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Questions and Answers
Questions and Answers
Which assessment does the nurse perform as a priority before administering enalapril maleate (Vasotec)?
Which assessment does the nurse perform as a priority before administering enalapril maleate (Vasotec)?
- Checking the client's blood pressure (correct)
- Checking the client's intake and output record for the last 24 hours
- Checking the client's peripheral pulses
- Checking the most recent potassium level
Which statement by the client indicates a need for further instruction regarding the upper GI series?
Which statement by the client indicates a need for further instruction regarding the upper GI series?
- The test will take about 30 minutes
- I need to fast for 8 hours before the test
- I need to take a laxative after the test is completed, because the liquid that I'll have to drink for the test can be constipating.
- I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test. (correct)
If a nurse notices that the prescribed medication dose is higher than normal and the physician cannot be reached, what should the nurse do?
If a nurse notices that the prescribed medication dose is higher than normal and the physician cannot be reached, what should the nurse do?
- Call the nursing supervisor
- Ask the answering service to contact the on-call physician (correct)
- Administer the medication but consult the physician when he becomes available
- Withhold the medication until the physician can be reached in the morning
What is the appropriate action when a nurse sees premature ventricular contractions (PVCs) and determines they are not resulting in perfusion?
What is the appropriate action when a nurse sees premature ventricular contractions (PVCs) and determines they are not resulting in perfusion?
What should the nurse do regarding the oral antihypertensive medication for a client scheduled for electroconvulsive therapy (ECT)?
What should the nurse do regarding the oral antihypertensive medication for a client scheduled for electroconvulsive therapy (ECT)?
Which response by the nurse is therapeutic for a client feeling depressed after coronary artery bypass graft surgery?
Which response by the nurse is therapeutic for a client feeling depressed after coronary artery bypass graft surgery?
Which information is most concerning to the nurse when caring for an older client with bilateral cataracts?
Which information is most concerning to the nurse when caring for an older client with bilateral cataracts?
What information is most important for the nurse to report regarding a client with Guillain-Barré syndrome?
What information is most important for the nurse to report regarding a client with Guillain-Barré syndrome?
A client with leukemia presents with which of the following symptoms?
A client with leukemia presents with which of the following symptoms?
Which response by the nurse is supportive for a client told she has advanced ovarian cancer?
Which response by the nurse is supportive for a client told she has advanced ovarian cancer?
Which factor(s) indicate that a client is at risk for metabolic syndrome?
Which factor(s) indicate that a client is at risk for metabolic syndrome?
Which clinical manifestation in the client with hyperthyroidism is most important to report to the health care provider?
Which clinical manifestation in the client with hyperthyroidism is most important to report to the health care provider?
Which response indicates that the atropine sulfate ophthalmic drops were effective in a client scheduled for cataract surgery?
Which response indicates that the atropine sulfate ophthalmic drops were effective in a client scheduled for cataract surgery?
Which drug should the nurse expect to administer to a client with a painful blistering skin rash due to HIV?
Which drug should the nurse expect to administer to a client with a painful blistering skin rash due to HIV?
What finding should be reported to the primary health care provider for a client taking rifampin?
What finding should be reported to the primary health care provider for a client taking rifampin?
Which finding in a client's urinary output from a Foley catheter should be reported?
Which finding in a client's urinary output from a Foley catheter should be reported?
Which task can be assigned to the licensed practical nurse (PN) during blood product administration?
Which task can be assigned to the licensed practical nurse (PN) during blood product administration?
Which data from the comprehensive metabolic panel requires the most immediate intervention?
Which data from the comprehensive metabolic panel requires the most immediate intervention?
What is the highest priority factor for safety assessment in an older adult?
What is the highest priority factor for safety assessment in an older adult?
What action should the nurse instruct the unit secretary when notified about a phone call from the health care provider?
What action should the nurse instruct the unit secretary when notified about a phone call from the health care provider?
Based on which law does the nurse inform the family that a client with schizophrenia has the right to make treatment decisions?
Based on which law does the nurse inform the family that a client with schizophrenia has the right to make treatment decisions?
Which vital sign in a pediatric client is most important to report to the primary health care provider?
Which vital sign in a pediatric client is most important to report to the primary health care provider?
Which finding is most important to report regarding a fetal heart rate during labor?
Which finding is most important to report regarding a fetal heart rate during labor?
In caring for a pregnant woman with gestational diabetes, which finding should the nurse be alert to?
In caring for a pregnant woman with gestational diabetes, which finding should the nurse be alert to?
Questions and Answers
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Study Notes
Study Notes
Card 1: Enalapril Maleate (Vasotec)
- Enalapril is an ACE inhibitor used primarily to treat hypertension.
- Before administration, checking the client's blood pressure is crucial due to the risk of postural hypotension.
Card 2: Upper GI Series Preparation
- An upper gastrointestinal series requires fasting for 8 hours prior to the test.
- The correct preparation does not involve citrate of magnesia or a Fleet enema; only NPO status is required.
- Clients may experience constipation after the barium is ingested, necessitating the use of a laxative post-test.
Card 3: Medication Dose Concern
- If a nurse identifies a higher-than-normal medication dose, the appropriate action is to contact the on-call physician through the answering service.
Card 4: Cardiac Monitoring Post-MI
- In cases of suspected acute myocardial infarction, sudden onset of PVCs indicates the need for immediate physician assessment, particularly if not resulting in perfusion.
Card 5: ECT NPO Status
- Clients undergoing electroconvulsive therapy (ECT) should have antihypertensive medications administered with a small sip of water, despite NPO status.
Card 6: Post-Surgery Depression
- Responding to a client expressing depression after coronary artery bypass surgery should be empathetic, encouraging them to share their feelings.
Card 7: Bilateral Cataracts Concerns
- Complaints of seeing cobweb-like structures in the visual field is more concerning than general color perception issues.
Card 8: Guillain-Barré Syndrome Developments
- A decrease in cognitive status indicates possible hypoxia, which is critical to report to the primary healthcare provider; other symptoms are less urgent.
Card 9: Manifestations of Leukemia
- Key manifestations include hyperplasia of the gums, elevated white blood count, and weakness.
Card 10: Supportive Responses for Cancer Patients
- Allowing clients to express their feelings regarding their diagnosis of advanced ovarian cancer is the most supportive response.
Card 11: Risk Factors for Metabolic Syndrome
- At risk factors include abdominal obesity, a sedentary lifestyle, being of Hispanic or Asian ethnicity, and increased triglycerides.
Card 12: Reporting Hyperthyroidism Symptoms
- An apical heart rate of 130 beats/min in a hyperthyroid client is a critical finding that must be reported immediately.
Card 13: Effectiveness of Atropine Drops
- Effectiveness of atropine sulfate ophthalmic drops is indicated by dilation of the right pupil.
Card 14: HIV Treatment
- Acyclovir sodium is expected to be administered for treating a painful blistering rash associated with HIV.
Card 15: Tuberculosis Medication Monitoring
- Elevated liver enzyme levels in a client taking rifampin for tuberculosis require immediate reporting.
Card 16: Urine Output from Foley Catheter
- A urinary output of 240 mL in 12 hours is a concerning finding that should be reported.
Card 17: Licensed Practical Nurse Responsibilities
- Licensed practical nurses are permitted to obtain vital signs after the infusion of blood products has begun.
Card 18: Airborne Precautions Equipment
- Proper personal protective equipment for airborne precautions includes a properly fitted N95 respirator or mask.
Card 19: Electrolyte Imbalance Urgency
- A sodium level of 125 mEq/L indicates a critical need for immediate intervention due to potential hyponatremia.
Card 20: Older Adult Fall Risks
- A history of repeated falls in older adults is the highest priority concern for nursing assessment.
Card 21: Communication Protocols in Healthcare
- The nurse should instruct the unit secretary to ask another nurse to take the urgent phone call from the healthcare provider.
Card 22: Client Rights in Treatment Planning
- Under the American with Disabilities Act of 1990, clients with schizophrenia have a right to be involved in their treatment decisions.
Card 23: Pediatric Vital Signs Concerns
- For a six-year-old, reporting a heart rate of 130 beats/min is essential due to its significance.
Card 24: Fetal Heart Rate Monitoring
- A fetal heart rate of 100 beats/min should be immediately reported as it may indicate distress.
Card 25: Gestational Diabetes Monitoring
- A 2-hour postprandial blood sugar level over 120 mg/dL in a pregnant woman with gestational diabetes indicates concern.
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