ATI Finals As Derived From ATI Text For Nursing Fundamentals, Part II
Questions derived from Fundamentals for Nursing Edition 7.0, application exercises. Chapter 35 through Chapter 57, pages 348 through 636. For any questions or suggestions, email at arnoldjr2@gmail. Com
- 1.
A nurse is teaching a group of young adults who are about to go for a marathon. Which of the following should she teach?
- A.
Increase fluid intake in dry climates
- B.
Decrease fluid intake in high altitudes
- C.
Include caffeine as a regular beverage
- D.
Decrease fluid intake after training
Correct Answer
A. Increase fluid intake in dry climatesExplanation
Fluid intake is even more needed with excessive, vigorous training in high altitudes. It should also be increased in dry climates. Caffeine should be avoided because it may lead to dehydration.Rate this question:
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- 2.
After an interview, a 90 year old patient told the nurse that he had diarrhea and vomiting for the past 2 days. Which of the following will indicate that the client might be suffering from hypovolemia? Select all that apply:
- A.
Tachypnea
- B.
Furrowed tongue
- C.
Sunken eyeballs
- D.
Bradycardia
- E.
Hypertension
Correct Answer(s)
A. Tachypnea
B. Furrowed tongue
C. Sunken eyeballsExplanation
A client whose fluid intake is not enough is at risk for dehydration and hypovolemia. Older adults are at greater risk. In the presence of hypovolemia, TACHYCARDIA, HYPOTENSION, TACHYPNEA, a FURROWED TONGUE, AND SUNKEN EYEBALLS may be seen.Rate this question:
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- 3.
A patient has been admitted for peritonitis and has signs of dehydration. Which of the following laboratory findings would be expected for this patient. Select all that apply:
- A.
Increased urine osmolality
- B.
Decreased serum osmolality
- C.
Decreased urine specific gravity
- D.
Increased serum sodium
- E.
Increased HCT
Correct Answer(s)
A. Increased urine osmolality
D. Increased serum sodium
E. Increased HCTExplanation
When dehydrated, urine osmolarity and urine specific gravity are increased. Due to hemoconcentration, serum osmolarity and serum sodium are also increasedRate this question:
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- 4.
A nurse has been assigned 4 patients. Which of them is at risk for HYERVOLEMIA?
- A.
A patient receiving loop diuretic
- B.
A patient who lost 500 ml of blood during surgery
- C.
A patient who had a myocardial infarction
- D.
A patient who is 3 hours postoperative is and under an NG suction
Correct Answer
C. A patient who had a myocardial infarctionExplanation
A patient with Myocardial Infarction (heart failure) is at risk for hypervolemia and fluid retention. All the other patients are at risk for HYPOVOLEMIARate this question:
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- 5.
After looking at the laboratory results for a group of patients, which of the following should be reported to the respective physician?
- A.
Serum potassium 4 mEq/L
- B.
Serum calcium 8.5 mg/dL
- C.
Serum chloride 99 mEq/L
- D.
Serum sodium 143 mEq/L
Correct Answer
B. Serum calcium 8.5 mg/dLExplanation
Calcium level of 8.5 mg/dL is below the expected reference range and should be reported to the physician. The other findings are within range. NOTE THE UNITS. THEY ARE NOT ALL THE SAME. Review the ranges.Rate this question:
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- 6.
Which of the following should be a part of a care plan designed for a hypernatremic patient?
- A.
Administer a loop diuretic
- B.
Increase sodium intake
- C.
Restrict oral intake of water
- D.
Infuse hypotonic IV fluids
Correct Answer
D. Infuse hypotonic IV fluidsExplanation
A hypernatremic patient should have an intake of hypotonic or isotonic fluids. Water intake is recommended. Sodium intake is restricted. A loop diuretic will increase the excretion of sodium.Rate this question:
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- 7.
When an infant has a heart attack, which of the following pulses should be palpated to determine how the heart is working?
- A.
Radial
- B.
Pedal
- C.
Carotid
- D.
Brachial
Correct Answer
D. BrachialExplanation
The brachial pulse is the most accessible for an infant. Radial and pedal pulses may not be reliable indicators of cardiac function, and the carotid pulse may be difficult to palpate in an infant because of fatty tissue surrounding the neck.Rate this question:
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- 8.
A nurse in the ER is assigned to a patient who has chest pain and is diaphoretic. The patient becomes unresponsive and the ECG device reveals ventricular fibrillation. Which of the following should the nurse do first?
- A.
Open the airway
- B.
Initiate rescue breathing
- C.
Deliver chest compressions
- D.
Provide defibrillation
Correct Answer
D. Provide defibrillationExplanation
The treatment for ventricular fibrillation is defibrillation. It should be provided prior to the initiation of CPR (airway, rescue breathing and chest compressions)Rate this question:
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- 9.
A nurse is treating a diabetic 15-year old patient two days after an appendectomy. The client can tolerate a regular diet quite well. He has walked around the unit with assistance and request pain medication every 6 to 8 hours at a 3 on a 0 to 10 pain scale. His wound is approximated, free of redness with slight serous drainage noted on the dressing. Which of the following risk factors for poor wound healing does this patient have? Select all that apply
- A.
Extremes in age
- B.
Impaired/suppressed immune system
- C.
Impaired circulation
- D.
Poor wound care such as breaches in aseptic technique
- E.
Malnutrition
Correct Answer(s)
B. Impaired/suppressed immune system
C. Impaired circulationExplanation
Diabetes places this patient at risk for impaired circulation and immune system function. The client is not at either extreme of the age spectrum. There are no indications of being malnourished or are there any breaches in aseptic technique during wound care.Rate this question:
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- 10.
An entry in a patient chart indicates wound drainage is "sanguineous". What does this mean?
- A.
Foul-smelling
- B.
Green-tinged or yellow
- C.
Watery in appearance
- D.
Bright red
Correct Answer
D. Bright redExplanation
Sanguineous drainage is bright red and the result of active bleeding. A watery appearance is characteristic of serous or serosanguineous drainage. Green or yellow and foul odor are typical of purulent drainage.Rate this question:
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- 11.
Which of the following is a wound or injury healing by secondary intention?
- A.
An open burn area
- B.
A bone fracture that is casted
- C.
A sprained ankle
- D.
A sutured surgical incision
Correct Answer
A. An open burn areaExplanation
An open burn area is a wound or injury that heals by secondary intention. This means that the wound is left open to heal naturally, without surgical closure or sutures. Secondary intention healing involves the formation of granulation tissue, followed by reepithelialization and wound contraction. In the case of an open burn area, the damaged tissue needs to be sloughed off and replaced with new tissue, which occurs through the process of secondary intention healing.Rate this question:
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- 12.
A 70-year old female has had a bowel obstruction surgery six days ago. During the past day, she has complained of nausea, and she threw up small amounts of clear liquid in the last 7 hours. Her vital signs are stable. Currently, her incision is well approximated without redness, tenderness or swelling. Which of the following could indicate the possibility of a wound infection?
- A.
Increased pain
- B.
Decreased pulse rate
- C.
Decrease WBC count
- D.
Increased thirst
Correct Answer
A. Increased painExplanation
An increase pain from an incision is an indication of a possible wound infection. With infection, pulse rate and WBC count both increase. Increased thirst has many possible causes and does not always mean an infection is taking place.Rate this question:
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- 13.
A surgical client acutely becomes agitated and pulls of her dressing. The nurse enters the room and finds out that the wound is separated with viscera protruding. Which of the following interventions are appropriate? Select all that apply
- A.
Repack the wound
- B.
Call for help
- C.
Cover the wound with sterile dressing moistened with 0.9% sodium chloride
- D.
Assist the client to a chair
- E.
Stay with the client
Correct Answer(s)
B. Call for help
C. Cover the wound with sterile dressing moistened with 0.9% sodium chloride
E. Stay with the clientExplanation
It is appropriate for the nurse to call for help, cover the wound with a sterile dressing moistened with 0.9% sodium chloride, and with the client. The nurse should not attempt to reinsert the organs or repack the wound. The nurse should have the client in supine position with her hips and knees bent.Rate this question:
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- 14.
An 85-year old diabetic patient must now use a wheelchair after a stroke 2 years ago that affected her right side. She feels no pain on this side. Although she has a good appetite, she needs help with eating. Which of the following factors could cause this patient to have pressure ulcers?
- A.
Dehyrdation
- B.
Limited mobility
- C.
Nutritional impairment
- D.
Incontinence
Correct Answer
B. Limited mobilityExplanation
Limited mobility as a result of a stroke (CVA) puts this patient at risk for skin breakdown. She is well-hydrated and nourished, and there are no data to indicate that she has urinary or fecal incontinence.Rate this question:
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- 15.
For a CVA patient who is wheel chair bound, which of the following can prevent skin breakdown?
- A.
Massage bony prominences frequently
- B.
Keep patient on high fowler's position while in bed
- C.
Have the client sit on a donut shaped cushion
- D.
Encourage repositioning every 15 minutes while the client is on a wheelchair.
Correct Answer
D. Encourage repositioning every 15 minutes while the client is on a wheelchair.Explanation
It is important to encourage and help a patient to change positions EVERY 15 MINUTES while sitting down to prevent continuous pressure on any skin area. While in bed, the head of the client's bed should be elevated no more than 30 degrees to prevent skin breakdown from shearing forces in the sacral area. Donut-shaped cushions increase pressure on the sacral area. A gel foam or air cushion would be better.Rate this question:
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- 16.
Which of the following is a STAGE III DECUBITUS?
- A.
Reddened skin and does not blanch with pressure
- B.
Ulcer is an abrasion or a blister
- C.
Bone is exposed at the center of the ulcer
- D.
Ulcer extends past the subcutaneous tissue to the muscle
Correct Answer
D. Ulcer extends past the subcutaneous tissue to the muscleExplanation
A stage III ulcer may extend past all the layers of the skin and subcutaneous tissue to the muscle. Reddened skin that does not blanch is Stage I. An abrasion or a blister is seen with STAGE II. Exposed bone is a Stage IV.Rate this question:
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- 17.
Which of the following formula contains a complete nutrition?
- A.
Polymeric
- B.
Modular
- C.
Elemental
- D.
Specialty
Correct Answer
A. PolymericExplanation
Polymeric formulas are nutritionally complete. Modular formulas provide a single macronutrient. Elemental formulas are composed of predigested nutrients, and specialty formulas are designed to meet specific nutritional needs and are not nutritionally complete.Rate this question:
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- 18.
The enteral access tube best suited for short-term use (less than 4 weeks)
- A.
Nasogastric tube
- B.
Gastrostomy tube
- C.
Jejunostomy tube
- D.
PEG tube
Correct Answer
A. Nasogastric tubeExplanation
NG tubes are short term and can be inserted through the nose. Insertion of a gastrostomy or jejunostomy is done by a surgical procedure, and a percutaneous endoscopic gastrostomy (PEG) tube is inserted endoscopically. Surgical and endoscopic insertion presents a risk for injury and infection; therefore they are only indicated for long term use.Rate this question:
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- 19.
After an enteral feeding is given, what is the purpose of flushing a tube?
- A.
Provide sufficient fluid intake
- B.
Dilute concentration of formula
- C.
Clear the tubing to prevent clogging
- D.
Ensure placement of tube is maintained
Correct Answer
C. Clear the tubing to prevent cloggingExplanation
Flushing the tube after feeding has been given helps maintain the patency of the tube by clearing any excess formula from the tube. If client requires more fluid, the small amount used for flushing will not be sufficient. If formula is to be diluted, it should be done before instilling the feeding. Flushing the tubes does not maintain proper placementRate this question:
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- 20.
Before initiating an enteral feeding, what is the highest priority assessment that the nurse must do?
- A.
Is the tube correctly placed?
- B.
Is the client alert and oriented?
- C.
How long has the feeding container been open?
- D.
Does the client have diarrhea?
Correct Answer
A. Is the tube correctly placed?Explanation
The greatest risk to the client receiving enteral feedings is injury from aspiration. Therefore, the priority nursing assessment before starting an enteral feeding is to determine the tube's proper place. Assessing the client's level of consciousness, the presence only complications of tube feeding (diarrhea) and the freshness of the formula are important but are not the highest priority with this patient.Rate this question:
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- 21.
While assessing a patent with a continuous enteral feeding, nurse noticed aspiration if the tube feeding. What should she do next?
- A.
Auscultate breath sounds
- B.
Stop the feeding
- C.
Obtain a chest x-ray
- D.
Provide oxygen
Correct Answer
B. Stop the feedingExplanation
The greatest risk to this client receiving enteral feeding is aspiration pneumonia. Therefore, the first action the nurse should take is to stop the feeding so that nor more formula can travel to the lungs. Auscultating for breath sounds, obtaining a chest x-ray, and providing oxygen are all important actions, but none of them is the highest priority.Rate this question:
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- 22.
The proper way to secure a nasogastric tube.
- A.
Tape from the client's nose to the nasogastric tube
- B.
A safety pin trough the nasogastric tube to the client's gown
- C.
Tape to the client's cheek with a short length of tubing looped on the nose
- D.
Tape around the connection of the nasogastric tube and the suction tubing
Correct Answer
A. Tape from the client's nose to the nasogastric tubeExplanation
Tape from the client's nose to the nasogastric tube secures the placement. Safety pins pose a risk for piercing the tubing. The tubing is too bulky to create a loop. Applying tape to the connection of the NG tube and suction tubing does not secure the tube.Rate this question:
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- 23.
Which of the following can cause a low pulse oximetry reading? Select all that apply:
- A.
Nail polish
- B.
Poor peripheral circulation
- C.
Edema
- D.
Hyperthermia
Correct Answer(s)
A. Nail polish
B. Poor peripHeral circulation
C. EdemaExplanation
Nail polish, poor peripheral circulation and edema can all generate a low reading. Hypothermia rather than hyperthermia and decreased hemoglobin level rather than increased hemoglobin level can result in a low reading.Rate this question:
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- 24.
Which of the following are early signs of hypoxemia? Select all that apply:
- A.
Pale skin and mucous membranes
- B.
Elevated blood pressure
- C.
Restlessness
- D.
Cyanotic skin and mucous membranes
- E.
Bradycardia
Correct Answer(s)
A. Pale skin and mucous membranes
B. Elevated blood pressure
C. RestlessnessExplanation
Pale skin and mucous membranes, elevated blood pressure, and restlessness are all early signs of hypoxemia. Hypoxemia refers to low oxygen levels in the blood, which can lead to various symptoms. Pale skin and mucous membranes occur due to decreased oxygenation in the body. Elevated blood pressure is a compensatory mechanism by the body to try to increase oxygen delivery. Restlessness is a common symptom of hypoxemia as the body tries to compensate for the lack of oxygen.Rate this question:
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- 25.
Which of the following are late signs of hypoxemia? Select all that apply:
- A.
Cyanotic skin and mucous membranes
- B.
Hypotension
- C.
Bradycardia
- D.
Confusion and stupor
- E.
Elevated blood pressure
Correct Answer(s)
A. Cyanotic skin and mucous membranes
B. Hypotension
C. Bradycardia
D. Confusion and stuporExplanation
Late signs of hypoxemia include cyanotic skin and mucous membranes, hypotension, bradycardia, and confusion and stupor. These signs indicate that the body is not receiving enough oxygen, leading to a decrease in blood pressure, heart rate, and mental status. Cyanotic skin and mucous membranes occur when there is a lack of oxygen in the blood, causing a bluish discoloration. Hypotension and bradycardia are the body's attempts to compensate for the lack of oxygen by slowing down the heart and reducing blood pressure. Confusion and stupor occur when the brain does not receive enough oxygen, leading to impaired cognitive function. Elevated blood pressure is not a late sign of hypoxemia and is not related to the condition.Rate this question:
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- 26.
A nurse is caring for a client who is dyspneic. What position should the client be in?
- A.
Supine
- B.
Dorsal Recumbent
- C.
Fowler's
- D.
Lateral
Correct Answer
C. Fowler'sExplanation
Fowler's position facilitates maximal lung expansion and thus optimizes breathing. Supine, dorsal recumbent and lateral positions will not do this.Rate this question:
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- 27.
Which of the following oxygen delivery systems should be used when a precise amount of oxygen needs to be delivered?
- A.
Venturi mask
- B.
Nonbreather mask
- C.
Nasal cannula
- D.
Simple face mask
Correct Answer
A. Venturi maskExplanation
A venturi mask incorporates an adaptor that allows a precise amount of oxygen to be delivered. The other oxygen delivery systems deliver an approximated amount of oxygen.Rate this question:
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- 28.
Which of the following directions should the nurse give to a client who is learning self-monitoring of blood glucose (SMBG)? Select all that apply:
- A.
Warm the hand before puncturing the finger
- B.
Perform SMBG once daily at bedtime
- C.
Calibrate the glucose monitor each time a new bottle of strips is opened
- D.
Wipe the hand with an alcohol swab
- E.
Prick the outer edge of the fingertip for a blood sample
Correct Answer(s)
A. Warm the hand before puncturing the finger
C. Calibrate the glucose monitor each time a new bottle of strips is opened
E. Prick the outer edge of the fingertip for a blood sampleExplanation
Warming the hand before obtaining a sample increases circulation and provides an adequate amount. The monitor needs calibration everytime a new bottle of strips is opened. The outer edge of the fingertip is an appropriate site for blood sampling. SMBG should be performed based on the client's medication schedule. It may be done as often before each meal and at bedtime. Monitoring once a day at bedtime does not provide enough information to monitor blood glucose control. The hand should be washed with warm water and soap. Alcohol can interfere with the blood glucose reading.Rate this question:
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- 29.
Which of the following can alter the results of blood glucose testing?
- A.
Amoxicillin (Amoxil)
- B.
Dexamethasone (Decadron)
- C.
Morphine (Duramorph)
- D.
Acetaminophen (Tylenol)
Correct Answer
B. Dexamethasone (Decadron)Explanation
Dexamethasone is a steroid that may raise blood glucose. Amoxicillin, morphine and acetaminophen should not affect blood glucose levels.Rate this question:
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- 30.
A client has an admission blood glucose reading of 350 mg/dL. The client has no history of elevated blood glucose, and there is an insulin order. Which of the following actions should the nurse take first?
- A.
Check the client's level of awareness
- B.
Check the client's dietary orders
- C.
Review the client's recent nutritional intake
- D.
Notify the provider
Correct Answer
A. Check the client's level of awarenessExplanation
Using "assessment first", the nurse should further assess the client for any other manifestations of hypeglycemia. Checking the client's dietary orders, reviewing the client's nutritional intake, and notifying the provider are important interventions but are not the priority.Rate this question:
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- 31.
In order to promote adherence with medication administration, which of the following instructions should be included? Select all that apply:
- A.
Only take medications when not feeling well
- B.
Place pill in daily pill holders
- C.
Contact physician if side effects take place
- D.
Ask a relative to assist once in a while
- E.
Refill prescriptions when the current supply is completed
Correct Answer(s)
B. Place pill in daily pill holders
C. Contact pHysician if side effects take place
D. Ask a relative to assist once in a whileExplanation
Placing pills in a daily pill holder reminds the client to take the pills as scheduled. The provider should be notified of side effects to determine if medications need to be adjusted; and assistance from a relative will provide emotional support. The client should take medications on a regular schedule. Prescriptions should be filled prior to the completion of the current supply to prevent a gap in treatment.Rate this question:
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- 32.
A patient claims that his pain medication is not working as it used to. The nurse should realize that the client is experiencing what?
- A.
Placebo effect
- B.
Tolerance
- C.
Accumulation
- D.
Dependence
Correct Answer
B. ToleranceExplanation
Tolerance occurs over time and the client will experience a decrease in responsiveness to a medication. The place effect occurs when the client experiences a positive effect due to a psychological factor. Accumulation occurs with an increase in medication concentration in the body due to inability to metabolize or excrete a medication rapidly enough, resulting in a toxic medication effect. Dependence is experienced as a psychological or physiological need for the medication.Rate this question:
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- 33.
A nurse is preparing medication for a pre-school child. Which of the following should the nurse recognize as a factor that would alter how a pre-school child is affected medication? Select all that apply:
- A.
Increased gastric acid production
- B.
Lower blood pressure
- C.
Increased first pass medication metabolism
- D.
Higher body water content
- E.
Increased absorption of topical medication
Correct Answer(s)
B. Lower blood pressure
D. Higher body water content
E. Increased absorption of topical medicationExplanation
Children have lower blood pressure, higher body water content, and experience an increase in absorption of topical medications. Children have decreased gastric acid production and decreased first pass metabolism.Rate this question:
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- 34.
Upon looking at the MAR, a nurse observes that one of her clients is taking four new mediations. Which of the following should be a concern?
- A.
The client is lactose intolerant
- B.
Two of the medications cause drowsiness
- C.
There are no generic forms available
- D.
The client has difficulty swallowing four pills at one one time
Correct Answer
B. Two of the medications cause drowsinessExplanation
A drug-drug interaction can cause an increased effect. If two of these medications cause drowsiness (CNS depression), they will have a synergistic effect and may increase CNS depression. Increasing CNS depression can progress from drowsiness to stupor as well as fatal respiratory depression. Lactose intolerance should not interfere with this client's medication. Trade name medications can be used, and nurse can administer each pill one at a timeRate this question:
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- 35.
A nurse tells a patient that a prescribed medication may have side effects. Which of the following instructions should the nurse give if anticholinergic effects are among the potential side effects? Select all that apply:
- A.
Keep a bottle of water available
- B.
Use a soft toothbrush when brushing teeth
- C.
Wear sun glasses when exposed to sunlight
- D.
Try to void before taking medication
- E.
Take medication with an antacid
Correct Answer(s)
A. Keep a bottle of water available
C. Wear sun glasses when exposed to sunlight
D. Try to void before taking medicationExplanation
Anticholinergic effects can cause dry mouth, photophobia, and urinary retention. Keeping a bottle of water can help alleviate dry mouth. Wearing sunglasses can minimize photophobia and voiding before taking medication will allow patient to empty the bladder before experiencing urinary retention. Bleeding gums is not a side effect of anticholinergic medications, so it is not necessary to use a soft toothbrush. Stomach irritation is also not experienced with anticholinergic medications, so a soft toothbrush is not needed. Stomach irritation is neither experienced with anticholinergic drugs, so this too is not necessary.Rate this question:
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- 36.
A patient is suffering from renal damages as a result of glomerulonephritis. Which of the following needs to be monitored when administering patient's medication?
- A.
Decreased efficacy of medication
- B.
Delayed clearance of medications from the blood
- C.
Increased risk of analphylaxis
- D.
Delayed clearance of medication from the blood
Correct Answer
D. Delayed clearance of medication from the bloodExplanation
Renal damage can delay excretion or clearance of medications from the blood increasing the risk of toxicity and adverse effects. Renal damage does not result in decreased efficacy of medications, increased risk of anaphylaxis, or increased susceptibility to infection.Rate this question:
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- 37.
A patient with chronic high blood pressure has been prescribed with an antihypertensive drug. Which of the following should the nurse teach to this patient with regards to over the counter (OTC) medications?
- A.
Continue taking OTC drugs with antihypertensive medication
- B.
Consult physician before taking an OTC drug
- C.
Stop taking antihypertensive drugs while taking OTC drugs
- D.
Take only one half the recommended dose of OTC medications.
Correct Answer
B. Consult pHysician before taking an OTC drugExplanation
Because of possible interactions between any type of drugs, it is not safe to self administer an OTC drug without the prior knowledge of the physician who prescribed regular medication. Consulting the physician before taking an OTC drug is the only teaching that can be done. The others are either irrelevant, not true or plain nonsense.Rate this question:
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- 38.
When assessing an IV site for infiltration, the following are indications that infiltration might have occurred. Select all that apply:
- A.
A drop in temperature around the site
- B.
An increased rate of infusion
- C.
Local swelling at the site
- D.
Reddened skin
- E.
A damp dressing
Correct Answer(s)
A. A drop in temperature around the site
C. Local swelling at the site
E. A damp dressingExplanation
A drop of temperature around the site, local swelling at the site, a damp dressing, a slowed infusion, and pale skin are all findings consistent with infiltrationRate this question:
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- 39.
The following should be included when documenting the insertion of an IV catheter. Select all that apply
- A.
Date and time of insertion; catheter size
- B.
Type of dressing (name and brand if available)
- C.
IV fluid and rate (if applicable)
- D.
Number, location, and conditions of site attempted cannulations
- E.
Insertion site and appearance
Correct Answer(s)
A. Date and time of insertion; catheter size
B. Type of dressing (name and brand if available)
C. IV fluid and rate (if applicable)
D. Number, location, and conditions of site attempted cannulations
E. Insertion site and appearanceExplanation
The correct answer includes all the necessary information that should be documented when inserting an IV catheter. This includes the date and time of insertion, the size of the catheter, the type of dressing used (including the name and brand if available), the IV fluid and rate if applicable, the number, location, and conditions of site attempted cannulations, and the insertion site and appearance. This comprehensive documentation ensures accurate and thorough record-keeping of the procedure and allows for proper monitoring and follow-up if needed.Rate this question:
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- 40.
A patient is receiving dextrose 5% in water IV. When monitoring for fluid overload, which of the following should be observed? Select all that apply:
- A.
Decreased blood pressure
- B.
Tachycardia
- C.
Flattened neck veins
- D.
Shortness of breath
- E.
Crackles heard in the lungs
Correct Answer(s)
B. Tachycardia
D. Shortness of breath
E. Crackles heard in the lungsExplanation
Fluid overload includes signs of increased blood pressure, tachycardia, shortness of breath, crackles heard in the lungs, and distended neck veinsRate this question:
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- 41.
A nurse is setting up an injection of morphine (Duramorph) to a patient who complains of pain. Before this however, another client in another room called and requested for a bedpan. This nurse then asked for a second nurse to give the injection so that she can help the client needing a bedpan. Which of the following actions should the second nurse take?
- A.
Give the injection prepared by the other nurse
- B.
Offer to assist the client needing a bedpan
- C.
Prepare another syringe and give the injection
- D.
Tell the client needing a bedpan that she will have to wait for her own nurse.
Correct Answer
B. Offer to assist the client needing a bedpanExplanation
The second nurse should offer to assist the client needing the bedpan. This will allow the nurse who prepared the injection to administer it. A nurse should only administer medications that he/she prepared. Preparing another syringe will delay the administration of the needed pain medication. Telling the client to waist is not an acceptable option for the client needing the bedpan.Rate this question:
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- 42.
According to the MAR, a medication was ordered for 9:00 in the morning. Which of the following are acceptable times? Select all that apply:
- A.
0905
- B.
0825
- C.
1000
- D.
0850
- E.
0935
Correct Answer(s)
A. 0905
D. 0850Explanation
There is a 30 minute window, before and after the scheduled time, that a medication may be given. 0905 and 0840 are within that window of time. 0825, 1000 and 0935 are not.Rate this question:
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- 43.
Which of the following prevents medication error?
- A.
Taking all medications out of the unit-dose wrappers before entering the bedside
- B.
Giving up the prescribed medication and then looking up the dosage range
- C.
Relying on another nurse to clarify a medication prescription
- D.
Checking with the physician when a single dose indicates an administration of multiple tablets
Correct Answer
D. Checking with the pHysician when a single dose indicates an administration of multiple tabletsExplanation
If a single dose requires multiple tablets, it is possible that an error has occurred in the transcription of the order. Errors may be prevented by taking unit-dose medications out of the wrapper at the bedside. Looking up usual dosage range prior to giving a medication may uncover an inaccurate dosage. If the order is unclear, the nurse must contact the prescribing physician for clarification.Rate this question:
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- 44.
When implementing medication therapy, the nurse's responsibilities include which of the following? Select all that apply:
- A.
Observe patient for drug side effects
- B.
Monitor for therapeutic effects
- C.
Prescribing an appropriate dose
- D.
Maintain a current knowledge base
- E.
Changing the dose if side effects take place
Correct Answer(s)
A. Observe patient for drug side effects
B. Monitor for therapeutic effects
D. Maintain a current knowledge baseExplanation
The nurse is responsible for observing medication side effects, monitoring for therapeutic benefits, and for maintaining an up-to-date knowledge base. The prescribing physician is responsible for ordering the right dosage and changing that dosage if side effects take place.Rate this question:
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- 45.
When medications act on receptors, what do they do? Select all that apply
- A.
Mimic the action of the body's own hormones
- B.
Change the enzymes made by the target cell
- C.
Block the action of the body's own compounds
- D.
Make the receptors respond in new ways
- E.
Change the receptors molecular structure
Correct Answer(s)
A. Mimic the action of the body's own hormones
C. Block the action of the body's own compoundsExplanation
Medications can only copy or block to action of endogenous compounds. Medications cannot change enzymes, cause new responses by receptors, or change a molecular structure.Rate this question:
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- 46.
After a PO medication has been absorbed, most of the medication is inactivated as the blood initially passes through the liver, producing an insignificant therapeutic effect. What do you call this?
- A.
Tolerance
- B.
Antagonism
- C.
Synergism
- D.
First pass effect
Correct Answer
D. First pass effectExplanation
Medications that are given orally are taken directly to the liver from the GI tract through the hepatic portal circulation. Some medications will be completely inactivated as they pass through the liver, and thus no therapeutic effect will happen. These medications must be administered through a NONENTERAL ROUTE.Rate this question:
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- 47.
Intravenous administration for a medication eliminates the need for ......
- A.
Distribution
- B.
Absorption
- C.
Metabolism
- D.
Excretion
Correct Answer
B. AbsorptionExplanation
IV administration delivers medication directly into the bloodstream, where it is rapidly distributed throughout the body.Rate this question:
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- 48.
Nitroglycerin (Nitrogard) tablets, often prescribed for patients with cardiovascular disorders, are given sublingually. What does this mean?
- A.
Crushed and ingested with a small amount of food
- B.
Held under the tongue until dissolved
- C.
Taken by mouth with a small amount of water
- D.
Placed between the cheek and gums
Correct Answer
B. Held under the tongue until dissolvedExplanation
Sublingual drugs are properly administered when placed under the tongue until they are dissolved. They are readily absorbed into the blood stream for systemic effects. They should not be crushed or taken with water. Medications places between the cheek and gums are delivered through the buccal route. The medication should dissolve and is usually used for local effects.Rate this question:
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- 49.
A nurse is taking care of a CVA patient with aphasia. Which of the following interventions promote communication?
- A.
Write down what the patient does not understand
- B.
Speak fast and loud
- C.
Allow plenty of time for the patient to respond
- D.
Reduce background noise
- E.
Use short sentences with simple words
Correct Answer(s)
A. Write down what the patient does not understand
C. Allow plenty of time for the patient to respond
D. Reduce background noise
E. Use short sentences with simple wordsExplanation
Reducing background noise provides a calm environment. Writing down what the patient does not understand allows time for the patient to respond, and using simple words and short sentences help promote communication with patients who are aphasic. The patient does not have hearing problems, so speaking loud and fast will not promote communication at all.Rate this question:
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- 50.
A patient who recently overdosed on amphetamines is experiencing sensory overload. Which of the following should be implemented?
- A.
Complete a thorough assessment ASAP
- B.
Transfer the client to a room with another hearing impaired client
- C.
Provide a private room and limit stimulation
- D.
Talk loudly to the patient and encourage ambulation.
Correct Answer
D. Talk loudly to the patient and encourage ambulation.Explanation
Minimizing stimuli helps patients with sensory overload. Immediately completing a thorough assessment might be overwhelming; therefore, brief assessments done over the course of the shift are preferred. Rooming the patient with another patient who is hearing impaired and/or talking in a loud voice would increase environmental stimuli and will be counter productive.Rate this question:
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Mar 21, 2023Quiz Edited by
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Jun 23, 2013Quiz Created by
Arnoldjr2
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