Answers & Rationales 1-d

7/30/2019 Answers & Rationales 1-d

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ANSWERS & RATIONALES

Question 1. The client is receiving preoperative teaching from the nurse. Which of theclients medications will the nurse advise the client to take the morning of surgery?

1. Parnate (tranylcypromine)

2. Lanoxin (digoxin)3.ASA (aspirin)4. Echinacea

Looking for answers(s):2Explanation: A is INCORRECT because Parnate is an antidepressant which is amonoamine oxidase inhibitor (MAOI). MAOIs can have serious interactions, such ashypertensive crisis, with some anesthetic medications used during surgery.B is CORRECT because in most cases, clients are advised to take routine cardiacmedications before surgery. All medications should be thoroughly reviewed beforesurgery and evaluated as to appropriateness.C is INCORRECT because aspirin inhibits platelet aggregation and as such interferes

with normal clotting. This can put the client at risk for excessive bleeding during and aftersurgery. Most surgeons ask their clients to stop taking aspirin at least 2 weeks beforesurgery.D is INCORRECT because herbal supplements, such as Echinacea, can haveundesirable interactions with anesthetic medications used during surgery.

Question 2. Which side effect is expected with bethanechol (Urecholine)?

1. Irritability2. Urinary urgency3. Tachycardia4. Hypertension

Looking for answers(s):2Explanation: A is INCORRECT because irritability is not a common side effect of thedrug.B is CORRECT because urinary urgency is a common side effect of the drug, which isused to treat urinary retention.C is INCORRECT because bradycardia is an adverse effect of the drug.D is INCORRECT because the cholinergic (muscarinic) effect causes hypotension andbradycardia, not hypertension. Syncope and cardiac arrest are also potentially life-threatening effects of the drug.

Question 3. The client takes digoxin (Lanoxin) 0.25 mg daily for atrial fibrillation. The

client also takes several herbal supplements. The nurse advises against taking whichherb?

1. Gingko2. Flaxseed3. Green tea4. Licorice


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Looking for answers(s):4Explanation: A is INCORRECT because gingko is not contraindicated with digoxin.B is INCORRECT because flaxseed is not contraindicated with digoxin.C is INCORRECT because green tea is not contraindicated with digoxin.D is CORRECT because licorice can contribute to digoxin toxicity.

Question 4. The nurse is giving Bactrim (trimethoprim-sulfamethoxazole) IV. Whichaction by the nurse would indicate a need for further instruction on the administration ofmedication?

1. Wearing gloves while giving the drug2. Recapping the needle after giving the drug3. Mixing the drug in 150 mL of diluent4. Discarding the tubing in a biomedical waste container

Looking for answers(s):2Explanation: A is INCORRECT because this action is not a concern; wearing gloves isalways a safe procedure.

B is CORRECT because this action indicates a need for further instruction; recappingincreases the risk of a needle stick, and potential exposure to HIV or hepatitis.C is INCORRECT because this is not a concern; the amount of diluent would beappropriate.D is INCORRECT because this action is not a concern; the infusion set should behandled safely, and placed in an appropriate biomedical waste container.

Question 5. For which effect(s) of a high dose of dopamine (Intropin), norepinephrine(Levophed), or phenylephrine (Neo-Synephrine) should the nurse assess?

1. Increased heart rate and contractility2. Vasodilation of blood vessels in heart and skeletal muscle

3. Relaxation of vascular smooth muscles4. Systemic vasoconstriction in GI tract, skin and kidneys

Looking for answers(s):4Explanation: A is INCORRECT because only dopamine increases contractility.Phenylephrine causes tachycardia, but norepinephrine causes bradycardia.B is INCORRECT because these drugs are vasopressors, causing vasoconstriction.C is INCORRECT because these drugs are vasopressors, causing vasoconstriction.D is CORRECT because all of these drugs cause vasoconstriction. They are used toincrease perfusion during shock.

Question 6. To administer psyllium (Metamucil) for constipation, the nurse should:

1. Have the pharmacy mix it in 6 oz. of orange juice and send it to the nursing unit2. Mix it in 2 oz. of water or juice at the clients bedside and have the client drink itimmediately3. Mix it in 8 oz of water at the bedside, have the client drink it immediately, and followwith 8 oz of water4. Mix it in applesauce, or other soft food, and give it with a hot drink


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Looking for answers(s):3Explanation: A is INCORRECT because the drug would be congealed by the time it wasreceived from the pharmacy. The drug may be mixed and taken with juice if the clientprefers.B is INCORRECT because this volume of liquid is inadequate.C is CORRECT because if the mixture is not taken immediately, it will congeal. Also, the

action of the drug is to combine with water to form an emollient gel, which promotesperistalsis. Adequate water or liquid is essential to drug effectiveness.D is INCORRECT because the granules are not to be chewed. Mixing with fluid formsthe emollient gel or viscous solution, which is key to the effectiveness of the bulk-forminglaxative.

Question 7. The drug Naprosyn (naproxen) would be contraindicated in a client with:

1. Dysmenorrhea2. Rheumatoid arthritis3. Gout4. Ulcer disease

Looking for answers(s):4Explanation: A is INCORRECT because Naprosyn is indicated for use in clients withdysmenorrhea.B is INCORRECT because Naprosyn is indicated for use in clients with rheumatoidarthritis.C is INCORRECT because Naprosyn is indicated for use in clients with gout.D is CORRECT because side effects of Naprosyn include GI ulceration, bleeding, andperforation, and would be contraindicated in a client with existing ulcer disease.

Question 8. The nurse tells the client who is using a client-controlled analgesia (PCA),that a desired outcome is:

1. Increased drug dependence2. Decreased drug tolerance3. Increased drug effectiveness4. Decreased drug dosage

Looking for answers(s):3Explanation: A is INCORRECT because dependence is not the desired outcome, and isnot as likely with effective pain management.B is INCORRECT because drug tolerance might increase, not decrease, with frequentuse of a drug.C is CORRECT because PCA provides the client with the greatest control and the

greatest drug effectiveness, because the client will be able to administer the drug asneeded before the pain level worsens.D is INCORRECT because the desired outcome is not necessarily a decreased dosage,but rather, less medication as an end-result of effective pain management.

Question 9. The nurse will know pilocarpine has produced the desired action whenwhich manifestation is observed?

1. Pupil constriction


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2. Clear appearance of iris3. Corneal cloudiness4. Pink conjunctiva

Looking for answers(s):1Explanation: A is CORRECT because the drug is a miotic which causes constriction of

the pupil. (Mydriatics cause dilation).B is INCORRECT because the drug has no effect on the iris.C is INCORRECT because cloudiness of the cornea would be abnormal, not a positiveeffect.D is INCORRECT because the drug is not used to treat conjunctival inflammation.

Question 10. The nurse knows that the optimal effect of an antacid for hyperacidityoccurs when it is given at which time?

1. 1 hour before meals2. With meals3. 12 hours after meals

4.As the need arises

Looking for answers(s):3Explanation: A is INCORRECT because this does not give the optimal effect.B is INCORRECT because H2 blockers, such as Tagamet, are taken with meals.C is CORRECT because the acidity is the greatest 12 hours after eating.D is INCORRECT because the question asks for the optimal time. The client may takethe antacid as needed until the H2 blocker, which is usually also prescribed, has takeneffect.

Question 11. The written order in the chart states 100,000 U Penicillin IV. Themedication rand says 1,000,000 U IV and the bag from the pharmacy has 1,000,000 U.

What should the nurse do?

1. Give 100,000 U2. Give 1,000,000 U3. Check with the pharmacy4. Check with the MD

Looking for answers(s):4Explanation: A is INCORRECT because there is a discrepancy between the chart andthe rand.B is INCORRECT because there is a discrepancy between the chart and the rand.C is INCORRECT because the dose from the pharmacy is different from the order in the

chart.D is CORRECT because the original order needs to be verified. The usual adult dose IVis 15 million units every 46 hours.

Question 12. For which reason is morphine sulfate (MS) given to a client with symptomsof pulmonary edema?

1. To reduce venous return2. To relieve chest pain


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3. To decrease alveolar congestion4. To decrease heart rate

Looking for answers(s):1Explanation: A is CORRECT because MS is a vasodilator which will reduce venousreturn and decrease the workload of the heart. The drug also slows respiratory rate and

decreases client anxiety.B is INCORRECT because chest pain is not a symptom of pulmonary edema.C is INCORRECT because MS does not decrease alveolar congestion. Positivepressure breathing treatments reduce the leaky capillary syndrome seen in pulmonaryedema.D is INCORRECT because slowing the heart rate is not the primary purpose, althoughthe drug does cause bradycardia.

Question 13. What manifestation should the nurse recognize as a side effect offurosemide (Lasix)?

1. Nystagmus

2. Stomatitis3. Muscle cramping4. Hematuria

Looking for answers(s):3Explanation: A is INCORRECT because jerking eye movements (nystagmus) areassociated with inner ear or cranial nerve damage.B is INCORRECT because mouth sores (stomatitis) are often a side effect ofchemotherapy.C is CORRECT because loop diuretics like Lasix, as well as thiazide diuretics, cause aloss of potassium, which affects muscle function.D is INCORRECT because hematuria, blood in the urine, would not be expected from

Lasix. Increased urine output would reflect the diuretic action of Lasix.

Question 14. The nurse tells the client an expected side effect of Pyridium(phenazopyridine hydrochloride) is:

1. Urinary frequency2. Jaundice3. Bright orange urine4. Urticaria

Looking for answers(s):3Explanation: A is INCORRECT because Pyridium is a urinary analgesic, and should

eliminate the symptom of frequency caused by an infection.B is INCORRECT because jaundice is not expected; however, the drug is hepatotoxic.C is CORRECT because Pyridium will turn the urine bright orange, which may stainclothing or bedding.D is INCORRECT because, although a rash may develop from this drug, it is not anexpected effect. If a rash develops, the physician should be notified.


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Question 15Client-controlled analgesia (PCA) is being planned for the client with bonemetastasis. Why would the nurse question this method of analgesia?

1. Central pain, not peripheral pain will be targeted2. Pulmonary function may be diminished3. The clients peripheral veins are fragile

4. The client may accidentally overdose

Looking for answers(s):1Explanation: A is CORRECT because with bone pain, NSAIDs and antispasmodics maybe more effective.B is INCORRECT because pulmonary function actually increases with PCA, becausesedation is less.C is INCORRECT because there is no data to support fragile veins.D is INCORRECT because there is a maximum dosage that is preset in the PCA.

Question 16. The nurse should question an order for atropine sulfate, an anticholinergic,for a client with acute glaucoma because:

1. Photosensitivity will result2.Aqueous humor flow will be obstructed3. Visual acuity will be diminished4. Intraocular pressure will be dangerously low

Looking for answers(s):2Explanation: A is INCORRECT because the drug does not cause photosensitivity.

B is CORRECT because anticholinergics cause mydriasis, or pupil dilation, whichimpairs aqueous humor flow, and would increase intraocular pressure.

C is INCORRECT because the drug does not directly cause diminished visual acuity(however, if intraocular pressure remained elevated, blindness would result).

D is INCORRECT because the concern with glaucoma is a dangerously high intraocularpressure, not low pressure.

Question 17. Which complaint by the client would be an expected side effect whenatropine is given preoperatively?

1. Dizziness2. Drowsiness

3. Urinary urgency4. Light sensitivity

Looking for answers(s):4Explanation: A is INCORRECT because dizziness is not a side effect of atropine.

B is INCORRECT because atropine is not a sedative.

C is INCORRECT because atropine, an anticholinergic, causes urinary retention.


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D is CORRECT because atropine is an anticholinergic, and causes pupil dilation andsensitivity to light

Question 18. Which nursing action would result in decreased absorption of Catapres viaa transdermal patch?

1. Washing skin with soap and water before application2.Applying patch to hairless site on upper arm3. Changing the system once every 7 days4. Placing the patch on the anterior or inner thigh

Looking for answers(s):4Explanation: A is INCORRECT because this is a proper nursing action to maximizeabsorption. The site should be dried thoroughly before application.

B is INCORRECT because this is a proper nursing action to maximize absorption. Any

hairless site may be used, but the sites should be rotated. Absorption is greatest whenplaced on the chest and upper arm. Avoid cuts or calluses.

C is INCORRECT because this is a proper nursing action to maximize absorption. Thepatch is applied once every 7 days.

D is CORRECT because absorption is decreased when placed on the thigh, most likelybecause the thigh frequently has more adipose.

Question 19. The client is to receive 30 mEq of potassium chloride in each 1000 mL ofIV fluid. 700 mL of IV fluid remains in the present infusion. A 10 mL-vial containing 20mEq of KCL is available. How much KCL should be added to the existing IV?

1. 5 mL2. 10.5 mL3. 15.5 mL4. 21 mL

Looking for answers(s):2Explanation: A is INCORRECT because this amount is insufficient.

B is CORRECT because there should be 3 mEq in each 100 mL. With 700 mLremaining, 21 mEq should be added to the existing IV10.5 mL.

C is INCORRECT because this amount is excessive.

D is INCORRECT because this amount is excessive.

Question 20. When should prescribed medication be given to achieve optimum painmanagement for a client 24 hours after surgery?


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1.After the pain becomes severe2. When the client asks3. Before the pain is severe4. When the client looks uncomfortable

Looking for answers(s):3

Explanation: A is INCORRECT because if pain is allowed to intensify before each doseof medication, it will take longer and require more medication to manage the pain.

B is INCORRECT because cultural norms and fear of addiction may cause a client toavoid asking for pain medication as often as needed.

C is CORRECT because if pain is allowed to intensify before each dose of medication, itwill take longer and require more medication to manage the pain.

D is INCORRECT because some clients may not appear to be in pain, although the painmay be severe and real.

Question 21.A client who has been taking digitalis for heart failure is admitted withnausea and a potassium level of 2.5 mEq/L. The nurse should first assess for signs of:

1. Metabolic acidosis2. Bowel obstruction3. Digitalis toxicity4. Renal failure


Explanation: A is INCORRECT because a low potassium would more likely beassociated with metabolic alkalosis.

B is INCORRECT because a bowel obstruction may cause a loss of fluids andelectrolytes, but there is insufficient data to draw that conclusion.

C is CORRECT because the combination of digitalis and low potassium increases therisk of digitalis toxicity. The client may complain of nausea, vomiting, and yellow vision.

D is INCORRECT because renal failure would likely cause an increase in potassium,and would not be associated with a decrease.

Question 22. To deliver 1000 mL of D5W in 12 hours (15 gtt/mL), at what drip rateshould the nurse set the infusion?

1. 20 gtt/min2. 25 gtt/min3. 30 gtt/min4. 35 gtt/min


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Looking for answers(s):1Explanation: A is CORRECT because the formula for calculating drops per minute is: mLper hour (83 mL) times drop factor (15 gtt/mL) divided by 60 minutes equals about 20drops per minute.

B is INCORRECT because this rate is too fast.

C is INCORRECT because this rate is too fast.

D is INCORRECT because this rate is too fast.

Question 23. The client takes phenytoin (Dilantin) 300 mg PO every evening for aseizure disorder. Which other medication will the nurse recommend against taking?

1. Prazosin (Minipress)2. Famotidine (Pepcid)3.Antacids (Maalox, Gelusil)4. Sumatriptan (Imitrex)

Looking for answers(s):3Explanation: A is INCORRECT because prazosin is not contraindicated with phenytoin.B is INCORRECT because famotidine is not contraindicated with phenytoin.

C is CORRECT because antacids decrease the effect of phenytoin, as they do withmany other medications.

D is INCORRECT because sumatriptan is not contraindicated with phenytoin.

Question 24. The nurse needs to start intravenous lines on 4 clients. Which IV lineshould be started first?

1.A client just admitted for severe pain from cancer2.A client who will be going to elective surgery in 1 hour3.A client who needs a new IV started for an antibiotic that is due in 15 minutes4.A client who will receive 2 units of packed red blood cells after being typed andcrossmatched

Looking for answers(s):1Explanation: A is CORRECT because the client with severe pain has the mostimmediate need for an intervention.

B is INCORRECT because the nurse still has some time before the client needs to havethe IV in place for surgery.

C is INCORRECT because, according to the 30 minute rule, the nurse still has 45minutes before the antibiotic must be administered.


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D is INCORRECT because the process of typing and crossmatching the blood will takeawhile, leaving the nurse time to start other IV lines.

Question 25. When the client returns to the post-anesthesia recovery room followingsurgery, the nurse should start oxygen via mask in order to initially:

1. Hyperventilate the lungs2. Prevent hypostatic pneumonia3. Minimize effects of hypoventilation4. Speed the elimination of anesthesia

Looking for answers(s):3Explanation: A is INCORRECT because the client does not experience hyperventilation.

B is INCORRECT because once the client is awake, if the client does not soon begin tobreathe deeply and cough, hypostatic pneumonia will result.

C is CORRECT because general anesthesia reduces respiratory muscle function, andpulmonary expansion decreases. Oxygen supplementation minimizes the effects ofhypoventilation until the client is awake.

D is INCORRECT because oxygen therapy, given by mask or cannula, does notincrease respiratory rate or depth. This is important in order to eliminate the anesthetic.

Question 26. Two hours after receiving morphine (MS) 8 mg IV, which is ordered q 4hr., the client complains of severe chest pain. What is the appropriate nursingintervention?

1. Tell the client to wait 2 hours for more medication2. Change the clients position and reassess the pain in one hour3. Reassess the clients vital signs and contact the physician4. Give 4 mg of MS, since half the time has passed

Looking for answers(s):3Explanation: A is INCORRECT because waiting two hours could be life-threatening if theclient is having another MI.

B is INCORRECT because the client may be having another MI, and waiting could belife-threatening.

C is CORRECT because the dosage is not sufficient to manage the clients pain. Theclient may be experiencing an extension of the infarction.

D is INCORRECT because the chest pain needs to be evaluated, not masked by anarcotic; moreover, the nurse cannot change the dosage or frequency without aphysicians order.


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Question 27. The nurse should teach relaxation techniques to a client in pain, in orderto:

1. Eliminate the need for analgesia2. Reduce pain stimulation

3. Enable the client to sleep better4. Enhance the effects of the analgesic

Looking for answers(s):4Explanation: A is INCORRECT because relaxation should not be a substitute forappropriate analgesics in managing pain.

B is INCORRECT because relaxation does not reduce the stimuli.

C is INCORRECT because the purpose is to achieve effective pain management. If thisis effective, the client should then be able to sleep.

D is CORRECT because relaxation will increase the effectiveness of the prescribedanalgesic.

Question 28. The nurse would recognize tetany following a thyroidectomy if the clientexperienced which symptom?

1. Hoarseness and weak voice2. Numbness and tingling around the mouth3. Hypotension and vertigo4. Tachycardia

Looking for answers(s):2Explanation: A is INCORRECT because hoarseness and a weak voice would indicatedamage to the laryngeal nerve, or irritation from endotracheal intubation.

B is CORRECT because numbness and tingling around the mouth, fingertips or toes aredue to hypocalcemia; tetany or carpopedal spasms are other signs of hypocalcemia.Calcium is necessary for normal nerve function. During thyroid surgery, the parathyroidglands may accidentally be removed, causing hypocalcemia after the surgery.

C is INCORRECT because hypotension would occur from blood loss.

D is INCORRECT because tachycardia could indicate an infection, bleeding or thyroidstorm.

Question 29. The client has received atropine 1 mg IV push. What effects would thenurse expect from this drug?

1. Decreased pulse and increased blood pressure2. Increased pulse and blurred vision


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3. Decreased pulse and bronchoconstriction4. Increased pulse and decreased blood pressure

Looking for answers(s):2Explanation: A is INCORRECT because the drug increases heart rate, and there is noexpected effect on blood pressure.

B is CORRECT because the anticholinergic (antimuscarinic) effects of atropine includeincreased heart rate and blurred vision. The drug is frequently used for bradycardia, buthas no expected effect on blood pressure.

C is INCORRECT because the drug increases heart rate and dries respiratorysecretions; it does not constrict the bronchioles.

D is INCORRECT because the drug does not affect the blood pressure.

Question 30. Which nursing measure would most likely prevent atelectasis in apostoperative client?

1. Encouraging fluids hourly2.Ambulating every shift3. Using an incentive spirometer4. Humidifying the room air

Looking for answers(s):3Explanation: A is INCORRECT because fluids do not promote deep breathing, althoughthey will liquefy secretions if they accumulate.

B is INCORRECT because ambulation is important to prevent venous stasis, relieve gas

distention, and promote intestinal motility.

C is CORRECT because an incentive spirometer promotes deep breathing, whichimproves oxygenation and prevents alveolar collapse.

D is INCORRECT because humidification does not promote deep breathing.

Question 31. What time frame reflects the onset of action for sublingual nitroglycerin?

1. 12 minutes2. 34 minutes3. 56 minutes

4. 78 minutes

Looking for answers(s):1Explanation: A is CORRECT because the onset of the drug is 13 minutes. The peakeffect is unknown. The duration of effects may be 3060 minutes. The half-life is 4minutes.


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B is INCORRECT because this amount of time is too long.

C is INCORRECT because this amount of time is too long.

D is INCORRECT because this amount of time is too long.

Question 32.A client has had a thyroidectomy. Which assessment during theimmediate postop period would be most important for the nurse to make?

1. Check behind the neck for bleeding2. Palpate the carotid pulse regularly3. Check the mouth and tongue for irritation4. Check for return of the gag reflex

Looking for answers(s):1Explanation: A is CORRECT because bloody drainage may pool behind the neck, andnot be visible on the dressing.

B is INCORRECT because the carotid pulse should not be damaged during the surgery.

C is INCORRECT because there is no reason to expect oral irritation.

D is INCORRECT because, when the effects of general anesthesia are gone, thereshould be no impairment of the gag reflex. (Cranial nerves IX and X govern the gagreflex; these are not affected by thyroid surgery).

Question 33. Which side effect of Synthroid should the nurse teach the client to report?

1. Irritability2. Stomatitis3.Ankle edema4. Hematuria

Looking for answers(s):1Explanation: A is CORRECT because the action of the drug is to increase the metabolicrate. Irritability, insomnia, and nervousness are frequent side effects.

B is INCORRECT because mouth sores are not expected.

C is INCORRECT because ankle edema, seen with heart failure or venous stasis, is nota common side effect. The drug does have cardiac effects, but the dosage would be

altered before cardiovascular failure would occur.

D is INCORRECT because there are no known urologic effects.

Question 34. What is an important nursing intervention for a client receiving allopurinol(Zyloprim) for hyperuricemia?

1. Encouraging the client to eat foods high in iron2. Giving the drug before meals


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3. Encouraging the client to drink at least 23L of fluid daily4. Straining the urine for sediment or stones

Looking for answers(s):3Explanation: A is INCORRECT because foods high in iron will have no effect on thepurine level, and will not reduce serum uric acid.

B is INCORRECT because the drug is frequently taken with milk or meals to minimizegastric irritation.

C is CORRECT because hyperuricemia (gout) may cause renal damage; large amountsof daily fluids (20003000mL) will flush the kidneys. Decreased kidney function mayresult in drug accumulation.

D is INCORRECT because straining is done for calculi. The development of kidneystones is a major concern, and hopefully will be avoided by drug therapy and fluids.

Question 35. Which assessment finding would reflect the desired effect of digoxin?

1. Decrease in heart rate2. Change in cardiac rhythm3. Increase in blood pressure4. Clearing of breath sounds

Looking for answers(s):1Explanation: A is CORRECT because digoxin, an inotropic drug, is given to slow the rateand increase the strength of cardiac contraction, and improve cardiac output. Byincreasing the force of myocardial contraction, an improvement in cardiac function will, in

turn, affect the blood pressure, and hopefully eliminate the signs of congestive failure.

B is INCORRECT because changes in the rhythm, such as bigeminy, would be a sideeffect.

C is INCORRECT because digoxin acts directly on the heart. Blood pressure will, in turn,be affected indirectly due to improved cardiac function.

D is INCORRECT because congested breath sounds, which will result from a failing leftheart, are treated directly with diuretics to reduce the circulating volume.

Question 36. Which needle gauge should the nurse select to administer a transfusion?

1. 18 gauge2. 20 gauge3. 22 gauge4. 24 gauge


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Looking for answers(s):1Explanation: A is CORRECT because the needle must be at least an 18 gauge, or therewill be lysis of the red blood cells.

B is INCORRECT because this gauge is too small, and will cause lysis of the red bloodcells.

C is INCORRECT because this gauge is too small, and will cause lysis of the red bloodcells.

D is INCORRECT because this gauge is too small, and will cause lysis of the red bloodcells.

Question 37. Which complaint would alert the nurse to an allergic reaction to IVcefazolin (Ancef)?

1. Itching at the IV site2.Abdominal cramps

3. Diarrhea4. Increased urinary output

Looking for answers(s):1Explanation: A is CORRECT because itching at the insertion site, as well as moregeneralized rashes or urticaria, indicates a hypersensitivity to the drug. Phlebitis is also acommon side effect at the IV site. The site should be changed every 48-72 hours.

B is INCORRECT because abdominal cramps are a side effect of oral administration.Nausea and vomiting may also occur.

C is INCORRECT because diarrhea is a side effect of oral administration.

D is INCORRECT because, although kidneys excrete cephalosporins, an allergicreaction will not increase urine output.

Question 38. The nurse should expect to give a preoperative enema to a client who is toundergo repair of a torn bladder in order to:

1. Prevent bacteria from the bowel entering the peritoneum2. Relieve gas distention in the bowel3. Prevent bowel evacuation during surgery4. Insure return of peristalsis after surgery

Looking for answers(s):3Explanation: A is INCORRECT because it is not intended that the bowel will be enteredduring the procedure; moreover, bowel sterilization preoperatively would be necessary toprevent contamination of the sterile field.


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B is INCORRECT because there is no indication of distention preoperatively, althoughthat may be a problem postoperatively.

C is CORRECT because having a bowel movement during surgery could potentiallycontaminate the operative field.

D is INCORRECT because peristalsis returns when the effects of anesthesia or surgeryhave resolved.

Question 39. The client complains of neck tension 12 hours after a thyroidectomy.Which nursing intervention would be appropriate?

1. Turning the neck from side to side slowly2. Gently rubbing the back of the neck3. Repositioning the sandbag to hold the neck to the right4.Administering an antispasmodic as ordered

Looking for answers(s):2Explanation: A is INCORRECT because during the immediate postop period, the neckshould remain immobile. Around the second to fourth day after surgery, range-of-motionexercises will be started.

B is CORRECT because the clients neck is immobilized with sandbags to prevent side-to-side movement, hyperextension or flexion, which would strain the suture line.

C is INCORRECT because turning the head to one side or the other will put a strain onthe incision.

D is INCORRECT because the neck tension is not from muscle spasm, but rather from

the need to keep the neck in one position initially after surgery.

Question 40. The nurse is to give 1 gram of lidocaine in 500 mL of D5W to run at 4 mgper minute. How many mL per minute will the client receive?

1. mL/min2. 1 mL/min3. 1 mL/min4. 2 mL/minLooking for answers(s):4Explanation: A is INCORRECT because this rate is too slow to deliver the ordered dose.

B is INCORRECT because this rate is too slow to deliver the ordered dose.

C is INCORRECT because this rate is too slow to deliver the ordered dose.

D is CORRECT because with 1 gram in 500 mL, the concentration is 2 mg per mL. Toadminister the ordered 4 mg/min, the IV should run at 2 mL/min.


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Question 41. The nurse discusses discharge planning with a client receiving cimetidine(Tagamet). Which side effect would influence the clients return to work?

1. Dizziness, which usually passes with time2. Diarrhea that can be controlled with diet3. Breast enlargement, which can be hidden by clothes

4.An unsightly rash that may be embarrassing in public

Looking for answers(s):1Explanation: A is CORRECT because a transient and short-lived side effect of cimetidineis dizziness. Initially it would be a problem, because driving to work would be unsafe.

B is INCORRECT because, although this is a side effect, it occurs in a very smallpercentage of clients, and is not a safety risk.

C is INCORRECT because, although this is a side effect, it occurs in a very smallpercentage of clients, and is not a safety risk.

D is INCORRECT because, although this is a side effect, it occurs in a very smallpercentage of clients, and is not a safety risk.

Question 42. The nurse needs to know that the primary purpose of Compazineprescribed for a client following a stapedectomy is to:

. Relieve dizziness2. Control vomiting3. Reduce inflammation4. Provide sedation

Looking for answers(s):1Explanation: A is CORRECT because ear surgery may cause dizziness. The dizzinessmay cause vomiting, resulting in excessive pressure in the ear. In many cases, thedizziness will resolve rapidly, not even requiring medication.

B is INCORRECT because vomiting is not expected unless dizziness is present. Theclient generally has received a local anesthetic with sedation. Nausea, often associatedwith general anesthesia, is therefore not a concern.

C is INCORRECT because Compazine has no anti-inflammatory properties

D is INCORRECT because, although sedation is a side effect of Compazine, it isirrelevant in this situation.

Question 43. The client is receiving Ceclor (cefaclor) for a respiratory infection, as wellas probenecid (Benemid); the client has no history of gouty arthritis. What is therationale for the use of probenecid?


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1. To prevent hyperuricemia secondary to anti-infective therapy2. To prolong serum levels of the anti-infective3. To replace normal flora destroyed by the anti-infective4. To reduce inflammation of the intercostals

Looking for answers(s):2Explanation: A is INCORRECT because there is not an increase in serum uric acidlevels with anti-infective therapy. Probenecid is used in the treatment of hyperuricemiawith gout.

B is CORRECT because concurrent administration of probenecid and anti-infective(most often penicillin) decreases renal excretion of the penicillin and increases the drughalf-life.

C is INCORRECT because the drug does not restore the normal flora, which isdestroyed with anti-infective therapy.

D is INCORRECT because there is no data indicating intercostal inflammation, andprobenecid is not an anti-inflammatory agent. It is classified as a uricosuric (antigout)agent.

Question 44. The client is 6 hours post-craniotomy, and is becoming increasinglyrestless. What is the appropriate action by the nurse?

1. Check Glasgow coma scale2. Obtain an order for sedation3. Place the client flat in bed4. Restrain the clients arms

Looking for answers(s):1Explanation: A is CORRECT because a client should be reassessed before calling theMD. None of the other options offered would provide data, or improve the clientscondition before calling the MD.

B is INCORRECT because restlessness may indicate hypoxia, or increasing ICP;sedation would mask the symptoms.

C is INCORRECT because, if restlessness were due to increasing ICP, this positionwould further increase the cerebral pressure.

D is INCORRECT because the cause of the restlessness needs to be found, rather thancontrolling the restless movements.

Question 45. To achieve optimal therapeutic effect from erythromycin, under whichcondition should the nurse administer the medication?


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1. With a full glass of water or juice2.At mealtime, to minimize GI irritation3. With an antacid, to increase absorption4.At least 1 hour before or 2 hours after meals

Looking for answers(s):4Explanation: A is INCORRECT because the drug should not be taken with juices, whichmay change stomach pH. It should be taken with a full glass of water.

B is INCORRECT because food affects absorption. If GI upset occurs, the drug may betaken with food, but it will not have the optimal therapeutic effect.

C is INCORRECT because the drug is best absorbed in an acid environment in theduodenum.

D is CORRECT because the optimal absorption is on an empty stomach, when theacidity of the stomach is the greatest.

Question 46. Discharge teaching on the proper use of nitroglycerin sublingually wouldinclude instructions to:

1. Take one tablet each morning before breakfast2. Take no more than three tablets within 15 minutes3. Store tablets in a clear glass container4. Call the MD if a tingling under the tongue occurs


Explanation: A is INCORRECT because NTG is taken only as needed, not on a regularschedule.

B is CORRECT because the maximum dosage is 3 tablets taken 5 minutes apart, over a15-minute period of time. The client needs to be assessed for a possible heart attack ifthe pain is not relieved by this dosage of NTG.

C is INCORRECT because the effectiveness of the tablets will decrease when stored inclear glass. The pills are kept in a dark glass bottle.

D is INCORRECT because the tingling is a normal, expected response, and indicatesthe tablets are still potent.

Question 47. Which nursing diagnosis would be a priority immediately after alaryngectomy?

1. Impaired swallowing2.Activity intolerance3. Hypothermia4. Ineffective airway clearance


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Looking for answers(s):4Explanation: A is INCORRECT because swallowing would be a concern later, whenresuming oral intake.

B is INCORRECT because there is no anticipated effect on activity.

C is INCORRECT because there is no anticipated effect on body temperature.

D is CORRECT because swelling in the operative area may result in airway obstruction.

Question 48. What action of levothyroxine sodium (Synthroid) would the nurse expect ina client with myxedema (hypothyroidism)?

1. Production of thyroid-stimulating hormone (TSH)2. Regeneration of the thyroid gland function3. Stimulation of thyroid function4. Replacement of thyroid hormone

Looking for answers(s):4Explanation: A is INCORRECT because the drug does not produce TSH, but isreplacement therapy.

B is INCORRECT because, with hypothyroidism, the gland does not regenerate.

C is INCORRECT because the drug is replacement therapy. Thyroid function ispermanently impaired.

D is CORRECT because Synthroid is a synthetic thyroid hormone, and replaces thehormone, which would normally be secreted by the thyroid gland.

Question 49. Which nursing action is indicated initially with a peripheral IV that is notinfusing properly?

1. Elevate the infusion site2. Check the skin around the infusion site3. Increase the height of the solution4. Irrigate the tubing with sterile saline

Looking for answers(s):2Explanation: A is INCORRECT because elevating the infusion site usually slows the

infusion rate. Straightening the limb may help, if the IV needle is in an elbow or wristarea.

B is CORRECT because inspection or assessment of the skin is the first action. If thereare no signs of infiltration or phlebitis, then the nurse should assess the tubing,reposition the clients hand (or arm) or elevate the solution.


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C is INCORRECT because, although elevating the solution higher above the infusionsite may help, it should be done only after checking for infiltration or phlebitis.

D is INCORRECT because irrigation should not be the initial action. If no signs ofinfiltration or phlebitis are present, irrigation may be done after aspirating for a bloodreturn, and if there is no indication of dislodging a clot at the tip of the needle.

Question 50. Which side effect of diltiazem (Cardizem) would the nurse instruct theclient to expect?

1. Postural hypotension with position changes2. Reflex tachycardia and hypertension3.Abdominal discomfort and diarrhea4. Bleeding gums with brushing


Explanation: is CORRECT because diltiazem is a calcium blocker which producescoronary vasodilation and lowers blood pressure.

B is INCORRECT because the drug may slow SA and AV conduction and pulse rate.

C is INCORRECT because the drug causes constipation.

D is INCORRECT because the drug may cause gingival hyperplasia.

Question 51. To evaluate the effects of isosorbide dinitrate (Isordil) given for heartfailure, the nurse must know that the drug reduces myocardial workload by:

1. Increasing venous capacity2. Increasing peripheral vascular resistance3. Increasing cardiac output4. Increasing afterload

Looking for answers(s):1Explanation: A is CORRECT because vasodilating agents, such as Isordil, relax thevenous smooth muscle and increase the capacity of the systemic venous bed, trappingblood, and decreasing venous return.

B is INCORRECT because resistance is decreased with the relaxation of the venoussmooth muscle.

C is INCORRECT because vasodilation will reduce cardiac output.

D is INCORRECT because vasodilation will reduce preload and afterload.

Question 52. What is the desired effect of pilocarpine hydrochloride when used to treatglaucoma?


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1. Reducing inflammation in the eyes2. Reducing intraocular pressure3. Increasing aqueous humor production4. Dilating the pupils

Looking for answers(s):2Explanation: A is INCORRECT because the drug has no anti-inflammatory properties.

B is CORRECT because pilocarpine is a miotic which constricts the pupil, improvesaqueous humor flow, and reduces the intraocular pressure.

C is INCORRECT because the drug does not increase the amount of aqueous humor; itimproves the flow of aqueous humor.

D is INCORRECT because the drug causes pupil constriction. Agents causing pupildilation are contraindicated with glaucoma.

Question 53.A client newly diagnosed with rheumatoid arthritis is started on ASA 4gm/day in divided doses. Which mild symptoms of toxicity should the nurse tell the clientthat the dosage will initially produce?

1. Tinnitus2. GI bleeding3. Dizziness4. Nausea


Explanation: A is CORRECT because high dosages, 26 gm per day in divided doses,may cause tinnitus (ringing in the ears). The dosage is reduced until the symptom isgone.

B is INCORRECT because using enteric-coated aspirin should prevent the risk of GIbleeding.

C is INCORRECT because dizziness may indicate anemia from GI bleeding.

D is INCORRECT because using enteric-coated aspirin can minimize nausea, which is aside effect.

Question 54. Which herbal supplement might the nurse recommend to a client formotion sickness?

1. Echinacea2. Glucosamine3. Chamomile4. Ginger


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Looking for answers(s):4Explanation: A is INCORRECT because echinacea is used to improve the immunesystem.

B is INCORRECT because glucosamine is an amino acid that plays a role in cartilagesynthesis and is used for arthritis and joint injuries.

C is INCORRECT because chamomile is considered an anti-inflammatory,antispasmodic, anti-infective, and a mild sedative.

D is CORRECT because ginger has some antiemetic properties, and in appropriatedoses can be used for nausea and vomiting as well as motion sickness.

Question 55. (What is the proper administration of trimethoprim-sulfamethoxazole(Bactrim) IV, used to treat Pneumocystis pneumonia?

1. Give the drug through a central line catheter

2. Give the drug slowly over one hour3. Mix the drug in normal saline4. Discard the drug if clearLooking for answers(s):2Explanation: A is INCORRECT because a peripheral site may be used. The site shouldbe checked frequently because phlebitis is common.

B is CORRECT because the drug should be given over 6090 minutes.

C is INCORRECT because each 5 mL ampule is diluted in 125 mL of D5W.

D is INCORRECT because the solution should be clear. Discard if cloudy or if a

precipitate is present.

Question 56. Postoperative coughing and deep breathing by the client will minimize theincidence of which complication?

1. Hypostatic pneumonia2. Bronchial constriction3.Acute bronchitis4.Aspiration pneumonia

Looking for answers(s):1Explanation: A is CORRECT because surgery and general anesthesia causehypoventilation, and increase the risk of atelectasis and hypostatic pneumonia whensecretions accumulate.

B is INCORRECT because the concern is with hypoventilation and collapsed alveoli.Large airways may become plugged with mucus, but they are not generally swollen andedematous as a result of surgery.


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C is INCORRECT because pneumonia, rather than bronchitis, results from surgery.

. D is INCORRECT because after surgery, the concern is with hypoventilation(hypostasis). (Aspiration pneumonia may result if the client vomits during or immediatelyafter surgery; coughing and deep breathing will not prevent this type of pneumonia).

Question 57. The physician orders phenytoin (Dilantin) 150 mg IV push for a seizureactivity. What is the appropriate intervention for safe administration of IV Dilantin?

1. Giving 50 mg/min slow IV push closest to the insertion site2. Mixing it in D5W and running over 3 minutes3. Injecting it at Y-connector to mix with existing IV solution4.Adding it to existing IV and running over 4 hours

Looking for answers(s):1Explanation: A is CORRECT because the rate for direct IV administration should not

exceed 50 mg over 1 minute (25 mg/min in elderly clients). Rapid administration maycause severe hypotension or CNS depression.

B is INCORRECT because the drug will precipitate with dextrose. If given by intermittentinfusion, the drug should be mixed in 0.9% NaCl in a concentration of 1 10 mg/mL. Donot exceed 50 mg/min. Follow with normal saline to minimize local irritation.

C is INCORRECT because the existing solution would need to be known. The drug willprecipitate with dextrose, and is incompatible with potassium chloride frequently addedto IV infusions.

D is INCORRECT because the existing IV may be incompatible with the drug,

particularly dextrose. If given intermittently, it should run within 4 hours at rate not toexceed 50 mg/min.

Question 58. Discontinuing steroid therapy abruptly may precipitate which life-threatening situation?

1. Increased appetite and weight gain2. Hypotension and hypoglycemia3. Edema and hypertension4. Decreased wound healing and petechiae

Looking for answers(s):2Explanation: A is INCORRECT because these are less serious side effects of the drug, aglucocorticoid, which results in hyperadrenalism.

B is CORRECT because these are signs of adrenal suppression, which is potentially life-threatening. Although the drug is used to manage adrenal insufficiency, it suppressesnormal adrenal function, and if it is stopped suddenly, adrenal suppression andcirculatory collapse may occur.


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C is INCORRECT because these are less serious side effects of the drug, aglucocorticoid, which results in hyperadrenalism.

D is INCORRECT because these are less serious side effects of the drug, aglucocorticoid, which results in hyperadrenalism.

Question 59The client is taking 80 mg of prednisone PO daily to treat graft-versus-host(GVH) disease one year after a bone marrow transplant. What should the client avoid?1.Alcohol2. Grapefruit juice3.Acetaminophen4. Foods high in potassium

Looking for answers(s):1Explanation: A is CORRECT because alcohol increases the side effects of prednisone.

B is INCORRECT because grapefruit juice is not contraindicated with prednisone.

C is INCORRECT because acetaminophen is not contraindicated with prednisone.

D is INCORRECT because foods high potassium are not contraindicated withprednisone

Question 60. Which nursing action is best to relieve severe gas pains following surgery?

1. Instruct the client on relaxation techniques2. Massage the abdomen from right to left3. Encourage the client to ambulate several times daily4. Offer sips of hot tea every hour

Looking for answers(s):3Explanation: A is INCORRECT because this is not the best action, although relaxationtechniques are useful in pain management.

B is INCORRECT because massage will not enhance diminished peristalsis, which isthe likely cause of the gas distention.

C is CORRECT because ambulation is the best intervention to relieve gas pains andpromote peristalsis.

D is INCORRECT because until peristalsis returns, the client may be NPO. Local heatmay help.

Question 61. What is the purpose of the nasogastric tube for a client post-cholecystectomy?


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1. Prevent accumulation of stomach contents2. Prevent accumulation of bile in the small intestine3. Promote passage of digestive enzymes through the pylorus4. Inhibit HCL acid production in the stomach

Looking for answers(s):1Explanation: A is CORRECT because general anesthesia and the gallbladderinflammation will affect normal digestion and peristalsis. The NG tube is used to removegastric secretions until peristalsis returns.

B is INCORRECT because the passage of bile into the small intestine is desired, notsomething to be prevented.

C is INCORRECT because until peristalsis returns, there is no movement of gastriccontents.

D is INCORRECT because the NG tube will not prevent HCL production; it will only

remove the gastric contents.

Question 62.A client, who has been taking aspirin for arthritis, is scheduled for surgery.For which postoperative problem should the nurse assess this client?

1. Electrolyte imbalance2. Postoperative bleeding3. Delayed wound healing4. Increased inflammation


Explanation: A is INCORRECT because aspirin does not contribute to an electrolyteimbalance.

B is CORRECT because aspirin has an anticoagulant effect, which can increasepostoperative bleeding. If possible, the drug should be discontinued, or the dosagelessened, before surgery.

C is INCORRECT because aspirin does not contribute to delayed wound healing.

D is INCORRECT because aspirin does not contribute to an increase in inflammation.Aspirin is an anti-inflammatory.

Question 63. Which technique would be inappropriate for the subcutaneousadministration of heparin?

1.Applying gentle pressure after removing the needle2. Drawing 0.1 mL air into the syringe before the heparin3.Aspirating before injecting the heparin4. Using the abdomen as an injection site


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Looking for answers(s):3Explanation: A is INCORRECT because gentle pressure is appropriate. The injectionsite should not be rubbed as with other injectable medications.

B is INCORRECT because drawing air into the syringe before the drug is appropriate; itfills the needle with air after the injection, and prevents leakage of heparin into the

intradermal site during insertion and withdrawal.

C is CORRECT because aspirating is thought to cause tissue damage when the needlemoves during aspiration. Small blood vessels may rupture, and bleeding and bruisingwill result.

D is INCORRECT because the abdomen, above the level of the iliac crests, is anappropriate site for heparin injection, as are the thighs, back and upper arms.

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Answers & Rationales 1-d