.
e. A school nurse provides screening for scoliosis for the students.
f. A nurse teaches new parents how to choose and use an infant car seat.
b, c. Tertiary health promotion and disease prevention begins after an illness is
diagnosed and treated to reduce disability and to help rehabilitate patients to a
maximum level of functioning. These activities include providing ROM exercises and
patient teaching for residual limb care. Providing immunizations and teaching parents
how to childproof their homes and use an appropriate car seat are primary health
promotion activities. Providing screenings is a secondary health promotion activity.

The agent-host-environment model of health and illness is based on what concept?

a. Risk factors
b. Demographic variables
c. Behaviors to promote health
d. Stages of illness
a. The interaction of the agent, host, and environment creates risk factors that increase
the probability of disease.

When providing health promotion classes, a nurse uses concepts from models of
health. What do both the health-illness continuum and the high-level wellness models
demonstrate?

a. Illness as a fixed point in time

b. The importance of family
c. Wellness as a passive state
d. Health as a constantly changing state
d. Both these models view health as a dynamic (constantly changing state).

A nurse follows accepted guidelines for a healthy lifestyle. How can this promote health
in others?

a. By being a role model for healthy behaviors

b. By not requiring sick days from work
c. By never exposing others to any type of illness
d. By spending less money on food
a. Good personal health enables the nurse to serve as a role model for patients and
families.

Nursing students are reviewing information about health care delivery systems in
preparation for a quiz the next day. Which statements describe current U.S. health care
delivery practices? Select all that apply.

a. Access to care depends only on the ability to pay, not the availability of services.
b. The Patient Protection and Affordable Care Act provides private health care insurance
to the underserved populations.
c. Every health insurance plan in the Marketplace offers comprehensive coverage, from
doctors to medications to hospital visits.
d. The uninsured pay for more than one-third of their care out of pocket and are usually
charged lower amounts for their care than the insured pay.
e. Fifty years ago, half of the doctors in America practiced primary care, but today fewer
than one in three do.
f. Quality of care can be defined as the right care for the right person at the right time.
c, e, f. The Marketplace is designed to help people more easily find health insurance
that fits their budget. Every health insurance plan in the Marketplace offers
comprehensive coverage, from doctors to medications to hospital visits. Fifty years ago,
half of the doctors in America practiced primary care, but today fewer than one in three
do. Quality is the right care for the right person at the right time. Access to care depends
on both the ability to pay and the availability of services. The Patient Protection and
Affordable Care Act provides Medicaid or subsidized coverage to qualifying people with
incomes up to 400% of poverty. The uninsured pay for more than one-third of their care
out of pocket and are often charged higher amounts for their care than the insured pay.

A nurse is providing secondary health care to patients in a health care facility. Which
patients are receiving this level of care? Select all that apply.

a. A patient enters a community clinic with signs of strep throat.

b. A patient is admitted to the hospital following a myocardial infarction.
c. A mother brings her son to the emergency department following a seizure.
d. A patient with osteogenesis imperfecta is being treated in a medical center.
e. A mother brings her son to a specialist to correct a congenital heart defect.
f. A woman has a hernia repair in an ambulatory care center.
b, c, f. Secondary health care treats problems that require specialized clinical expertise,
such as an MI, a seizure, and a hernia repair. Treating strep throat is primary health
care.Tertiary health care involves management of rare and complex disorders, such as
osteogenesis imperfecta and congenital heart malformations.

A nurse working in a physician's office prepares insurance forms in which the provider is
given a fixed amount per enrollee of the health plan. What is the term for this type of
reimbursement?

a. Capitation
b. Prospective payment system
c. Bundled payment
d. Rate setting
a. Capitation plans give providers a fixed amount per enrollee in the health plan in an
effort to build a payment plan that consists of the best standards of care at the lowest
cost. The prospective payment system groups inpatient hospital services for Medicare
patients into DRGs. With bundled payments, providers receive a fixed sum of money to
provide a range of services. Rate setting means that the government could set targets
or caps for spending on health care services.

A nursing instructor is teaching students about the utilization of health care services and
how the U.S. health care dollar is spent. Place the following care areas in order from the
highest percentage of health care money spent to the lowest.

a. Physician/clinical services
b. Home health care
c. Long-term care facility services
d. Retail prescription drugs
e. Government administration
f. Hospital care
f, a, d, c, b, e. The national health expenditures in 2010 were hospital care 31%,
physician/clinical services 20%, retail prescription drugs 10%, long-term care facility
services 5%, home health care 3%, and government administration 1%.

A nurse researcher keeps current on the trends to watch in healthcare delivery. What
trends are likely included? Select all that apply.

a. Globalization of economy and society

b. Slowdown in technology development
c. Decreasing diversity
d. Increasing complexity of patient care
e. Changing demographics
f. Shortages of key health care professionals and educators
a, d, e, f. Trends to watch in health care delivery include: globalization of the economy
and society, increasing complexity of patient care, changing demographics, shortages of
key health care professionals and educators, technology explosion, and increasing
diversity.

A nurse is caring for patients in a primary care center. What is the most likely role of this
nurse based on the setting?

a. Assisting with major surgery

b. Performing a health assessment
c. Maintaining patients' function and independence
d. Keeping student immunization records up to date
b. Performing patient assessments is a common role of the nurse in a primary care
center. Assisting with major surgery is a role of the nurse in the hospital setting.
Maintaining patients' function and independence is a role of the nurse in an extended-
care facility, and keeping student immunization records up to date is a role of the school
nurse.

A caregiver asks a nurse to explain respite care. How would the nurse respond?

a. "A service that allows time away for caregivers"

b. "A special service for the terminally ill and their family"
c. "Direct care provided to individuals in a long-term care facility"
d. "Living units for people without regular shelter"
a. Respite care is provided to enable a primary caregiver time away from the day-to-day
responsibilities of homebound patients.

A nurse caring for patients in a primary care setting submits paperwork for
reimbursement from managed care plans for services performed. Which purpose best
describes managed care as a framework for health care?

a. A design to control the cost of care while maintaining the quality of care
b. Care coordination to maximize positive outcomes to contain costs
c. The delivery of services from initial contact through ongoing care
d. Based on a philosophy of ensuring death in comfort and dignity
a. Managed care is a way of providing care designed to control costs while maintaining
the quality of care.

A nurse cares for dying patients by providing physical, psychological, social, and
spiritual care for the patients, their families, and other loved ones. This service is known
as:

a. Respite care
b. Palliative care
c. Hospice care
d. Extended care
c. The hospice nurse combines the skills of the home care nurse with the ability to
provide daily emotional support to dying patients and their families. Respite care is a
type of care provided for caregivers of homebound ill, disabled, or older patients.
Palliative care, which can be used inconjunction with medical treatment and in all types
of health care settings, is focused on the relief of physical, mental, and spiritual distress.
Extended-care facilities include transitional subacute care, assisted-living facilities,
intermediate and long-term care, homes for medically fragile children, retirement
centers, and residential institutions for mentally and developmentally or physically
disabled patients of all ages.

A nurse is evaluating a patient diagnosed with renaldisease for treatment in a Hospital

at Home program. Whichstatement accurately describes a step in this program?

a. The patient is evaluated upon hospital admission and is given daily nursing care in
the home after discharge for as long as necessary.
b. Any urgent or emergent situation requires an ambulance trip from the home to the
hospital.
c. Patients are transported to physicians' offices from the home for weekly evaluations.
d. The clinicians use care pathways, clinical outcome evaluations, and specific
discharge criteria.
d. In the Hospital at Home program, the clinicians use care pathways including illness-
specific care maps, clinical outcome evaluations, and specific discharge criteria. A
patient requiring admission for one of the target illnesses is identified in the emergency
department or ambulatory site. Staff assess whether the patient is a good candidate for
the program using validated criteria. If the patient is eligible and consents to participate,
the Hospital at Home physician evaluates the patient, who is then transported home,
usually by ambulance. Nurses are available 24 hours a day/7 days a week for any
urgent or emergent situations. The patient is evaluated daily in the home by the Hospital
at Home physician, who completes an assessment and continues to implement
appropriate diagnostic and therapeutic measures.

A 9-year-old weighs 55 pounds and is to receive cefuroxime sodium 750 mg IV every 6

hours. The recommended dose of cefuroxime sodium for children older than 1 month is
50-133 mg/kg every 24 hours. Is the ordered dose within the recommended limits?
(YES or NO) __________
55 lb = 25 kg

Recommended 24-hour dose range =

[(lower dose range) 50 x 25] to [(higher dose) 133 x 25]= 1,250 mg to 3,325 mg

Medication order: 750 mg x 4 times a day = 3,000 mg/day

Yes, dose is within acceptable limits.

A nurse is caring for a patient with 2nd degree burns all over her body. The nurse knows
that which of the following measures is appropriate when the patient is prescribed
application of silver sulfadiazine cream?

SELECT ALL THAT APPLY:

1. The nurse checks the patient's chart for allergies to sulfa medications.
2. The nurse tells the patient, "I'm going to apply the cream the doctor ordered. It won't
hurt a bit."
3. The lab technician draws blood specimens the day after the cream has been applied.
4. The patient signs a consent form to be able to apply the cream.
5. The nurse uses sterile technique to care for the patient.
6. The nurse gives the patient pain medication after the cream has been applied.
1. The nurse checks the patient's chart for allergies to sulfa medications.
3. The lab technician draws blood specimens the day after the cream has been applied.
5. The nurse uses sterile technique to care for the patient.

Any patient allergic to sulfa will be allergic to the cream, which is treatment for burns. As
it is applied, it causes a burning sensation as a normal side effect. A consent form is
unnecessary. Sterile technique for burns is recommended. Labs need to be drawn to
check for neutropenia as a complication of the medication. Patients should be pre-
medicated before having treatment for burns.

The nurse is administering an unpleasant-tasting liquid medication to a 2-year-old child.

Which intervention should the nurse implement?

1. Tell the child the medication will not taste bad.

2. Prepare the medication in the child's favorite food.
3. Use a dropper to place the medication between the gum and cheek.
4. Put the medication in 4 ounces of apple juice.
3. Use a dropper to place the medication between the gum and cheek.

This action promotes swallowing and prevents the medication from being aspirated or
spit out. Do not use a favorite food or essential dietary item when administering a
medication because the child may refuse the food in the future.

The nurse works in a NICU (neonatal intensive care unit). The doctor orders Digoxin
6mcg/kg/day IV in two divided doses to be given to one of the nurse's patients. The
patient weighs 7 pounds. Calculate the amount, in mcg, the nurse will give per dose.
First, convert the infant's weight into kilograms from pounds. There are a couple of
formulas to do this. You can divide the number of pounds by 2.2 or multiply the number
of pounds by 0.454.

7lbs divided by 2.2 = 3.18kg

Now calculate the medication to be given to the patient per day.

6mcg x 3.18kg = 19.08mcg/day

Divide in 2 to get the per-dose amount: 19.08 ÷ 2 = 9.54mcg per dose.

A primipara is in the transition phase of labor on the maternity unit. On the fetal heart
monitor, the nurse observes a contraction begin. Shortly after a delay, the fetal heart
rate dips. It only recovers after the contraction has already been ended for a period of
30 seconds. Please place the following actions in order from first to last.

Stop the Pitocin drip.

Call the physician.
Administer oxygen by facial mask.
Reassure the mother.
Turn the mother on her left side.
Stop the Pitocin drip.
Turn the mother on her left side.
Administer oxygen by facial mask.
Call the physician.
Reassure the mother.

Stop the Pitocin drip first. Pitocin can cause the late decelerations that are described
above. Reposition and give oxygen to the mom, then call the physician, and reassure
the mother (psychosocial item is last).

A patient with tuberculosis asks why he must take two drugs for his one disease. The
nurse explains that:

1. "It works better with two medications. No one knows why."

2. "The combination of two drugs against tuberculosis will help eliminate resistance from
forming against the medications."
3. "The drug companies want more money."
4. "We use two medications against tuberculosis to reduce the amount of time it takes to
make your condition non-transmissible."
2. "The combination of two drugs against tuberculosis will help eliminate resistance from
forming against the medications."

It is better to completely eliminate tuberculosis in the first attempt than only take one
med and leave 5% of the organism alive... creating a resistant strain.

The nurse cares for a patient on the medical/surgical unit. The patient rings the call bell
and exclaims, "My urine has been orange today! What medication is doing this to me?"
Which of the following medications, if noted in the patient's chart, would explain this side
effect?

SELECT ALL THAT APPLY:

1. Pyridium.
2. Pantoprazole.
3. Rifampin.
4. Bleomycin.
5. INH (Isoniazid).
1. Pyridium.
3. Rifampin.

These two medications can cause orange urine. Bleomycin can turn urine blue/green.
INH and Pantoprazole do not affect urine color.
A patient with type I diabetes asks the nurse why he can't take the new diabetic drug
that he sees on the commercials. Which of the following is the best explanation for the
nurse to give the patient?

1. "I don't see why you couldn't. Let's talk to the doctor."
2. "The cells that make insulin have been completely destroyed in your body, so drugs
won't work. You can only receive shots of insulin."
3. "The new medications don't work as effectively as the old ones."
4. "Type 1 diabetes only responds minimally to medication."
2. "The cells that make insulin have been completely destroyed in your body, so drugs
won't work. You can only receive shots of insulin."

Diabetes I means that the beta cells of the pancreas have been completely destroyed
by the body. The patient will be unable to get any effect from the med because he
doesn't have the cells to use it!

A busy, harried-looking physician comes onto the floor and writes out four orders in less
than one minute. He leaves, shoving over a stack of the nurse's charting on the way out
the door. Which of the following four orders should the nurse question?

1. Sitz bath for a patient recovering from an episiotomy.

2. Heating pad for a patient with rheumatoid arthritis.
3. Cold compresses and elevation for a patient whose IV infiltrated two hours ago.
4. Heating pad for a diabetic patient with a foot ulcer.
4. Heating pad for a diabetic patient with a foot ulcer. 

The diabetic patient might have neuropathy and be unable to correctly sense the
temperature of the heating pad, resulting in a burn.

The nurse works on a medical/surgical unit and cares for a patient receiving Lanoxin
(Digoxin) and Furosemide (Lasix). The nurse knows that which of the following, if
reported by the patient, must be assessed IMMEDIATELY?

1. Vomiting and halos around lights.

2. Night sweats and headache.
3. Low blood pressure and dark urine.
4. Stomach upset and headache.
1. Vomiting and halos around lights.

Lasix causes the patient to lose potassium. Digoxin, if taken with a low potassium level,
can become toxic and show signs/symptoms of nausea, vomiting, and halos around
lights.

A patient is sent home on prescribed Nitroglycerin, to be taken as needed for angina.

Which of the following instructions, if stated by the patient to the nurse, would require
further teaching?

SELECT ALL THAT APPLY:

1. "I will place this drug in the sunlight before I take it to make it easier to digest."
2. "I will keep the nitroglycerin sublingual tablet under my tongue without swallowing it."
3. "I will take my blood pressure pill at the usual time even if I have taken nitroglycerin in
the past hour."
4. "If I become pale and light-headed, this is a normal side effect."
5. "I sometimes take Viagra to enjoy spending time with my wife."
1. "I will place this drug in the sunlight before I take it to make it easier to digest." 
3. "I will take my blood pressure pill at the usual time even if I have taken nitroglycerin in
the past hour."
4. "If I become pale and light-headed, this is a normal side effect."
5. "I sometimes take Viagra to enjoy spending time with my wife." 

Viagra is a vasodilator. When combined with nitroglycerin, it can cause a patient to have
a hypotensive crisis where he becomes pale and light-headed- not a normal side effect.
This drug should be protected from light and kept under the tongue without swallowing.
Taking a blood pressure pill within an hour of the nitroglycerin might cause a patient to
bottom out.

A patient takes Nardil for depression and is confused by the dietary restrictions and
allowances that are required with the medication. Which food on the list below is NOT
permitted when taking Nardil?

SELECT ALL THAT APPLY:

1. Cheddar cheese and crackers.

2. A four (4) ounce glass of wine.
3. Miso soup.
4. An apple and a cup of tea.
5. Smoked salmon and cream cheese on a bagel.
6. Sandwich with fresh lunchmeat.
1. Cheddar cheese and crackers.
2. A four (4) ounce glass of wine.
3. Miso soup. 
5. Smoked salmon and cream cheese on a bagel.
6. Sandwich with fresh lunchmeat. 

The patient may not eat foods containing preservatives or foods/wine that have been
aged.

A client with myasthenia gravis is instructed to take anticholinesterase medications on

time to eat meals 45-60 minutes later. The client asks the nurse why the timing of the
medication is so important. What is the nurse's best response?

1. "The timing allows the medication to have its greatest effect so it is easier for you to
chew, swallow, and not choke."
2. "The medication is very irritating to your stomach and you could develop ulcers if you
take it too early before meals."
3. "The medication can cause nausea and vomiting. By waiting a while to eat after you
have taken the medication, you are less likely to vomit."
4. "The timing prevents your blood sugar level from dropping too low and causing you to
be at risk for falling."
1. "The timing allows the medication to have its greatest effect so it is easier for you to
chew, swallow, and not choke." 

The skeletal muscle weakness extends to the ability to chew and swallow, so clients
with myasthenia gravis are at risk for aspiration during meals. The majority of the meal
should be eaten at a time when the medication is having its peak effect, thereby
enhancing the client's chewing and swallowing abilities.

A patient has been taking a heavy aspirin regimen for the past two months. Which side
effects, if noted by the patient, are directly related to overdose of aspirin?

SELECT ALL THAT APPLY:

1. Confusion.
2. Tinnitus.
3. Edema.
4. Blood in stools.
5. Increased INR.
2. Tinnitus.
4. Blood in stools.
5. Increased INR (bleeding time). 

Aspirin can increase bleeding time (INR) and can also cause some GI bleeding
(resulting in the bloody stools). It can also lead to tinnitus. Aspirin does not generally
cause confusion or edema.

A patient taking Fluoxetine Hcl (Prozac) asks the nurse when the medication will start to
work. The patient started this medication two weeks ago. The nurse's response is
CORRECT if she states:

1. "Prozac needs three months to work, so you will need to give it more time."
2. "In another two weeks, you should start to feel a difference in your mood."
3. "Prozac works as soon as you take it and should be working now."
4. "It should be another day or two. Then you will feel much better."
2. "In another two weeks, you should start to feel a difference in your mood."

Prozac needs four weeks for the full effect of the medication.

The physician prescribes alprazolam (Xanax) 0.25 mg p.o. TID for a client with anxiety
and physical symptoms related to work pressures. The nurse should assess the client
for the most common adverse effect of this drug, which is?

1. Agranulocytosis
2. Bradycardia
3. Tardive dyskinesia
4. Drowsiness
4. Drowsiness 

Benzodiazepines potentiate the action of GABA, enhance presympathetic inhibition, and

inhibit spinal polysynaptic afferent pathways; drowsiness, dizziness, and blurred vision
are common adverse effects.

A graduate nurse prepares a patient to undergo a liver biopsy. The graduate nurse
administers what pre-op medication?

1. Vitamin K.
2. Coumadin.
3. Vitamin A.
4. Vitamin B-12.
1. Vitamin K.

Vitamin K is administered before a liver biopsy to reduce the risk of bleeding.

A patient on several medications is being cared for on a medical/surgical unit by the
nurse. Which of the following laboratory values, if reported to the nurse, would require
follow-up?

SELECT ALL THAT APPLY:

1. Lithium level of 1.3mEq/L.

2. Calcium 8.5 mg/dL.
3. Blood sugar of 103 mg/dL.
4. Digoxin level of 2.4 mEq/L.
5. Potassium level of 5.5 mEq/L.
6. Urine specific gravity of 1.016.
4. Digoxin level of 2.4 mEq/L.
5. Potassium level of 5.5 mEq/L. 

These are the only abnormal labs- digoxin should be between 1 and 2, while potassium
should never stray from between 3.5 to 5.0.

A patient has been prescribed the medication spironolactone (aldasterone). When

preparing the patient for discharge, the nurse should include which of the following
instructions?

SELECT ALL THAT APPLY:

1. "This medication will make you urinate more often."

2. "Do not take this medication before bedtime."
3. "Be sure to take this with meals."
4. "It is important to increase your intake of dark leafy greens."
5. "Check your weight daily and keep a record to bring with you to your next
appointment."
6. "Remember to eat salt substitutes instead of actual sodium."
1. "This medication will make you urinate more often."
2. "Do not take this medication before bedtime."
3. "Be sure to take this with meals." 
5. "Check your weight daily and keep a record to bring with you to your next
appointment." 

This patient should be avoiding salt substitutes because they are generally made of
potassium. Spironolactone is a potassium-sparing diuretic. Therefore, the patient should
eat a normal potassium diet and regular salt intake. The other four answers are correct.
A 40 year-old client who is receiving a MAOI is going home on a weekend pass.
Considering the drug, the nurse plans to instruct the client to avoid?

SELECT ALL THAT APPLY:

1. Banana peel.
2. Peanut butter.
3. Cheddar cheese.
4. Ice cream and milk.
5. Beer.
6. Chocolates.
1. Banana peel.
3. Cheddar cheese.
5. Beer.
6. Chocolates. 

These foods are high in tyramine, which in the presence of an MAOI inhibitor, like
Marplan, can cause an excessive epinephrine-type response that can result in a
hypertensive crisis.

The nurse notes that a physician new to the hospital's computer system has input three
out of four orders INCORRECTLY for a patient. Which of the following medications is
CORRECT for a patient with the following criteria: Diabetes Insipidus, Dehydration,
Hypertension.

1. Insulin.
2. DDAVP.
3. Furosemide.
4. Hypertonic saline.
2. DDAVP. (Geneneric: Desmopressin)

Lasix is a diuretic, which is not good for a dehydrated patient. Insulin is for diabetes
mellitus, not diabetes inspidius. Hypertonic saline is for SIADH, not diabetes insipidus.
DDAVP will help the patient hold onto more water.

A patient on the psychiatric unit has been taking Haldol for three days as ordered by the
physician. During the nurse's shift, she enters the patient's room to find the patient in a
prolonged muscle spasm, with his eyes looking upward, and a fever of 103.5 degrees.
Which of the following actions, if performed by the nurse, would be considered
CORRECT?

SELECT ALL THAT APPLY:

1. Withhold all medications.
2. Retrieve a cooling blanket for the patient.
3. Call the physician.
4. Withhold the next dose of Haldol.
5. Prepare the patient to move to ICU (intensive care unit).
2. Retrieve a cooling blanket for the patient.
3. Call the physician.
4. Withhold the next dose of Haldol.
5. Prepare the patient to move to ICU (intensive care unit). 

These are all the correct actions in responding to the signs/symptoms of neuroleptic
malignant syndrome. Withholding all medications would not be appropriate.

A patient is ordered to receive omeprazole (Prilosec) 40mg PO daily. The pharmacy

dispenses Prilosec 20mg capsules. How many capsules should the nurse administer to
this patient for a single dose?

1. 1 capsule.
2. ½ a capsule.
3. 2 capsules.
4. 1.5 capsules.
2 capsules.

To give the 40mg dose, the patient will need 2 capsules of 20mg each (20 x 2 = 40).

The nurse is reviewing the client's medications and she noticed a prescription of Versed.
Which medication is important to have available for clients who have received Versed?

1. florinef (Fludrocortisone)
2. naloxone (Narcan)
3. flumazenil (Romazicon)
4. diazepam (valium)
3. flumazenil (Romazicon)

Romazicon is the antidote for Versed. Versed is used for conscious sedation and is an
antianxiety agent.

A physician on the medical/surgical unit orders Mellaril (thioridazine hydrochloride)

75mg PO once daily for one of the nurse's patients. The pharmacy sends up liquid
Mellaril with a concentration of 30mg/mL. How much Mellaril, in mL, will the nurse give
for ONE dose?

A patient has the following medication orders: Pantaprozole 40mg PO qAM, Metoprolol
50mg PO bid, Lorazepam 0.5mg PO now, Albuterol 1 puff PRN. The patient's medical
history includes high cholesterol and asthma. Which of the orders should the nurse
question?

1. Metoprolol.
2. Pantaprozole.
3. Lorazepam.
4. Albuterol.
1. Metoprolol.

A patient with a history of breathing issues like asthma cannot take a beta blocker like
Metoprolol because it affects beta-1 and beta-2 receptors and can result in
brochospasm.

The nurse on an oncology unit is administering Cisplatin to a patient. The nurse knows
that which of the following symptoms, if reported by the patient, is expected with this
type of medication?

SELECT ALL THAT APPLY:

1. Diarrhea.
2. Lower backache.
3. Numbness in hands and feet.
4. Nausea.
5. Alopecia.
6. Alterations in vision.
1. Diarrhea.
3. Numbness in hands and feet.
4. Nausea.
5. Alopecia.

Cisplatin is a cancer drug. Side effects may include nausea, vomiting, hair loss
(alopecia), numbness or paresthesias, and diarrhea.

A patient is started on a daily amount of Phenytoin (Dilantin) 200mg PO in two divided

doses. What instruction, if given by the nurse to the patient, is INCORRECT?
1. "You need to increase your intake of vitamin D while taking this medication."
2. "You will need annual labs to determine the medication level in your body."
3. "Remember to never skip a dose of this medication."
4. "Maintain good oral hygiene and visit your dentist regularly."
2. "You will need annual labs to determine the medication level in your body."

It is important for a patient newly started on Dilantin to receive weekly labs initially to
check the CBC. Patients need to have their RBCs, WBCs, and platelets monitored
because Dilantin can cause those numbers to fall.

Which of the following statements is true regarding the responsibility of the Licensed
Practical Nurse when it comes to IV therapy? The LPN may:

1. administer any medication by direct IV push.

2. administer an IV fluid bolus for plasma volume expansion.
3. discontinue or remove any central venous access device.
4. monitor and adjust flow rates of an infusion of colloidal solutions such as TPN and
hang a subsequent bag of the exact same solution or component.
4. monitor and adjust flow rates of an infusion of colloidal solutions such as TPN and
hang a subsequent bag of the exact same solution or component. 

The delegation of IV therapy to a Licensed Practical Nurse is still under the

responsibility and accountability of the Registered Nurse. Among the choices given this
is the only one that states the allowed activity for an LPN in relation to IV therapy.

A client receiving Zyprexa (olanzapine) will most likely have another prescription of
which medications?

1. Antihypertensives.
2. Antiparkinsonian drugs.
3. Antianxiety.
4. Anticholinergic.
2. Antiparkinsonian drugs.

Olanzapine is an antipsychotic medication that decreases dopamine secretion. This

decrease in dopamine can lead to development of extrapyramidal symptoms (EPS),
including akathisia (inability to sit still, no pattern to movements), tardive dyskinesia
(bizarre movements of jaw, mouth, tongue, extremities), and pseudoparkinsonism
(rigidity, tremors, pill rolling, shuffling gait). These symptoms can be managed with the
administration of antiparkinsonian drugs.