Claytons Basic Pharmacology for Nurses 18th by Willihnganz. All 48 Chapters TEST BANK by ACADEMIAMILL

Test Bank for Claytons Basic Pharmacology for Nurses 18th by Willihnganz

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Test Bank for Claytons Basic Pharmacology for Nurses 18th by Willihnganz Chapter 1: Drug Definitions, Standards, and Information Sources Test Bank MULTIPLE CHOICE

What is the name under which a drug is listed by the U.S. Food and Drug Administration (FDA)?

Brand

Nonproprietary

Official

Trademark

ANS: C The official name is the name under which a drug is listed by the FDA. The brand name, or trademark, is the name given to a drug by its manufacturer. The nonproprietary, or generic, name is provided by the U.S. Adopted Names Council.

DIF:

Cognitive Level: Knowledge

REF: p. 1

OBJ: 2 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

Which source contains information specific to nutritional supplements?

USP Dictionary of USAN & International Drug Names

Natural Medicines Comprehensive Database

United States Pharmacopoeia/National Formulary (USP NF)

Drug Interaction Facts

ANS: C United States Pharmacopoeia/National Formulary contains information specific to nutritional supplements. USP Dictionary of USAN & International Drug Names is a compilation of drug names, pronunciation guide, and possible future FDA approved drugs; it does not include nutritional supplements. Natural Medicines Comprehensive Database contains evidence based information on herbal medicines and herbal combination products; it does not include information specific to nutritional supplements. Drug Interaction Facts contains comprehensive information on drug interaction facts; it does not include nutritional supplements.

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DIF:

Cognitive Level: Knowledge

REF: p. 2

OBJ: 4 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

What is the most comprehensive reference available to research a drug interaction?

Drug Facts and Comparisons

Drug Interaction Facts

Handbook on Injectable Drugs

Martindale—The Complete Drug Reference

ANS: B

First published in 1983, Drug Interaction Facts is the most comprehensive book available on drug interactions. In addition to monographs listing various aspects of drug interactions, this information is reviewed and updated by an internationally renowned group of physicians and pharmacists with clinical and scientific expertise.

DIF:

Cognitive Level: ComprehensionREF: p. 3

OBJ: 3 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

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4. The physician has written an order for a drug with which the nurse is unfamiliar. Which section of the Physicians’ Desk Reference (PDR) is most helpful to get information about this drug? a.

Manufacturer’s section

Brand and Generic Name section

Product Category section

Product Information section

ANS: B A physician’s order would include the brand and/or generic name of the drug. The alphabetic index in the PDR would make this section the most user friendly. Based on a physician’s order, manufacturer’s information and classification information would not be known. The Manufacturer’s section is a roster of manufacturers. The Product Category section lists products subdivided by therapeutic classes, such as analgesics, laxatives, oxytocics, and antibiotics. The Product Information section contains reprints of the package inserts for the major products of manufacturers.

DIF:

Cognitive Level: ComprehensionREF: p. 3

OBJ: 4 TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity

5. Which online drug reference makes available to health care providers and the public a standard, comprehensive, up to date look up and downloadable resource about medicines? a.

American Drug Index

American Hospital Formulary

DailyMed

Physicians’ Desk Reference (PDR)

ANS: C DailyMed makes available to health care providers and the public a standard, comprehensive, up to date look up and downloadable resource about medicines. The American Drug Index is not appropriate for patient use. The American Hospital Formulary is not appropriate for patient use. The PDR is not appropriate for patient use.

DIF: Cognitive Level: Knowledge Implementation

REF: p. 4

OBJ: 5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

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Which legislation authorizes the FDA to determine the safety of a drug before its marketing?

Federal Food, Drug, and Cosmetic Act (1938)

Durham Humphrey Amendment (1952)

Controlled Substances Act (1970)

Kefauver Harris Drug Amendment (1962)

ANS: A The Federal Food, Drug, and Cosmetic Act of 1938 authorized the FDA to determine the safety of all drugs before marketing. Later amendments and acts helped tighten FDA control and ensure drug safety. The Durham Humphrey Amendment defines the kinds of drugs that cannot be used safely without medical supervision and restricts their sale to prescription by a licensed practitioner. The Controlled Substances Act addresses only controlled substances and their categorization. The Kefauver Harris Drug Amendment ensures drug efficacy and greater drug safety. Drug manufacturers are required to prove to the FDA the effectiveness of their products before marketing them.

DIF:

Cognitive Level: Knowledge

REF: p. 4

OBJ: 8 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

7. Meperidine (Demerol) is a narcotic with a high potential for physical and psychological dependency. Under which classification does this drug fall? a. I b. II c. III

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d. IV

ANS: B Meperidine (Demerol) is a Schedule II drug; it has a high potential for abuse and may lead to severe psychological and physical dependence. Schedule I drugs have high potential for abuse and no recognized medical use. Schedule III drugs have some potential for abuse. Use may lead to low to moderate physical dependence or high psychological dependence. Schedule IV drugs have low potential for abuse. Use may lead to limited physical or psychological dependence.

DIF:

Cognitive Level: ComprehensionREF: p. 4 | p. 5 OBJ: 7 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

8. What would the FDA do to expedite drug development and approval for an outbreak of smallpox, for which there is no known treatment? a.

List smallpox as a health orphan disease.

Omit the preclinical research phase.

Extend the clinical research phase.

Fast track the investigational drug.

ANS: D Once the Investigational New Drug Application has been approved, the drug can receive highest priority within the agency, which is called fast tracking. A smallpox outbreak would become a priority concern in the world. Orphan diseases are not researched in a priority manner. Preclinical research is not omitted. Extending any phase of the research would mean a longer time to develop a vaccine. The FDA must ensure that all phases of the preclinical and clinical research phase have been completed in a safe manner.

DIF:

Cognitive Level: Knowledge

REF: p. 7

OBJ: 8 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

Which statement is true about over the counter (OTC) drugs?

They are not listed in the USP NF.

A prescription from a health care provider is needed.

They are sold without a prescription.

They are known only by their brand names.

ANS: C

https://studentmagic.indiemade.com/ OTC medications do not require a prescription. A variety of names, both generic and trade, can be used for individual drugs sold OTC. OTC drugs are listed in the USP NF. Prescription drugs require an order by a health professional who is licensed to prescribe, such as a physician, nurse practitioner, physician assistant, or dentist.

DIF:

Cognitive Level: ComprehensionREF: p. 2

OBJ: 2 TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity

10.

Which is the most authoritative reference for medications that are injected?

Physician’s Desk Reference

Handbook on Injectable Drugs

DailyMed

Handbook of Nonprescription Drugs

ANS: B The Handbook on Injectable Drugs is the most comprehensive reference available on the topic of compatibility of injectable drugs. It is a collection of monographs for more than 300 injectable drugs that are listed alphabetically by generic name.

DIF:

Cognitive Level: ComprehensionREF: p. 3

OBJ: 4 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

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11. The nurse is administering Lomotil, a Schedule V drug. Which statement is true about this drug’s classification? a.

Abuse potential for this drug is low.

Psychological dependency is likely.

There is a high potential for abuse.

This drug is not a controlled substance.

ANS: A Lomotil, a Schedule V drug, has an abuse potential of limited physical or psychological dependence liability compared with drugs in Schedule IV. Because abuse potential is low with a Schedule V drug, a prescription may not be required. Psychological dependency is not likely with a Schedule V drug. Schedule V drugs are classified as controlled substances.

DIF:

Cognitive Level: Knowledge

REF: p. 5

OBJ: 7 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

12. The nurse is transcribing new orders written for a patient with a substance abuse history. Choose the medication ordered that has the greatest risk for abuse.

Lomotil

Diazepam

Phenobarbital

Lortab

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ANS: D Lortab is a Schedule III drug with a high potential for abuse but less so than drugs in Schedules I and II. Lomotil is a Schedule V drug with a low potential for abuse compared with those in Schedule V. Diazepam is a Schedule IV drug with a low potential for abuse compared with those in schedule III. Phenobarbital is a Schedule IV drug with a low potential for abuse compared with those in Schedule III.

DIF:

Cognitive Level: Application

REF: pp. 4-5

OBJ: 7 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

MULTIPLE RESPONSE

13. The nurse is caring for a patient newly diagnosed with type 1 diabetes mellitus. Which approach(es) to therapeutic methods would be considered in this patient’s treatment? (Select all that apply.) a.

Therapeutic drugs

Concentrated carbohydrate diet

Family centered care

Regular daily exercise and activity

Daily baths

ANS: A, B, D Therapeutic methods include drug therapy, diet therapy, physiotherapy, and psychological therapy. Therapeutic methods do not include family centered care or daily baths.

DIF:

Cognitive Level: Application

REF: p. 1

OBJ: 1 TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity

14. An older adult experiencing shortness of breath is brought to the hospital by her daughter. While obtaining the medication history from the patient and her daughter, the nurse discovers that neither has a list of the patient’s current medications or prescriptions. All the patient has is a weekly pill dispenser that contains four different pills. The prescriptions are filled through the local pharmacy. Which resource(s) would be appropriate to use in determining the medication names and doses? (Select all that apply.) a.

Martindale—The Complete Drug Reference

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Physicians’ Desk Reference, Section 4

Senior citizens’ center

Patient’s home pharmacy

ANS: B, D

The Physicians’ Desk Reference, Section 4, has full color images of commonly dispensed tablets and capsules. The patient’s pharmacy would have an accurate account of all the medications the client is currently taking. Martindale—The Complete Drug Reference has written information on medications and would not be an appropriate resource. The senior citizens’ center is not likely to have specific patient medication information.

DIF: Cognitive Level: Application Assessment

REF: p. 3

OBJ: 3 | 4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

15.

The nurse planning patient teaching regarding drug names would include which statement(s)?

(Select all that apply.) a.

Most drug companies place their products on the market under generic names.

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b. The official name is the name under which the drug is listed by the U.S. Food and Drug Administration (FDA). c.

Brand names are easier to pronounce, spell, and remember.

The first letter of the generic name is not capitalized.

The chemical name is most meaningful to the patient.

ANS: B, C, D The official name is the name under which the drug is listed by the FDA. Brand names are easier to pronounce, spell, and remember. The first letter of the generic name is not capitalized. Most drug companies place their products on the market under brand names instead of generic names. The chemical name is most meaningful to the chemist.

DIF:

Cognitive Level: Application

REF: p. 1

OBJ: 2 TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity

16.

When categorizing, the nurse is aware that which drug(s) would be considered Schedule II?

(Select all that apply.) a.

Marijuana

Percodan

Amphetamines

Fiorinal

Flurazepam

ANS: B, C Schedule II drugs have a high potential for abuse, they are currently accepted in the United States, and use may lead to severe psychological or physical dependence. Percodan and amphetamines are considered Schedule II drugs. Marijuana is a Schedule I drug. Fiorinal is a Schedule III drug. Flurazepam is a Schedule IV drug.

DIF:

Cognitive Level: Analysis

REF: pp. 4-5

OBJ: 7 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

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Chapter 2: Basic Principles of Drug Action and Drug Interactions Test Bank

MULTIPLE CHOICE

1. The nurse assesses hives in a patient started on a new medication. What is the nurse’s priority action? a.

Notify physician of allergic reaction.

Notify physician of idiosyncratic reaction.

Notify physician of potential teratogenicity.

Notify physician of potential tolerance.

ANS: A An allergic reaction is indicative of hypersensitivity and manifests with hives and/or urticaria, which are easily identified. An idiosyncratic reaction occurs when something unusual or abnormal happens when a drug is first administered. A teratogenic reaction refers to the occurrence of birth defects related to administration of the drug. Tolerance refers to the body’s requirement for increasing dosages to achieve the same effects that a lower dose once did.

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DIF:

Cognitive Level: Application

REF: p. 17

OBJ: 7 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

2. The nurse administers an initial dose of a steroid to a patient with asthma. Thirty minutes after administration, the nurse finds the patient agitated and stating that “everyone is out to get me.” What is the term for this unusual reaction? a.

Desired action

Adverse effect

Idiosyncratic reaction

Allergic reaction

ANS: C Idiosyncratic reactions are unusual, abnormal reactions that occur when a drug is first administered. Patients typically exhibit an overresponsiveness to a medication related to diminished metabolism. These reactions are believed to be related to genetic enzyme deficiencies. Desired actions are expected responses to a medication. Adverse effects are reactions that occur in another system of the body; they are usually predictable. Allergic reactions appear after repeated medication dosages.

DIF:

Cognitive Level: ComprehensionREF: p. 17

OBJ: 7 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

Which is the best description of when drug interactions occur?

On administration of toxic dosages of a drug

On an increase in the pharmacodynamics of bound drugs

On the alteration of the effect of one drug by another drug

On increase of drug excretion

ANS: C

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https://studentmagic.indiemade.com/ Drug interactions may be characterized by an increase or decrease in the effectiveness of one or both of the drugs. Toxicity of one drug may or may not affect the metabolism of another one. Drug interactions may result from either increased or decreased pharmacodynamics. Drug interactions may result from either increased or decreased excretion.

DIF:

Cognitive Level: ComprehensionREF: p. 17

OBJ: 8 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

4. What occurs when two drugs compete for the same receptor site, resulting in increased activity of the first drug? a.

Desired action

Synergistic effect

Carcinogenicity

Displacement

ANS: D The displacement of the first drug from receptor sites by a second drug increases the amount of the first drug because more unbound drug is available. An expected response of a drug is the desired action. A synergistic effect is the effect of two drugs being greater than the effect of each chemical individually, or the sum of the individual effects. Carcinogenicity is the ability of a drug to cause cells to mutate and become cancerous.

DIF: Cognitive Level: ComprehensionREF: p. 17 Implementation

OBJ: 9 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

What do drug blood levels indicate?

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They confirm if the patient is taking a generic form of a drug.

They determine if the patient has sufficient body fat to metabolize the drug.

They verify if the patient is taking someone else’s medications.

They determine if the amount of drug in the body is in a therapeutic range.

ANS: D The amount of drug present may vary over time and the blood level must remain in a therapeutic range in order to obtain the desired result. Generic drugs do not necessarily produce a different drug blood level than proprietary medications. Body fat is not measured by drug blood levels. Drug blood levels only measure the amount of drug in the body; they do not determine the source of the medication.

DIF:

Cognitive Level: ComprehensionREF: p. 16

OBJ: 7 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

What is the process by which a drug is transported by circulating body fluids to receptor sites?

Osmosis

Distribution

Absorption

Biotransformation

ANS: B

Distribution refers to the ways in which drugs are transported by the circulating body fluids to the sites of action (receptors), metabolism, and excretion. Osmosis is the process of moving solution across a semipermeable membrane to equalize the dilution on each side. Absorption is the process by which a drug is transferred from its site of entry into the body to the circulating fluids for distribution. Biotransformation, also called metabolism, is the process by which the body inactivates drugs.

DIF:

Cognitive Level: ComprehensionREF: p. 13

OBJ: 4 TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity

7. The nurse assesses which blood level to determine the amount of circulating medication in a patient? a.

Peak

Trough

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Drug

Therapeutic

ANS: C When a drug is circulating in the blood, a blood sample may be drawn and assayed to determine the amount of drug present; this is known as the drug blood level. Peak levels are only those drug blood levels that are at their maximum before metabolism starts to decrease the amount of circulating drug. Trough levels are only those drug blood levels that are at their minimum when metabolism has decreased the amount of circulating drug and before an increase caused by a subsequent dose of the medication. Therapeutic levels are only those within a prescribed range of blood levels determined to bring about effective action of the medication.

DIF:

Cognitive Level: ComprehensionREF: p. 16

OBJ: 7 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

8. The nurse administers 50 mg of a drug at 6:00 AM that has a half life of 8 hours. What time will it be when 25 mg of the drug has been eliminated from the body? a.

8:00 AM

b. 11:00 AM c.

2:00 PM

6:00 PM

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ANS: C Fifty percent of the medication, or 25 mg, will be eliminated in 8 hours, or at 2:00 PM. 8:00 AM is 2 hours after administration; the half life is 8 hours. 11:00 AM is 4 hours after administration; the half life is 8 hours. 6:00 PM is 12 hours after administration; the half life is 8 hours.

DIF:

Cognitive Level: Analysis

REF: p. 14

OBJ: 6 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

What will the nurse need to determine first in order to mix two drugs in the same syringe?

Absorption rate of the drugs

Compatibility of the drugs

Drug blood level of each drug

Medication adverse effects

ANS: B Knowledge of absorption is important but not in order to mix drugs. In order to mix two drugs, compatibility is determined so there is no deterioration when the drugs are mixed in the same syringe. Drug level does not indicate if it is acceptable to mix medications in the same syringe. Adverse effects are important for the nurse to know, but not in order to mix drugs.

DIF: Cognitive Level: Application Implementation

REF: p. 18

OBJ: 9 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

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10. A patient developed hives and itching after receiving a drug for the first time. Which instruction by the nurse is accurate? a. Stop the medication and encourage the patient to wear a medical alert bracelet that explains the allergy. b.

Explain to the patient that these are signs and symptoms of an anaphylactic reaction.

c. Emphasize to the patient the importance to inform medical personnel that in the future a lower dosage of this drug is necessary. d. Instruct the patient that it would be safe to take the drug again because this instance was a mild reaction. ANS: A This initial allergic reaction is mild, and the patient is more likely to have an anaphylactic reaction at the next exposure; a medical alert bracelet is necessary to explain the reaction. Signs and symptoms of an anaphylactic reaction are respiratory distress and cardiovascular collapse. A more severe reaction will occur at the next exposure, and the patient should not receive the drug again.

DIF: Cognitive Level: Application Implementation

REF: p. 17

OBJ: 7 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

11. When obtaining a patient’s health history, which assessment data would the nurse identify as having the most effect on drug metabolism? a.

History of liver disease

Intake of a vegetarian diet

Sedentary lifestyle

Teacher as an occupation

ANS: A Liver enzyme systems are the primary site for metabolism of drugs. Intake of a vegetarian diet may affect absorption but not metabolism. Sedentary lifestyle and occupations could affect metabolism (exposure to environmental pollutants), but these do not have the most significant effect on metabolism.

DIF:

Cognitive Level: Application

REF: p. 14

OBJ: 5 TOP: Nursing Process Step: Assessment

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MSC: NCLEX Client Needs Category: Physiological Integrity

12. A physician’s order indicates to administer a medication to the patient via the percutaneous route. The nurse can anticipate that the patient will receive this medication: a.

intramuscularly.

subcutaneously.

topically.

rectally.

ANS: C The percutaneous route refers to drugs that are absorbed through the skin and mucous membranes. Methods of the percutaneous route include inhalation, sublingual (under the tongue), or topical (on the skin) administration. The parenteral route bypasses the gastrointestinal (GI) tract by using subcutaneous (subcut), intramuscular (IM), or intravenous (IV) injection. The parenteral route bypasses the GI tract by using subcut, IM, or IV injection. In the enteral route, the drug is administered directly into the GI tract by the oral, rectal, or nasogastric route.

DIF: Cognitive Level: Application Implementation

REF: p. 12

OBJ: 1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

13. A nurse is preparing to administer tetracycline to a patient diagnosed with an infection. Which medication should not be administered with tetracycline?

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Ativan

Tylenol

Colace

Mylanta

ANS: D Administering tetracycline with Mylanta can provide an antagonistic effect that will result in decreased absorption of the tetracycline. Ativan, Tylenol, and Colace are not contraindicated to administer with tetracycline.

DIF: Cognitive Level: Application Implementation

REF: p. 18

OBJ: 9 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

MULTIPLE RESPONSE

14.

Which statement(s) about liberation of drugs is/are true? (Select all that apply.)

A drug must be dissolved in body fluids before it can be absorbed into body tissues.

b. A solid drug taken orally must disintegrate and dissolve in GI fluids to allow for absorption into the bloodstream for transport to the site of action. c. The process of converting the drug into a soluble form can be controlled to a certain degree by the dosage form. d. Converting the drug to a soluble form can be influenced by administering the drug with or without food in the patient’s stomach. e.

Elixirs take longer to be liberated from the dosage form.

ANS: A, B, C, D Regardless of the route of administration, a drug must be dissolved in body fluids before it can be absorbed into body tissues. Before a solid drug taken orally can be absorbed into the bloodstream for transport to the site of action, it must disintegrate and dissolve in the GI fluids and be transported across the stomach or intestinal lining into the blood. The process of converting a drug into a soluble form can be partially controlled by the pharmaceutical dosage form used (e.g., solution, suspension, capsules, and tablets with various coatings). The conversion process can also be influenced by administering the drug with or without food in the patient’s stomach. Elixirs are already drugs dissolved in a liquid and do not need to be liberated from the dosage form.

DIF: Cognitive Level: ComprehensionREF: p. 13 Implementation

OBJ: 3 TOP: Nursing Process Step:

https://studentmagic.indiemade.com/ MSC: NCLEX Client Needs Category: Physiological Integrity

15.

Which are routes of drug excretion? (Select all that apply.)

GI tract; feces

Genitourinary (GU) tract; urine

Lymphatic system

Circulatory system; blood/plasma

Respiratory system; exhalation

ANS: A, B, E The GI system is a primary route for drug excretion. The GU and the respiratory systems do function in the excretion of drugs. The lymphatic and circulatory systems are involved with drug distribution, not drug excretion.

DIF:

Cognitive Level: Knowledge

REF: p. 14

OBJ: 5 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

16. Which route(s) enable(s) drug absorption more rapidly than the subcut route? (Select all that apply.)

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IV route

IM route

Inhalation/sublingual

Intradermal route

Enteral route

ANS: A, B, C IV route of administration enables drug absorption more rapidly than the subcut route. IM route of administration enables drug absorption more rapidly because of greater blood flow per unit weight of muscle. Inhalation/sublingual route of administration enables drug absorption more rapidly than the subcut route. Intradermally administered drugs are absorbed more slowly because of the limited available blood supply in the dermis. Enterally administered drugs are absorbed more slowly because of the biotransformation process.

DIF:

Cognitive Level: ComprehensionREF: p. 13

OBJ: 1 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity 17. The nurse recognizes that which factor(s) would contribute to digoxin toxicity in a 92-year- old patient? (Select all that apply.) a.

Taking the medication with meals

Prolonged half life of the drug digoxin

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Impaired renal function

Diminished mental capacity

ANS: B, C Impaired renal and hepatic function in older adults impairs metabolism and excretion of drugs, thus prolonging the half life of a medication. Food would decrease the absorption of the drug. Diminished mental capacity does not contribute to drug toxicity unless it is due to administration errors.

DIF: Cognitive Level: Application Assessment

REF: p. 14

OBJ: 5 | 6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

18.

Which statement(s) about variables that influence drug action is/are true? (Select all that apply.)

a. An older adult will require increased dosage of a drug to achieve the same therapeutic effect as that seen in a younger person. b.

Body weight can affect the therapeutic response of a medication.

Chronic smokers may metabolize drugs more rapidly than nonsmokers.

A patient’s attitude and expectations affect the response to medication.

Reduced circulation causes drugs to absorb more rapidly.

ANS: B, C, D Body weight can affect response to medications; typically, obese patients require an increase in dosage and underweight patients a decrease in dosage. Chronic smoking enhances metabolism of drugs. Attitudes and expectations play a major role in an individual’s response to drugs. Older adults require decreased dosages of drugs to achieve a therapeutic effect. Decreased circulation causes drugs to absorb more slowly.

DIF: Cognitive Level: ComprehensionREF: p. 13 Implementation

OBJ: N/A TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

19.

Which factor(s) affect(s) drug actions? (Select all that apply.)

Teratogenicity

Age

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Body weight

Metabolic rate

Illness

ANS: B, C, D, E Age, body weight, metabolic rate, and illness may contribute to a variable response to a medication. Teratogenicity does not contribute to a variable response to a medication.

DIF: Cognitive Level: ComprehensionREF: p. 14 Assessment

OBJ: N/A TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

OTHER

20. A patient receives 200 mg of a medication that has a half life of 12 hours. How many mg of the drug would remain in the patient’s after 24 hours?

ANS: 50

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The half life is defined as the amount of time required for 50% of the drug to be eliminated from the body. If a patient is given 200 mg of a drug that has a half life of 12 hours, then 50 mg of the drug would remain in the body after 24 hours.

DIF:

Cognitive Level: Analysis

REF: p. 14

OBJ: 6 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

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Chapter 3: Drug Action Across the Life Span Test Bank

MULTIPLE CHOICE

1. What time will the trough blood level need to be drawn if the nurse administers the intravenous medication dose at 9:00 AM? a.

6:30 AM

https://studentmagic.indiemade.com/ b.

8:30 AM

9:30 AM

d. 11:30 AM ANS: B Trough blood levels measure the lowest blood level of medicine and are obtained just before the dose is administered. In this case, 6:30 AM is too early to obtain the blood level. The other two times occur after the medication is administered.

DIF: Cognitive Level: Application Implementation

REF: p. 26

OBJ: 3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

2. What will the nurse expect the health care provider’s order to be when starting an older adult patient on thyroid hormone replacement therapy? a.

Administering a loading dose of the drug

Directions on how to taper the drug

A dosage that is one third to one half of the regular dosage

A dosage that is double the regular dosage

ANS: C To prevent toxicity, dosages for new medications in older adults should be one third to one half the amount of a standard adult dosage. Loading doses of drugs could cause severe toxicity. Tapering off is characteristic of discontinuation of medications and is not appropriate for this situation. Older adults generally need a lower medication dosage than younger patients.

DIF: Cognitive Level: Application Implementation

REF: p. 29

OBJ: 3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Which drugs cause birth defects?

Teratogens

Carcinogens

Metabolites

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Placebos

ANS: A Teratogens are drugs that cause birth defects. Carcinogens cause cancer. Metabolites are the end product of metabolism. Placebos are drugs that have no pharmacologic activity.

DIF:

Cognitive Level: Knowledge

REF: p. 30

OBJ: 6 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

4. Which life threatening illness may occur as a result of aspirin (salicylate) administration during viral illness to patients younger than 20 years of age? a.

Anaphylactic shock

Reye’s syndrome

Chickenpox

Influenza A

ANS: B Children are susceptible to Reye’s syndrome if they ingest aspirin at the time of or shortly after a viral infection of chickenpox or influenza. Anaphylactic shock is caused by a hypersensitivity reaction. Chickenpox is the result of being infected with a virus. Influenza A is caused by a pathogen.

DIF: Cognitive Level: Knowledge Implementation

REF: pp. 27-28 OBJ: 3 TOP: Nursing Process Step:

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Which classification of medications commonly causes allergic reactions in children?

Antacids

Analgesics

Antibiotics

Anticonvulsants

ANS: C Antibiotics, especially penicillins, commonly cause allergic reactions in children. Intravenous antibiotics can cause rapid reactions; therefore, the pediatric patient’s response to a medication should be assessed and monitored closely. Antacids rarely cause allergic reactions. Children are not particularly allergic to analgesics or anticonvulsants.

DIF:

Cognitive Level: Knowledge

REF: p. 28

OBJ: 3 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

6. After giving instructions to an expectant mother about taking medications during pregnancy, which patient statement indicates the need for further teaching? a.

“I will not take herbal medicines during pregnancy.”

“For morning sickness, I will try crackers instead of taking a drug.”

“If I get a cold, I will avoid taking nonprescription medications until I check with my physician.”

“I will limit my alcohol intake to only one glass of wine weekly.”

ANS: D Alcohol needs to be eliminated during pregnancy and for 2 to 3 months prior to conception. Limited studies are available regarding the use of herbal medications in general, and thus they should be avoided during pregnancy. Alternative nonpharmacologic treatments are appropriate to use during morning sickness. The pregnant woman should also avoid using nonprescription drugs because few data are available about safe use in pregnancy. Because few medicines can be considered completely safe for use in pregnancy, the physician needs to approve and recommend the use of nonprescription drugs.

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DIF: Cognitive Level: Application Implementation

REF: p. 30

OBJ: 6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

When is the ideal time for a nursing mother to take her own medications?

Before the infant latches on to begin to breastfeed

As soon as the mother wakes up in the morning

Right before the mother goes to sleep at night

As soon as the infant finishes breastfeeding

ANS: D Taking medications after breastfeeding reduces the amount of the medication that will reach the baby. Medications taken directly before breastfeeding may have a high concentration in the milk and possibly pass on to the baby. The mother must take into consideration when her medications are ordered to be taken, and schedule them around breastfeeding.

DIF: Cognitive Level: ComprehensionREF: p. 31 Implementation

OBJ: 6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

8. Which age-related change would affect transdermal drug absorption in geriatric patients the most? a.

Difficulty swallowing

Diminished kidney function

Changes in pigmentation

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Altered circulatory status

ANS: D The decreased circulation that occurs with aging will affect transdermal drug absorption. Difficulty swallowing would not affect transdermal drugs being absorbed. Kidney function affects drug excretion. Changes in pigmentation would not affect transdermal drug absorption.

DIF:

Cognitive Level: Application

REF: p. 22

OBJ: 3 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

9. Which intervention would be considered to reduce accumulation of a drug in a patient who has decreased liver function? a.

Decreasing the time interval between dosages

Reducing the dosage

Administering the medication intravenously

Changing the drug to one that has a longer half life

ANS: B Dosages must be reduced to prevent accumulation. Decreasing the time interval between dosages would increase the accumulation of the drug. The intravenous route has the fastest absorption and with liver dysfunction would increase the accumulation of the drug. A similar drug with a longer half life would stay in the system longer; with impaired liver function, the result would be increased accumulation.

DIF:

Cognitive Level: ComprehensionREF: p. 24

OBJ: 3 TOP: Nursing Process Step: Planning

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MSC: NCLEX Client Needs Category: Physiological Integrity

10. The nurse is teaching an elderly patient with difficulty swallowing about his medications. Which explanation by the nurse is most helpful? a.

“Enteric coated tablets can be crushed and taken with applesauce.”

“Tablets that are scored can be broken in half.”

“Medications labeled ‘SR’ can be crushed.”

“Avoid taking medications in liquid form.”

ANS: B It is acceptable to break scored tablets in half to facilitate swallowing of the medication. Enteric coated tables should never be crushed because of the effect on the absorption rate and potential for toxicity. Medications labeled “SR” indicate “sustained release” and should not be crushed because of the effect on the absorption rate. Medication in liquid form may be easier to swallow.

DIF: Cognitive Level: Application Implementation

REF: p. 29

OBJ: 3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

11. The nurse is administering an antibiotic intravenously. Which blood level determines the lowest amount of medication present in the patient? a.

Peak

Serum

Therapeutic

Trough

ANS: D The lowest amount of a medication in the blood is the trough. The peak is the highest amount of medication in the blood. Serum level identifies the amount of medication present. Therapeutic levels identify the range in which a medication is effective.

DIF: Cognitive Level: Knowledge Assessment

REF: p. 26

OBJ: none TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

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12. Which patient would the nurse identify as having the lowest rate of absorption of enteral medications? a.

A 5-year-old boy

An 18-year-old woman

A 55-year-old man

An 85-year-old woman

ANS: A Males’ stomachs empty more rapidly; children have increased motility, resulting in decreased absorption time. As one gets older, gastrointestinal (GI) motility is decreased, allowing for increased absorption time; women have slower gastric emptying, resulting in more time for absorption. Males’ stomachs empty more rapidly; however, as one gets older, GI motility is decreased, resulting in an increase in absorption time. As one gets older, GI motility is decreased, allowing for increased absorption time; women have slower gastric emptying, resulting in more time for absorption.

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DIF: Cognitive Level: Application Assessment

REF: pp. 20-21 OBJ: 3 | 4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

13.

What is the definition of cumulative effect of a drug?

Drug toxicity related to overmedication

Drug buildup related to decreased metabolism

The inability to control the ingestion of drugs

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The need for higher dosage to produce the same effect as previous lower dosages

ANS: B Cumulative effects are related to diminished metabolism or excretion of a drug that causes it to accumulate. Cumulative effects can lead to drug toxicity. Toxicity occurs when adverse effects are severe. Inability to control the ingestion of drugs is drug dependence. The need for higher dosage to produce the same effect as previous lower dosages is the definition of tolerance.

DIF:

Cognitive Level: Knowledge

REF: p. 22

OBJ: 2 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

14. Which patient, when compared with the general population, would require a larger dose or more frequent administration of a drug to attain a therapeutic response? a.

A 29 year old who has been diagnosed with kidney failure

A 35 year old obese male who is being evaluated for an exercise program

A 52 year old diagnosed with hypothyroidism and decreased metabolic rate

A 72 year old with decreased circulatory status

ANS: B An obese individual would require a larger dose of a drug to attain a therapeutic response. An individual with kidney failure would require less medication because of decreased excretory ability. Individuals with decreased metabolic rate would metabolize drugs more slowly and require smaller doses or less frequent administration. Individuals with decreased circulation would require less medication.

DIF:

Cognitive Level: Application

REF: p. 20

OBJ: 3 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

15. A resident in a long term care facility reports difficulty swallowing enteric coated aspirin and asks the nurse to crush it prior to administration. The most appropriate action for the nurse to take is to: a.

crush the tablet and mix with applesauce.

encourage the resident to swallow the tablet with a full glass of water.

hold the medication and notify the physician.

substitute a regular aspirin for the enteric coated tablet.

ANS: C

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The medication should be held and the physician notified. The physician has the authority to determine how to proceed in this situation. Enteric coated tablets should not be crushed because this will increase the absorption rate and the potential for toxicity. Geriatric patients may have difficulty swallowing and are at risk for choking and aspiration. They should not be encouraged to swallow medications if they report difficulty swallowing. The physician must determine if a substitution can be ordered. Prescribing is not in the nurse’s scope of practice.

DIF: Cognitive Level: Analysis Implementation

REF: p. 22

OBJ: 3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

MULTIPLE RESPONSE

16. One of the prescribed medications for a 36 week gestational age baby girl is a topical water soluble medication to be applied to the perineum daily to treat an inflammatory rash. What considerations is the nurse aware of before medication administration? (Select all that apply.) a.

Age of the client

Location of topical application

Increased intestinal transit rate

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Condition of the skin

Gastric pH of 8

ANS: A, B, D The premature infant’s outer layer of skin is not fully developed, although it is more hydrated, which will enhance the absorption of the topical water soluble medication. Neonates often wear diapers, which will act as an occlusive dressing, thereby increasing absorption. The client’s inflammatory condition will increase the absorption of medication. The intestinal transit rate increases as the newborn matures. This is irrelevant when a medication is applied topically. Gastric pH would not factor into metabolism of a medication that is applied topically.

DIF: Cognitive Level: Application Implementation

REF: p. 20 | p. 22

OBJ: 3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

17. The nurse is caring for a 4 month old child who is on a water soluble medication for seizures. The child’s mother voices concern that the dosage seems “too much” for the child’s age and would like the dosage verified. What actions will the nurse take? (Select all that apply.) a.

Verify dosage requirements in the Physicians’ Desk Reference( PDR) in mg/kg.

Compare the water composition requirements of adults and children.

Evaluate lean body mass and total fat content in adults and infants.

Chart “refused per mother” on the MAR and do not administer.

e. Compare transportation in the circulation of plasma bound proteins between adults and children. ANS: A, B

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The PDR lists the recommended dosages for all age groups. Because dilution may vary among age groups, the water concentration should be verified prior to administration. As we age, lean body mass and total body water decrease while total fat content increases; however, this drug is not fat soluble. The nurse is responsible for administering the medication as ordered after verifying that it is correct; the mother is asking for verification, not refusal of administration. Drugs that are relatively insoluble are transported in the circulation by being bound to plasma proteins; however, this drug is water soluble.

DIF: Cognitive Level: Application Implementation

REF: p. 27

OBJ: 3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

18.

For which reason(s) is/are elderly patients at increased risk for drug interactions and toxicity?

(Select all that apply.) a.

They have a higher incidence of malnourishment.

Their renal function is enhanced.

They have increased use of multiple medications.

Hepatic function is reduced.

There are often issues with swallowing.

ANS: A, C, D Older adult patients have an increased incidence of malnourishment, are often on multiple medications, and have reduced hepatic function, all of which puts them at increased risk for drug interactions and toxicity. Renal function diminishes in the elderly as a result of decreased renal blood flow, reduced cardiac output, loss of glomeruli, and diminished tubular function and concentrating ability. Older adults have swallowing difficulties, leading to compliance issues, but taking drugs less often would not result in toxicity.

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DIF:

Cognitive Level: ComprehensionREF: p. 28

OBJ: 3 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

19. Which patient(s) require(s) special considerations for medication administration? (Select all that apply.) a.

A 29-year-old pregnant woman

A 2-month-old baby

An 18-year-old college student

A 45-year-old farmer

An 82-year-old retired nurse

ANS: A, B, E Drug therapy during pregnancy should be avoided. Recommendations by the provider are necessary during any stage of pregnancy. Pediatric and elderly patients are affected by differences in muscle mass and blood flow to muscles, as well as other physiological systems. Teenagers and adult patients do not typically require special considerations for medication administration.

DIF: Cognitive Level: Application Planning

REF: pp. 20-21 OBJ: 3 | 4 | 5 | 6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

20. Which factor(s) in a patient would influence GI absorption of medications? (Select all that apply.) a.

Stomach pH

Level of consciousness

Fever

Blood flow to gastric mucosa

Weight

Body surface area

ANS: A, D Absorption by passive diffusion across the membranes depends on the pH of the environment. Increased blood flow to gastric mucosa increases absorption of medication and decreases time of absorption. Drug absorption does not depend on the mental status of the patient. Fever does not affect drug absorption. The patient’s absolute weight and body surface area do not affect drug absorption, although problems associated with weight greater than or less than normal may be a factor in the process.

https://studentmagic.indiemade.com/ DIF:

Cognitive Level: Application

REF: p. 22

OBJ: 3 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

21. When receiving a report on a new admission from the emergency room, the nurse learns that the patient is newly diagnosed with renal failure. Which medication(s) in the patient’s medication history will require dosage adjustment by the physician? (Select all that apply.) a.

Lithium

Tobramycin

Atenolol

Quinidine

Ampicillin

ANS: A, B, C, D, E Lithium, tobramycin, atenolol, quinidine, and ampicillin are all select medications that require dosage adjustment in renal failure.

DIF:

Cognitive Level: Application

REF: p. 26

OBJ: 3 TOP: Nursing Process Step: Assessment

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MSC: NCLEX Client Needs Category: Physiological Integrity

22. Prenatal education is being provided by the nurse at a maternal family child clinic. What information should be relayed? (Select all that apply.) a.

Herbal medicines are considered safe.

Limit tobacco consumption to less than two cigarettes per day.

Encourage a folic acid supplement.

One alcoholic beverage per day is acceptable in the last trimester.

Encourage nonpharmacologic treatments for symptoms such as nausea.

ANS: C, E Good nutrition with appropriate ingestion of vitamins (especially folic acid) is particularly important during pregnancy to prevent birth defects. Before using medicines, pregnant women should be encouraged to try nonpharmacologic treatments. Herbal medicines that have not been scientifically tested in women during pregnancy should be avoided. Advise against the use of tobacco. Mothers who smoke have a higher frequency of miscarriage, stillbirths, premature births, and low birth weight infants. Consumption of alcohol should be eliminated 2 to 3 months before planned conception, as well as during pregnancy.

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DIF:

Cognitive Level: Application

REF: pp. 30-31 OBJ: 6 TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

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Chapter 4: The Nursing Process and Pharmacology Test Bank

MULTIPLE CHOICE

What is the primary purpose of the nursing assessment?

Identifying underlying pathologic conditions

Assisting the physician in identifying medical conditions

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Determining the patient’s mental status

Exploring patient responses to health problems

ANS: D A nursing assessment is done to identify the patient’s response to health problems. During the nursing assessment phase, a comprehensive information base is developed through a physical examination, nursing history, medication history, and professional observation. Identifying underlying pathologic conditions and assisting the physician in identifying medical conditions is not part of the nursing process. Determining the patient’s mental status is one part of the nursing assessment, but it is not the primary purpose.

DIF: Cognitive Level: ComprehensionREF: p. 36 Assessment

OBJ: 1 | 3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

What is the basis of the NANDA I taxonomy?

Functional health patterns

Human response patterns

Basic human needs

Pathophysiologic needs

ANS: B The NANDA I taxonomy identifies human response patterns. Functional components of health patterns are limited to activity, fluid volume, nutrition, self care, and sensory perception. Basic human needs comprise less than merely health patterns. Pathophysiologic needs are not part of the scope of NANDA I.

DIF:

Cognitive Level: Knowledge

TOP:

Nursing Process Step: Diagnosis

REF: pp. 37-38 OBJ: 5

MSC: NCLEX Client Needs Category: Physiological Integrity

Which task is included in the assessment step of the nursing process?

Establishing patient goals/outcomes

Implementing the nursing care plan (NCP)

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Measuring goal/outcome achievement

Collecting and communicating data

ANS: D

Data are collected and communicated in the assessment phase of the nursing process. Establishing goals is the function of planning. Implementing the NCP is the function of implementation. Measuring outcome achievement is the function of evaluation.

DIF: Cognitive Level: ComprehensionREF: p. 36 Assessment

OBJ: 2 | 3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

Which statement regarding nursing diagnoses is accurate?

Nursing diagnoses remain the same for as long as the disease is present.

Nursing diagnoses are written to identify disease states.

Nursing diagnoses describe patient problems that nurses treat.

Nursing diagnoses identify causes related to illness.

ANS: C Diagnostic statements identify problems a nurse is independently able to treat within the scope of professional practice. Nursing diagnoses vary with the changing condition of the patient. The response patterns are unique to the patient and are not disease specific. Nursing diagnoses describe the patient’s human response pattern.

DIF:

Cognitive Level: ComprehensionREF: pp. 37-38 OBJ: 5 TOP: Nursing Process Step: Diagnosis

MSC: NCLEX Client Needs Category: Physiological Integrity

What do the classification systems NIC and NOC provide?

Individualized data banks of treatments related to disease processes

Standardized language for reporting and analyzing nursing care delivery

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A measure for cost containment within medical institutions

Specialized interventions for rare diseases

ANS: B Nursing classification systems such as NIC and NOC are designed to provide a standardized language for reporting and analyzing nursing care delivery that is individualized for each patient. Standardized terminology assists practitioners in the implementation of the five phases of the nursing process. Classification systems are not related to disease process and are not used for financial purposes. Classification systems include interventions for all health conditions.

DIF: Cognitive Level: Knowledge Implementation

REF: p. 34

OBJ: 11 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

6. Which type of nursing diagnosis will be written when the patient exhibits factors that makes him or her susceptible to the development of a problem? a.

Actual diagnosis

Risk diagnosis

Possible diagnosis

Wellness diagnosis

ANS: B When patients have the potential or risk for a problem to develop, a risk diagnosis is written. These diagnoses are two part statements such as Risk for falls related to unsteady gait. An actual diagnosis consists of a NANDA diagnostic label, contributing factor (if known), and defining characteristics such as signs and symptoms. A possible nursing diagnosis identifies a problem that may occur, but the assembled data are insufficient to confirm it. A wellness diagnosis applies to individuals for whom an enhanced level of wellness is possible.

DIF:

Cognitive Level: ComprehensionREF: p. 38

OBJ: 5 TOP: Nursing Process Step: Diagnosis

MSC: NCLEX Client Needs Category: Physiological Integrity

Which outcome statement identified by the nurse is written correctly?

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After surgery, patient will express acceptance of loss of breast.

Patient will die with dignity.

At the end of the shift, the nurse will determine whether the patient is more comfortable.

Within the next 8 hours, urine output will be greater than 30 mL/hr.

ANS: D The statement, “Within the next 8 hours, urine output will be greater than 30 mL/hr” is patient oriented, realistic, and measurable, and has an appropriate time frame.

DIF:

Cognitive Level: Application

REF: p. 42

OBJ: 11 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

Which is an example of an interdependent nursing action?

Assess lung sounds every 4 hours.

Educate the patient about the prescribed medication.

Administer Demerol 50 mg intramuscularly (IM) every 4 hours PRN.

Encourage the patient to express feelings.

ANS: C “Administer Demerol 50 mg IM every 4 hours PRN” requires the nurse to follow the parameters of the order, yet use nursing judgment to determine how often the medication is to be administered; therefore, it is an interdependent nursing action. Assessing lung sounds, educating the patient about medication, and encouraging the patient to express feelings are independent nursing actions.

DIF: Cognitive Level: Application Implementation

REF: p. 45

OBJ: 12 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

What is the nurse’s primary source of information when obtaining a patient history?

The physician

The patient record

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The family

The patient

ANS: D The focus of the nursing process is the patient. Although family members contribute to the nursing history, this information is secondhand. It is important that the nurse continue to assess patient data for validation of this information. The physician is not to be relied on to provide information about a complete patient history. The patient record reflects only recorded past information and not current input that may be relevant. The family may provide information about a patient history if the patient is unable to provide it, but the information is subject to interpretation by someone other than the patient.

DIF:

Cognitive Level: Knowledge

REF: p. 43

OBJ: 13 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

10. An obese patient did not meet the goal of “by the end of the second week, is able to follow a 1500 calorie diet.” What will the nurse and the patient reassess? a.

Patient’s weight

Patient’s understanding of the 1500 calorie diet

Nurse’s feelings about obese patients

Health care agency’s ability to provide the prescribed diet

ANS: B When goals are not met, the nurse must reassess the patient’s understanding of the interventions and commitment to reaching the identified goal. All phases of the nursing process are ongoing as the nurse continues to evaluate, assess, and readjust interventions as indicated to facilitate patient achievement of outcomes. The patient may have followed the diet but not lost any weight. The nurse’s feelings should not be a factor in the assessment. The agency’s ability to provide the prescribed diet should have been determined before implementation of the plan.

DIF:

Cognitive Level: Analysis

REF: pp. 42-43 OBJ: 12

TOP:

Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

11. What is the priority nursing diagnosis for an older adult with diabetes who is hospitalized for pneumonia?

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Deficient knowledge related to lack of information about diabetic medication

Risk for falls related to weakness

Impaired gas exchange related to decreased pulmonary ventilation

Imbalanced nutrition: more than body requirements related to obesity

ANS: C

Airway is the first priority in a needs assessment (ABCs = airway, breathing, circulation). Medication, weakness, and nutrition are less of a priority than the patient’s respiratory status.

DIF:

Cognitive Level: Analysis

REF: pp. 37-38 OBJ: 9

TOP:

Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

12.

What is a critical care pathway?

A nursing care plan for a patient in a critical care unit

A standardized care plan derived from best practice patterns

A care plan that has been critiqued by a quality improvement officer

A care plan based on measurable goals and outcomes

ANS: B A critical care pathway is a standardized care plan derived from best practice patterns, enabling the nurse to develop a treatment plan that sequences detailed clinical interventions to be performed over a projected amount of time for a specific case type of disease process. A nursing care plan for a patient in a critical care unit is not a critical care pathway. A care plan that has been critiqued by a quality improvement officer is not a critical care pathway. All good care plans are based on measurable goals and outcomes.

DIF:

Cognitive Level: Knowledge

TOP:

Nursing Process Step: Planning

REF: p. 40

OBJ: 7

MSC: NCLEX Client Needs Category: Physiological Integrity

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13. When a nursing diagnosis statement is written, who or what directs the nurse to identify appropriate nursing interventions? a.

Other nurses on staff who have experience with the diagnoses

The patient and family who have an interest in the outcome

The etiologies of the problems identified in the nursing diagnoses

The medical staff who have more expertise than the nurses

ANS: C Nursing actions are suggested by the etiologies of the problems identified in the nursing diagnoses and are used to implement plans. Nursing actions are not suggested by other nurses, the patient and family, or by the medical staff.

DIF:

Cognitive Level: ComprehensionREF: p. 42

OBJ: 12 TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity

14. A patient is experiencing adverse effects of a medication. Which information obtained by the nurse is subjective? a.

Cough

Edema

Nausea

Tachycardia

ANS: C Nausea is a symptom for which only the person experiencing it can provide the information. Cough is heard by the nurse. Edema is measured and seen by the nurse. Tachycardia is assessed by the nurse.

DIF:

Cognitive Level: Application

REF: p. 43

OBJ: 13 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

15. The nurse has determined that the pain medication given to a patient an hour ago has been effective. The nurse is using which step of the nursing process?

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Evaluation

Intervention

Nursing diagnosis

Planning

ANS: A The nurse has used evaluation to assess the response to the administered medication. Intervention is the administration of the medication or teaching about the medication in this situation. This situation is not an example of making a nursing diagnosis. Planning is developing goal statements and prioritizing patient problems.

DIF:

Cognitive Level: Application

REF: pp. 42-43 OBJ: 15

TOP:

Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

16. Prior to the administration of a nephrotoxic drug, the nurse determines that the kidney lab data are within normal range. Which step of the nursing process is being used? a.

Assessment

Nursing diagnosis

Planning

Evaluation

ANS: A The nurse is collecting information about renal function through lab data; this is baseline assessment data. This action is not an example of the development of a nursing diagnosis. Planning is developing goal statements and prioritizing patient problems. Evaluation determines if goals have been met.

DIF:

Cognitive Level: Application

REF: p. 36

OBJ: 2 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

17.

Which statement best describes the planning phase of the nursing process?

Administer insulin subcutaneously (subcut) in the abdominal area.

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Patient is at high risk for falls related to hypotension.

c. The patient will state the expected adverse effects of medication by the end of the teaching session. d.

Itching has resolved; medication given is effective.

ANS: C “The patient will state the expected adverse effects of medication by the end of the teaching session” is an example of a goal statement that is developed in the planning phase. Administration of insulin subcut is an example of the implementation phase. Noting a high risk for falls related to hypotension is an example of the second phase or nursing diagnosis. Stating that the medication given is effective is an example of the evaluation phase.

DIF:

Cognitive Level: Application

TOP:

Nursing Process Step: Planning

REF: p. 39

OBJ: 2 | 7

MSC: NCLEX Client Needs Category: Physiological Integrity

18. The nurse is prioritizing care of a pediatric patient diagnosed with cystic fibrosis. Which nursing diagnosis would the nurse consider the highest priority? a.

Risk for altered nutrition: less than body related to decreased appetite

Altered breathing pattern related to thickened mucus secretions

Knowledge deficit related to disease process

Impaired skin integrity related to decreased mobility

ANS: B Altered breathing pattern would be the highest priority because the physiologic need of oxygenation is required for total body function. Risk for altered nutrition, knowledge deficit, and impaired skin integrity would not be of higher priority than oxygenation.

DIF:

Cognitive Level: Analysis

REF: p. 40

OBJ: 9 TOP: Nursing Process Step: Diagnosis

MSC: NCLEX Client Needs Category: Physiological Integrity

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MULTIPLE RESPONSE

19.

Which statement(s) regarding critical pathways is/are true? (Select all that apply.)

Efficient for specific diseases or case types

The same as medical plans

Standardized and enhanced quality care

Evaluated less frequently than care plans

Enhanced communication for a variety of health care providers

ANS: A, C, E

Critical pathways are standardized care plans that detail clinical interventions to be performed over a projected time frame for a specific disease or case type. Physician interventions are included in the pathways. Critical pathways enhance the quality of care and require evaluation and modification on an ongoing basis. Critical pathways assist as a communication system for all health care providers. Medical plans are distinct to physicians. Critical pathways should be evaluated as needed to achieve desired outcomes.

DIF:

Cognitive Level: ComprehensionREF: p. 40

OBJ: 7 | 8 TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

20.

In which way(s) is nursing diagnosis different from a medical diagnosis? (Select all that apply.)

Statement of the patient’s alterations in structure and functions

Description of the patient’s ability to function in relation to impairment

Tend to remain the same throughout the course of illness or recovery from injury

Varies depending on patient’s state of recovery

Based on research done by nurses

Conditions can be accurately identified by nursing assessment methods

ANS: B, D, E, F Nursing diagnoses, as exemplified by the NANDA I taxonomy, are statements about the patient’s ability to function in relation to an illness or injury, vary with the patient’s state of recovery, are based on

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research done by nurses, and can be determined based on nursing assessment methods. Nursing diagnoses do not include statements of the patient’s alterations in structure and function and do not remain the same throughout the course of illness or recovery from injury.

DIF:

Cognitive Level: ComprehensionREF: pp. 37-38 OBJ: 6

TOP:

Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

21. The nurse is participating in the planning phase of the nursing process for a new admission to a long term care facility. When formulating a plan to meet the patient’s needs, the nurse will take which action(s)? (Select all that apply.) a.

Formulate nursing interventions.

Collect data.

Make a clinical judgment about the patient.

Set priorities.

Develop measurable goals.

ANS: A, D, E

Planning is the third phase of the five step nursing process. Once the patient has been assessed and problems have been diagnosed, plans should be formulated to meet the patient’s needs. Planning usually encompasses four phases: (1) priority setting, (2) development of measurable goal and outcome statements, (3) formulation of nursing interventions, and (4) formulation of anticipated therapeutic outcomes that can be used to evaluate the patient’s status. Collecting data is part of the assessment phase of the nursing process. Making a clinical judgment about the patient takes place during the diagnosis phase.

DIF:

Cognitive Level: Application

TOP:

Nursing Process Step: Planning

REF: p. 39

OBJ: 7 | 8

MSC: NCLEX Client Needs Category: Physiological Integrity

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22. The nurse is preparing a patient’s prescribed medications. In order to ensure patient safety, the nurse will perform which intervention(s)? (Select all that apply.) a.

Select the correct supplies.

Administer the medication by the correct route.

Use room number to identify correct patient.

Educate patient regarding medications prescribed.

Document in chart all aspects of medication administration.

ANS: A, B, D, E The nurse prepares prescribed medications using procedures to ensure patient safety, including selecting correct supplies, administering medication by the correct route, educating patients regarding medications prescribed, and documenting in chart all aspects of medication administration. To improve the accuracy of patient identification, it is now recommended that two patient identifiers, neither of which is the room number, be used when administering medications. Best practice would be to look at the patient’s name band for identity and to request that the patient state his or her name and birth date.

DIF: Cognitive Level: Application Implementation

REF: p. 45

OBJ: 13 | 14 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

OTHER

23. Rank the patient needs according to Maslow’s hierarchy, beginning with the lowest level need to the highest level need. (Enter your answer with a comma and space between each lettered option as follows: A, B, C, D, E.) A.

A patient would like to write a book.

A patient becomes frightened when no one answers the call light during the night.

A pediatric patient is worrying that school friends will forget him.

A patient needs to be repositioned in bed.

A chronically ill patient states that he feels worthless because he is unable to support his family.

https://studentmagic.indiemade.com/ ANS: D, B, C, E, A The needs should be addressed in the following order: The patient’s need for repositioning represents a basic need for comfort; the patient’s alarm when the call light is not answered represents fear for safety; the patient’s worry about his school friends forgetting him represents a threat to sense of love and belonging; the patient’s feeling of worthlessness represents threatened self esteem; and the patient’s desire to write a book is related to self actualization.

DIF:

Cognitive Level: Analysis

REF: p. 40

OBJ: 9 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

Chapter 5: Patient Education to Promote Health Test Bank

MULTIPLE CHOICE

1. The nurse is educating a 13-year-old boy newly diagnosed with diabetes and his parents about diet and glucose monitoring. Which domain of learning is represented when the patient expresses concern about feeling different from his peers? a.

Cognitive

Psychomotor

Affective

Learning style

ANS: C The affective domain is characterized by conduct that expresses feelings, needs, beliefs, values, and opinions. The cognitive domain relates to basic factual knowledge. The psychomotor domain relates to kinesthetic knowledge, implemented in performance and skills requiring coordination. Learning style is not one of the three domains of learning.

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DIF:

Cognitive Level: ComprehensionREF: p. 48

OBJ: 1 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

2. The nurse has taught a patient’s spouse to administer an injectable medication. After the spouse completed a return demonstration of the injection in the hospital, the nurse does not feel confident that this can be carried out independently at home and requests referral for a home health nurse. The nurse is using which phase of the nursing process? a.

Assessment

Implementation

Planning

Evaluation

ANS: D The nurse has evaluated the injection technique of the patient’s spouse and determines additional instruction is needed. The nurse is not assessing the situation because she is not at the beginning of the process. The nurse is past implementation in the timeline of the process. The nurse has already planned and implemented interventions.

DIF:

Cognitive Level: Application

REF: p. 46

OBJ: 6 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

3. In preparing for health teaching with a patient who has an auditory learning style, which would be most appropriate? a.

Pamphlets from a pharmaceutical company

Models of equipment used in a procedure

Verbal description of the steps of a procedure

A workbook with space to record actions and results

ANS: C

https://studentmagic.indiemade.com/ Hearing the nurse present the information optimizes the patient’s perception of the data. Pamphlets from a pharmaceutical company or a workbook would be suitable for a patient who has a visual learning style. Models of equipment would be suitable for a patient with a psychomotor learning style.

DIF: Cognitive Level: Analysis Evaluation

REF: p. 49 | p. 53

OBJ: 3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

Which is the most intangible portion of the learning process?

Cognitive

Affective

Psychomotor

Eminent

ANS: B The affective domain concerns feelings, needs, beliefs, values, and opinions. The cognitive domain is the level at which basic knowledge is learned and stored; it is the thinking portion of the learning process. The psychomotor domain involves learning new procedures or skills; it is often referred to as the “doing domain.” Eminent domain in common law legal systems is the lawful power of the state to expropriate private property without the owner’s consent, either for its own use or on behalf of a third party.

DIF:

Cognitive Level: Knowledge

REF: p. 48

OBJ: 1 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

Which would positively affect readiness to learn?

Fear and denial

Willingness to attain an optimal level of health

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Poor cognitive and motor development

Lack of trust and confidence in the staff

ANS: B Readiness or the ability to engage in learning depends on motive, relevant preparatory learning, and physiologic maturation. In fear and denial, the patient is neither prepared nor willing to accept the limitations imposed by the disease process and learn to manage lifestyle changes. Poor cognitive and motor development handicap the patient’s willingness and ability to learn. Trust is essential in the process of patient education. The patient must have confidence in the staff in order to be receptive to teaching efforts.

DIF:

Cognitive Level: ComprehensionREF: p. 50

OBJ: 2 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

Which represents the psychomotor domain of learning?

The patient draws up insulin in a syringe.

The patient expresses a belief about medication use.

The patient is able to verbalize foods that should be avoided.

The patient relates past experience with smoking cessation.

ANS: A

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The psychomotor domain involves the learning of a new procedure and is usually done by demonstration of the task. The patient expressing beliefs is an example of the affective domain. The patient verbalizing foods to be avoided is an example of the cognitive domain. The patient relating past experiences is an example of the affective domain.

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DIF:

Cognitive Level: ComprehensionREF: pp. 48-49 OBJ: 1 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

Which is an example of ethnocentrism?

A 5-year-old Native American child colors in a book about diabetes.

A 14-year-old African American attends a support group to learn about disease management.

A 36-year-old Asian prefers to take herbs instead of an oral medication.

d. A 72-year-old Hispanic asks questions about potential adverse effects to a newly prescribed medication. ANS: C Ethnocentrism is the assumption that one’s culture provides the right way, and taking herbs instead of the medication exemplifies this belief. A 5-year-old Native American child coloring in a book about diabetes is an example of age appropriate learning process. A 14-year-old African American attending a support group to learn about disease management is an example of developmental impact on learning. A 72-year-old Hispanic person asking questions about potential adverse effects to a newly prescribed medication is demonstrating learning readiness.

DIF:

Cognitive Level: ComprehensionREF: p. 53

OBJ: 4 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

8. What is the most important nursing consideration when teaching an older adult patient about a newly prescribed medication? a.

Provide detailed information.

Lengthen the time of each teaching session.

Present information slowly.

Limit discussion on the necessity of learning the information.

ANS: C When teaching older adults, it is important to slow the pace of the presentation. Older adults process information more slowly because of limited short term memory. Detailed information may be too overwhelming. The length of sessions should be limited for the older adult patient. Adults need to understand why they must learn something before they undertake the effort to learn.

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DIF:

Cognitive Level: ComprehensionREF: p. 52

OBJ: 6 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

9. The nurse caring for a Spanish speaking patient uses the assistance of an interpreter to help with preoperative teaching. While implementing the education, the nurse should: a.

look directly at the patient.

never use pantomime gestures.

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ask lengthy questions to provide clarity.

ask a family member to assist with interpretation.

ANS: A When using an interpreter, the nurse should look directly at the patient, not at the interpreter, while conversing. Sometimes supplementing questions with pictures and pantomime gestures may be helpful. The nurse should keep questions brief, asking them one at a time to give the interpreter an opportunity to rephrase the question and obtain a response. Whenever a third person enters into the communication cycle, lack of clarity and misinterpretation can occur.

DIF: Cognitive Level: Application Implementation

REF: p. 53

OBJ: 2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Psychological Integrity

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10. A teaching plan has been developed by the nurse to educate the mother of a pre term infant on prescribed medications. Before initiating this teaching plan, the nurse should: a.

recognize the individual’s health beliefs.

provide a formal learning setting.

ensure that information is generalized.

be sure that all care to the patient has been delivered.

ANS: A Before initiating a teaching plan, the nurse must recognize the individual’s health beliefs. Teaching does not require a formal setting. Because health teaching requires the integration of the patient’s beliefs, attitudes, values, opinions, and needs, an individualized teaching plan must be developed or a standardized teaching plan must be adapted to the individual’s beliefs and needs. Some of the most effective teaching can be done while care is being delivered.

DIF: Cognitive Level: Application Implementation

REF: p. 50

OBJ: 3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Psychosocial Integrity

MULTIPLE RESPONSE

11.

Which item(s) would be considered characteristic of the cognitive domain level of learning?

(Select all that apply.) a.

A patient’s opinion regarding wellness

Basic mathematical formulas learned in grade school

Incorporation of a person’s previous experiences and perceptions

Skill demonstration using a step by step approach

Relationship between prior experiences and new concepts

ANS: B, C, E Basic mathematical formulas learned previously, incorporating a person’s previous experiences and perceptions, and a relationship between prior experiences and new concepts characterize the cognitive domain level of learning. A patient’s opinion regarding wellness is an example of the affective domain. Skill demonstration using a step by step approach is an example of the psychomotor domain.

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DIF:

Cognitive Level: ComprehensionREF: p. 48

OBJ: 1 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

12. The nurse is preparing to instruct a patient and his wife on technique and importance of assessing pulse prior to taking heart medication. Which principle(s) of learning would be appropriate in this situation? (Select all that apply.) a.

The learning environment

The patient’s and wife’s learning styles

The objectives/goal statements listed on the patient’s care plan

The patient’s financial ability to purchase the medication

The patient’s understanding of the seriousness of his illness

ANS: A, B, C, E Learning environment, learning style, listing clear objectives and goal statements, and understanding the seriousness of the situation are all principles of learning. Financial ability is not a principle of learning, but should be an important consideration and assessment when preparing for discharge of the patient and future compliance of the treatment regimen.

DIF:

Cognitive Level: Application

REF: p. 49

OBJ: 3 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

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13. The nurse is writing a teaching plan for a 30-year-old patient who has AIDS. Which objective(s) is/are written in the correct format? (Select all that apply.) a.

The patient will state adverse effects of the daily medications before discharge.

b. The patient will correctly fill the daily medication pillbox with the correct medications in the appropriate time slots prior to discharge. c.

The patient will adjust the medications accordingly.

The patient will schedule an appointment with the infectious disease physician before discharge.

The patient will have lab tests performed regularly.

ANS: A, B, D Each of correct objectives noted are measurable and specific.

DIF:

Cognitive Level: Analysis

REF: p. 55

OBJ: 6 TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity

14. Which action(s) by the nurse can foster patient responsibility for adhering to the therapeutic regimen? (Select all that apply.) a.

Assessing the patient’s readiness to learn

Determining the patient’s level of understanding of content

Determining the patient’s education level and learning style

Maintaining an aloof attitude toward presented content

Documenting expected outcomes independently

ANS: A, B, C The nurse should assess the patient’s readiness to learn when teaching the patient. The nurse should determine the patient’s level of understanding of the content and the patient’s education level and learning style when teaching the patient. The nurse should portray a positive attitude when teaching the patient. Goals should be mutually written with the patient.

DIF:

Cognitive Level: ComprehensionREF: p. 55

OBJ: 4 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

15. What should the nurse include during discharge in addition to verbal instructions? (Select all that apply.) a.

Written instructions for the patient’s reference

https://studentmagic.indiemade.com/ b.

A phone number of the provider or hospital unit for follow up questions

Written instructions for monitoring of parameters used to evaluate therapy

d. Documentation in the nurse’s discharge notes of the nursing and collaborative problems that require continued monitoring and intervention e.

Identification of the patient’s unreasonable expectations of therapy

ANS: A, B, C, D Learning is an ongoing process. Verbal instructions should be followed up with instructions in writing. Patients should be given a contact number for future reference. Written instructions for monitoring of parameters used to evaluate therapy should be given to the patient. Documentation is an essential part of validating the patient’s understanding of the instructions provided. Although identifying the patient’s expectations will affect the outcome, they are not part of the discharge planning documentation.

DIF:

Cognitive Level: Application

REF: p. 49

OBJ: 5 | 6 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

16.

Which action(s) would let the nurse know that the patient has mastered a psychomotor skill?

(Select all that apply.) a.

Describe the process verbally.

Write a description of the process.

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Give a reciprocal demonstration of the process.

Ask questions about the process.

Demonstrate the process to another person while the nurse supervises.

State whether the patient feels the process has been mastered.

ANS: C, D Having the patient demonstrate the process to the nurse or to another person is the best way to ensure that he can perform the skill correctly. Having the patient describe the process or write a description of the process is not sufficient. Asking questions may reinforce learning but may also mask some deficiencies. Asking the patient whether he feels he has mastered the process is not sufficient.

DIF:

Cognitive Level: ComprehensionREF: p. 50

OBJ: 6 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

17. The nurse and patient are participating in cooperative goal setting regarding drug therapy. The nurse is aware that it is imperative to encourage the patient to perform which task(s)? (Select all that apply.) a.

Contact the hospital for advice regarding discontinuation of medication.

Keep records of essential data needed to evaluate prescribed therapy.

See the health care provider regularly.

Avoid community based agencies for assistance.

Monitor parameters used to evaluate therapy.

ANS: B, C, E

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An attitude of shared input into the goals and outcomes can encourage the patient into a therapeutic alliance. Therefore, the patient should be taught to help monitor the parameters used to evaluate therapy, keep records of essential data, and contact the health care provider for advice rather than alter or discontinue the medication entirely. The health care provider, not the hospital, should be contacted. In the event that the patient, family, or significant others do not understand all aspects of the continuing therapy prescribed, they may be referred to a community based agency for help in achieving long term health care requirements.

DIF:

Cognitive Level: Application

REF: p. 56

OBJ: 3 TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

https://studentmagic.indiemade.com/ Chapter 06: Principles of Medication Administration and Medication Safety

MULTIPLE CHOICE

https://studentmagic.indiemade.com/ 1.

Where would the procedures and treatments directed by the health care provider be found? a. Summary sheet

Physician’s order form

Physician’s progress notes

History and physical examination form

ANS: B The physician’s order form contains all procedures and treatments ordered by the health care provider. A summary sheet provides a brief overview of the hospital course at discharge. Physician’s progress notes provide regular observations on the patient’s course of treatment and response. A history and physical examination form provides information about baseline information from the patient.

DIF: Cognitive Level: Knowledge Assessment

REF:

Page 61OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment NOT: CONCEPT(S): Clinical Judgment

2. Which action will the nurse take when it is determined that the narcotic count is incorrect while obtaining a medication from the narcotic area? a.

Determine the cause of the discrepancy at the end of the shift.

Notify the health care provider stat.

Call the nurse from the previous shift to determine if there was a discrepancy earlier.

Report the discrepancy to the charge nurse immediately.

ANS: D Reporting the discrepancy to the charge nurse immediately enables the supervisory staff to narrow the time frame during which a medication was taken and not documented. The discrepancy needs to be addressed immediately, and therefore determining the cause of the discrepancy at the end of the shift is not the most appropriate action for the nurse to take. It is not appropriate to contact the health care provider for an incorrect narcotic count. The count would have been verified at shift change; calling the nurse from the previous shift is not an appropriate action for the nurse to take.

DIF: Cognitive Level: Analysis Implementation

REF:

Page 70OBJ:

3 TOP: Nursing Process Step:

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MSC: NCLEX Client Needs Category: Safe, Effective Care Environment NOT: CONCEPT(S): Clinical Judgment; Safety

Which action will the nurse take if a dosage is unclear on a health care provider’s order?

Ask the patient what dosage was given in the past.

Ask another physician to determine the correct dosage.

Tell the patient that the medication will not be given.

Contact the health care provider to verify the correct dosage.

ANS: D Any questionable orders should be verified by the health care provider who wrote the orders. The patient is not a reliable source of verification. The physician who wrote the order should verify it. It would be a medication error to withhold the dose instead of verifying it.

DIF: Cognitive Level: Application Step: Planning

REF:

Page 76 | Page 77 OBJ: 5

TOP: Nursing Process

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

What is the most reliable method to calculate a pediatric patient’s medication dosage?

Age

Height

Body surface area (BSA)

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Placement on a growth scale

ANS: C The most reliable method is by proportional amount of BSA or body weight. Because of the differences in weight among children, age is not a reliable method. Because of the differences in height among children, this is not a reliable method. Placement on a growth scale identifies how the child corresponds to other children on a percentile. Although it is determined by a specific measurement, the percentile identified would not be a specific measurement; therefore, this is not a reliable method.

DIF: Cognitive Level: ComprehensionREF: Assessment

Page 77OBJ:

7 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Development

5. Which medication route provides the most rapid onset of a medication but also poses the greatest risk of adverse effects? a.

Intradermal

Subcutaneous (subcut)

Intramuscular (IM)

Intravenous (IV)

ANS: D IV medications are delivered directly into the bloodstream and avoid the “first pass” effect of the liver. Intradermal, subcut, and IM administration have a slower absorption rate.

DIF: Cognitive Level: Knowledge Assessment

REF:

Page 78OBJ:

7 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

Which is known as the “fifth vital sign”?

Temperature

Respirations

Pain

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Pulse

ANS: C Pain is known as the “fifth vital sign.”

DIF: Cognitive Level: Knowledge Assessment

REF:

Page 63OBJ:

8 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Pain

Which is true regarding the unit dose drug distribution system?

The inventory is delivered to each nursing unit on a regular and recurring basis.

b. The system delivers one dose of each medication to be administered until the subsequent delivery of inventory. c.

The use of single dose packages of drugs dispensed to fill each dose requirement as it is ordered.

The amount of inventory needed to dose all patients on the unit for a 24-hour interval.

ANS: C The unit dose drug distribution system uses single unit packages of drugs dispensed to fill each dose requirement as it is ordered.

DIF: Cognitive Level: ComprehensionREF: Implementation

Page 68OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

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The nursing assessment identifies that the client is nauseated and cannot take acetaminophen

(Tylenol) orally. Which is true regarding the substitution of this medication to suppository form? a.

It is standard practice when the patient is unable to take the ordered medication.

It is acceptable if the patient agrees to the altered route form.

It is preferable to having the patient miss a dose of the medication.

It is contraindicated without an order from the health care provider.

ANS: D One dosage form of medication should never be substituted for another unless the prescriber is consulted; there can be a great variation in the absorption rate of the medication through different routes of administration. The substitution of one form for another is not standard practice and is not acceptable or preferable without the prescriber’s order.

DIF: Cognitive Level: Application Step: Implementation

REF:

Page 77 | Page 78 OBJ: 1

TOP: Nursing Process

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

Which medication order requires nursing judgment and means “administer if needed”?

Morphine 4 mg IV stat

Morphine 4 mg IV prior to procedure

Morphine 4 mg IV four times a day

Morphine 4 mg IV every 4 hours PRN

ANS: D PRN indicates for the nurse to administer morphine every 4 hours if needed and requires nursing judgment. Stat means the dose of morphine would be given immediately, not as needed. The orders for the dose of morphine to be given prior to the patient’s scheduled procedure and four times a day do not indicate to give the dose as needed.

DIF: Cognitive Level: ComprehensionREF: Implementation

Page 73OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

10.

What is medication reconciliation?

4 | 8 TOP: Nursing Process Step:

https://studentmagic.indiemade.com/ a.

Comparing the patient’s current medication orders to all of the medications actually being taken

b. The administration of high alert medications that have been ordered on admission to an acute care facility c.

The completion of an incident report following a variance that resulted in a serious complication

d. A printout of computerized patient data that identifies the times that all of the ordered medications are to be administered ANS: A Medication reconciliation is the process of comparing a patient’s current medication orders to all of the medications that the patient is actually taking. Administering high alert medications and completing an incident report are not the same as medication reconciliation. A printout of computerized patient data that identifies the times that all of the ordered medications are to be administered is a description of the medication administration record (MAR), not a description of medication reconciliation.

DIF: Cognitive Level: Knowledge Assessment

REF:

Page 74OBJ:

2 | 6 | 8 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Care Coordination; Health Promotion

11.

Which example best demonstrates safe drug administration by the nurse?

Administering an oral medication with the patient sitting upright

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Asking children to say their name before administering the medication

Leaving the medications on the bedside stand after verifying patient identification

Returning the unused portion of a medication to a stock supply bottle

ANS: A Sitting the patient upright for oral medications is safe medication practice. Children should never be asked their names as a means of positive identification. Remaining with a patient until the drug is swallowed is safe practice. Returning an unused portion of medication to the stock supply bottle is not safe medication practice.

DIF: Cognitive Level: Application Implementation

REF:

Page 79OBJ:

7 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

NOT: CONCEPT(S): Clinical Judgment; Safety

12. The nurse determines that a prescribed medication has not been administered as ordered on the previous shift. What action will the nurse take? a.

Administer the medication immediately.

Complete an incident report.

Notify the nurse responsible for the error.

Record the occurrence in the nurse’s notes.

ANS: B

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An incident report is completed when a medication error occurs. Depending on the medication and frequency of administration, the medication may not be given immediately. It is not the nurse’s responsibility to notify another nurse of the error. Medication errors are not recorded in the nurse’s notes.

DIF: Cognitive Level: Application Implementation

REF:

Page 75OBJ:

1 | 8 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

13.

A patient’s liquid cough medicine has been discontinued with one half of the bottle remaining.

The home health nurse is aware that according to the U.S. Food and Drug Administration ( FDA) guidelines on prescription medication disposal, the next step should be to a.

save the remainder for another patient with the same prescription.

flush the remainder down the toilet.

read the drug label for specific disposal instructions.

pour remaining medication into a hazardous waste container.

ANS: C The nurse must follow specific disposal instructions on the drug label or in the patient information leaflet that accompanies the medication. Prescription medications should not be shared among patients. Prescription drugs should not be flushed down the toilet unless specifically instructed to do so by the manufacturer. The first action to be taken is to follow disposal instructions on the label. If the drug label indicates it should be emptied into a hazardous waste container, measures should be taken to prevent leaking and/or accidental ingestion.

DIF: Cognitive Level: Analysis Implementation

REF:

Page 72OBJ:

6 | 7 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment| NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

MULTIPLE RESPONSE

Who defines the standards of care for the practice of nursing? (Select all that apply.)

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State boards of nursing

Hospital policy and procedures

Federal laws regulating health care facilities

The Joint Commission

Professional nursing associations

ANS: A, C, D, E Standards of care are defined by state boards of nursing, federal laws regulating health care facilities, The Joint Commission, and professional nursing associations such as the American Nurses Association. Individual hospital policies and procedures incorporate federal and state guidelines into their respective policies and procedures and are often more stringent than state and federal regulations.

DIF: Cognitive Level: Knowledge Assessment

REF:

Page 60OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment NOT: CONCEPT(S): Health Care Law; Health Care Organizations

What must the nurse have before administering any medication? (Select all that apply.) a. A current license to practice

A medication order signed by a practitioner licensed with prescription privileges

Knowledge of the medication

Consultation with a pharmacist

Knowledge of the client’s diagnosis

ANS: A, B, C, E

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Physicians must be licensed to prescribe medications; nurses must be licensed to administer medications. Safe medication administration includes knowledge of the medication, pathophysiology of patient diagnoses, and pharmacodynamics of the ordered medication on the pathophysiology. It is not necessary for the nurse to consult with a pharmacist each time medication is to be administered to a patient.

DIF: Cognitive Level: ComprehensionREF: Implementation

Page 60OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment NOT: CONCEPT(S): Health Care Law; Clinical Judgment

Which advantage(s) does the unit dose drug distribution system include? (Select all that apply.)

There is decreased participation by the pharmacy.

b. The pharmacist is able to analyze prescribed medications for each client for drug interactions and contraindications. c.

There is less waste of medications.

The time spent by nursing personnel preparing these medications is increased.

Credit is given to the patient for unused medications.

ANS: B, C, E Because the pharmacist has a profile of all medications for each patient, he or she is able to analyze prescribed medications for each patient for drug interactions and contraindications. This is an advantage of the unit dose drug distribution system. Less waste of medications is an advantage of the unit dose drug distribution system. Because each dose is individually packaged, credit can be given to the patient for unused medications. There is increased pharmacist involvement and better use of his or her extensive drug knowledge, and nursing personnel time is decreased with this method.

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DIF: Cognitive Level: Knowledge Implementation

REF:

Page 68OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

https://studentmagic.indiemade.com/

NOT: CONCEPT(S): Care Coordination; Safety; Health Policy

Which statement(s) is/are true regarding the types of medication orders? (Select all that apply.)

Stat orders are the same as single dose orders.

Standing orders indicate the number of specified doses of a medication to be given.

Renewal orders facilitate physician review before continuance of high-risk medications.

d. PRN medications will designate a mandatory number of times the medication is to be administered. e.

Verbal orders should be used as much as possible.

ANS: B, C Standing orders state the frequency of medication dosages to be administered or indicate the time frame of administration. Renewal orders require the physician to review medications that have “expired orders,” as determined by facility policy. Renewal policies facilitate physician verification of the necessity to continue a medication beyond a “usual” time frame and help ensure patient safety. Single dose and stat orders are not the same. PRN medications are not ordered a mandatory number of times, although a maximum number might be specified. Verbal orders should be avoided whenever possible.

DIF: Cognitive Level: ComprehensionREF: Step: Planning

Page 72 | Page 73 OBJ: 1 | 8

TOP: Nursing Process

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Health Care Policy

https://studentmagic.indiemade.com/ 5. Which statement(s) is/are true regarding computerized prescriber order entry (CPOE)? (Select all that apply.) a.

Integrates the ordering system with the pharmacy, laboratory, and nurses’ stations

Provides instant access to online information to facilitate patient care needs

Facilitates review of ordered medications for potential drug interactions

Facilitates review of drugs for appropriateness of dosages

Alleviates the need to perform mathematical computations

ANS: A, B, C, D CPOE systems integrate patient information, provide instant access, facilitate review of ordered medications for potential drug interactions, and facilitate review of drugs for appropriateness of dosages. Alleviation of the need to perform mathematical computations is not a component of the CPOE system.

DIF: Cognitive Level: Knowledge Step: Assessment

REF:

Page 68 | Page 69 OBJ: 1 | 8

TOP: Nursing Process

MSC: NCLEX Client Needs Category: Physiological Integrity| NCLEX Client Needs Category: Safe, Effective Care Environment NOT: CONCEPT(S): Clinical Judgment; Safety; Care Coordination; Technology and Informatics

6. Which lab test(s) would be used to assess liver and/or renal function before administering medications? (Select all that apply.) a.

CBC

LDH

ALT

Crs

BUN

aPTT

ANS: B, C, D, E Liver function tests include LDH (lactic dehydrogenase) and ALT (alanine aminotransferase). Renal function tests include Crs (serum creatinine) and BUN (blood urea nitrogen). Although a CBC (complete blood count) and an aPTT are useful in assessing the patient before administration of medication, they are not renal or hepatic function tests.

DIF: Cognitive Level: Knowledge Step: Assessment

REF:

Page 76 | Page 77 OBJ: N/A

TOP: Nursing Process

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Health Promotion

https://studentmagic.indiemade.com/ 7. The nurse is preparing to administer Lanoxin to a patient on the telemetry unit. In addition to understanding the patient’s diagnosis, the nurse must also know which characteristic(s) of the medication? (Select all that apply.) a.

Chemical composition

Adverse effects

Expected actions

Contraindications for use

Usual dosing

ANS: B, C, D, E The nurse must understand the individual patient’s diagnosis and symptoms that correlate with the rationale for drug use. The nurse should also know why a medication is ordered, expected actions, usual dosing, proper dilution, route and rate of administration, adverse effects, and contraindications for the use of a particular drug. It is not required that the nurse know the chemical composition of the medication prior to administration.

DIF: Cognitive Level: Application Step: Implementation

REF:

Page 73 | Page 76 OBJ: 6

TOP: Nursing Process

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MSC: NCLEX Client Needs Category: Safe, Effective Care Environment| NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

8. The nurse transcribes an order to administer Valium 10 mg IV stat. This order is correctly interpreted by the nurse to mean it should be provided how? (Select all that apply.) a.

As needed

Immediately

One time only

In divided doses

Intravenously

ANS: B, C, E The stat order is generally used on an emergency basis. It means that the drug is to be administered as soon as possible, but only once. IV indicates the route is intravenous. A PRN order means “administer if needed.” The order would specify “divided doses” and amount per dose if indicated.

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DIF: Cognitive Level: Analysis Assessment

REF:

Page 72OBJ:

8 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Chapter 7: Principles of Medication Administration and Medication Safety Test Bank

MULTIPLE CHOICE

Where would the procedures and treatments directed by the health care provider be found?

Summary sheet

Physician’s order form

Physician’s progress notes

History and physical examination form

DIF:

Cognitive Level: Knowledge

REF: p. 80

OBJ: 2 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

2. Which action will the nurse take when it is determined that the narcotic count is incorrect while obtaining a medication from the narcotic area? a.

Determine the cause of the discrepancy at the end of the shift.

Notify the health care provider stat.

Call the nurse from the previous shift to determine if there was a discrepancy earlier.

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Report the discrepancy to the charge nurse immediately.

DIF: Cognitive Level: Analysis Implementation

REF: p. 95

OBJ: 3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

Which action will the nurse take if a dosage is unclear on a health care provider’s order?

Ask the patient what dosage was given in the past.

Ask another physician to determine the correct dosage.

Tell the patient that the medication will not be given.

Contact the health care provider to verify the correct dosage.

DIF:

Cognitive Level: Application

REF: p. 99

OBJ: 5 TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity

What is the most reliable method to calculate a pediatric patient’s medication dosage?

Age

Height

Body surface area (BSA)

Placement on a growth scale

https://studentmagic.indiemade.com/ identified would not be a specific measurement; therefore, this is not a reliable method.

DIF:

Cognitive Level: ComprehensionREF: p. 101

OBJ: 10 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

5. Which medication route provides the most rapid onset of a medication, but also poses the greatest risk of adverse effects? a.

Intradermal

Subcutaneous (subcut)

Intramuscular (IM)

Intravenous (IV)

ANS: D IV medications are delivered directly into the bloodstream and avoid the “first pass” effect of the liver. Intradermal, subcut, and IM administration have a slower absorption rate.

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DIF:

Cognitive Level: Knowledge

REF: p. 102

OBJ: 10 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

Which is known as the “fifth vital sign”?

Temperature

Respirations

Pain

Pulse

ANS: C Pain is known as the “fifth vital sign.”

DIF:

Cognitive Level: Knowledge

REF: p. 86

OBJ: 2 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

Which is true regarding the unit dose drug distribution system?

The inventory is delivered to each nursing unit on a regular and recurring basis.

b. The system delivers one dose of each medication to be administered until the subsequent delivery of inventory. c.

The use of single dose packages of drugs dispensed to fill each dose requirement as it is ordered.

The amount of inventory needed to dose all patients on the unit for a 24 hour interval.

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ANS: C The unit dose drug distribution system uses single unit packages of drugs dispensed to fill each dose requirement as it is ordered.

DIF: Cognitive Level: ComprehensionREF: p. 93 Implementation

OBJ: 7 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

8. The nursing assessment identifies that the client is nauseated and cannot take acetaminophen (Tylenol) orally. Which is true regarding the substitution of this medication to suppository form? a.

It is standard practice when the patient is unable to take the ordered medication.

It is acceptable if the patient agrees to the altered route form.

It is preferable to having the patient miss a dose of the medication.

It is contraindicated without an order from the health care provider.

ANS: D One dosage form of medication should never be substituted for another unless the prescriber is consulted; there can be a great variation in the absorption rate of the medication through different routes of administration. The substitution of one form for another is not standard practice, and is not acceptable or preferable without the prescriber’s order.

DIF: Cognitive Level: Application Implementation

REF: p. 99

OBJ: N/A TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Which medication order requires nursing judgment and means “administer if needed”?

Morphine 4 mg IV stat

Morphine 4 mg IV prior to procedure

Morphine 4 mg IV four times a day

Morphine 4 mg IV every 4 hours PRN

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the dose of morphine to be given prior to the patient’s scheduled procedure and four times a day, do not indicate to give the dose as needed.

DIF: Cognitive Level: ComprehensionREF: p. 89 | p. 97 Implementation

OBJ: 2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

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10.

What is medication reconciliation?

Comparing the patient’s current medication orders to all of the medications actually being taken

b. The administration of high alert medications that have been ordered on admission to an acute care facility c.

The completion of an incident report following a variance that resulted in a serious complication

DIF: Cognitive Level: Knowledge Assessment

REF: p. 98

OBJ: 4 | 9 | 10 TOP: Nursing Process Step:

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MSC: NCLEX Client Needs Category: Physiological Integrity

11.

Which example best demonstrates safe drug administration by the nurse?

Administering an oral medication with the patient sitting upright

Asking children to say their name before administering the medication

Leaving the medications on the bedside stand after verifying patient identification

Returning the unused portion of a medication to a stock supply bottle

DIF: Cognitive Level: Application Implementation

REF: p. 103

OBJ: 10 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

12. The nurse determines that a prescribed medication has not been administered as ordered on the previous shift. What action will the nurse take? a.

Administer the medication immediately.

Complete an incident report.

Notify the nurse responsible for the error.

Record the occurrence in the nurse’s notes.

ANS: B An incident report is completed when a medication error occurs. Depending on the medication and frequency of administration, the medication may not be given immediately. It is not the nurse’s responsibility to notify another nurse of the error. Medication errors are not recorded in the nurse’s notes.

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DIF: Cognitive Level: Application Implementation

REF: p. 100

OBJ: 6 | 11 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

13. A patient’s liquid cough medicine has been discontinued with one half of the bottle remaining. The home health nurse is aware that according to the U.S. Food and Drug Administration (FDA) guidelines on prescription medication disposal, the next step should be to: a.

save the remainder for another patient with the same prescription.

flush the remainder down the toilet.

read the drug label for specific disposal instructions.

pour remaining medication into a hazardous waste container.

DIF: Cognitive Level: Analysis Implementation

REF: p. 96

OBJ: 7 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment; Physiological Integrity

MULTIPLE RESPONSE

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14.

Who defines the standards of care for the practice of nursing? (Select all that apply.)

State boards of nursing

Hospital policy and procedures

Federal laws regulating health care facilities

The Joint Commission

Professional nursing associations

DIF: Cognitive Level: Knowledge Assessment

REF: p. 79 | p. 91 | p. 92 OBJ: 1TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

15.

What must the nurse have before administering any medication? (Select all that apply.)

A current license to practice

A medication order signed by a practitioner licensed with prescription privileges

Knowledge of the medication

Consultation with a pharmacist

Knowledge of the client’s diagnosis

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ANS: A, B, C, E Physicians must be licensed to prescribe medications; nurses must be licensed to administer medications. Safe medication administration includes knowledge of the medication, pathophysiology of patient diagnoses, and pharmacodynamics of the ordered medication on the pathophysiology. It is not necessary for the nurse to consult with a pharmacist each time medication is to be administered to a patient.

DIF: Cognitive Level: ComprehensionREF: p. 80 Implementation

OBJ: 1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

16.

Which advantage(s) does the unit dose drug distribution system include? (Select all that apply.)

There is decreased participation by the pharmacy.

b. The pharmacist is able to analyze prescribed medications for each client for drug interactions and contraindications. c.

There is less waste of medications.

The time spent by nursing personnel preparing these medications is increased.

Credit is given to the patient for unused medications.

ANS: B, C, E Because the pharmacist has a profile of all medications for each patient, he or she is able to analyze prescribed medications for each patient for drug interactions and contraindications. This is an advantage of the unit dose drug distribution system. Less waste of medications is an advantage of the unit dose drug distribution system. Because each dose is individually packaged, credit can be given to the patient for unused medications. There is increased pharmacist involvement and better use of his or her extensive drug knowledge and nursing personnel time is decreased with this method.

DIF: Cognitive Level: Knowledge Implementation

REF: p. 93

OBJ: 7 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

17.

Which statement(s) is/are true regarding the types of medication orders? (Select all that apply.)

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Stat orders are the same as single dose orders.

Standing orders indicate the number of specified doses of a medication to be given.

Renewal orders facilitate physician review before continuance of high risk medications.

d. PRN medications will designate a mandatory number of times the medication is to be administered. e.

Verbal orders should be used as much as possible.

ANS: B, C

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Standing orders state the frequency of medication dosages to be administered or indicate the time frame of administration. Renewal orders require the physician to review medications that have “expired orders,” as determined by facility policy. Renewal policies facilitate physician verification of the necessity to continue a medication beyond a “usual” time frame and help ensure patient safety. Single dose and stat orders are not the same. PRN medications are not ordered a mandatory number of times, although a maximum number might be specified. Verbal orders should be avoided whenever possible.

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DIF:

Cognitive Level: ComprehensionREF: p. 97

OBJ: 8 TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity

18. Which statement(s) is/are true regarding computerized prescriber order entry (CPOE)? (Select all that apply.) a.

Integrates the ordering system with the pharmacy, laboratory, and nurses’ stations

Provides instant access to online information to facilitate patient care needs

Facilitates review of ordered medications for potential drug interactions

Facilitates review of drugs for appropriateness of dosages

Alleviates the need to perform mathematical computations

DIF:

Cognitive Level: Knowledge

REF: p. 92

OBJ: 8 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity; Safe, Effective Care Environment

19. Which lab test(s) would be used to assess liver and/or renal function before administering medications? (Select all that apply.) a.

CBC

LDH

ALT

Crs

BUN

aPTT

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DIF: Cognitive Level: Knowledge Assessment

REF: p. 101

OBJ: N/A TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

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20. The nurse is preparing to administer Lanoxin to a patient on the telemetry unit. In addition to understanding the patient’s diagnosis, the nurse must also know which characteristic(s) of the medication? (Select all that apply.) a.

Chemical composition

Adverse effects

Expected actions

Contraindications for use

Usual dosing

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DIF: Cognitive Level: Application Implementation

REF: p. 80

OBJ: 5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment; Physiological Integrity

21. The nurse transcribes an order to administer Valium 10 mg IV stat. This order is correctly interpreted by the nurse to mean it should be provided how? (Select all that apply.) a.

As needed

Immediately

One time only

In divided doses

Intravenously

DIF:

Cognitive Level: Analysis

REF: p. 80 OBJ: 8 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

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Chapter 8: Percutaneous Administration Test Bank

MULTIPLE CHOICE

1. A patient has an infected wound with large amounts of drainage. Which type of dressing would the nurse use? a.

Telfa

OpSite

DuoDerm

AlgiDERM

ANS: D AlgiDERM is manufactured from seaweed and is recommended for infected wounds because it is an exudate absorber. Telfa and OpSite do not absorb exudates. DuoDerm is for light to moderate wound drainage. According to the manufacturer, it does absorb exudates, but it is best for wounds with moderate drainage.

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DIF: Cognitive Level: ComprehensionREF: p. 105 Implementation

OBJ: 1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Where would the nurse apply nitroglycerin ointment on a male patient?

The same site that was previously used

A hairy area of the chest

The upper arm

The back of the knee

ANS: C Any area without hair may be used. Most people prefer the chest, flank, or upper arm areas. Sites should be rotated. The back of the knee is not suitable for applying medication because of the joint motion and difficulty of keeping a dressing in place.

DIF: Cognitive Level: ComprehensionREF: p. 107 Implementation

OBJ: 2 | 5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Where will the nurse administer a medication that was ordered to be given sublingually?

Between the molar teeth and cheek

Below the skin surface

Under the tongue

Into the conjunctival sac

ANS: C The sublingual area is underneath the tongue. Between the molar teeth and cheek is the buccal area. Medication administered below the skin surface is intradermal administration. The conjunctival sac is between the eyelids and eyeball.

DIF: Cognitive Level: Knowledge Implementation

REF: p. 113

OBJ: 9 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

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Why are sublingual and buccal medications rapidly absorbed?

Their action is localized to the mouth.

They are metabolized in the liver.

Blood flow is diminished in these sites.

These drugs pass directly into systemic circulation.

ANS: D Sublingual medications are rapidly absorbed into systemic circulation because of the increased blood flow to these areas and avoid the “first pass” effect of the liver where extensive metabolism usually takes place. These routes do not contain drug effects to the oral area and they bypass the liver. These sites are highly vascular.

DIF:

Cognitive Level: ComprehensionREF: p. 113

OBJ: 9 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

Which medications must be sterile?

Topical

Vaginal

Ophthalmic

Nasal

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ANS: C Ophthalmic (eye) medications must be sterile. Topical, vaginal, and nasal applications do not need to be sterile.

DIF: Cognitive Level: Knowledge Implementation

REF: p. 113

OBJ: 9 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

6. Which action will the nurse perform when doing a wet to dry dressing every 4 hours on a patient with a deep wound? a.

Pack the wound tightly with gauze.

Saturate the dressing with as much liquid as possible.

Use Montgomery tapes or a binder to secure the dressing.

Apply the new moist dressing over the existing one.

ANS: C The use of Montgomery tapes or a binder reduces the irritation of nearby skin tissue. The dressing should be packed into the wound loosely. The dressings should be wrung out to prevent dripping. The previous dressing should always be completely removed.

DIF: Cognitive Level: Application Implementation

REF: p. 106

OBJ: 2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

When applying nitroglycerin topically, which nursing intervention is correct?

Secure the paper on two sides with tape.

Shave the area prior to application of the paper.

Wear gloves while placing the new paper.

Remind the patient to discontinue use of the medication if chest pain is relieved.

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ANS: C Wearing gloves prevents accidental exposure to the medication. The area where the paper is placed should be covered with plastic wrap and taped into place to prevent medication from seeping out. Shaving may cause skin irritation. The dosage and frequency of application should be gradually reduced over 4 to 6 weeks, and the patient should contact the health care provider if adjustment is desired.

DIF: Cognitive Level: Application Implementation

REF: p. 109

OBJ: 5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Where does the nurse correctly administer ophthalmic medication?

At the inner canthus of the eye

In the lower conjunctival sac

Directly onto the eyeball

To the outer corner of the eyelid

ANS: B The lower conjunctival sac is exposed by applying gentle traction to the lower lid at the bony rim of the orbit. The inner canthus allows medication to flow out of the eye. Applying directly to the eyeball risks injury to the globe. The outer corner of the eyelid allows medication to flow out of the eye.

DIF: Cognitive Level: Knowledge Implementation

REF: p. 113

OBJ: 9 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

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9. Which effect would be important for the nurse to address when teaching a patient about the overuse of nose drops? a.

Rebound

Ceiling

Idiosyncratic

Measured

ANS: A Rebound effect may occur with overuse of some medications. Ceiling effect is the greatest attainable response. An idiosyncratic effect may occur even with prudent use of nose drops. Measured effect is the patient’s response to the medication.

DIF: Cognitive Level: Application Implementation

REF: p. 117

OBJ: 9 | 11 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

10.

Which nursing assessment accurately describes the results of an intradermal skin test?

Itching and weeping

Erythema and induration

Swelling and coolness

Pallor and drainage

ANS: B

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The result should be measured by diameter of erythema in millimeters, and the induration should be palpated and measured in millimeters. Itching is not relevant to the results; weeping should be reported to the health care provider but is not pertinent to the evaluation of the skin test. Swelling, coolness, pallor, and drainage are not relevant to evaluation; reporting this to the health care provider is appropriate, but not pertinent to the evaluation of the skin test.

DIF:

Cognitive Level: ComprehensionREF: p. 107

OBJ: 4 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

11. The nurse is teaching a patient about nitroglycerin ointment. Which is an advantage of this form of the medication? a.

It does not give the patient a bad taste in the mouth.

The amount of ointment does not matter in obtaining a therapeutic response.

It does not cause headaches as an adverse effect.

It provides relief of anginal pain for several hours longer than sublingual medication.

ANS: D Nitroglycerin ointment provides relief of anginal pain for several hours longer than sublingual preparations. Nitroglycerin pills do not have a bad taste. Dosage is critical to the success of use. All nitroglycerin preparations may cause headaches because of vasodilation.

DIF: Cognitive Level: ComprehensionREF: p. 109 Implementation

OBJ: 5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

12. A patient with metastatic cancer is being admitted for pain control. Which action will the nurse perform in administering a transdermal patch? a.

After removal, dispose of the old patch in a receptacle in the patient’s room.

Change the fentanyl patch every day, either in the morning or at bedtime.

Hold the short acting oral pain medication when a fentanyl patch is initiated.

Label the patch with date, time, dosage, and initials after patch placement.

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ANS: D Labeling is appropriate when transdermal disks are placed. Patches are to be disposed of in a receptacle on the medication cart, not in the patient’s room. Fentanyl patches are changed every 72 hours. Fentanyl patches take up to 12 hours to be effective; therefore, short acting pain medication is continued.

DIF: Cognitive Level: Application Implementation

REF: p. 111

OBJ: 7 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

13. What is the rationale for the nurse applying gentle pressure to the inner corner of the eyelid after instilling eye drops? a.

Decreases the risk of infection

Maintains intraocular pressure

Prevents systemic effects

Provides comfort to the patient

ANS: C

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Application of pressure to the inner corner of the eye prevents the medication from entering the canal, where it would be absorbed in the vascular mucosa of the nose and produce systemic effects. Application of pressure to the inner corner of the eye does not decrease infection, maintain intraocular pressure, or promote patient comfort.

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DIF: Cognitive Level: Application Implementation

REF: p. 114

OBJ: 9 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

14. The nurse is instructing a patient to use a corticosteroid inhaler. Which statement by the patient indicates the need for further teaching? a.

“I will shake the inhaler before I use it.”

“I need to rinse my mouth after I use the inhaler.”

“I will use this when I’m lying in bed in the morning.”

“After I inhale, I will hold my breath and then breathe out slowly.”

ANS: C The sitting position allows for maximum lung expansion. Shaking the inhaler helps to disperse the medication. The mouth needs to be rinsed after the inhalation of a corticosteroid. Holding the breath then exhaling slowly allows the drug to settle into pulmonary tissue.

DIF: Cognitive Level: Application Implementation

REF: p. 119

OBJ: 11 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

15.

What is the appropriate nursing action when administering a vaginal suppository?

Ask the patient to urinate prior to insertion.

Assist the patient to a side lying position.

Keep suppository refrigerated prior to insertion.

Insert the suppository 1 inch into the vagina.

ANS: A An empty bladder facilitates insertion. Side lying position would not facilitate insertion of a vaginal suppository. Suppository needs to be warmed to room temperature before it is administered. The suppository is inserted more than 1 inch.

DIF: Cognitive Level: Application Implementation

REF: p. 121

OBJ: 12 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

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16.

Which is an accurate nursing action when treating a patient’s rash with a lotion?

Avoid shaking the container prior to application.

Cleanse area with alcohol prior to treatment.

Cover the area with gauze because of the oil base.

Pat on the area with a gloved hand.

ANS: D To prevent increased circulation and itching, lotions should be gently but firmly patted on the skin, rather than rubbed in. Shake all lotions thoroughly immediately before application. Lotions are aqueous and are easily cleansed with water. Lotions are not oil based.

DIF:

Cognitive Level: Application

REF: p. 105

OBJ: 2

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TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

17. A 2-year-old child is hospitalized with the diagnosis of tonsillitis and bilateral otitis media. The nurse is preparing to administer ear drops. When instilling the ear drops, the nurse will pull the earlobe: a.

upward and back.

sideways and down.

downward and back.

sideways and up.

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ANS: C For children under 3 years, pull the earlobe downward and back with ear drop instillation to straighten the external auditory canal. The earlobe is pulled up and back for adults and children ages 3 and over.

DIF: Cognitive Level: ComprehensionREF: p. 116 Implementation

OBJ: 10 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

18. The nurse is preparing an otic solution. When instructing the patient in regard to area of administration, the nurse will explain that the solution will be placed: a.

into the eye.

under the tongue.

topically.

into the ear.

ANS: D Medications for use in the ear are labeled otic. Ophthalmic solutions are administered into the eye. Sublingual medications are administered under the tongue. Topical medications are applied to the skin.

DIF: Cognitive Level: Application Implementation

REF: p. 115

OBJ: 10 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

MULTIPLE RESPONSE

19. Which order(s) would be examples of percutaneous medication administration? (Select all that apply.) a.

Timolol 0.5% 1 drop to each eye daily

Albuterol nebulizer 2.5 mg qid

Heparin 5000 units IV

Lasix 20 mg PO every AM

Silvadene 1% topically to affected area

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ANS: A, B, E Percutaneous administration refers to applying medications to the skin or mucous membranes for absorption, such as eye drops.

DIF:

Cognitive Level: Application

REF: p. 105

OBJ: 1

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TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

20.

Which action(s) will the nurse perform when preparing to administer a topical medication?

(Select all that apply.) a.

Wash hands before and after administration.

Maintain a dry environment to encourage wound healing.

Wear gloves during the application process.

Use sterile dressings for all wounds.

ANS: A, C Handwashing is an essential part of medication administration. Gloves are worn with topical medication to prevent absorption into the practitioner’s own skin. Dryness does not encourage wound healing. Sterile dressings do not work well for all wounds.

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DIF: Cognitive Level: Application Implementation

REF: p. 106

OBJ: 1 | 2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

21.

Which dressings would be appropriate to use for treating wounds with exudates?

AlgiDERM

Telfa

Kaltostat

Sorbsan

OpSite

ANS: A, C, D AlgiDERM, Kaltostat, and Sorbsan are exudate absorbers for use in treating infected wounds. Telfa and OpSite are not appropriate to use on wounds with exudates.

DIF: Cognitive Level: Knowledge Implementation

REF: p. 105

OBJ: 1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

OTHER

22. Place the following steps for administration of nose drops in the correct order. (Enter your answer with a comma and space between each lettered option as follows: A, B, C, D, E.) A.

Draw medication into the dropper.

Instruct patient to blow the nose gently.

Review practice setting policy.

Explain the steps to the patient.

Position the patient into supine position with head backward over edge of bed.

Instill medication.

ANS:

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C, D, B, E, A, F

DIF: Cognitive Level: Analysis Implementation

REF: pp. 116-117

OBJ: 11 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

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Chapter 09: Parenteral Administration: Safe Preparation of Parenteral Medications

MULTIPLE CHOICE

Which part of the syringe contains the calibrations for drug volume measurement?

Plunger

Tip

Luer Lok

Barrel

ANS:

The barrel contains the calibrations necessary for measurement. The plunger, the tip, and the Luer Lok do not have the calibrations indicated on them.

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DIF: Cognitive Level: Knowledge Implementation

REF:

Page 116

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment NOT: CONCEPT(S): Clinical Judgment; Safety

2. Which needle will the nurse use to administer an intramuscular (IM) immunization on an 18 month-old child? a.

18-gauge, 1 inch needle

20-gauge,

inch needle

27-gauge, 1

inch needle

25-gauge,

inch needle

ANS:

The most appropriate needle gauge for pediatric IM injections is a 25- or 27-gauge, 1 18-gauge, 1 inch needle is too short and too large in diameter for pediatric

inch needle. An

injections. A 20-gauge, inch needle is too short and too large in diameter for pediatric injections. A 25gauge, inch needle is too short for pediatric IM injections. DIF: Cognitive Level: Application Implementation

REF:

Page 119

OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Development

Which syringe will the nurse use to administer insulin subcutaneously to a patient?

A syringe calibrated in minims

A syringe calibrated in units

A syringe calibrated in tenths of mL

A syringe calibrated in mL

ANS:

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A syringe calibrated in units is used for insulin. A tuberculin syringe is not properly calibrated for use with insulin. A syringe calibrated in mL or in tenths of mL would not be an accurate way to measure insulin doses.

DIF:

Cognitive Level: ComprehensionREF:

Page 117

OBJ:

2|4

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TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

Which action by the nurse is most accurate when drawing up medication from an ampule?

Consider the rim of the ampule as sterile.

Use a filter needle to withdraw the medication.

Wrap a paper towel around the neck of the ampule before breaking it.

Inject 0.5 mL of air into the ampule before withdrawing the medication.

ANS: B Filtered needles are used to withdraw the medication and then changed before administration of the injection. The rim of the ampule is considered to be contaminated because of the possible presence of broken glass. Paper towels do not protect the nurse from broken glass. The ampule is not airtight, so no air needs to be injected into it before removing the medication.

DIF: Cognitive Level: Application Implementation

REF:

Page 125

OBJ:

6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

Which action by the nurse is accurate when withdrawing medication into a syringe from a vial?

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Inject an amount of air equal to the medication into the vial.

Break the thin neck of the vial container.

Remove the rubber stopper on the top of the vial.

Discard the initial 0.5 mL of medication to ensure sterility.

ANS: A An equal amount of air is first injected into the vial to help displace the needed medication upon withdrawal. Vials are not meant to be broken at the neck. Removal of the rubber stopper on a vial is unsafe and not recommended. Medication should not be discarded because it is sterile as long as the vial is airtight and has not been contaminated.

DIF: Cognitive Level: Application Implementation

REF:

Page 127

OBJ:

6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

6. An adult patient is to receive two medications IM. Which action by the nurse is most important in order to mix the medications in one syringe? a.

Assess for the presence of adequate muscle mass.

Ensure that the combined medication amount is less than 2 mL.

Determine the compatibility of the medications.

Use a needle that is 25 gauge.

ANS: C Compatibility is determined to prevent a reaction between the mixed medications. This is important once the medication will be administered, but first it needs to be determined that the medications can be mixed. IM injections in the adult can exceed 2 mL. A 25-gauge needle is not appropriate for an IM injection.

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DIF: Cognitive Level: Analysis Implementation

REF:

Page 128

OBJ:

7 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

The nurse is preparing to administer insulin. What does U 100 indicate?

100 mL per unit

10 units per mL

100 units per mL

10 units per 100 mL

ANS: C U 100 means 100 units per mL.

DIF: Cognitive Level: ComprehensionREF: Assessment

Page 117

OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

8. After teaching a diabetic patient about proper disposal of used syringes and needles, which statement by the patient indicates a need for further teaching? a.

“Even needles with sleeves should be disposed of appropriately.”

“It is unusual that anyone could get a needle injury or disease from used needles.”

“It is important for me to use the designated container to dispose of my syringes and needles.”

“I am going to purchase the ‘Sharps by Mail Disposal System’ once I am home.”

ANS: B The patient needs more education because injury from needlesticks and transfer of pathogens is a health concern. It is accurate that even needles with sleeves should be disposed of appropriately and that a designated container to dispose of syringes and needles should be used. The patient should be encouraged to purchase the “Sharps by Mail Disposal System.”

DIF: Cognitive Level: Application Process Step: Evaluation

REF:

Page 115 | Page 116 OBJ:

TOP: Nursing

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MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Patient Education

Which nursing action is accurate when administering parenteral medication?

Adjust the route of the medication, if needed.

Document the response to PRN medications at the end of the shift.

Request the pharmacist to provide education about the medication to the patient.

Use clinical judgment when rescheduling missed doses of a medication.

ANS: D The nurse must exercise clinical judgment about the scheduling of new drug orders, missed dosages, modified drug orders or substitution of therapeutically equivalent medicines by the pharmacy, or changes in the patient’s condition that require consultation with the physician, health care provider, or pharmacist. Adjusting the route is not within the role of the nurse. Documenting the response to PRN medications at the end of the shift is not an acceptable time frame. Educating the patient about the medication is within the nurse’s role.

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DIF: Cognitive Level: Application Implementation

REF:

Page 115

OBJ:

N/A TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment NOT: CONCEPT(S): Clinical Judgment; Safety

10.

What is an advantage of administering a drug parenterally?

The duration of action is longer.

Medications given by this route are inexpensive.

The onset of action is more rapid.

The dose is usually larger than an oral dose.

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ANS: C The onset of drug action is generally more rapid but of shorter duration. Duration of action is not affected by administering a drug parenterally. Parenteral administration can be expensive. The dose of parenteral medications is typically smaller than an oral dose.

DIF: Cognitive Level: ComprehensionREF: Implementation

Page 115

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment NOT: CONCEPT(S): Clinical Judgment; Safety

11. Which information provided by the nurse is most important to include when teaching a patient about the use of an EpiPen? a.

“Hold the syringe at a 45-degree angle against the skin.”

“Monitor the expiration date of this medication.”

“After using the EpiPen, lie down for 1 hour.”

“Place the syringe in a cartridge prior to using.”

ANS: B It is important to monitor the expiration date of this medication on a regular basis. The syringe is held perpendicular to the skin. The patient should go to the emergency department after use of an EpiPen. Placing the syringe into a cartridge is not accurate for use of an EpiPen.

DIF: Cognitive Level: Application Implementation

REF:

Page 119

OBJ: 5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment NOT: CONCEPT(S): Clinical Judgment; Safety; Patient Education

12. Which type of parenteral medication container is made of glass, is scored, and needs to be broken open before withdrawing the medication? a.

Ampule

Carpuject

Mix-O-Vial

Vial

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ANS: A Ampules are glass containers that need to be broken open before withdrawing medication. Carpujects are prefilled syringes. Mix-O-Vial containers have two compartments for mixing medications and are not scored. Vials are glass or plastic containers that are not broken open.

DIF: Cognitive Level: Knowledge Implementation

REF:

Page 124

OBJ:

6 TOP: Nursing Process Step:

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MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

13. The operating room (OR) nurse is preparing medications for use in a sterile field during a surgical procedure. While preparing these medications, the nurse will a.

save unused portions of medication for use in another procedure.

differentiate between sterile and nonsterile medications to be used in the OR.

ensure the scrub (sterile) nurse retrieves the medication from storage.

read the label aloud for verification against the order from the surgeon.

ANS: D It is best to read the label aloud to ensure that both individuals are verifying the contents against the verbal order from the surgeon. Unused portions of medication should not be saved for use in another procedure. All medication during an operative procedure must remain sterile. The circulating (nonsterile) nurse retrieves the medication from storage.

DIF: Cognitive Level: Application Implementation

REF:

Page 130

OBJ:

N/A TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment| NCLEX Client Needs Category: Physiological Integrity

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NOT: CONCEPT(S): Clinical Judgment; Safety; Care Coordination; Communication

14. The mother of a 6-year-old child informs the school nurse that the child is allergic to insect stings and requires an EpiPen. If the child is stung by an insect while in school, the nurse must a.

hold the EpiPen perpendicularly against the thigh and activate.

provide additional care in the nurse’s office prior to sending the child back to class.

call the physician prior to administration.

provide a second dose within 2 minutes following initial dose.

ANS: A When held perpendicularly against the thigh and activated, the needle of the EpiPen penetrates the skin and a single dose of epinephrine is injected into the muscle. Once the epinephrine is administered, the person should go to a hospital emergency department because additional treatment may be necessary. The physician does not have to be notified prior to administration. A second dose should not be provided at this time.

DIF: Cognitive Level: Application Implementation

REF:

Page 119

OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Development

MULTIPLE RESPONSE

Which principle(s) is/are correct for mixing insulin? (Select all that apply.)

Insulin orders and calculations must be checked with another nurse.

Air is injected into the vial of the shorter-acting insulin first.

The longer-acting insulin is drawn up first.

The nurse must verify the compatibility of the insulin types.

Withdraw the shorter-acting insulin first.

ANS: A, D, E

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Two nurses should verify orders and prepared insulin amounts to prevent inaccuracy in administration. When two medications are mixed in the same syringe, compatibility must be determined. The shorteracting insulin is withdrawn first and air is injected into the longeracting insulin first.

DIF: Cognitive Level: Application Implementation

REF:

Page 128

OBJ:

7 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

2. Which risk factor(s) should be considered when administering medications by injection? (Select all that apply.) a.

Trauma at the site of the needle puncture

Possibility of infection

Irretrievability of the medication once administered

Delayed absorption

Delayed onset of action

Chance of allergic reaction

ANS: A, B, C, F Injecting medications involves risk for trauma, infection, and allergic reaction and increases the difficulty of treating adverse reactions or errors because of the inability to retrieve the medication. Delayed absorption and onset of action are not risks of injecting medications.

DIF: Cognitive Level: ComprehensionREF: Implementation

Page 115

OBJ:

N/A TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Health Promotion

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3. When preparing parenteral medications, the nurse should perform which intervention(s)? (Select all that apply.) a.

Check the expiration date.

Use sterile technique throughout the entire procedure.

Check the drug dose form ordered against the source available.

Prepare the drug in a clean well-lighted area.

Check calculations.

ANS: A, C, D, E The standard procedure for preparing all parenteral medications includes checking the expiration date on the medication container, checking the drug dose form ordered against the source available, preparing the drug in a clean well-lighted area, and checking calculations for accuracy. Aseptic technique is used at times during preparation. The primary rule is “sterile to sterile” and “unsterile to unsterile.”

DIF: Cognitive Level: Application Implementation

REF:

Page 125

OBJ:

N/A TOP: Nursing Process Step:

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MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Health Promotion

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Chapter 10: Parenteral Administration: Intradermal, Subcutaneous, and Intramuscular Routes MULTIPLE CHOICE

1. The nurse is educating a patient about diabetes. Based on recommendations from the American Diabetes Association, which statement by the nurse is best regarding site rotation? a. “Insulin injection sites should always be in the abdomen to ensure absorption into the stomach.” b. “It is important to rotate injection sites systematically within one area before progressing to a new site for injection.” c. “Following exercise, site rotation is not indicated because the circulation in the muscles will absorb the medication efficiently.” d. “If you aspirate, site rotation can be done every other day to avoid developing problems with absorption.” ANS: B The American Diabetes Association Clinical Practice recommendations include rotating injections systematically at one site before progressing to another. Insulin is not absorbed into the stomach. Failure to rotate sites can result in lipohypertrophy or lipoatrophy. When subcutaneous (subcut) insulin is administered, aspiration should never be performed.

DIF: Cognitive Level: Application Implementation

REF:

Page 132

OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment NOT: CONCEPT(S): Clinical Judgment; Safety; Patient Education

2. Which technique by the nurse is accurate when administering heparin to a thin, older adult patient? a.

Aspirate before injecting the medication.

Inject at a 45-degree angle.

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Inject at a 90-degree angle.

Massage site following injection.

ANS: B For thin individuals, the skin may need to be pinched and a 45-degree angle used to avoid administration into the muscle. Heparin should never be aspirated. Subcut injections are properly administered at a 45-degree angle. The injection site of heparin should never be massaged.

DIF: Cognitive Level: Application Implementation

REF:

Page 136

OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Development

The nurse is preparing to administer kindergarten immunizations at the local health clinic.

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Which anatomic site would be best for the injection of the immunizations containing 0.5 mL? a.

Rectus femoris

Dorsogluteal

Deltoid

Ventrogluteal

ANS: C

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The deltoid muscle is often used because of its easy access and the fact that it can tolerate 0.5 mL of medication volume. Having the child disrobe is not efficient in this setting.

DIF: Cognitive Level: Application Process Step: Implementation

REF:

Page 138 | Page 139 OBJ:

TOP: Nursing

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Development

4. A 65-year-old man who weighs 180 lb (81.8 kg) is to receive 1.5 mL of a viscous antibiotic by intramuscular (IM) injection. Which needle and syringe will be used? a.

5 /8 inch, 25-gauge needle with 5 mL syringe

1 inch, 28-gauge needle with 4 mL syringe

c. 1

inch, 21-gauge needle with 3 mL syringe

3 inch, 16-gauge needle with 1.5 mL syringe

ANS: C It is important to correlate the syringe size to the size of the patient and the tissue mass. The usual amount injected intramuscularly is 0.5 to 2 mL. Needle lengths commonly used for adults are 1 to 1 inches long. A longer needle may be used for a significantly obese adult. Commonly used needle gauges for IM injections are 20 to 22 gauge. A 5/8 inch, 25- gauge needle is too short and too small to administer a viscous medication. A 1 inch, 28- gauge needle is too small to administer a viscous medication. A 3 inch, 16-gauge needle is too large and too long to administer medication to a patient this size.

DIF: Cognitive Level: Application Implementation

REF:

Page 136

OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

Which is the preferred IM site for injecting a 6-month-old child?

Dorsogluteal

Abdominal

3 TOP: Nursing Process Step:

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Vastus lateralis

Deltoid muscle

ANS: C The vastus lateralis is generally the preferred IM site in infants because it has the largest muscle mass for that age group. The muscles are not well developed in other areas for this age group. The dorsogluteal muscle is not developed well enough in a child this age to provide a safe site for injection. The abdominal muscles are not appropriate for IM injection.

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The deltoid muscle is not developed well enough in a child this age to provide a safe site for injection.

DIF: Cognitive Level: Knowledge Implementation

REF:

Page 137

OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Development 6. Which angle is appropriate when administering an IM medication in the dorsogluteal site to a 46- year-old obese man? a.

45 degrees

60 degrees

75 degrees

90 degrees

ANS: D A 90-degree angle is used to reach the IM area of the dorsogluteal site. A 45-, 60-, or 75degree angle does not ensure that the needle will penetrate to the muscle in an obese patient.

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DIF: Cognitive Level: Application Implementation

REF:

Page 138

OBJ: 3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

Which parenteral route has the longest absorption time?

Intradermal

Subcut

Intravenous (IV)

ANS: A Absorption rate is determined by the proximity of the medication to the vascular system. Medication injected into an intradermal site is farther away from the vascular system than the other sites. Therefore, absorption in this site is the slowest. Subcut tissue is more vascular than intradermal tissue. IM tissue is more vascular than intradermal tissue. IV administration places medication directly into the vascular system.

DIF: Cognitive Level: Knowledge Assessment

REF:

Page 132

OBJ: 1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment NOT: CONCEPT(S): Clinical Judgment; Safety; Care Coordination

Which site is identified by the posterior superior iliac spine and greater trochanter? a.

Ventrogluteal b.

Dorsogluteal

Vastus lateralis

Rectus femoris

ANS: B

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The dorsogluteal site is identified by drawing an imaginary line from the posterior superior iliac spine to the greater trochanter of the femur. The injection is then administered at any point between the imaginary straight line and below the curve of the iliac crest (hipbone).

DIF: Cognitive Level: ComprehensionREF: Implementation

Page 138

OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment 9.

Which nursing action is accurate when administering an IM injection using the Z track method?

Use a 1-inch needle.

Add 0.5 mL of air to the syringe.

Vigorously massage the injection site.

Pinch up the skin.

ANS: B Adding 0.5 mL of air ensures that the drug will clear the needle. A 1-inch needle may not ensure deep muscle penetration. Massaging the injection site could cause the medication to leak into the muscle tissue. The skin should be stretched, not pinched up.

DIF: Cognitive Level: ComprehensionREF: Implementation

Page 140

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment

10.

Which gauge needles are used for subcut injections?

14 to 16 gauge

OBJ:

3 TOP: Nursing Process Step:

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18 to 21 gauge

22 to 24 gauge

25 to 29 gauge

ANS: D Commonly used gauges for subcut injection are 25 to 29 gauge. Needles that are 14 to 16 gauge are used for administration of blood or large volumes of fluid in a short period of time. Needles that are 18 to 21 gauge are used for routine parenteral fluid administration. Needles that are 22 to 24 gauge are used for administering fluids or medication via small veins.

DIF: Cognitive Level: Knowledge Implementation

REF:

Page 135

OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

11.

When is it acceptable to use the deltoid muscle as an injection site for infants?

Medication is irritating.

Dose is a long-acting medication.

Child is combative.

Volume is quite small.

ANS: D

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The deltoid site should be used in infants only when the volume is quite small, the medication is nonirritating, and the dose will be quickly absorbed. Irritating and long-acting medications should be

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injected in deep muscle tissue such as the vastus lateralis. A combative child should be adequately restrained and injected in a fairly large muscle mass.

DIF: Cognitive Level: ComprehensionREF: Implementation

Page 138

OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

12.

Which action by the nurse is most accurate when administering an intradermal injection?

Insert the needle at a 45-degree angle.

Inject 0.1 mL.

Use a 22-gauge needle.

Wipe the site with alcohol after injection.

ANS: B Small volumes, usually 0.1 mL, are injected. The needle is inserted at a 15-degree angle. A 26- gauge needle is used. After injection, the site should not be wiped with alcohol.

DIF: Cognitive Level: Application Implementation

REF:

Page 133

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

13. Which assessment by the nurse is most important to obtain prior to performing allergy sensitivity testing? a.

Identify areas of loose connective tissue.

Question the patient about frequency of exercise.

Determine if the patient is using aspirin.

Palpate and measure the size of induration.

ANS: C It is important to determine if the patient has taken any antihistamines or anti-inflammatory agents for 24 to 48 hours prior to allergy testing. Loose connective tissue is assessed prior to administering injections subcutaneously. Exercise routine is not significant prior to allergy testing. Palpation and measurement of the size of induration are done after the procedure.

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DIF: Cognitive Level: Application Assessment

REF:

Page 132

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

14. The nurse administers a skin prick test (SPT) to a patient at 9:00 AM. The earliest time the nurse can expect to read the test is a.

the next day at 9:00 AM.

by 9:00 PM the same day.

by 9:10 AM the same day.

one week from the date and time of administration.

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ANS: C The SPT can be read in 10 to 20 minutes after administration, depending on protocol.

DIF: Cognitive Level: Application Implementation

REF:

Page 134

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Care Coordination

15.

The nurse cleansing the skin surface of a patient prior to injection will start at the

periphery and work inward in a back and forth motion.

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periphery and work inward in a cyclical motion.

injection site and work outward in a straight line.

injection site and work outward in a circular motion.

ANS: D The skin surface is cleansed prior to injection starting at the injection site and working outward in a circular motion toward the periphery.

DIF: Cognitive Level: Application Implementation

REF:

Page 139

OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Infection

MULTIPLE RESPONSE

1. The nurse is preparing to administer allergy sensitivity testing to a patient. Which statement(s) pertain(s) to this type of administration? (Select all that apply.) a.

Allergy sensitivity testing requires the intradermal route.

Injections are made into the loose connective tissue.

Equipment needed includes gloves, antiseptic pledget, metric ruler, and physician’s order sheet.

Record of previous injection sites is needed.

The needle should be inserted at a 15-degree angle with the needle bevel up.

ANS: A, C, E Allergy sensitivity testing requires the intradermal route. Before administering allergy testing, gathering of equipment and physician’s orders are necessary. This route is injected into the dermal layer of skin, using a 15-degree angle. Connective tissue, having poor blood supply, is not appropriate for injection of medication. Previous injection sites would not factor into the decision about where to conduct allergy testing.

DIF: Cognitive Level: ComprehensionREF: Implementation

Page 132

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

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2. Which statement(s) about administering medications parenterally is/are true? (Select all that apply.) a.

Subcut absorption is slower than intradermal absorption.

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Two mL or less should be administered in a subcut site.

The gluteal area is recommended for children. d.

Needles 1 to 1 inches in length are common for IM injections. e.

The scapular areas of the back may be used for intradermal injections.

ANS: B, D, E No more than 2 mL of medication should be injected into a subcut site. Needle length of 1 to 1 inches is common for IM injections. The upper chest, scapular areas of the back, and the inner aspect of the forearms are commonly used as sites for intradermal injections. Subcutaneous absorption is faster than intradermal absorption. Because of the undeveloped muscle mass in children, the gluteal area is not recommended for IM injection.

DIF: Cognitive Level: Knowledge Step: Implementation

REF:

Page 132

MSC: NCLEX Client Needs Category: Physiological Integrity

OBJ:

1 | 2 | 3 TOP: Nursing Process

https://studentmagic.indiemade.com/ NOT: CONCEPT(S): Clinical Judgment; Safety

The vastus lateralis muscle is appropriate for injections for which patient(s)? (Select all that

apply.) a.

Children younger than 3 years of age

Elderly

Debilitated

Nonambulatory

Ambulatory

Healthy

ANS:

A, E, F

Children younger than 3 years of age, ambulatory patients, and otherwise healthy patients may receive injections in the vastus lateralis. Elderly, debilitated, and nonambulatory patients may have reduced muscle mass in the vastus lateralis and therefore poor absorption of injected medications.

DIF:

Cognitive Level: ComprehensionREF:

Page 132 | Page 134

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OBJ:

4 |5

TOP:

Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Development

4. The nurse administers B12 IM to a patient in a long-term care facility. After administering this medication, the nurse will (Select all that apply.) a.

carefully recap the needle.

identify the patient.

massage site of injection.

dispose of the used needle according to policy.

apply a small bandage to the site.

ANS:

D, E

After administering an IM injection, the nurse should dispose of used needles according to policy and apply a small bandage to the site. Needles shouldnever be recapped following use. The patient requires identification before the injection is given. After the needle is removed, gentle pressure should be applied to the site. Massage can increase the pain if the muscle mass is stressed by the amount of medication given.

DIF: Cognitive Level: Application Process Step: Implementation

REF:

Page 136 | Page 137 OBJ:

TOP:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment| NCLEX Client Needs Category: Physiological IntegrityNOT: CONCEPT(S): Clinical Judgment; Safety

Nursing

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Chapter 11: Parenteral Administration: Intravenous Route

MULTIPLE CHOICE

1. A patient is diagnosed with cancer and requires 6 months of chemotherapy infusions. Which type of intravenous (IV) access device will likely be used? a.

Peripheral venous access device

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Midline catheter

Winged needle venous access device

Implantable venous infusion port

ANS: D Implantable venous infusion ports are placed into central veins for long term therapy. Chemotherapy treatment is often irritating and best tolerated in the larger central veins. Peripheral lines are not used for administration of chemotherapy because of the risk of extravasation. A midline catheter is intended only for a 2 to 4 week interval, less than the projected length of time for chemotherapy infusion. Winged needles are for use in peripheral veins that are too small for ongoing infusion of chemotherapy.

DIF: Cognitive Level: Application Process Step: Implementation

REF:

Page 147 | Page 149 OBJ:

TOP: Nursing

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment

2. The nurse notes that a patient with cardiac disease has IV heparin infusing and that it is behind by 2 hours. What is the best nursing action? a.

Increase the IV rate and recheck in 1 hour.

Change the infusion rate to TKO.

Discontinue the solution using aseptic technique.

Contact the health care provider for consultation.

ANS: D The patient has a history of cardiac problems and is receiving a critical care medication, IV heparin. In this case, contacting the patient’s health care provider would be appropriate to avoid harm. Increasing the infusion rate might place the patient into fluid overload and might infuse too much heparin in a short time. Reducing the infusion rate to TKO or discontinuing the solution would put the schedule even further behind.

DIF: Cognitive Level: Application Implementation

REF:

Page 154

OBJ:

8 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment NOT: CONCEPT(S): Clinical Judgment; Safety; Collaboration; Communication

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What is the composition of hypotonic intravenous solutions such as 0.45% NaCl?

Fewer dissolved particles than blood

Approximately the same number of dissolved particles as blood

Higher concentrations of dissolved particles than blood

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Electrolytes and dextrose

ANS: A Hypotonic solutions have fewer dissolved particles than blood. Half normal saline does not contain dextrose.

DIF: Cognitive Level: Knowledge Assessment

REF:

Page 150

OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Fluid and Electrolyte Balance; Cellular Regulation

Which condition would the nurse expect to be treated with an isotonic solution?

Fluid overload

Hemorrhagic shock

Cellular dehydration

Cerebral edema

ANS: B Isotonic solutions have approximately the same osmolality as blood. Isotonic fluids are ideal replacement fluids for patients experiencing an intravascular fluid deficit that occurs in conditions such

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as acute blood loss from hemorrhage and gastrointestinal bleeding. Isotonic fluids increase vascular volume, thus counteracting hypovolemia and hypotension. Administering isotonic solutions for fluid overload would exacerbate the problem. Hypotonic solutions are administered for cellular dehydration. Hypertonic solutions are administered for cerebral edema.

DIF: Cognitive Level: Application Implementation

REF:

Page 150

OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Fluid and Electrolyte Balance; Cellular Regulation

5. The nurse determines that an elderly patient’s IV of D50.2 NS with 20 mEq KCl at 75 mL/hr is running 3 hours behind. After determining the IV site is patent, what action will the nurse take? a.

Call the health care provider to obtain an order to decrease the IV rate.

Administer a bolus to make up the deficit.

Recalculate the flow rate and slowly make up the fluids.

Maintain the ordered rate.

ANS: D The safest action is to maintain the ordered rate. The health care provider should be consulted if the patient has not received critical IV replacement therapy. Increasing an IV rate without a health care provider’s order can be detrimental for patients who have cardiac, renal, or circulatory impairment. Normal aging process results in decreased cardiac, renal, and circulatory function. The rate ordered is the one the provider intended for the administration of fluids; changing it to fit the prevailing situation is not appropriate. The bolus technique should only be used for the administration of medications or fluid challenges in patients who need a volume of IV fluid quickly. The flow rate must be consistent with the provider’s order.

DIF:

Cognitive Level: Application

REF:

Page 154

OBJ:

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TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe, Effective Care Environment NOT: CONCEPT(S): Clinical Judgment; Fluid and Electrolyte Balance; Cellular Regulation

Which technique by the nurse accurately maintains asepsis of a peripheral IV access device?

Wear gloves when hanging all IV solutions.

Apply a topical antibiotic ointment to the insertion site.

Change fluid administration sets according to institutional policy.

Flush with heparin before use.

ANS: C Generally all IV solution bag and bottles should be changed every 24 hours to minimize the development of new infections. IV administration sets used to deliver blood and blood products are changed after each unit is administered. Administration sets to deliver lipids and TPN are often changed every 4 hours, whereas administration sets for maintenance fluids may be changed every 72 hours. It is important to follow institutional policies. All IV bags, bottles, and administration sets should be labeled with the date, time, and nurse’s initials of the set change. Wearing gloves is not required for maintenance of routine infusion. Topical antibiotics may promote fungal infections and antimicrobial resistance. A peripheral line that is infusing should not need an anticoagulant to maintain patency.

DIF: Cognitive Level: Application Implementation

REF:

Page 153

OBJ:

8 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment NOT: CONCEPT(S): Clinical Judgment; Safety; Infection; Health Promotion

Which needle is used to access implanted infusion devices?

Jamshidi

Huber

Gigli

Crutchfield

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ANS: B The Huber needle is a special noncoring 90-degree needle used to penetrate the skin and septum of the implanted device. The Jamshidi needle is used for biopsy purposes such as bone marrow. The Gigli saw is a wire with serrations used to cut through cranial bone. Crutchfield tongs are used to stabilize the cervical spine by traction in cases of fracture.

DIF: Cognitive Level: ComprehensionREF: Implementation

Page 149

OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment

8. The nurse assesses erythema, warmth, and burning pain along the patient’s IV site. Which complication is this patient most likely experiencing? a.

Air embolism

Extravasation

Phlebitis

Pulmonary edema

ANS: C

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Erythema, warmth, and tenderness along the course of the vein and swelling are signs of phlebitis. Air embolism occurs as a result of an air bubble entering the vascular system, and shortness of breath, chest pain, and hypotension are indicative of this complication. Extravasation is the leakage of an irritant and is accompanied by redness, warmth or coolness, swelling, and a dull ache to severe pain at the venipuncture site. Pulmonary edema is caused by fluid infusing too

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rapidly; dyspnea, cough, anxiety, rales, and possible cardiac dysrhythmias are indicative of pulmonary edema.

DIF: Cognitive Level: ComprehensionREF: Evaluation

Page 171

OBJ:

9 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Infection; Tissue Integrity; Perfusion

9. An elderly patient receiving an infusion of an isotonic fluid at 100 mL/hr complains of dyspnea. The nurse notes shallow rapid respirations and a cough that produces frothy sputum. Which is the priority nursing action? a.

Assess the urine output.

Elevate the head of the bed.

Encourage the patient to cough.

Maintain the IV rate.

ANS: B Elevating the head of the bed is an appropriate action for signs and symptoms of pulmonary edema. Urine output is important to assess, but it is not the priority nursing action. Encouraging the patient to cough and take deep breaths is not the priority nursing action. The IV rate should be slowed immediately based on the signs and symptoms the patient is displaying.

DIF: Cognitive Level: Application Implementation

REF:

Page 172

OBJ:

9 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Fluid Electrolyte Balance; Perfusion

10. A diabetic patient requires the administration of insulin continuously at home. Which system would most likely be used in this instance? a.

Central line catheter

Microdrip set

Piggyback system

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Syringe pump

ANS: D Syringe pumps are used in patients with diabetes. A central line is not appropriate for the diabetic patient requiring insulin. A microdrip set is a type of IV tubing that is used when small volumes of fluid are given to patients with fluid volume concerns. A piggyback system is a type of administration set that connects to a primary setup and administers a small volume over 20 to 60 minutes.

DIF: Cognitive Level: Application Implementation

REF:

Page 147

OBJ:

2 TOP: Nursing Process Step:

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NOT: CONCEPT(S): Clinical Judgment; Safety 11. A patient is admitted with hypovolemia resulting from lack of fluid intake and requires an infusion of isotonic fluids. Which IV solution will the nurse administer? a.

D50.2 NS

D5W

0.45 NS

0.9 NS

ANS: D 0.9 NS is an isotonic solution appropriate for hypovolemia. D50.2 NS, D5W, and 0.45 NS are hypotonic solutions.

DIF: Cognitive Level: ComprehensionREF: Implementation

Page 150

MSC: NCLEX Client Needs Category: Physiological Integrity

OBJ:

3 TOP: Nursing Process Step:

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NOT: CONCEPT(S): Clinical Judgment; Fluid and Electrolyte Balance; Cellular Regulation

12.

Which potential complication will the nurse expect in patients with a venous access device?

Circulatory overload

Extravasation

Infection

Pain

ANS: C Because venipuncture alters skin integrity, the patient is vulnerable to infection at all times. Circulatory overload is a concern but does not occur with any type of venous access device because the device may just be used for administration of small volumes of drugs (e.g., chemotherapy in cancer patients). Extravasation is a potential complication when there is infusion of an irritating chemical. IV drug administration is usually more comfortable for patients than other routes, and pain would not be considered a complication.

DIF: Cognitive Level: Application Assessment

REF:

Page 171

OBJ:

9 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Infection; Tissue Integrity

13. A patient has a peripherally inserted central catheter (PICC) line inserted to continue IV antibiotic therapy at home. With proper care, how long can this type of venous access device remain in place? a.

2 months

4 months

6 months

12 months

ANS: D PICC lines routinely remain in place for 1 to 3 months but can last for a year or more if cared for properly.

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DIF: Cognitive Level: Knowledge Implementation

REF:

Page 148

OBJ:

2 | 5 TOP: Nursing Process Step:

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NOT: CONCEPT(S): Clinical Judgment; Safety; Infection; Tissue Integrity 14. In assessing a patient with a central venous access device, which sign or symptom indicates that the patient is experiencing an air embolism? a.

Chest pain

Erythema

Frothy sputum

Sweating

ANS: A Chest pain is a symptom associated with air embolism. Erythema occurs with infiltration or extravasation. Frothy sputum occurs with circulatory overload or pulmonary edema. Sweating is indicative of a pulmonary embolism.

DIF: Cognitive Level: Application Assessment

REF:

Page 172

OBJ:

9 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Perfusion; Gas Exchange

15. Following the insertion of a central venous access device, the nurse notes a weak, thready pulse and decreased blood pressure. The patient complains of shortness of breath and palpitations. Which action will the nurse take first?

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Place the patient on the left side.

Reassess vital signs.

Stop the infusion.

Verify placement of the device.

ANS: A Signs and symptoms indicate an air embolism. The nurse’s immediate action will be to place the patient onto his or her left side. The nurse has determined change in pulse and blood pressure already, and although it is appropriate to reassess, it is not the first action the nurse will take. There is no indication that anything is infusing into this venous access device. Verifying the placement of the device is not the first action the nurse would take.

DIF: Cognitive Level: Application Implementation

REF:

Page 172

OBJ:

9 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Perfusion; Gas Exchange

16. The nurse is about to administer a prescribed medication IV push into a patient's Hickman catheter. When providing this medication, the nurse will first a.

administer the prescribed drug.

flush with saline.

flush with heparin.

prepare a pump.

ANS: B Drugs given by IV push or bolus through a Hickman catheter generally follow the SASH guideline: saline flush first; administer the prescribed drug; saline flush following the drug; heparin flush line. A pump is not used when a drug is administered by push technique.

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DIF: Cognitive Level: Application Implementation

REF:

Page 154

OBJ:

2 | 4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment| NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Health Promotion

17. A 90-year-old woman is admitted to an acute care facility with the diagnosis of pneumonia. She has a past medical history of diabetes mellitus, hypertension, and right-sided mastectomy. When starting an IV for infusion of antibiotic therapy, the nurse will a.

insert the IV catheter into the left hand.

use a lower extremity vein for insertion.

choose the left radial artery for insertion.

attempt insertion into the left antecubital space vein.

ANS: D IV insertion should not be initiated in an arm with compromised lymphatic or venous flow such as a mastectomy. The left antecubital space vein would be a good choice for this patient given her age and medical history. In the older adult, using the veins in the hand area may be a poor choice because of the fragility of the skin and veins in this area. When possible, the veins of the lower extremities should be avoided for IV insertion because of the danger of developing thrombi and emboli. IV therapy should never be started in an artery.

DIF: Cognitive Level: Application Implementation

REF:

Page 154

OBJ:

4 | 5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment NOT: CONCEPT(S): Clinical Judgment; Safety; Perfusion; Tissue Integrity

MULTIPLE RESPONSE

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What will the nurse explain when teaching a patient about a PICC line? (Select all that

apply.) a.

The catheter may have a single or double lumen.

There is greater risk of clotting and infiltration with this type of catheter.

The patient will be receiving infusions continuously to ensure patency.

The tip of the catheter may be open or valved.

The catheter may be used for drawing blood.

ANS: A, D PICC lines may have more than one lumen. The catheter may have an open tip or a valved (Groshong) tip. The risk of infiltration and clotting is less than with other types of central lines. The line should be flushed with a saline heparin solution after every use, or daily, in order to maintain patency if it is not in continuous use. PICC lines are not appropriate for blood drawing because of their small size.

DIF: Cognitive Level: ComprehensionREF: Implementation

Page 148

OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Patient Education

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2. Which patient assessment finding(s) suggest(s) extravasation of an IV solution? (Select all that apply.) b.

Coolness

Edema

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Fever

Pain at venipuncture site

https://studentmagic.indiemade.com/ f.

Redness at the site

Shortness of breath

ANS:

A, B, D, E

Coolness, edema, pain, and redness are indicative of extravasation. Fever does not indicate extravasation. Shortness of breath does not indicate extravasation.

DIF: Cognitive Level: ComprehensionREF: Assessment

Page 171

OBJ:

9 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Tissue Integrity

3. The nurse assesses a patient’s right hand IV site to be infiltrated. Appropriate nursing actions include (Select all that apply.) a.

stopping the infusion.

attempting to aspirate the medication.

elevating the affected limb.

checking capillary refill.

removing the catheter as directed by policy.

ANS:

A, C, D, E

For an infiltration, stop the infusion. Elevate the affected limb. Assess for circulatory compromise; check capillary refill and pulses proximal and distal to the area of infiltration. If the infiltration is caused by an IV solution, remove the catheter as directed by policy. For extravasation, attempts may be made to aspirate the medication.

DIF: Cognitive Level: Analysis REF: Page 171 | Page 172 OBJ: 9 TOP: Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Tissue Integrity

Nursing

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Chapter 12:Drugs Affecting the Autonomic Nervous System

MULTIPLE CHOICE

1. Charlie is a 65-year-old male who has been diagnosed with hypertension and benign prostatic hyperplasia. Doxazosin has been chosen to treat his hypertension because it: A.

Increases peripheral vasoconstriction

Decreases detrusor muscle contractility

Lowers supine blood pressure more than standing pressure

Relaxes smooth muscle in the bladder neck

ANS:

To reduce potential adverse effects, patients taking a peripherally acting alpha1 antagonist

PTS:

should do all of the following EXCEPT: A.

Take the dose at bedtime

Sit up slowly and dangle their feet before standing

Monitor their blood pressure and skip a dose if the pressure is less than 120/80

Weigh daily and report weight gain of greater than 2 pounds in one day

ANS:

PTS:

3. John has clonidine, a centrally acting adrenergic blocker, prescribed for his hypertension. He should: A.

Not miss a dose or stop taking the drug because of potential rebound hypertension

Increase fiber in the diet to treat any diarrhea that may occur

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Reduce fluid intake to less than 2 liters per day to prevent fluid retention

Avoid sitting for long periods, as this can lead to deep vein thrombosis

ANS:

Clonidine has several off-label uses, including:

Alcohol and nicotine withdrawal

Post-herpetic neuralgia

Both A and B

Neither A nor B

ANS:

Jim is being treated for hypertension. Because he has a history of heart attack, the drug chosen

PTS:

is atenolol. Beta blockers treat hypertension by: A.

Increasing heart rate to improve cardiac output

Reducing vascular smooth muscle tone

Increasing aldosterone-mediated volume activity

Reducing aqueous humor production

ANS:

Which of the following adverse effects are less likely in a beta1-selective blocker?

Dysrhythmias

Impaired insulin release

PTS:

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C. D. ANS:

Reflex orthostatic changes Decreased triglycerides and cholesterol B

PTS:

7. Richard is 70 years old and has a history of cardiac dysrhythmias. He has been prescribed nadolol. You do his annual lab work and find a CrCl of 25 ml/min. What action should you take related to his nadolol? A.

Extend the dosage interval

Decrease the dose by 75%

Take no action since this value is expected in the older adult

Schedule a serum creatinine level to validate the CrCl value

ANS:

Beta blockers are the drugs of choice for exertional angina because they:

Improve myocardial oxygen supply by vasodilating the coronary arteries

Decrease myocardial oxygen demand by decreasing heart rate and vascular resistance

Both A and B

Neither A nor B

ANS:

Adherence to beta blocker therapy may be affected by their:

Short half-lives requiring BID dosing

PTS:

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Tendency to elevate lipid levels

Effects on the male genitalia, which may produce impotence

None of the above

ANS:

PTS:

10. Beta blockers have favorable effects on survival and disease progression in heart failure. Treatment should be initiated when the: A.

Symptoms are severe

Patient has not responded to other therapies

Patient has concurrent hypertension

As soon as LV dysfunction is diagnosed

ANS:

11.

Abrupt withdrawal of beta blockers can be life threatening. Patients at highest risk for serious

PTS:

consequences of rapid withdrawal are those with: A.

Angina

Coronary artery disease

Both A and B

Neither A nor B

ANS:

12.

To prevent life-threatening events from rapid withdrawal of a beta blocker:

The dosage interval should be increased by 1 hour each day

An alpha blocker should be added to the treatment regimen before withdrawal

PTS:

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C. D. ANS:

The dosage should be tapered over a period of weeks The dosage should be decreased by one-half every 4 days D

PTS:

13. Beta blockers are prescribed for diabetics with caution because of their ability to produce hypoglycemia and block the common symptoms of it. Which of the following symptoms of hypoglycemia is not blocked by these drugs and so can be used to warn diabetics of possible decreased blood glucose? A.

Dizziness

Increased heart rate

Nervousness and shakiness

Diaphoresis

ANS:

14.

Combined alpha-beta antagonists are used to reduce progression of heart failure because they:

Vasodilate the peripheral vasculature

Decrease cardiac output

Increase renal vascular resistance

Reduce atherosclerosis secondary to elevated serum lipoproteins

ANS:

PTS:

15. Carvedilol is heavily metabolized by CYP2D6 and 2C9, resulting in drug interactions with which of the following drug classes?

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Histamine 2 blockers

Quinolones

Serotonin re-uptake inhibitors

All of the above

ANS:

16.

Alpha-beta blockers are especially effective to treat hypertension for which ethnic group?

White

Asian

African American

Native American

ANS:

17.

Bethanechol:

Increases detrusor muscle tone to empty the bladder

Decreases gastric acid secretion to treat peptic ulcer disease

Stimulates voluntary muscle tone to improve strength

Reduces bronchial airway constriction to treat asthma

ANS:

18.

Clinical dosing of this drug:

Begins at the highest effective dose to obtain a rapid response

PTS:

B. Starts at 5 mg to 10 mg PO and is repeated every hour until a satisfactory clinical response is achieved

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C. D. ANS:

Requires dosing only once daily Is the same for both the oral and parenteral route B

PTS:

19.

Patients are taught to avoid which drug due to its antimuscarinic effects?

Levothyroxine

Prilosec

Dulcolax

Diphenhydramine

ANS:

20.

Anticholinesterase inhibitors are used to treat:

Peptic ulcer disease

Myasthenia gravis

Both A and B

Neither A nor B

ANS:

21.

Which of the following drugs used to treat Alzheimer’s disease is not an anticholinergic?

Donepezil

Memantine

PTS:

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Rivastigmine

Galantamine

ANS:

22.

Taking which drug with food maximizes it bioavailability?

Donepezil

Galantamine

Rivastigmine

Memantine

ANS:

PTS:

23. Which of the following drugs should be used only when clearly needed in pregnant and breastfeeding women? A.

Memantine

Pyridostigmine

Galantamine

Rivastigmine

ANS:

PTS:

24. There is a narrow margin between first appearance of adverse reaction to AChE inhibitors and serious toxic effects. Adverse reactions that require immediate action include: A.

Dizziness and headache

Nausea

Decreased salivation

Fasciculations of voluntary muscles

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25.

Adherence is improved when a drug can be given once daily. Which of the following drugs

can be given once daily? A.

Tacrine

Donepezil

Memantine

Pyridostigmine

ANS:

PTS:

26. Nicotine has a variety of effects on nicotinic receptors throughout the body. Which of the following is NOT an effect of nicotine? A.

Vasodilation and decreased heart rate

Increased secretion of gastric acid and motility of the GI smooth muscle

Release of dopamine at the pleasure center

Stimulation of the locus ceruleus

ANS:

27.

Nicotine gum products are:

Chewed to release the nicotine and then swallowed for a systemic effect

“Parked” in the buccal area of the mouth to produce a constant amount of nicotine release

Bound to exchange resins so the nicotine is only released during chewing

Approximately the same in nicotine content as smoking two cigarettes

ANS:

PTS:

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28.

Nicotine replacement therapy (NRT):

Is widely distributed in the body only when the gum products are used

Does not cross the placenta and so is safe for pregnant women

Delays healing of esophagitis and peptic ulcers

Has no drug interactions when a transdermal patch is used

ANS:

29.

Success rates for smoking cessation using NRT:

Are about the same regardless of the method chosen

Vary from 40% to 50% at 12 months

Both A and B

Neither A nor B

ANS:

30.

Cholinergic blockers are used to:

Counteract the EPS effects of phenothiazines

Control tremor and relax smooth muscle in Parkinson’s disease

Inhibit the muscarinic action of ACh on bladder muscle

All of the above

ANS:

PTS:

1 ANS: D PTS: 1

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31.

Several classes of drugs have interactions with cholinergic blockers. Which of the following

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true about these interactions? A.

Drugs with a narrow therapeutic range given orally may not stay in the GI tract

long enough to produce an action. B.

Additive antimuscarinic effects may occur with antihistamines.

Cholinergic blockers may decrease the sedative effects of hypnotics.

Cholinergic blockers are contraindicated with antipsychotics.

ANS:

PTS:

32. Scopolamine can be used to prevent the nausea and vomiting associated with motion sickness. The patient is taught to: A.

Apply the transdermal disk at least 4 hours before the antiemetic effect is desired

Swallow the tablet 1 hour before traveling where motion sickness is possible

Place the tablet under the tongue and allow it to dissolve

Change the transdermal disk daily for maximal effect

ANS:

PTS:

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Chapter 13: Drugs Used for Sleep Test Bank

MULTIPLE CHOICE

1. The nurse finds that a patient is extremely agitated, yells frequently, and is attempting to get out of bed without assistance. What is the nurse’s initial action? a.

Administer zolpidem after taking the patient’s vital signs.

Close the patient’s door for privacy after administering Tylenol.

Administer benzodiazepine before calling the health care provider.

Spend uninterrupted time listening to the patient.

ANS:

Assessing the patient’s level of anxiety is important. The patient may only need someone to listen to what stressors he or she is facing. The nurse must assess the patient before medication can be administered.

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DIF: Cognitive Level: Analysis Assessment

REF:

p. 214 OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

2. An older adult patient received a hypnotic agent at 9:00 PM. At 2:00 AM, the nurse discovers that the patient has removed her gown and is attempting to get out of bed without assistance. What type of medication effect is the patient exhibiting? a.

Allergic

Hypersensitivity

Paradoxical

Therapeutic

ANS:

A paradoxical effect may occur in older adult patients. This includes periods of excitement, confusion, restlessness, and euphoria. Allergies to medications tend to manifest in skin or respiratory symptoms. A patient who is hypersensitive to a hypnotic would be difficult to rouse. A therapeutic effect for a hypnotic would be sedation.

DIF: Cognitive Level: Application Evaluation

REF:

p. 217 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

For what conditions are benzodiazepines prescribed?

Chronic amnesia

Chronic insomnia

Preoperative sedation

Psychotic episodes

ANS:

The sedative hypnotic effect of benzodiazepines facilitates surgical sedation. Short acting benzodiazepines are administered intramuscularly for preoperative sedation. They are also given intravenously for conscious sedation before short diagnostic procedures or for the

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induction of general anesthesia. Benzodiazepines are not recommended for long term use and do not affect amnesia. Benzodiazepines are a poor choice for the treatment of chronic insomnia because of their risk for habituation. Benzodiazepines do not have an antipsychotic effect.

DIF: Cognitive Level: Knowledge Assessment

REF:

pp. 217-218

OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

4. A patient receiving diazepam (Valium) is complaining of nausea and vomiting and is becoming jaundiced. Which type of blood work will be performed? a.

Renal function tests

Liver function tests

Clotting times

Electrolyte panels

ANS: B Liver function tests will be performed because nausea, vomiting, and jaundice can be indicative of hepatotoxicity. Abnormal liver function test results (i.e., elevated bilirubin, aspartate transaminase [AST], alanine transaminase [ALT], gamma glutamyl transferase [GGT], and alkaline phosphatase levels, as well as prothrombin time) are indicative of hepatotoxicity. Benzodiazepines do not affect the kidneys, clotting times, and electrolytes.

DIF:

Cognitive Level: Application

REF:

p. 220 OBJ:

6 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

In addition to facilitating sleep, what is another benefit of sedatives?

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Increased pain control postoperatively

Reduced bronchial secretions

Decreased patient anxiety

Increased patient alertness

ANS: C Preoperatively, sedatives will help decrease patient anxiety and facilitate sleep. Sedatives are not long acting enough to affect postoperative pain control. Sedatives do not affect bronchial secretions. Sedatives diminish patient alertness.

DIF: Cognitive Level: Knowledge Planning

REF:

pp. 213-214

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Which two phases make up normal sleep?

Hypnagogic and hypnopompic

Rapid eye movement (REM) and non REM

Alpha and beta

Delta and theta

ANS: B

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Normal sleep can be divided into two phases, REM and non REM. Hypnagogic is the state between waking and sleeping; hypnopompic is the transition between sleeping and waking states. Beta waves are those associated with day to day wakefulness. During periods of relaxation while still awake, our brain

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waves become slower, increase in amplitude, and become more synchronous. These types of waves are called alpha waves. The first stage of sleep is characterized by theta waves. During a normal night’s sleep, a sleeper passes from the theta waves of stages 1 and 2 to the delta waves of stages 3 and 4. Delta waves are the slowest and highest amplitude brain waves.

DIF: Cognitive Level: Knowledge Assessment

REF:

p. 212 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Which sleep pattern stage diminishes as an effect of aging?

Stage I

Stage II

Stage III

Stage IV

ANS: D As we age, stage IV sleep diminishes. Many people older than 75 years do not demonstrate any stage IV sleep patterns. Between 2% and 5% of sleep is stage I. Stage II comprises about 50 % of normal sleep time. Stage III is a transition between lighter sleep and deeper sleep.

DIF: Cognitive Level: Knowledge Assessment

REF:

p. 212 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

8. A patient has been prescribed lorazepam (Ativan), a benzodiazepine used to treat insomnia. Which action will the nurse take? a.

Advise the patient to take the medication with food.

Assess the patient’s blood pressure in sitting and lying positions.

Inform the patient to discontinue the medication once sleep improves.

Instruct the patient to lie down before taking the medication.

ANS: B Measuring blood pressure in sitting and lying positions is important to assess for transient hypotension. Ativan does not have to be taken with food. Rapid discontinuance of the medication after long term use

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may result in symptoms similar to those of alcohol withdrawal. Gradual withdrawal of benzodiazepines is over 2 to 4 weeks. Medications should be taken sitting up.

DIF: Cognitive Level: Application Implementation

REF:

p. 218 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Which disease is associated with insufficient sleep?

Cancer

Glaucoma

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Myocardial infarction

Renal failure

ANS: C Individuals who sleep less than 5 hours a night have a threefold increased risk of heart attacks. Cancer, glaucoma, and renal failure are not associated with lack of sleep.

DIF: Cognitive Level: Knowledge Implementation

REF:

p. 212 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

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10. The nurse is caring for an older patient recently admitted to an assisted living center who is experiencing insomnia associated with the recent relocation. At bedtime, which nursing action will assist the patient to sleep? a.

Offering the patient hot tea

Encouraging the patient to ambulate in the hallway

Performing back massage

Administering an analgesic

ANS: C Providing a back rub will promote relaxation and reduce anxiety associated with a new environment. This would also provide an opportunity for the nurse to encourage the patient to express feelings. The patient should avoid products containing caffeine, such as coffee, tea, soft drinks, and chocolate. A quiet unwinding activity before bedtime is helpful for sleep promotion. Administering an analgesic is not an appropriate action.

DIF: Cognitive Level: Application Implementation

REF:

p. 214 OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

11. The nurse is explaining the use of medications to a patient with insomnia. Which statement about sedatives is true? a.

A sedative will produce sleep.

Sedatives increase the total time in REM sleep.

Increased relaxation occurs with sedatives.

Sedatives are more potent than hypnotics.

ANS: C A hypnotic is a drug that produces sleep; a sedative quiets the patient and gives a feeling of relaxation and rest, not necessarily accompanied by sleep. Sedatives do not increase the total time in REM sleep. A small dose of a drug may act as a sedative, whereas a larger dose of the same drug may act as a hypnotic and produce sleep.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 214 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

1 TOP: Nursing Process Step:

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12. The nurse is assessing a patient who is being evaluated in an outpatient clinic for complaints of back pain. The patient reports taking diphenhydramine for insomnia related to job stress. Which statement by the nurse is accurate regarding this medication?

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“This medication should only be taken for 1 week.”

“This medication can cause nausea.”

“The medication should not be taken after eating a high fat meal.”

“This is an herbal medication that has been used for hundreds of years.”

ANS: A Antihistamines (particularly diphenhydramine and doxylamine) have sedative properties that may be used for short term treatment of mild insomnia. They are common ingredients in over the counter (OTC) sleep aids. Tolerance develops after only a few nights of use; increasing the dose actually causes a more restless and irregular sleep pattern. Diphenhydramine does not cause nausea. There is no restriction on taking diphenhydramine after a high fat meal. Diphenhydramine is not an herbal medication.

DIF: Cognitive Level: Application Implementation

REF:

p. 220 OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

13. When reviewing a patient’s history and physical information, the nurse notes that the patient has physician’s orders for chloral hydrate and warfarin. During assessment of this patient, the nurse observes areas of petechiae and ecchymosis on the upper and lower extremities. The most appropriate lab work for the nurse to assess next is:

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liver function studies.

C-reactive protein.

sedimentation rate.

prothrombin time.

ANS: D Chloral hydrate may enhance the anticoagulant effects of warfarin. The patient should be observed for petechiae, ecchymoses, nosebleeds, bleeding gums, dark tarry stools, and bright red or coffee ground emesis. Prothrombin time should be monitored, and the physician should reduce the dosage of warfarin, if necessary.

DIF: Cognitive Level: Application Implementation

REF:

p. 222 OBJ:

6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

14. The nurse is administering Somnote to a patient. When providing medication education to the patient, the nurse will include that Somnote should be: a.

thoroughly chewed.

taken with a full glass of water.

taken on an empty stomach.

taken only before bedtime.

ANS: B Somnote is available in capsule form and should not be chewed, should be taken with a full glass of water, should be taken after meals, and is usually ordered to be taken three times a day after meals.

DIF: Cognitive Level: Application Implementation

REF:

p. 221 OBJ:

4 TOP: Nursing Process Step:

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MSC: NCLEX Client Needs Category: Physiological Integrity

MULTIPLE RESPONSE

15.

Why are benzodiazepines often preferred over barbiturates? ( Select all that apply. )

They have selective action at specific receptor sites.

There is a wide range of safety between therapeutic and lethal levels.

REM sleep is decreased to a lesser extent.

Accidental overdoses are well tolerated.

There are no hypotensive episodes when rising to a sitting position.

ANS: A, B, C, D The selectivity of specific drugs at receptor sites accounts for the wide variety of uses. There is a wide safety margin between the therapeutic and lethal dosages for these drugs. Benzodiazepines decrease REM sleep to a lesser extent. Intentional and unintentional overdoses of benzodiazepines are often well tolerated and not fatal. There are transient hypotensive episodes with benzodiazepine therapy.

DIF:

Cognitive Level: ComprehensionREF:

p. 217 OBJ:

4 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

16.

Barbiturates have which common adverse effect(s)? ( Select all that apply. )

Residual daytime sedation

Headache

Hyperactivity

Blurred vision

Impaired coordination

ANS: A, B, D, E The long half life of a barbiturate medication often causes residual daytime sedation. Headache is a general adverse effect of barbiturates. Blurred vision is an adverse effect associated with the hypnotic

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dosages of long acting barbiturates. Impaired coordination is an adverse effect of barbiturates. Hyperactivity is not generally an adverse effect of barbiturates unless the patient is experiencing a paradoxical response.

DIF: Cognitive Level: Knowledge Evaluation

REF:

pp. 215-217

OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

17.

What can occur as a result of rapid withdrawal from long term use of barbiturate therapy?

( Select all that apply. ) a.

Anxiety

Delirium

Weakness

Grand mal seizures

Severe pain

ANS: A, B, C, D

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Anxiety, delirium, weakness, and grand mal seizures can be symptoms of rapid withdrawal from long term use of barbiturate therapy. Severe pain is not a symptom of rapid withdrawal from long term use of barbiturate therapy.

DIF:

Cognitive Level: Knowledge

REF:

p. 216 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

4 TOP: Nursing Process Step: Planning

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18.

The nurse is assessing a patient prior to discharge from same day surgery following an

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incisional breast biopsy. When assessing the patient’s central nervous system (CNS) function following sedative hypnotic therapy, what will the nurse include?(Select all that apply.) a.

Level of alertness

Orientation

Ability to perform motor functions

Blood pressure

Usual pattern of sleep

ANS:

A, B, C

Because sedative hypnotics depress overall CNS function, the nurse should identify the patient’s level of alertness and orientation and ability to perform motor functions. Blood pressure is a vital sign and falls under cardiovascular assessment. Usual sleep pattern should be obtained for information on sleep pattern disruption, but not for CNS function.

DIF:

Cognitive Level: Application

REF:

TOP:

Nursing Process Step: Assessment

p. 214 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

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Chapter 15: Drugs Used for Anxiety Disorders Test Bank

MULTIPLE CHOICE

1. What is the recommended time over which antianxiety medications must be gradually tapered before discontinuation? a.

1 week

1 month

6 months

1 year

ANS:

Withdrawal from medication should be done under a health care provider’s supervision. Withdrawal usually takes 4 weeks and requires a gradual reduction in dosage and greater intervals between medication administrations. One week is an inadequate interval for cessation of antianxiety medication therapy. Six months to 1 year is much longer than necessary for cessation of antianxiety medication therapy.

DIF:

Cognitive Level: Knowledge

REF:

p. 246 OBJ:

5 TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Psychosocial Integrity

Which is a benzodiazepine of choice when treating anxiety associated with alcohol withdrawal?

Chlordiazepoxide (Librium)

Oxazepam (Serax)

Diazepam (Valium)

Clorazepate (Tranxene)

ANS:

Oxazepam and lorazepam are the drugs of choice in treating anxiety disorders because they have no active metabolites. Chlordiazepoxide and clorazepate are not the drugs of choice when treating anxiety

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associated with alcohol withdrawal. Diazepam has not been studied as fully as oxazepam in treating patients who have hepatic function impairment.

DIF: Cognitive Level: Knowledge Implementation

REF:

pp. 245-246

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Psychosocial Integrity

Which is the drug of choice to treat a patient with obsessive compulsive disorder (OCD)?

Lorazepam (Ativan)

Buspirone (BuSpar)

Fluvoxamine (Luvox)

Hydroxyzine (Vistaril)

ANS:

Fluvoxamine inhibits the reuptake of serotonin at the nerve endings, thus prolonging serotonin activity. Fluvoxamine is used for the treatment of OCD when the obsessions or

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compulsions cause marked distress or interfere substantially with social or occupational responsibilities. Fluvoxamine does not prevent the obsessions or compulsions; the therapeutic outcome of this drug is to assist the patient in their management. Lorazepam, buspirone, and hydroxyzine do not treat the symptoms of OCD.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 243 OBJ:

1 TOP: Nursing Process Step:

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MSC: NCLEX Client Needs Category: Psychosocial Integrity

4. The outcome statement for a patient suffering from anxiety disorder reads, “After 1 week on alprazolam (Xanax) therapy, patient will exhibit a manageable level of anxiety.” Which assessment finding validates that this outcome is met? a.

Patient is unable to participate in group therapy conversations.

Patient reports persistent fear about dying of a rare illness.

Patient verifies that family reunions trigger anxiety and excessive drinking.

Patient reports sleeping better and increased interest in activities.

ANS: D The primary therapeutic outcome expected from benzodiazepine antianxiety agents is a decrease in the level of anxiety to a manageable level. Physical signs of anxiety have decreased, and coping is improved. Being unable to participate in group therapy, persistent fears, and choosing inappropriate coping mechanisms for noncatastrophic events indicate that the anxiety is not manageable.

DIF: Cognitive Level: Application REF: p. 244 | p. 246 OBJ: 4 TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Psychosocial Integrity

Which is true regarding psychological drug dependence?

It is easier to treat than physiological dependence.

It is not considered a true addiction.

It is easily controlled by influencing the patient’s perceptions.

It requires medical intervention to treat.

ANS: D Medical intervention is required to treat psychological drug dependence. Psychological addictions are often more difficult to overcome than physiological addictions. Psychological drug dependence can be very difficult to treat.

DIF:

Cognitive Level: ComprehensionREF:

p. 246 OBJ:

5 TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Psychological Integrity

The nurse is preparing to educate a patient and significant other about antianxiety

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medications before the patient’s discharge. What is pertinent information to be included in the teaching plan? a. Discuss, review, and validate the behavior monitoring system and intervention flow sheet the patient and significant other will continue to use following discharge. b. Discuss the possible dependence associated with the medication at length to make sure the patient does not overuse the drug.

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c. Instruct the patient to educate family members about the medication therapy, based on recollection of discussions with the nurse. d.

Provide all instructions verbally, with repetition as needed when requested by the patient.

ANS: A It is the responsibility of the nurse to educate patients about their therapy, monitoring for therapeutic benefit and adverse effects to expect and report, and intervening whenever possible to optimize therapeutic outcomes. Making the patient fearful of the medication therapy defeats the purpose of using the drug to control anxiety. The topic should be mentioned because it is important, but it should not be emphasized. Family members or significant others should participate in discussions with the nurse whenever possible, and the patient should be given written instructions to refer to after discharge. Verbal instruction should be backed up with written documents for the patient to refer to after discharge.

DIF: Cognitive Level: Application Implementation

REF:

p. 244 OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

7. What will the nurse caution a patient about when providing information about the prescribed azaspirone antidepressant?

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Risk for addiction

Adverse effect of nausea

Risk of injury when using machinery

Additive effects of central nervous system (CNS) depression with alcohol

ANS: C The most common adverse effects of azaspirone therapy include dizziness, nervousness, drowsiness, and lightheadedness. Azaspirones do not have a risk for abuse or addiction. Nausea and vomiting are not common adverse effects of treatment with azaspirones. Azaspirones do not have CNS depression, but it is recommended that they not be combined with alcohol or sedatives.

DIF:

Cognitive Level: ComprehensionREF:

p. 246 | p. 247

OBJ: 3 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

Which patient is most likely to respond quickly to antianxiety therapy with benzodiazepines?

Patient with a history of long-term anxiety

Patient with recent anxiety reactions

Patient with severe depression in addition to being anxious

Patient with incidents of auditory hallucinations

ANS: B Patients with anxiety reactions to recent events and those with a treatable medical illness that induces anxiety respond most readily to benzodiazepine therapy. Long term anxiety is best treated with medications other than benzodiazepines (e.g., prescription medications such as Zoloft, Paxil, Prozac, Effexor, and Wellbutrin). Severe depression does not improve with treatment of benzodiazepines. Patients who are having psychotic symptoms do not respond to benzodiazepines. DIF:

Cognitive Level: ComprehensionREF:

p. 245 OBJ:

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TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity

9. What instruction is most important for the nurse to teach the patient who has recently been prescribed alprazolam (Xanax)? a.

“The medication needs to be taken on an empty stomach.”

“You may feel dizzy or unsteady when rising to a standing position.”

“Smoking will require a reduction in dosage of the medication.”

“Over the counter medications are safe to take while on this medication.”

ANS: B Patients may experience a transient episode of hypotension on arising. This medication does not need to be taken on an empty stomach. Smoking enhances the metabolism of benzodiazepines; larger doses may be necessary to maintain effects. Over the counter medications are to be approved by the health care provider. Antihistamines, for example, increase toxic effects.

DIF: Cognitive Level: Application Implementation

REF:

p. 246 OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

10. The nurse is developing a teaching plan for patients prescribed buspirone (BuSpar). Which information about this medication should be included? a.

There is minimal potential for abuse.

Signs of improvement can be seen within 3 days.

Sedation is increased compared with other antianxiety medications.

It stimulates the action of gamma-aminobutyric acid (GABA).

ANS: A There is minimal potential for abuse with buspirone. It takes longer than 3 days to see signs of improvement. Buspirone has lower sedative properties and does not affect GABA receptors.

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DIF: Cognitive Level: Application Implementation

REF:

p. 247 OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

11. A newly admitted psychiatric patient repetitively states, “I wish I were dead. I just want to kill myself.” The priority nursing at this time is to: a.

establish a trusting relationship.

encourage a nonstimulating environment.

provide for patient safety.

identify signs of increased anxiety.

ANS: C If the patient has suicidal ideas, intervention to provide patient safety is the priority nursing action. Although establishing a trusting relationship should occur, safety is the nursing priority. Once safety is established, support and reassurance may be provided. A nonstimulating environment should be encouraged once safety is established. Once patient safety is established signs of increased anxiety can be identified. DIF:

Cognitive Level: Application

REF:

p. 244 OBJ:

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TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Psychosocial Integrity

12. The nurse transcribes an order for lorazepam for a patient experiencing nausea and vomiting as a result of alcohol withdrawal. The most appropriate route of administration for lorazepam with this patient would be:

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by mouth.

rectally.

intramuscularly.

subcutaneously.

ANS: C The use of lorazepam is somewhat limited for use with symptoms of alcohol withdrawal for those who cannot tolerate oral administration because of nausea and vomiting. The most appropriate route in this situation would be intramuscularly.

DIF: Cognitive Level: Analysis Assessment

REF:

pp. 245-246

OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment; Physiological Integrity

MULTIPLE RESPONSE

13. A female patient is admitted to the adult psychiatric floor with a diagnosis of generalized anxiety disorder. Anxiolytic medications and group therapy have been prescribed. Evaluation of therapeutic outcomes related to her acute stay can be measured by which assessment(s)? ( Select all that apply. ) a.

She is able to sleep 5 hours during the night.

The tremor and pacing she exhibited on admission are reduced.

She is able to attend and actively participate in group sessions.

She is eating only 10% of her meals.

She complains of chest pain before group therapy.

ANS: A, B, C A primary therapeutic outcome expected from antianxiety therapy agents is a decreased level of anxiety to a manageable level with the ability to get adequate rest and nourishment, a decrease or elimination of somatic complaints, and active and appropriate participation in group therapy. Improved appetite would be a sign of decreased anxiety. Chest pain may be an example of somatization, especially when experienced during emotionally stressful times, such as group therapy.

DIF:

Cognitive Level: Application

REF:

p. 243 OBJ:

MSC: NCLEX Client Needs Category: Psychological Integrity

4 TOP: Nursing Process Step: Evaluation

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14.

Which substance(s) may increase the toxic effects of benzodiazepines? ( Select all that apply.

) a.

Alcohol

Antihistamines

Analgesics

Sedatives

Vitamins

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Hypnotics

ANS: A, B, C, D, F Alcohol, antihistamines, analgesics, sedatives, and hypnotics may cause excessive sedation and impaired psychomotor function when taken concurrently with benzodiazepines. Vitamins do not cause excessive sedation and impaired psychomotor function when taken concurrently with benzodiazepines.

DIF:

Cognitive Level: ComprehensionREF:

TOP: Nursing Process Step: Planning

p. 246 OBJ:

MSC: NCLEX Client Needs Category: Evaluation

15. In addition to the relief of mild to moderate anxiety, hydroxyzine (Vistaril) has which additional therapeutic outcome(s)? ( Select all that apply. ) a.

Reduced need for sedation and analgesia before and after surgery

Elimination of psychotic thinking

Control of itching in allergic reactions

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Control of vomiting

Control of obsessive compulsive thoughts

Prevention of extrapyramidal adverse effects and tardive dyskinesia

ANS: A, C, D Hydroxyzine has sedative, antihistamine, and antiemetic effects in addition to antianxiety activity. Hydroxyzine does not control psychotic thinking, obsessive compulsive thinking, or movement disorders caused by other medications.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 248 OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

16. Which assessment(s) would be included in the evaluation of a patient with anxiety? ( Select all that apply.) a.

Physical examination

Psychological evaluation

History of precipitation stressors

Medication history

Substance abuse history

Blood glucose level

ANS: A, B, C, D, E Physical examination, psychological evaluation, history of precipitation stressors, medication history, and substance abuse history are important in evaluating a patient with anxiety to get a complete background on the patient. The blood glucose level is not included in evaluation of a patient with anxiety.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 243 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Psychological Integrity

17. The prenatal nurse is educating a woman regarding preconception care. The patient informs the nurse that she is currently taking a benzodiazepine drug for management of anxiety.

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Appropriate teaching for this patient will include that benzodiazepines: ( Select all that apply. ) a.

readily cross into breast milk.

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are safe to take throughout pregnancy.

enter fetal circulation.

are not associated with ill effects on the infant following birth.

may increase newborn muscle tone.

ANS:

A, C

It is recommended that benzodiazepines not be administered during at least the first trimester of pregnancy. There may be an increased incidence of birth defects because these agents readily cross the placenta and enter fetal circulation. Mothers who are breast feeding should not receive benzodiazepines regularly. The benzodiazepines readily cross into breast milk and exert a pharmacologic effect on the infant. If benzodiazepines are taken regularly during pregnancy, the infant should be monitored closely after delivery for signs of withdrawal, including hypotonia.

DIF:

Cognitive Level: Application

REF:

p. 246 OBJ:

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TOP:

Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Psychosocial Integrity

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Chapter 16: Drugs Used for Depressive and Bipolar Disorders

MULTIPLE CHOICE

What occurs with mania associated with bipolar disorder?

Varying degrees of sadness

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Distinct episodes of elation

Suicide

Psychomotor retardation

ANS: B Mania is characterized by distinct episodes of euphoria and elation. Sadness is characteristic of depression. Suicide is not generally associated with mania; it is more commonly associated with depression. Psychomotor retardation is not associated with mania.

DIF: Cognitive Level: ComprehensionREF: Assessment

Page 230

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Psychosocial Integrity NOT: CONCEPT(S): Clinical Judgment; Mood and Affect

2. Which postoperative narcotic analgesic will most likely be prescribed to a patient whose current medications include a monoamine oxidase inhibitor (MAOI), a thyroid hormone, and a multivitamin? a.

Meperidine (Demerol)

Morphine

Ibuprofen (Advil)

Acetaminophen (Tylenol)

ANS: B Morphine is the narcotic analgesic of choice because it will not interact with the patient’s MAOI. Meperidine will interact with the patient’s medication. Ibuprofen and acetaminophen are not narcotic analgesics.

DIF: Cognitive Level: Application Assessment

REF:

Page 239

OBJ:

2 | 4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment

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3. What is the major advantage of selective serotonin reuptake inhibitors (SSRIs) over other types of antidepressant therapy? a.

They are less expensive than the other classes of antidepressants.

They cure major depressive illnesses.

They do not cause the anticholinergic and cardiovascular adverse effects.

Therapeutic relief is immediate.

ANS: C

SSRIs are the most widely used class of antidepressants. Although they are as effective in treating depression as the tricyclic antidepressants, they do not cause the anticholinergic and cardiovascular adverse effects that often limit the use of tricyclic antidepressants. SSRIs tend to be more expensive than other available antidepressants. SSRIs do not cure major depressive illnesses. As with other antidepressants, it takes 2 to 4 weeks to obtain the full therapeutic benefit when taking SSRIs.

DIF: Cognitive Level: Knowledge Planning

REF:

Page 239

OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

Lithium (Eskalith) is the drug of choice for which of the following disorders?

Psychotic episodes

Obsessive compulsive disorders (OCDs)

Bipolar disorders

Depressive disorders

ANS: C Lithium is used to treat acute mania and for prophylactic treatment of recurrent manic and depressive episodes in bipolar disorders. Psychotic episodes are treated with major tranquilizers that have an antipsychotic effect. The drugs of choice for treating OCD are SSRIs. Depressive disorders are not primarily treated with lithium.

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DIF: Cognitive Level: ComprehensionREF: Process Step: Assessment

Page 223 | Page 249 OBJ:

1|7

TOP: Nursing

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment

5. Which psychological manifestation of depression will improve in response to antidepressant therapy? a.

Loss of energy

Palpitations

Sleep disturbances

Social withdrawal

ANS: D Social withdrawal and lack of interest in surroundings are psychological responses that will improve within 2 to 4 weeks of the patient receiving an effective dosage of antidepressant therapy. An increase in energy, decreased palpitations, and improvement in sleep patterns are physiological responses.

DIF: Cognitive Level: ComprehensionREF: Implementation

Page 232

OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Psychological Integrity

NOT: CONCEPT(S): Clinical Judgment; Mood and Affect 6.

On what is the choice of tricyclic antidepressants based?

The need to decrease the action of norepinephrine, dopamine, or serotonin

Patient age and gender

An absence of adverse effects, such as orthostatic hypotension

The need for stimulation and increased mental alertness

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ANS: B The choice of tricyclic antidepressants is based on their individual therapeutic characteristics. Tricyclics prolong the action of norepinephrine, dopamine, and serotonin. All tricyclics produce orthostatic hypotension to some degree. All tricyclics produce sedation, not stimulation.

DIF: Cognitive Level: ComprehensionREF: Assessment

Page 241

OBJ:

2 | 6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Psychosocial Integrity NOT: CONCEPT(S): Clinical Judgment

7. The nurse is teaching a patient about medication treatment for depression. The patient asks how long it will take before sleep and appetite will begin to improve. Which response by the nurse is most accurate? a.

3 days

1 week

4 weeks

2 months

ANS: B The physiological manifestations of depression (sleep disturbance, change in appetite, loss of energy, fatigue, palpitations) begin to be alleviated within the first week of therapy. It takes longer than 3 days for the symptoms to improve. Four weeks and 2 months are longer than it takes for the symptoms to improve.

DIF: Cognitive Level: ComprehensionREF: Implementation

Page 232

OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Patient Education

What is the action of MAOIs on neurotransmitters?

Blocking their reuptake

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Increasing their production

Blocking their destruction

Increasing their reuptake

ANS: C

MAOIs act by blocking the metabolic destruction of epinephrine, norepinephrine, dopamine, and serotonin neurotransmitters by the enzyme monoamine oxidase in the presynaptic neurons of the brain. They prevent the degradation of these central nervous system (CNS) neurotransmitters so that their concentration is increased. MAOIs do not block or increase the reuptake of neurotransmitters. MAOIs do not increase production of neurotransmitters.

DIF: Cognitive Level: ComprehensionREF: Implementation

Page 235

OBJ:

2 | 4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment

9. A patient who is taking an MAOI to treat depression admits to eating pickled herring and cheese and drinking red wine. Which assessment finding alerts the nurse to a potential complication? a.

Constipation

Hypotension

Neck stiffness

Urinary retention

ANS: C Hypertensive crisis is a major potential complication. Common prodromal symptoms of hypertensive crisis include severe occipital headache, stiff neck, sweating, nausea, vomiting, and sharply elevated blood pressure. Constipation, hypotension, and urinary retention are not indicative of a major potential complication when patients consume foods high in tyramine.

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DIF: Cognitive Level: Application Assessment

REF:

Page 238

OBJ:

2 | 4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

10. Which assessment would the nurse expect to observe in a patient who has been prescribed trazodone for treatment anxiety? a.

Excessive thirst

Hand tremor

Drowsiness

Diarrhea

ANS: C Drowsiness is a common adverse effect, and people who work with machinery, drive a car, administer medicines, or perform other duties in which they must remain mentally alert should not take trazodone while working. Excessive thirst, hand tremors, and diarrhea are not adverse effects associated with trazodone.

DIF:

Cognitive Level: ComprehensionREF:

Page 247

OBJ:

2|3

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment 11. The nurse is caring for a patient who is taking a newly prescribed drug, nefazodone, for treatment of depression. Which physical assessment finding is most important for the nurse to report to the health care provider immediately? a.

Bradycardia

Dizziness

Drowsiness

Urinary retention

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ANS: A Bradycardia with a drop in 15 beats/min is to be reported to the health care provider immediately; withholding the dose is warranted until approved. Dizziness, drowsiness, and urinary retention are common adverse effects that would not need to be reported to the health care provider.

DIF: Cognitive Level: ComprehensionREF: Assessment

Page 246

OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment

12. The nurse is providing education to a patient who has been prescribed bupropion (Wellbutrin) for smoking cessation. Which statement by the patient would indicate the need for further teaching? a.

“My dose will increase after 3 days.”

“I should swallow this medication whole.”

“If I have the urge to smoke, I will take more medication.”

“I do not need to taper my dose when the drug is discontinued.”

ANS: C Dosage will begin at 150 mg/day for the first 3 days and then, for most patients, be increased to 300 mg/day. The patient is maintained on doses of 300 mg/day for 7 to 12 weeks and dosage is not based on a desire to smoke. Bupropion should be swallowed whole, not crushed, divided, or chewed. Dose tapering is not required when discontinuing bupropion.

DIF: Cognitive Level: Application Step: Evaluation

REF:

Page 243

OBJ:

2 | 3 | 6 TOP: Nursing Process

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Patient Education

13. Which nursing action is most important when providing care to a patient diagnosed with a mood disorder? a.

Assess the patient for thoughts of suicide.

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Provide supplemental feedings as needed.

Assist with activities of daily living.

Offer opportunities for interaction with other patients.

ANS: A Determining if there is a risk for suicide, monitoring at specified intervals, and providing patient safety and supervision are the highest priorities with severe mood disorders. Providing supplemental feedings, assisting with activities of daily living, and offering opportunities for interaction with other patients are not priorities of care.

DIF: Cognitive Level: Application Process Step: Intervention

REF:

Page 231 | Page 232 OBJ:

TOP: Nursing

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Mood and Affect

14. A patient is admitted to a long-term psychiatric setting. The MAOI medication previously prescribed is discontinued by the physician. New orders are obtained to initiate imipramine therapy. The nurse will provide the first dose of imipramine to the patient the MAOI drug. a.

immediately following the last dose of

in 1 week following the last dose of

in 14 days following the last dose of

before discontinuing

ANS: C

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MAOIs and TCAs, especially imipramine and desipramine, should not be administered concurrently. It is recommended that at least 14 days lapse between discontinuing an MAOI and starting SSRI/SNRI therapy.

DIF: Cognitive Level: Analysis Implementation

REF:

Page 238

OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment| NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment

15. A patient taking vilazodone has been vomiting persistently for 12 hours. The priority nursing diagnosis for this patient is a.

nausea.

imbalanced nutrition (less than body requirements).

fluid volume deficit.

altered peripheral tissue perfusion.

ANS: C Nausea and vomiting are common adverse effects of vilazodone. Persistent vomiting should be evaluated for other causes, as well as for the development of electrolyte imbalance. Fluid

volume deficit can lead to life-threatening cardiac arrhythmias and therefore is the priority nursing diagnosis. The nursing diagnosis nausea is appropriate but is not the priority. Imbalanced nutrition is an appropriate nursing diagnosis but is not the priority at this time. Altered peripheral tissue perfusion does not apply to this scenario.

DIF: Cognitive Level: Analysis Diagnosis

REF:

Page 248

OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Fluid and Electrolyte Balance; Safety MULTIPLE RESPONSE

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1. Which area(s) should be addressed by the nurse when obtaining a history of a patient admitted with depression? (Select all that apply.) a.

Current medications and medical history

Recent stressors and support system

Family history of mood disorder

Dietary patterns

Insurance coverage

ANS: A, B, C, D It is important to obtain a thorough history when assessing the patient with depression, including current medical status and medications, recent stressors, support system, family history of mood disorders, and nutritional patterns. Financial matters should not be part of the nursing assessment.

DIF: Cognitive Level: Application Step: Assessment

REF:

Pages 232-233 OBJ:

TOP: Nursing Process

MSC: NCLEX Client Needs Category: Psychosocial Integrity NOT: CONCEPT(S): Clinical Judgment

2. Which instruction(s) is/are most pertinent to include in the discharge teaching of a patient on lithium (Eskalith) who is being discharged? (Select all that apply.) to ls.”

“You will be gradually weaned off this medication.”

“Take the medication with food or milk.”

ANS: A, B, D, F Patients should be informed of the importance of toxic symptoms to report and monitoring therapeutic lithium levels. Nausea, vomiting, and abdominal cramps are common adverse

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effects and tend to resolve. Lithium should be administered with food or milk. Chianti wine and aged cheeses are to be avoided during MAOI therapy. The bipolar patient may be on lithium treatment for the rest of his or her life and will not be weaned from the medication.

DIF: Cognitive Level: Application Implementation

REF:

Page 250

OBJ:

2 | 7 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Psychosocial Integrity NOT: CONCEPT(S): Clinical Judgment; Patient Education 3. What will the nurse include in a teaching plan for a patient with depression being treated with amitriptyline (Elavil)? (Select all that apply.) a.

Dryness of the mouth is normal; sucking on sugar free hard candy and ice chips or

chewing gum may help alleviate this problem. b.

Rise slowly from a supine or sitting position to avoid dizziness and orthostatic hypotension.

Avoid alcohol and barbiturates.

If adverse effects occur, discontinue the medication.

An immediate elevation in mood will be noted.

ANS: A, B, C Common adverse effects associated with tricyclic antidepressants are dry mouth and orthostatic hypotension. Alcohol and barbiturates should be avoided while taking tricyclic antidepressants because they enhance sedation. Adverse effects are likely to occur, and the medication should not be discontinued without the direction of the health care provider. Tricyclic antidepressants typically take several weeks to produce a therapeutic effect.

DIF: Cognitive Level: Application Implementation

REF:

Page 242

OBJ:

6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Patient Education

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4. Which food(s) containing significant amounts of tyramine will be contraindicated when a patient is on MAOI therapy? ( Select all that apply.)

ANS: A, C, E Beer, red wines, well-ripened cheeses (such as camembert, edam, roquefort, parmesan, mozzarella, and cheddar), and overripe bananas contain tyramine. Red meat and green vegetables do not contain tyramine.

DIF: Cognitive Level: Knowledge Planning

REF:

Page 238

OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Patient Education; Health Promotion; Safety

Which nursing assessment(s) is/are important before the initiation of antidepressant therapy?

(Select all that apply.) a.

Compliance with medication therapy within the last 2 months

Nonverbal interactions among patient and significant others present

Evaluation of the coherency, relevancy, and organization of thoughts in responses

Appearance and posture

Elimination pattern

ANS: A, B, C, D

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Compliancy with prescribed medications over the last 2 months provides the health care provider with information regarding the patient’s state of mind and ability to follow through with medication administration independently. Patients with altered thought processes often display inconsistencies between statements of feelings and behavior norms in social settings. Coherency, relevancy, and organization of thoughts are often affected by thought disorders. This assessment also provides information regarding the accuracy of other information that the patient has offered. Note general appearance and appropriateness of attire and posture because these are often affected by mood disorders. Elimination pattern is not a priority premedication assessment.

DIF: Cognitive Level: Analysis Assessment

REF:

Page 229

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment

6. Which statement(s) is/are true regarding the pharmacologic actions of certain antidepressant drugs? (Select all that apply.)

SNS.

ANS: B, D, E SSRIs block the destruction and storage of serotonin at the synaptic cleft, therefore increasing the amount of serotonin available. Monocyclic antidepressants have an unknown mechanism of action. They are weaker inhibitors of the reuptake and inactivation of the neurotransmitters serotonin norepinephrine and dopamine. SNRIs act by inhibiting the reuptake and destruction of serotonin and norepinephrine and, to a lesser extent, dopamine, from the synaptic cleft, thereby prolonging the action of the neurotransmitters. MAOIs act by

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blocking the metabolic destruction of dopamine, so concentration is increased. Tricyclics block the reuptake of neurotransmitters, not their effects.

DIF: Cognitive Level: ComprehensionREF: TOP: Nursing Process Step: Implementation

Page 239 | Page 240 | Page 243 OBJ:

2|3|4|5|6

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment

Which drug(s) interact(s) with SSRI agents? (Select all that apply.)

Tranylcypromine (Parnate)

Lithium (Eskalith)

Warfarin (Coumadin)

Furosemide (Lasix)

Propranolol (Inderal)

ANS: A, B, C, E A 14-day lapse is recommended between MAOIs, such as Parnate, and SSRI agents. The incidence of lithium toxicity is increased with SSRI agents. The anticoagulant effects of warfarin may be enhanced with SSRIs. The SSRIs fluvoxamine and citalopram inhibit the metabolism of beta-adrenergic blocking agents such as propranolol. Lasix does not interact with SSRI agents.

DIF: Cognitive Level: ComprehensionREF: Pages 239-240 OBJ: 3 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

8. The nurse must be sure to instruct the patient about which potential adverse effect(s) of tricyclic antidepressants? (Select all that apply.)

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ANS: B, C, E, F The patient may experience difficulty with dryness of the mouth, nose, and throat as well as smooth muscle contraction (resulting in constipation, urinary retention, and blurred vision). Diarrhea and nocturia are not adverse effects of tricyclic antidepressants.

DIF: Cognitive Level: Knowledge Assessment

REF:

Page 242

OBJ:

6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

9. The nurse is preparing 0800 medications for a patient with the medical diagnosis of end stage renal disease. When reviewing the medication administration record (MAR), the nurse notices the patient is scheduled to receive an MAOI drug. Which intervention(s) will the nurse perform before administering the drug? (Select all that apply.) a.

Assess temperature.

Provide an alternative drug.

Hold the MAOI drug.

Consult with the prescribing health care provider.

Assess urine output prior to administration.

ANS: C, D If the patient prescribed an MAOI drug has a history of severe renal disease, the medication must not be given and the prescribing health care provider consulted. It is not necessary to assess temperature at this time. An alternative medication needs to be ordered by a health care provider licensed to prescribe. Assessing urine output does not apply to this situation.

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DIF: Cognitive Level: Analysis Process Step: Implementation

REF:

Page 237 | Page 261 OBJ:

2|4

TOP: Nursing

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment| NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

Chapter 17: Drugs Used for Psychoses Test Bank

MULTIPLE CHOICE

1. The nurse is assessing a patient who is complaining of hearing voices. What is this patient experiencing? a.

Delusions

Flight of ideas

Disorganized thinking

Hallucinations

ANS: D Hallucinations are false sensory perceptions that are experienced without an external stimulus but seem real to the patient. Auditory hallucinations are prominent in a schizophrenic patient. Additional sensory hallucinations include those of touch, sight, smell, and body sensation. Delusions are false beliefs that persist despite evidence to the contrary. Flight of ideas is characterized by rapid changes in thought from one topic to another. Disorganized thinking is commonly associated with psychoses and consists of a flight of ideas during which the individual jumps from one idea or topic to another one.

DIF: Cognitive Level: Knowledge Assessment

REF:

p. 274 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Psychosocial Integrity

2. A patient with schizophrenia has been nonadherent with his home medication regimen. He requires frequent admissions to the intensive psychiatric unit for treatment of acute psychotic episodes. Which medication regimen would be appropriate for this patient? a.

Daily home nursing visits to administer the prescribed oral medication

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Continuous inpatient hospitalization for medication therapy

Administration of depot antipsychotic medication

Subcutaneous medication administration

ANS: C Depot antipsychotic medications are long acting injections that may be used with noncompliant patients and may assist in avoiding repeated hospital admissions. Daily home nursing visits are not an efficient way to ensure medication compliance. Continuous inpatient hospitalization is not an efficient way to ensure medication compliance. Subcutaneous medication administration is not an option for this patient.

DIF: Cognitive Level: Application Evaluation

REF:

pp. 274-276

OBJ:

2 | 3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Psychosocial Integrity

What is the most common cause of nonadherence to antipsychotic pharmacologic treatment? a. Expense

Increased symptoms of chemical dependency

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Extrapyramidal effects

Inability of the patient to understand the need to take medications

ANS: C Extrapyramidal effects are the most common reason for nonadherence to antipsychotic therapy. The four categories of extrapyramidal effects are dystonic reactions, pseudoparkinsonism, akathisia, and tardive dyskinesia. Although expense may be a concern, it is not the most common reason for

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noncompliance. Chemical dependency is not a feature of therapy with antipsychotic drugs. Although knowledge deficit is a concern, it is not the most common reason for noncompliance.

DIF:

Cognitive Level: ComprehensionREF:

p. 279 OBJ:

3 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

4. Which type of adverse effects is present when a patient displays prolonged tonic contractions of the tongue, oculogyric crisis, and torticollis? a.

Dystonic reactions

Pseudoparkinsonism

Akathisia

Tardive dyskinesia

ANS: A Dystonic reactions are the first extrapyramidal symptoms to occur when a patient is taking antipsychotic agents. Dystonias are spasmodic movements of muscle groups such as tongue protrusion, rolling back of the eyes (oculogyric crisis), jaw spasms (trismus), or neck torsion (torticollis). Pseudoparkinsonism is characterized by tremor and rigidity. Akathisia is characterized by subjective feelings of anxiety and restlessness, accompanied by pacing and the inability to remain in one place for extended periods. Tardive dyskinesia is characterized by persistent involuntary hyperkinetic movements.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 279 OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

5. The nurse is teaching a patient who is taking clozapine (Clozaril) to have weekly blood tests for the first 6 months of treatment to monitor for which potential complication? a.

Agranulocytosis

Vitamin deficiencies

Clotting abnormalities

Polycythemia

ANS: A

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The use of clozapine requires a baseline and weekly white blood cell (WBC) counts because of the high incidence of agranulocytosis. Clozapine does not cause vitamin deficiencies. Clozapine does not interfere with clotting abilities. Clozapine does not affect red blood cell volume.

DIF: Cognitive Level: Knowledge REF: p. 278 | p. 281 OBJ: 4 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

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6. A male patient becomes verbally aggressive and insists the nurse is poisoning him as she attempts to administer haloperidol (Haldol). Which action will the nurse take? a.

Support the patient’s decision to refuse the medication.

Discreetly ask an assistant to put the medication in the patient’s food.

Firmly redirect the patient to take the medication.

Speak privately with the patient and reinforce medication action.

ANS: C During episodes of acute psychosis, the patient is out of touch with reality and often does not understand the need for medication in stabilizing his or her condition. Target symptoms such as agitation, suspicion, and paranoia are common. Health care providers must be supportive yet firm in their expectations. An open and direct manner in handling patients who are highly suspicious is critical. Delusions should not be supported. The patient is not competent to determine his need for medication. It is dishonest to hide medication in a patient’s food and destroys a trusting relationship. Reasoning with the patient is unlikely to change his mind; he needs external structure for making decisions when he is aggressive and paranoid.

DIF: Cognitive Level: Analysis Implementation

REF:

p. 276 OBJ:

1 TOP: Nursing Process Step:

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MSC: NCLEX Client Needs Category: Psychosocial Integrity

7. Which statement is true regarding the adverse effects associated with antipsychotic medications? a.

Tardive dyskinesia is a common, reversible condition.

Painful dystonic reactions can occur in the first 72 hours of initiation of therapy.

Neuroleptic malignant syndrome (NMS) is a common adverse effect.

Pseudoparkinsonian symptoms can cause Parkinson’s disease.

ANS: B Approximately 90% of all dystonic reactions occur in the first 72 hours of antipsychotic therapy. These symptoms are often frightening and painful. Tardive dyskinesia is present in 20% to 25% of patients and may become irreversible. NMS is not a common adverse effect. Pseudoparkinsonism is not related to Parkinson’s disease.

DIF:

Cognitive Level: ComprehensionREF:

p. 279 OBJ:

4 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

To what does potency of an antipsychotic medication refer?

Severity of adverse effects associated with the drug

Length of time that it takes to reach a therapeutic blood level of the drug

Milligram doses used for the medication

Effectiveness of the drug in alleviating psychotic behavior

ANS: C Low and high potency refers only to the milligram doses used for the medications and does not suggest any difference in effectiveness. Potency is not related to severity of adverse effects or onset of action. Potency does not refer to effectiveness.

DIF:

Cognitive Level: ComprehensionREF:

p. 275 OBJ:

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TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 9. Dystonic reactions, pseudoparkinsonism, akathisia, and tardive dyskinesia are types of which effect? a.

Extrapyramidal symptoms

Allergic reactions

Idiosyncratic reactions

Therapeutic responses

ANS: A There are four categories of extrapyramidal symptoms: dystonic reactions, pseudoparkinsonism, akathisia, and tardive dyskinesia. These are not allergic reactions, idiosyncratic reactions, or therapeutic responses.

DIF: Cognitive Level: Knowledge Evaluation

REF:

pp. 279-280

OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

10. Which is an appropriate nursing intervention for a patient who has recently been prescribed clozapine (Clozaril)? a.

Assess for signs and symptoms of hypoglycemia.

Encourage a low fiber diet.

Measure the patient’s waist circumference.

Monitor for insomnia.

ANS: C

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Waist circumference baseline measurement is appropriate because of the weight gain and onset of diabetes with use of these medications. Hypoglycemia and insomnia do not occur with this medication. A low fiber diet is not appropriate.

DIF:

Cognitive Level: Application

REF:

p. 280 OBJ:

2 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

11. A young male patient taking an antipsychotic is experiencing an oculogyric crisis. The nurse prepares to administer: a.

diphenhydramine.

haloperidol.

aripiprazole.

risperidone.

ANS: A Acute dystonic reactions may be controlled by intramuscular injections of diphenhydramine. Haloperidol, aripiprazole, and risperidone are not used for dystonic reactions.

DIF: Cognitive Level: Application Implementation

REF:

p. 279 OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

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MULTIPLE RESPONSE

12. A patient admitted to the hospital is exhibiting psychotic behavior. Which sign(s) and/or symptom(s) would support the diagnosis of psychosis? ( Select all that apply. ) a.

Constant eye contact during the admission history

Deterioration of social functioning

Reporting that the FBI has solicited important secret information from his phone conversations

Confirmation of hearing voices in his head

Changing the topic of conversation inappropriately

ANS: B, C, D, E Social deterioration, disordered thinking (including delusions), disordered perception, (including hallucinations), and flight of ideas are symptoms of psychotic behavior. It is uncommon for a psychotic patient to maintain eye contact.

DIF: Cognitive Level: Application Assessment

REF:

p. 274 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Psychosocial Integrity

13. Why is a combination of antipsychotic agents with benzodiazepines useful in initial treatment of the agitated patient? ( Select all that apply. ) a.

Antipsychotics are not effective for 2 days.

b. Benzodiazepines allow for lower dosages of antipsychotic agents to be used, thereby decreasing serious adverse effects seen with high dose therapy. c.

It assists in calming the psychotic patient.

d. It allows for rapid increase in dosing of the antipsychotic agents to expedite treatment of hallucinations. e.

It effectively treats extrapyramidal adverse effects associated with antipsychotic agents.

ANS: B, C The use of benzodiazepines allows lower dosages of antipsychotic agents to be used. Benzodiazepines assist in calming the agitated psychotic patient. Antipsychotic medications can be effective in a matter

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of minutes when injected. Benzodiazepines do not facilitate the increase of antipsychotic medications or treat extrapyramidal adverse effects associated with antipsychotic agents.

DIF: Cognitive Level: Application Implementation

REF:

p. 276 OBJ:

2 | 3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Psychosocial Integrity

14.

Which is/are extrapyramidal adverse effect(s) of antipsychotic agents? ( Select all that apply.

) a.

Spasmodic movements of muscle groups

Masklike expression

Lip smacking

Inability to sit in one place for an extended period

Weight gain

ANS: A, B, C, D

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Dystonic reactions, pseudoparkinsonism, tardive dyskinesia, and akathisia are extrapyramidal symptoms of antipsychotic agents. Antipsychotic drug therapy often causes substantial weight gain, but this is not classified as a extrapyramidal adverse effect.

DIF: Cognitive Level: Application Assessment

REF:

p. 279 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

4 TOP: Nursing Process Step:

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Nursing interventions for patients with psychosis must be individualized and based on patient

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Chapter 18: Drugs Used for Seizure Disorders Test Bank

MULTIPLE CHOICE

Which condition is associated with hydantoin therapy?

Postictal state

Atonia

Seizure threshold reduction

Gingival hyperplasia

ANS: D Encouraging good oral hygiene practices is indicated when a patient is on hydantoin therapy because its use contributes to gingival hyperplasia. Postictal state is a characteristic of generalized tonic clonic seizures. Atonia is not associated with hydantoin therapy. Hydantoin raises the seizure threshold.

DIF: Cognitive Level: Knowledge Implementation

REF:

p. 295 OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

2. The nurse is preparing discharge instructions for a patient with a history of diabetes who has just been diagnosed with seizure disorder. The patient has been prescribed hydantoin therapy. What will the patient most likely experience? a.

Hunger

Hyperglycemia

Diarrhea

Pupil dilation

ANS: B Hydantoins may elevate blood sugar levels. Hunger, diarrhea, and pupil dilation are adverse effects of hydantoin therapy. Constipation and nystagmus are potential adverse effects.

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DIF: Cognitive Level: Application Implementation

REF:

p. 294 OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

What is a guideline for the nurse when administering phenytoin (Dilantin) intravenously? a.

Deliver rapidly. b.

Monitor for signs of tachycardia.

Assess for hypertensive crisis.

Administer without mixing with other medications.

ANS: D Phenytoin should not be mixed in the same syringe with other medications or added to other intravenous (IV) solutions because a precipitate will form. Phenytoin should be administered slowly at a rate of 25 to 50 mg/min. Patients should be monitored with an ECG closely for bradycardia. Patients should be monitored for hypotension.

DIF:

Cognitive Level: Application

REF:

p. 292 OBJ:

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MSC: NCLEX Client Needs Category: Physiological Integrity

For which condition may carbamazepine (Tegretol) be used?

Tardive dyskinesia

Psychotic episodes

Trigeminal neuralgia pain

Sedation

ANS: C

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Carbamazepine has been used successfully to treat pain associated with trigeminal neuralgia and for bipolar disorders when lithium therapy has not been optimal. Carbamazepine does not have antidepressant, antipsychotic, or sedative effects.

DIF:

Cognitive Level: Knowledge

REF:

p. 296 OBJ:

4 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

What is the drug of choice when treating a generalized tonic clonic seizure?

Diazepam (Valium)

Haloperidol (Haldol)

Valproic acid (Depakene)

Risperidone (Risperdal)

ANS: C Anticonvulsant therapy should start with the use of a single agent selected from a group of first line agents based on the type of seizure. Valproic acid is indicated for generalized tonic clonic seizures. Diazepam is not the drug of choice for treatment of tonic clonic seizures. Haloperidol is an antipsychotic medication. Risperidone is an antipsychotic agent.

DIF:

Cognitive Level: ComprehensionREF:

p. 306 OBJ:

3 TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity

6. Which response by the nurse is accurate when a patient who has been on lamotrigine ( Lamictal) for seizure control reports a skin rash and urticaria? a.

Reassure the patient that this is a common adverse effect of the medication and not to worry.

Instruct the patient to discontinue use of the drug immediately.

Instruct the patient to decrease the dosage of the medication until the rash disappears.

d. Advise the patient that this adverse effect usually resolves but should be reported to the health care provider. ANS: D The nurse is not authorized to recommend dosage changes to the patient. The nurse should not trivialize the patient’s concern about the adverse effect; it is common only in 10% of patients who take lamotrigine and can lead to more serious adverse effects. The nurse should not recommend

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discontinuing the medication without orders from the health care provider. This is not a common adverse effect and should be monitored. Approximately 10% of patients receiving lamotrigine develop a skin rash in the first 4 to 6 months of therapy. The health care provider should be notified promptly because the rash could be an indicator of a more serious condition. DIF:

Cognitive Level: Analysis

REF:

p. 300 OBJ:

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https://www.coursehero.com/file/8889643/19-seizures/

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

Which medication is used to control seizures or prevent migraine headaches?

Topiramate (Topamax)

Zonisamide (Zonegran)

Valproic acid (Depakene)

Tiagabine (Gabitril)

ANS: A Topiramate has been approved for adults in the prevention (but not treatment) of migraine headaches. Zonisamide, valproic acid, and tiagabine do not affect migraine headaches.

DIF: Cognitive Level: Knowledge Implementation

REF:

p. 305 OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Which condition would indicate to the nurse that a patient has phenytoin (Dilantin) toxicity?

Oculogyric crisis

Nystagmus

Strabismus

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Amblyopia

ANS: B Nystagmus (involuntary rhythmic, uncontrollable movements of one or both eyes) may be a sign of phenytoin toxicity. Oculogyric crisis is an adverse effect of some antipsychotic medications. Strabismus is a visual disorder in which the eyes are misaligned and point in different directions. Amblyopia is a loss of visual acuity in the nondominant eye caused by lack of use of the eye in early childhood.

DIF:

Cognitive Level: ComprehensionREF:

p. 295 OBJ:

4 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

9. What information would be most important for the nurse to provide to a patient when teaching about the adverse effects of succinimide therapy? a.

Nausea, vomiting, and indigestion are common during the initiation of therapy.

Avoid taking the medication with food or milk to minimize adverse effects.

Sedation, drowsiness, and dizziness tend to worsen with continued therapy.

Reducing the dosage of medication will relieve symptoms of nausea.

ANS: A Nausea, vomiting, and indigestion are common during initiation of therapy. Taking the medicine with food or milk reduces the nausea and indigestion. Sedation, drowsiness, and dizziness tend to disappear with continued therapy. Gradual increases in dosage tend to decrease nausea and vomiting.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 296 OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity 10. What dose is within the acceptable range for administering IV phenytoin (Dilantin) to a patient with a seizure disorder? a.

5 mg/min

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30 mg/min

60 mg/min

100 mg/min

ANS: B Phenytoin is administered slowly at a rate of 25 to 50 mg/min. A rate of 5 mg/min is too slow. A rate of 60 mg/min or 100 mg/min is too fast.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 295 OBJ:

6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

11. The nurse is providing discharge teaching to a patient prescribed phenytoin (Dilantin) for management of a seizure disorder. Which patient statement indicates a need for further teaching? a.

“I need to avoid or limit caffeine intake.”

“I will check with the pharmacist before taking over the counter medication.”

“If I develop enlarged gums, I will stop taking the medication.”

“It is important for me to take my medicine at the same time daily.”

ANS: C Medications are not discontinued unless approved by the health care provider. Gingival hyperplasia is a common adverse effect that can be reduced by oral hygiene. Limiting caffeine intake, checking with the pharmacist about any additional over the counter medications, and taking the medication at the same time every day are appropriate actions by the patient.

DIF: Cognitive Level: Application Implementation

REF:

p. 295 OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

12. Which premedication assessment by the nurse is most important prior to the initiation of carbamazepine (Tegretol) therapy? a.

Determine patient’s ancestry.

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Monitor blood pressure (BP) lying, sitting, and standing.

Auscultate lung sounds.

Obtain smoking history.

ANS: A The nurse needs to review the patient’s history to exclude Asian ancestry, including South Asian Indians. If the patient does have this ancestry, bring it to the prescriber’s attention so that genetic testing may be completed. BP monitoring is important and hypotension is an adverse effect, but it is not as significant to monitor prior to the initiation of therapy. Lung sound assessment and smoking history assessment are important assessments, but not prior to the initiation of carbamazepine therapy.

DIF: Cognitive Level: Application Assessment

REF:

p. 297 OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity 13. The nurse is providing education to a patient recently prescribed pregabalin (Lyrica). Which statement by the patient indicates a need for further instruction? a.

“I may feel tired at first, but this should improve with continued use.”

“Once my pain improves, I will stop taking this medication.”

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“Taking sleeping aids will increase the sedative effect of this medication.”

“This drug may affect my mental alertness, so I need to be careful around machinery.”

ANS: B When discontinuing therapy, taper over at least 1 week to minimize the potential for withdrawal symptoms. Drowsiness tends to disappear with continued use of the medication. Sleeping aids enhance the sedative effects of pregabalin. Pregabalin causes sedation, so people who work around machinery, drive a car, or perform other duties in which they must remain mentally alert should be particularly cautious.

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DIF:

Cognitive Level: Application

REF:

p. 303 OBJ:

3 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

14. The pediatric nurse is caring for a patient diagnosed with refractory seizures. The physician orders a ketogenic diet. When the child receives his food tray, the nurse should remove any food containing high levels of: a. fat. b.

salt.

carbohydrates.

vitamin K.

ANS: C The ketogenic diet is used in children and includes restriction of carbohydrate and protein intake. Fat is the primary fuel that produces acidosis and ketosis in the ketogenic diet. Salt and vitamin K are not restricted in the ketogenic diet.

DIF:

Cognitive Level: Application

REF:

p. 289 OBJ:

3 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

MULTIPLE RESPONSE

15. What is included in the nursing management of the patient with generalized tonic clonic seizure activity? ( Select all that apply. ) a.

Restraining the patient’s arms to avoid further injury

Placing padding around or under the patient’s head

Attempting to insert a tongue depressor into the patient’s mouth

d. Positioning the patient on the side once the relaxation stage is entered to allow oral secretions to drain e. Requesting additional assistance and/or necessary equipment in case the patient does not begin breathing spontaneously when the seizure is over ANS: B, D, E Managing a patient during a seizure includes protecting the patient from further injury, (placing padding around or under the head to help prevent head injury), positioning the patient in the recovery position

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to facilitate respiratory effort, clearing the airway, and initiating ventilations should the patient lack spontaneous respirations after seizure. Restraining a patient who is having a seizure can cause, rather than prevent, injury. Inserting anything into the mouth of someone who is having a seizure can cause injury.

DIF: Cognitive Level: Application Implementation

REF:

p. 288 OBJ:

3 TOP: Nursing Process Step:

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16. The health care provider orders diazepam (Valium) 10 mg IV stat for a patient who was admitted with status epilepticus. What important nursing interventions(s) associated with administration of this medication IV should the nurse perform? ( Select all that apply. ) a.

Apply a cardiac monitor to the patient to assess for continuous heart rate, if not already done.

Administer the prescribed dosage over 1 minute.

Mix diazepam in a primary IV solution to avoid overdosing.

Continuously assess the patient’s airway.

Obtain the correct dose (10 mg) and administer over slow IV push.

ANS: A, D, E It is important to monitor the patient for bradycardia during administration of diazepam. During a seizure of any type, it is important to assess for airway patency continuously. Diazepam should be administered slowly by the IV route at a rate of no more than 5 mg/min. For status epilepticus, 5 to 10 mg is typical, preferably by slow IV. The dose may be repeated every 5 to 10 minutes, up to a total dosage of 30 mg. If necessary, repeat therapy in 2 to 4 hours; other drugs are preferable for long term control. Diazepam is incompatible with most other IV medications and should not be combined.

DIF: Cognitive Level: Analysis Implementation

REF:

p. 292 OBJ:

6 TOP: Nursing Process Step:

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MSC: NCLEX Client Needs Category: Physiological Integrity

17. Patients taking phenytoin (Dilantin) for control of seizures must be aware of the risk for which adverse effect(s)? ( Select all that apply. ) a. Blood dyscrasias b.

Hyperglycemia

Urinary retention

Gingival hyperplasia

Insomnia

Sedation

ANS: A, B, D, F Phenytoin may cause blood dyscrasias, gingival hyperplasia, and sedation and may elevate blood glucose levels, especially if higher doses are used. Urinary retention and insomnia are not adverse effects of phenytoin.

DIF: Cognitive Level: Knowledge Assessment

REF:

p. 295 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

4 TOP: Nursing Process Step:

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18. The nurse is preparing to administer zonisamide (Zonegran) to a newly admitted patient with the diagnosis of adult partial seizures. The nurse should hold this medication if the patient has which sign(s) or symptom(s)? (Select all that apply.) a.

Skin rash

Urinary frequency

Drowsiness

Allergy to Bactrim

Pruritus

ANS: A, D, E Zonisamide should not be administered without specific approval if the patient has an allergy to Bactrim or a dermatologic reaction such as a skin rash and/or pruritus. Urinary frequency is not associated with zonisamide. Drowsiness is a common adverse effect of zonisamide.

DIF:

Cognitive Level: Application

REF:

TOP:

Nursing Process Step: Assessment

p. 308 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

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19. A patient on anticonvulsant therapy confides to the nurse at an outpatient clinic that she sus pects she may be pregnant. The nurse should encourage the patient to take which action(s)? (Select all that apply.) a.

Consult an obstetrician.

Discontinue medications.

Carry an identification card.

Provide a list of seizure medications.

Consider oral contraception.

ANS:

A, C, D

Pregnancy considerations include encouraging the patient to consult with an obstetrician, provide a list of seizure medications, and carry an identification card. Medications should not be discontinued unless told to do so by the health care provider. If pregnancy is suspected, oral contraceptives should not be encouraged.

DIF: Cognitive Level: Application Implementation

REF:

p. 291 OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment; Physiological Integrity

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Chapter 19: Drugs Used for Pain Management Test Bank

MULTIPLE CHOICE

1. The nurse is completing an assessment on a nonverbal adult patient. Which type of pain scale assessment tool is the most accurate to use? a.

TPPPS

FLACC

POCIS

MOPS

ANS:

The Face, Legs, Activity, Cry, Consolability (FLACC) scale would be used to assess pain in the nonverbal patient. The Toddler Preschooler Postoperative Pain Scale (TPPPS), Pain Observation Scale for Young Children (POCIS), and Modified Objective Pain Scale (MOPS) would not be appropriate for this patient.

DIF: Cognitive Level: Application Assessment

REF:

p. 314 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

2 TOP: Nursing Process Step:

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2. Which action will the nurse take when a patient receiving morphine sulfate via percutaneous coronary angioplasty (PCA) has a shallow, irregular respiratory rate of 6 breaths/min? a.

Elevate the patient’s head of bed to facilitate lung expansion.

Increase the patient’s primary intravenous (IV) flow rate.

Complete the FLACC scale.

Notify the health care provider and prepare to administer naloxone (Narcan).

ANS:

The patient is exhibiting signs of respiratory depression. Administration of the antidote naloxone would be the most appropriate nursing intervention. Lung expansion or increasing the primary IV infusion rate would not relieve respiratory depression. Assessing the patient’s pain at this point is a lesser priority than treating the respiratory depression.

DIF: Cognitive Level: Application Implementation

REF:

p. 326 OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Which patient assessment would indicate to the nurse that salicylate toxicity is occurring?

Gastrointestinal (GI) bleeding

Increased bleeding times

Tinnitus

Occasional nausea

ANS:

Symptoms of salicylism include ringing in the ears (tinnitus), impaired hearing, dimming of vision, sweating, fever, lethargy, dizziness, mental confusion, nausea, and vomiting. Although salicylates may cause GI bleeding over time, it is not a symptom associated with toxicity.

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Increased bleeding time is an effect associated with the treatment of clots. Occasional nausea is a common adverse effect of treatment with salicylates; it is not a sign of toxicity.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 330 OBJ:

6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

4. What is the advantage of taking a nonsteroidal anti inflammatory drug (NSAID) that is a COX 2 inhibitor? a.

The medication is cheaper than aspirin.

There are fewer GI adverse effects.

They are more effective than COX 1 inhibitors.

They have no known adverse effects.

ANS: B COX 2 inhibitor NSAIDs have fewer GI adverse effects than salicylates or COX 1 inhibitors. Aspirin is one of the least expensive analgesics available. The anti inflammatory actions of NSAIDs are caused by COX 2 inhibition; the unwanted adverse effects are caused by inhibition of COX 1. All these medications have adverse effects.

DIF:

Cognitive Level: Knowledge

REF:

p. 335 OBJ:

9 TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity

5. An 86 year old patient who was admitted with GI bleeding as a result of salicylate therapy is being discharged. As the nurse reviews the discharge medication list, the patient states that she doesn’t understand why Tylenol doesn’t work as well as the aspirin she had been taking. What would be the nurse’s best response? a.

“Tylenol and aspirin are chemically the same drug.”

“Tylenol is appropriate for only minor pain.”

“Tylenol does not help with inflammatory discomfort.”

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“A therapeutic blood level must be established with Tylenol.”

ANS: C Acetaminophen (Tylenol) is effective as an analgesic or antipyretic. Tylenol does not possess any anti inflammatory activity and is therefore ineffective in relieving symptoms related to inflammation. Tylenol and aspirin are distinctly different drugs. Tylenol can be useful in the relief of moderate pain. Tylenol can be effective in a single dose, without needing treatment over a period of time.

DIF: Cognitive Level: Application Implementation

REF:

p. 329 OBJ:

7 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

What term is used to define an awareness of pain?

Tolerance

Threshold

Perception

Sensation

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ANS: C Pain perception, also known as nociception, is an individual’s awareness of the feeling of pain. Pain tolerance is an individual’s ability to endure pain. Pain threshold is the point at which an individual first acknowledges or interprets a sensation as being painful. Pain is a sensation characterized by a group of unpleasant perceptual and emotional experiences that trigger autonomic, psychological, and somatomotor responses.

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DIF: Cognitive Level: Knowledge Assessment

REF:

p. 310 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Which statement is true about neuropathic pain?

This pain is the result of a stimulus to pain receptors.

Patients describe it as dull and aching.

It commonly originates in the abdominal region.

The pain is a result of nerve injury.

ANS: D Neuropathic pain results from injury to the peripheral or central nervous system, such as trigeminal neuralgia. Nociceptive pain is the result of a stimulus to pain receptors. Nociceptive pain is usually described as dull and aching. Visceral pain originates from the abdominal and thoracic regions.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 311 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

8. How long after the administration of a parenteral pain medication will the nurse complete the next pain assessment to evaluate the effectiveness of the medication? a.

10 minutes

30 minutes

1 hour

2 hours

ANS: B Evaluation of pain effectiveness of parenteral pain medications needs to occur within 15 to 30 minutes of administration. Ten minutes, 1 hour, and 2 hours are not accurate time frames to evaluate the effectiveness of parenteral medications.

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DIF:

Cognitive Level: Application

REF:

p. 314 OBJ:

2 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

Which sign or symptom displayed by a patient would be indicative of opiate withdrawal? a.

Bradycardia b.

Diarrhea

Lethargy

Hypothermia

ANS: B

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Symptoms of opiate withdrawal include muscular spasms; severe aches in the back, abdomen, and legs; abdominal and muscle cramps; hot and cold flashes; insomnia; nausea, vomiting, and diarrhea; severe sneezing; and increases in body temperature, blood pressure, and respiratory and heart rates. Bradycardia is not a sign of opiate withdrawal; increased heart rate is a sign of opiate withdrawal. Lethargy is not a sign of opiate withdrawal; restlessness is a sign of opiate withdrawal. Hypothermia is not a sign of opiate withdrawal; fever is a sign of opiate withdrawal.

DIF: Cognitive Level: Application Assessment

REF:

p. 323 OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

10. Aspirin

Which medication is contraindicated when a patient is taking warfarin (Coumadin)? a.

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Acetaminophen (Tylenol)

Propoxyphene (Darvon)

Morphine (Roxanol)

ANS: A Salicylates enhance the anticoagulant effect of warfarin. Acetaminophen, propoxyphene, and morphine are not contraindicated with warfarin use.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 333 OBJ:

6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

11.

What is the best way for the nurse to evaluate the effectiveness of the patient’s opiate agonist?

Ability of the patient to tolerate more activity

Increased sleep time throughout the night

Reduction of respiratory rate from 24 to 18 breaths/min

Verbal report of 2 on a 1 to 10 scale

ANS: D A verbal report is the best indicator because pain is individually perceived and using a pain rating scale is a consistent manner of assessment. Toleration of activity and an increased sleep pattern are not the most accurate methods of pain evaluation. Reduction of respiratory rate is not an appropriate measurement of pain control.

DIF: Cognitive Level: Application Assessment

REF:

p. 314 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

12. Which medication would the nurse administer to a patient who is rating the pain at 8 on a 0 to 10 scale? a.

Acetaminophen (Tylenol)

Morphine (Roxanol)

Oxycodone (OxyContin)

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Oxycodone and aspirin (Percodan)

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ANS: B Severe pain is treated with an opiate agonist (i.e., morphine). Severe pain is not treated with acetaminophen, oxycodone, or Percodan. DIF: Cognitive Level: Application Implementation

REF:

p. 323 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

13.

In which case would the nurse be correct in withholding an opiate agonist?

Evidence of postural hypotension

Presence of constipation

Pain rating of 7 on a 0 to 10 scale

Respiratory rate of 10 breaths/min

ANS: D The nurse would withhold the medication if respirations are less than 12 breaths/min. Postural hypotension is a common adverse effect that most frequently occurs when therapy is initiated. Providing for patient safety is important, but it does not warrant withholding the medication. Constipation is an expected adverse effect and does not warrant withholding an opiate agonist. A pain rating of 7 would not warrant holding an opiate agonist.

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DIF: Cognitive Level: Application Assessment

REF:

pp. 323-324

OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

14.

What information is most accurate regarding the nurse’s understanding of pain management?

Older patients have difficulty describing their pain level.

Encourage patients to report pain before the pain becomes too severe.

Use the smallest dose of medication possible to control pain.

Pain medication administration ordered PRN will maintain a constant blood level.

ANS: B Even though pain medicine administration may be scheduled, encourage the patient to request pain medication before the pain escalates and becomes severe. Although the smallest dose possible to control the pain is the goal of therapy, it is also important that the dose be sufficient to provide adequate relief. Older patients are able to describe pain; a variety of tools are available for a variety of patient populations. Analgesics given on a scheduled basis every 3 to 4 hours will maintain a more constant plasma level.

DIF: Cognitive Level: Application Implementation

REF:

p. 318 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

15. The nurse is assessing a patient’s pain. When the patient describes his pain as cramping and burning, which component of the pain history is being addressed? a.

Depth

Location

Quality

Severity

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ANS: C The actual sensation of the pain is often described as stabbing, dull, cramping, sore, burning, or a combination of these. Depth of pain, location of pain, and severity of pain are not described as cramping and burning. DIF: Cognitive Level: Application Assessment

REF:

p. 317 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

16. A patient experiencing chronic pain as a result of metastatic cancer has a new order for fentanyl (Duragesic) transdermal patch. The initial patch is applied at 8 AM on Monday. At 8 PM on Monday, the patient reports a pain level of 8. The nurse’s best response is to: a.

immediately contact the physician.

reassess pain level in 30 to 45 minutes.

remove current patch and reapply a new patch.

provide a PRN analgesic medication as ordered.

ANS: D The fentanyl (Duragesic) patch takes approximately 12 to 24 hours for the initial patch of medication to reach a steady blood level, so other analgesics must be used during this time. Therefore, it is not necessary to immediately contact the physician. The patient is reporting severe pain and requires immediate intervention to help relieve this discomfort.

DIF: Cognitive Level: Analysis Implementation

REF:

p. 319 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

17. A patient is taking meperidine (Demerol) as needed for moderate to severe pain following an open appendectomy. The nurse assesses the following: current pain level 2, temperature 99° F, BP 130/76, respirations 10, lung sounds clear, abdomen soft and tender, bowel sounds present. Based on this assessment information, the priority nursing diagnosis is:

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altered breathing pattern.

risk for altered body temperature.

risk for constipation.

pain.

ANS: A Meperidine (Demerol) is an opiate agonist and can cause respiratory depression. Respirations less than 12/min indicates altered breathing pattern and requires immediate intervention. Temperature of 99° F is not the priority concern. The abdomen is soft, so there is no indication of constipation. Pain level of 2 is considered mild; therefore, this is not the top priority.

DIF:

Cognitive Level: Analysis

REF:

p. 324 OBJ:

3 TOP: Nursing Process Step: Diagnosis

MSC: NCLEX Client Needs Category: Physiological Integrity

MULTIPLE RESPONSE

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18. Which additional nursing intervention(s) would be effective with pain management in the pediatric population? ( Select all that apply. ) a.

Provide diversional activities such as coloring, puzzles, and games.

Allow uninterrupted sleep and rest.

Perform hygiene measures.

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Encourage parental participation with caregiving to diminish the child’s anxiety.

e. With the health care provider’s approval, encourage the child to drink eight to ten 8 ounce glasses of fluid daily. ANS: A, B, C, D Diversional activities, adequate sleep, comfort measures (such as hygiene), and parental participation with care are alternative nursing interventions that may be used in pain management. Forcing fluids is not likely to assist with pain management in the child.

DIF: Cognitive Level: Application Implementation

REF:

p. 317 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

19.

Which common adverse effect(s) is/are associated with opiate agonists? (Select all that apply.)

Dizziness

Orthostatic hypotension

Respiratory depression

Confusion

Diarrhea

Urinary urgency

ANS: A, B, C, D Dizziness, orthostatic hypotension, respiratory depression, and confusion are adverse effects associated with opiate agonists. Constipation, not diarrhea, is an adverse effect associated with opiate agonists. Urinary retention, not urgency, is an adverse effect associated with opiate agonists.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 323 OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

20.

Which condition(s) may be managed by salicylates? ( Select all that apply. )

Migraine headache

Swollen joints

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Fever

Muscle aches

Myocardial infarction

ANS: B, C, D, E Salicylates inhibit prostaglandins that produce the signs and symptoms of inflammation, inhibit the synthesis and release of prostaglandins in the brain that cause the elevation of body temperature, inhibit the formation of prostaglandins that sensitize pain receptors (providing analgesia), and inhibit platelet aggregation and decrease the risk of clot development. Salicylates are not typically used for migraine headache.

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DIF: Cognitive Level: Application Assessment

REF:

pp. 329-330

OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

21. When teaching a patient who is starting therapy with NSAIDs, the nurse must be sure to mention drug interactions with which drug(s)? ( Select all that apply. ) a.

Warfarin (Coumadin)

Lithium (Eskalith)

Hydroxyzine (Vistaril)

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Insulin

Diuretics

Digitalis (Digoxin)

ANS:

A, B, E

NSAIDs may enhance the effects of warfarin, lithium, and diuretics. NSAIDs are not known to interact with hydroxyzine, insulin, or digitalis.

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DIF: Cognitive Level: Knowledge Assessment

REF:

pp. 330-331

OBJ:

9 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

22. When performing a baseline neurologic assessment prior to the administration of an NSAID medication, the nurse will assess which patient characteristic(s)?(Select all that apply.) a.

Vital signs

Orientation to date, time, and place

Mental alertness

Bowel sounds

Concurrent use of anticoagulant agents

ANS:

B, C

Orientation to date, time, and place as well as assessment of mental alertness are components of a baseline neurologic assessment to be completed prior to medicating with an NSAID. Vital signs, bowel sounds, and assessment of concurrent use of anticoagulant drugs are not considered components of a neurologic assessment.

DIF:

Cognitive Level: Application

REF:

TOP:

Nursing Process Step: Assessment

p. 335 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

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Chapter 20: Introduction to Cardiovascular Disease and Metabolic Syndrome Test Bank

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MULTIPLE CHOICE

1. A patient with a body mass index (BMI) of 25 would be considered to be in which weight category? a.

Underweight

Normal weight

Overweight

Obese

ANS:

A BMI of less than 18.5 is considered underweight. A BMI of 18.5 to 24.9 is considered normal weight. A BMI of 25 to 29.9 is considered overweight. A BMI of 30 to 34.9 is considered obesity, class I; 35 to 39.9 is considered obesity, class II; and more than 40 is considered extreme obesity.

DIF: Cognitive Level: Knowledge Assessment

REF:

p. 340 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

What is the most critical approach to the treatment of metabolic syndrome?

Psychotherapy

Pharmacotherapy

Lifestyle management

Patient education

ANS:

Lifestyle management is critical for managing metabolic syndrome; other approaches will not be effective without it. Psychotherapy, pharmacotherapy, and patient education are not the most critical approaches to treating metabolic syndrome.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 338 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

2 TOP: Nursing Process Step:

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3. Healthy diets should include no more than which percentage of saturated fat based on total calories? a. 30% b. 10% c.

ANS: C A healthy diet should have no more than 7% of calories from saturated fat. A diet with 30% or 10% saturated fat would not be considered a healthy diet. A diet can have up to 7% saturated fat before it is considered unhealthy.

DIF: Cognitive Level: Knowledge Assessment

REF:

p. 342 OBJ:

3 TOP: Nursing Process Step:

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MSC: NCLEX Client Needs Category: Physiological Integrity

Which ethnic group or gender is at greatest risk for developing metabolic syndrome?

Hispanic women

Asian men

African American men

White women

ANS: A

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Hispanic women have the highest incidence rate of metabolic syndrome at 27%. Asian men, African American men, and white women are not at the highest risk for metabolic syndrome.

DIF: Cognitive Level: Knowledge Assessment

REF:

p. 339 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

What is the incidence of metabolic syndrome in the United States?

a. 1

4000

b. 1

400

d. 1

ANS: D The incidence of metabolic syndrome in the United States is 1 in 4, or about 50 million adults. One in 4000, one in 400, and one in 40 are each less than the incidence of metabolic syndrome in the United States.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 339 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Which is the mechanism of action demonstrated by exercise in managing blood glucose levels?

Exercise causes release of glucose and promotes a reduced blood glucose level.

b. Exercise on a regular basis causes a reduction in lean body mass, which helps regulate blood glucose levels. c. Increased muscle mass and less fat tends to normalize blood glucose levels because glucose is used by muscle cells when exercising. d. Exercise stimulates the liver, the primary storage and utilization site of glucose, to release glucose. ANS: C Exercise leads to more muscle and less fat, so blood glucose levels tend to return to normal. Exercise increases the rate of glucose uptake in the contracting skeletal muscles. Exercise on a regular basis

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prevents reduction in lean body mass and protein wasting. The liver is not the primary storage and utilization site of glucose.

DIF:

Cognitive Level: ComprehensionREF:

p. 342 OBJ:

3 TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity

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7. Which instruction by the nurse is accurate to include in a patient’s care to manage metabolic syndrome? a.

Encourage the client to exercise 20 minutes every day.

Eliminate alcohol intake.

Increase simple carbohydrates in the diet.

Reduce stress.

ANS: D Stress reduction is important in the management of metabolic syndrome. Twenty minutes of exercise is not adequate. Alcohol intake needs to be restricted but does not have to be eliminated. Complex carbohydrates are appropriate in the management of metabolic syndrome.

DIF: Cognitive Level: Application Implementation

REF:

p. 340 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

MULTIPLE RESPONSE

2 TOP: Nursing Process Step:

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What lifestyle choice(s) may aggravate metabolic syndrome? ( Select all that apply. )

Excessive tobacco smoking

Inadequate hydration

Excessive exercise

Inadequate caloric intake

Excessive consumption of alcohol

ANS: A, E Smoking and excessive consumption of alcohol may aggravate metabolic syndrome. Metabolic syndrome is not directly affected by inadequate hydration. Metabolic syndrome is directly affected by a sedentary lifestyle, not excessive exercise. Metabolic syndrome is directly affected by increased, not inadequate, caloric intake.

DIF: Cognitive Level: Knowledge Assessment

REF:

p. 340 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

9. In addition to type 2 diabetes and heart disease, which condition(s) is/are associated with metabolic syndrome? ( Select all that apply. ) a.

Dementia

Insomnia

Renal disease

Obstructive sleep apnea

Orthostatic hypotension

Polycystic ovary syndrome

ANS: A, C, D, F Dementia, renal disease, obstructive sleep apnea, and polycystic ovary syndrome are associated with metabolic syndrome. Insomnia and orthostatic hypotension are not associated with metabolic syndrome.

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DIF: Cognitive Level: Knowledge Assessment

REF:

p. 339 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

10. Drug therapy for initial treatment of metabolic syndrome is targeted at controlling which condition(s)? ( Select all that apply. ) a.

Obstructive sleep apnea

Diabetes mellitus

Hypertension

Obesity

Dyslipidemia

Insulin resistance

ANS: B, C, E Pharmacologic approaches to managing metabolic syndrome are targeted toward controlling diabetes, hypertension, and dyslipidemia. There is no pharmacologic intervention for obstructive sleep apnea. Obesity should be addressed before pharmacologic therapy begins. Insulin resistance is not dealt with pharmacologically in the early management of metabolic syndrome.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 342 OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

11. Which cardiovascular condition(s) is/are related to coronary artery diseases (CADs)? (Select all that apply.) a.

Angina pectoris

Pulmonary stenosis

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Acute myocardial infarction

Pericarditis

Venous stasis ulcers

ANS: A, C Angina pectoris and acute myocardial infarction are considered CADs. Pulmonary stenosis is a congenital heart disease. Pericarditis is inflammation of the tissue surrounding the heart. Venous stasis ulcers are not related to CAD.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 338 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

12.

Metabolic syndrome includes which key characteristic(s)? ( Select all that apply. )

Hyperglycemia

Abdominal obesity

Low high density lipoproteins

Hypertension

Osteoporosis

ANS: A, B, C, D

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Metabolic syndrome is characterized by hyperglycemia, abdominal obesity, low high density lipoproteins, and hypertension. Osteoporosis is not a characteristic of metabolic syndrome.

DIF:

Cognitive Level: Analysis

REF:

p. 339 OBJ:

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TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

13. The mother of a school aged child asks the nurse how to help prevent her child from acquiring metabolic syndrome. The nurse informs the child’s mother that education for children in primary grades should focus on which action(s)? (Select all that apply.) a.

Treatment of dyslipidemia

Prevention of smoking

Importance of moderate activity

Discouraging use of alcohol

Increase in saturated fat

ANS:

B, C, D

Primary prevention of metabolic syndrome is becoming a common thread in curriculum for children in the primary grades. This education focuses on the importance of moderate activity, dietary choices, and the prevention of alcohol and smoking. Treatment of dyslipidemia is not considered primary prevention. Diet should include reduced intake of saturated fat.

DIF: Cognitive Level: Application Implementation

REF:

p. 342 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

OTHER

3 TOP: Nursing Process Step:

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14.

Weight: 140 pounds. Height: 5 feet 4 inches. What is the BMI?

ANS: 24.03 140 ÷ (64)2 703 = 24.03

DIF:

Cognitive Level: Analysis

REF:

TOP:

Nursing Process Step: Assessment

p. 340 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

15.

Weight: 70 kilograms. Height: 164 cm (1.65 m). What is the BMI?

ANS: 25.71

70 ÷ (1.65)2 = 25.71

DIF:

Cognitive Level: Analysis

REF:

TOP:

Nursing Process Step: Assessment

p. 340 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

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Chapter 21: Drugs Used to Treat Dyslipidemias Test Bank

MULTIPLE CHOICE

Which lipoprotein contributes to the development of atherosclerosis?

Chylomicrons

Very-low-density lipoprotein (VLDL)

Low-density lipoprotein chylomicron (LDL C)

High-density lipoprotein chylomicron (HDL C)

ANS:

The probability that atherosclerosis will develop is related directly to the concentration of LDL C. Chylomicrons are intermediate-density lipoproteins. VLDLs are not as important in the development of atherosclerosis as low-density lipoproteins. HDLs do not contribute to the development of atherosclerosis.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 344 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

2 TOP: Nursing Process Step:

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2. The nurse is preparing medications for a patient. When is the best time for the nurse to administer lovastatin (Mevacor)? a.

2 hours after breakfast

During the patient’s dinner

1 hour before breakfast

30 minutesbefore lunch

ANS:

Lovastatin should be administered with food to enhance absorption, and in the evening, because this is when the production of cholesterol is at its highest. It is not recommended that lovastatin be taken after food but while eating to enhance absorption. Taking the medication a half hour or an hour before eating would not benefit the patient or enhance absorption.

DIF: Cognitive Level: Application Implementation

REF:

pp. 350-351

OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

3. The nurse has completed an admitting patient history and notes the patient’s current medications to be simvastatin (Zocor) and warfarin (Coumadin). What is the result of the interaction of these drugs? a.

Abdominal distention

Increased INR

Low serum level of simvastatin

Hypertension

ANS:

The combined therapy of simvastatin and warfarin may prolong the patient’s INR. Additional nursing assessments would include monitoring for possible overcoagulation and bleeding. Abdominal distention and a low serum level of simvastatin does not occur with the combined

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therapy of simvastatin and warfarin. Increased blood pressure is not a complication of combining simvastatin and warfarin therapy.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 353 OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Which deficiency may develop in patients taking cholestyramine?

Potassium deficiency

Sodium deficiency

Vitamin K deficiency

Hydrochloric acid deficiency

ANS: C Patients on long term bile acid–sequestering resin therapy may become deficient in fat soluble vitamins (i.e., D, E, A, K). Cholestyramine does not affect electrolyte levels or hydrochloric acid.

DIF: Cognitive Level: Knowledge Assessment

REF:

p. 348 OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

5. A patient is prescribed a bile acid resin. The nurse instructs the patient to report which adverse reaction related to vitamin K deficiency? a.

Constipation

Coffee ground emesis

Nausea

Changes in skin pigmentation

ANS: B

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Vitamin K is essential for blood clotting. Signs and symptoms of a vitamin K deficiency include bleeding gums, bruising, dark tarry stools, and coffee ground emesis (blood vomited from the stomach). Constipation, nausea, and a change in skin pigmentation are not signs of vitamin K deficiency.

DIF: Cognitive Level: Application Assessment

REF:

p. 347 OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

Which vitamin has antilipemic actions?

ANS: D It is thought that niacin inhibits VLDL synthesis by liver cells, causing a decrease in LDL and triglyceride production. Vitamins A, C, and D do not have an antilipemic effects. DIF: Cognitive Level: Knowledge Implementation

REF:

p. 349 OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

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Why are statins, or HMG CoA reductase inhibitors, administered at bedtime?

The stomach is empty.

Metabolic needs of the body are decreased.

Cholesterol production is at its peak.

The body temperature is increased.

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ANS: C The peak production of cholesterol is during the night. Therefore, HMG CoA reductase inhibitors are more effective when administered at bedtime. Statins should be taken with food, not on an empty stomach. Metabolic needs of the body and body temperature do not affect the administration of statins.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 350 OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

What is the desired effect of any antilipemic therapy?

Reduced LDLs and total cholesterol levels

Reduced HDLs and total cholesterol levels

Reduced LDLs and HDLs

Reduced HDLs and dietary cholesterol levels

ANS: A LDLs account for 60% to 70% of total serum cholesterol and are a major contributor to atherosclerosis. The therapeutic outcome of antilipemic therapy is to lower the LDL and total cholesterol levels and raise the HDL and HDL/LDL ratio. HDLs are not reduced in treating hyperlipidemia.

DIF: Cognitive Level: ComprehensionREF: Assessment

pp. 344-346

OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

In addition to controlling hyperlipidemia, what are bile acid–binding resins prescribed to treat?

Constipation secondary to excess fecal bile acids

Constipation related to pseudomembranous colitis

Pruritus secondary to biliary stasis

Jaundice related to cholelithiasis

ANS: C Bile acid–binding resins may be used to treat pruritus as a result of partial biliary stasis. Excess fecal bile acids produce diarrhea. Pseudomembranous colitis produces diarrhea. Bile acid–binding resins are not used to treat jaundice.

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DIF: Cognitive Level: ComprehensionREF: Implementation

p. 348 OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity 10.

Which antilipemic agent is most potent?

Niacin

HMG CoA reductase inhibitor

Bile acid–binding resin

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Fibric acid

ANS: B HMG CoA reductase inhibitors are the most potent antilipemic agents available. Niacin, bile acid– binding resins, and fibric acid are not as potent as HMG CoA reductase inhibitors.

DIF: Cognitive Level: Knowledge Implementation

REF:

p. 350 OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

11. The nurse is teaching a patient about statin therapy. Which statement by the patient indicates a need for further teaching? a.

“I will take this medication at night.”

“This medication will reduce blood clot formation.”

“I will avoid drinking grapefruit juice.”

“If I get a headache, I will notify my health care provider.”

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ANS: D Headaches are usually mild and disappear with continued therapy. Statins are to be taken at night. Statins reduce blood clot formation by reducing platelet aggregation and thrombin formation. Grapefruit juice inhibits the metabolism of this medication.

DIF:

Cognitive Level: Application

REF:

p. 350 OBJ:

5 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

12. The nurse is providing education to a patient who has recently been prescribed niacin. Which information given by the nurse is accurate? a.

“Weigh yourself weekly because of the risk of fluid retention.”

“Nausea can be decreased if you take this medication with food.”

“Because your blood pressure may increase while taking this drug, have it checked monthly.”

“You should not take aspirin while on this medication.”

ANS: B Niacin is administered with food to decrease gastrointestinal (GI) upset. Fluid retention and increased blood pressure are not adverse effects of niacin. Aspirin can minimize adverse effects and is safe to take.

DIF: Cognitive Level: Application Implementation

REF:

p. 349 OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

13. The nurse is assessing a patient who is being evaluated for hyperlipidemia. Which assessment will most increase the risk of coronary artery disease (CAD)? a.

Blood pressure, 168/90 mm Hg

Hemoglobin A1c, 6%

Walks 3 miles briskly, usually 4 days a week

Eats five servings of fruits and vegetables daily

ANS: A

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Major treatable causes of CAD are hypertension, cigarette smoking, type 2 diabetes mellitus, and atherosclerosis. A hemoglobin A1c level of 6% does not increase the risk for CAD. Exercise and eating fruits and vegetables decrease the risk for CAD.

DIF: Cognitive Level: Application Assessment

REF:

p. 344 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

14. A patient is taking a HMG CoA reductase inhibitor and reports muscle aches, soreness, and weakness. The nurse suspects these symptoms to indicate early signs of myopathy. When notifying the physician of these symptoms, the nurse will also be sure to report the results of the patient’s: a.

serum creatine phosphokinase levels.

red blood cell count.

urine culture.

echocardiogram.

ANS: A Serum creatine phosphokinase levels more than 10 times the upper limit of normal confirm the diagnosis of myopathy. Red blood cell and urine cultures and an echocardiogram would not confirm the diagnosis of myopathy.

DIF: Cognitive Level: Application Assessment

REF:

p. 352 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

MULTIPLE RESPONSE

5 TOP: Nursing Process Step:

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15. The nurse is educating a patient about niacin prescribed to treat his hyperlipidemia. Which important teaching point(s) should be included in the educational plan? ( Select all that apply. ) a.

Effectiveness of niacin in lowering total cholesterol

Information on high cholesterol foods and food preparation using unsaturated fats

Importance of smoking cessation and daily exercise

Alternative funding resource information because of the high cost of niacin

Adverse effects to report (e.g., fatigue, anorexia, nausea, malaise, jaundice, muscle aches)

ANS: A, B, E Therapeutic outcomes expected with niacin use include reduction in LDL and total cholesterol levels, reduction in triglyceride levels, and increase in HDL levels. Niacin is used in conjunction with dietary therapy to decrease elevated cholesterol concentrations in hyperlipidemia and to reduce the risks of atherosclerosis leading to coronary heart disease. Initial adverse effects to expect include nausea, gas, abdominal discomfort, dizziness, faintness, and hypotension. Jaundice, malaise, muscle aches, and anorexia should be reported to the health care provider. Although these are healthy lifestyle behaviors, they are not indicated in patient teaching about antilipemic medications. Niacin is not expensive in comparison with other antilipemic medications. DIF: Cognitive Level: Application Implementation

REF:

p. 349 OBJ:

5 TOP: Nursing Process Step:

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MSC: NCLEX Client Needs Category: Physiological Integrity

16.

Which nutritional concept(s) is/are necessary to provide to patients receiving colestipol?

( Select all that apply. ) a.

Take on an empty stomach to enhance absorption.

Whole grains, raw fruits, and vegetables will minimize constipation.

c. Drink eight to ten 8 ounce glasses of water daily to eliminate dehydration that results from frequent loose stools.

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d. Report signs of vitamin K deficiency, including bleeding gums, dark tarry stools, and coffee ground emesis. e.

Supplemental fat soluble vitamins may be necessary.

ANS: B, D, E Adequate fluid and fiber in the diet will help prevent constipation, as well as additional expected GI adverse effects. High doses of resins may reduce absorption of fat soluble vitamins; this interaction is not usually significant in normally nourished patients. If these severe symptoms appear, they should be reported to the health care provider. Patients who are taking bile acid–sequestering resins may require supplemental fat soluble vitamin therapy (A, D, E, K). The recommended time of administration is with meals, but this may be modified to avoid interference with absorption of other medications. Constipation is a more likely adverse effect than loose stools.

DIF: Cognitive Level: Application Implementation

REF:

p. 348 OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

17. A teaching plan for a patient with hyperlipidemia would instruct the patient to avoid which food(s)? ( Select all that apply. ) a.

Hard cheeses

Egg whites

Unsaturated vegetable oils

Green vegetables

Liver

ANS: A, E Patients with hyperlipidemia should avoid foods high in cholesterol, such as cheeses and organ meats. Egg whites, unsaturated vegetable oils, and green vegetables do not negatively affect hyperlipidemia.

DIF: Cognitive Level: Analysis Implementation

REF:

pp. 345-346

OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

18. What will the nurse review when teaching a patient about therapy with statins? ( Select all that apply.)

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Statins are the most potent antilipemic agents available.

Statins should be taken with food.

Statins replace dietary therapy for the control of hyperlipidemia.

Statins cause mild increases in HDL levels.

Statins are administered in the morning when cholesterol production is high.

Statins reduce inflammation, platelet aggregation, and plasma viscosity.

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ANS: A, B, D, F Statins are the most potent drugs available for treatment of hyperlipidemia, should be taken with food, may increase HDL levels, and reduce inflammation, platelet aggregation, and plasma viscosity. Statins are used in conjunction with dietary therapy; they do not replace it. Cholesterol production is highest at night, so statins should be taken at night with food.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 350 OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

19. The nurse transcribes a new order for Lovaza on a patient in a long term care facility. When providing education to the patient about this medication, the nurse will include which statement(s)? ( Select all that apply. ) a.

Liver function tests should be completed before initiating therapy.

Lovaza is available in tablet form.

Triglyceride levels should increase with use.

Lovaza should be used with caution if the patient has an allergy to fish.

Lovaza does not cause myositis.

ANS: A, D, E

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Liver function tests (AST, ALT) should be completed before initiating therapy and every 6 to 8 weeks during the first year of therapy with Lovaza. Lovaza should be used with caution if patient’s have an allergy or sensitivity to fish. Lovaza may have an advantage over the fibrates and niacin because it does not cause myositis or rhabdomyolysis. Lovaza is not available in tablet form; it is in capsule form. Triglyceride levels should be reduced.

DIF: Cognitive Level: Application Implementation

REF:

p. 354 OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

20. The nurse is preparing to administer niacin for the first time to a patient being treated for dyslipidemia. Before administering this medication, the nurse will assess: (Select all that apply.) a.

blood glucose levels.

blood pressure.

heart rate.

temperature.

oxygen saturation.

ANS: A, B, C Baseline blood glucose, blood pressure, and heart rate should be determined before initiating niacin therapy. Temperature and oxygen saturation levels are not necessary prior to administering niacin.

DIF: Cognitive Level: Application Assessment

REF:

p. 349 OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

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Chapter 22: Drugs Used to Treat Hypertension Test Bank

MULTIPLE CHOICE

1. A patient who has just begun taking an angiotensin converting enzyme (ACE) inhibitor calls the nurse and reports feeling very dizzy when standing up, and asks if the medication should be discontinued. What is the nurse’s best response? a.

“Stop taking the medication immediately.”

“Rise to a sitting or standing position slowly; your symptoms will resolve.”

“I will schedule you to visit the health care provider today.”

“Cut the pill in half and take a reduced dosage.”

ANS: B

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Dizziness is a common initial adverse effect of this medication, which is usually transient. The patient should be instructed to rise from a lying position slowly to avoid orthostatic hypotension and avoid falling. Medications should not be stopped immediately unless a serious adverse effect occurs. Because this is a common occurrence with ACE inhibitors, there is no need for a visit to the health care provider. A change in dosage will not alter the effect and should not be made without the advice of the primary care provider.

DIF:

Cognitive Level: Application

REF:

p. 366 | p. 370

OBJ: 6 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

2. Which nursing assessment confirms that the angiotensin II receptor blocker (ARB) that a patient is taking is effective? a.

Weight loss of more than 2 pounds/week

LDL cholesterol levels have decreased.

Urinary output is increased.

Blood pressure has decreased.

ANS: D The primary therapeutic outcome expected from angiotensin II receptor antagonists is reduction of blood pressure to within a normal range. Angiotensin II receptor antagonists bind angiotensin II receptor sites in the vascular smooth muscle, brain, heart, kidneys, and adrenal gland. The blood pressure– elevating (vasoconstricting) and sodium retaining effects of angiotensin II are thus blocked. Weight loss, although advisable for treatment of hypertension, is not affected by ARBs. ARBs do not affect cholesterol levels. Urine output is not affected by ARBs.

DIF: Cognitive Level: Application Assessment

REF:

p. 373 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

How does propranolol (Inderal) control hypertension?

7 TOP: Nursing Process Step:

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Blocks alpha receptors throughout the body

Increases the diuretic response in the renal tubules

Reduces the sympathetic stimulation in cardiac muscle

Inhibits the conversion of angiotensin I to angiotensin II

ANS: C The beta adrenergic–blocking agents block beta receptor stimulation in the heart, which then inhibits cardiac response to sympathetic nerve stimulation. This results in a decrease in heart rate, cardiac output, and blood pressure. Beta blockers do not affect alpha receptors. Beta blockers do not have a diuretic effect. ACE inhibitors are in the class of drugs that affects angiotensin conversion.

DIF: Cognitive Level: Knowledge Implementation

REF:

p. 367 OBJ:

7 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

4. Which class of antihypertensive agents should be avoided by patients with asthma? a. inhibitors b.

Diuretics

Aldosterone receptor antagonists

Beta adrenergic blocking agents

ACE

ANS: D Beta adrenergic blocking agents can cause bronchoconstriction, which will aggravate asthmatic conditions. ACE inhibitors do not affect respiratory function. Diuretics have the effect of improving respiratory function in cases of congestive heart failure. Aldosterone receptor antagonists do not affect respiratory function.

DIF: Cognitive Level: Knowledge Implementation

REF:

p. 367 OBJ:

7 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

Which is true about postural hypotension during therapy with direct vasodilators?

It indicates a therapeutic effect.

It gradually resolves with continued medication use.

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It is a dose limiting complication of drug therapy.

It is a precursor to hypertensive crisis.

ANS: B Orthostatic hypotension can occur particularly at the initiation of therapy. Patients should be encouraged to change positions slowly. Symptoms generally will resolve as the patient becomes used to the medication. Postural hypotension is not a therapeutic effect and is not a precursor to a hypertensive crisis. Postural hypotension is an adverse effect with vasodilator therapy.

DIF: Cognitive Level: ComprehensionREF: Step: Assessment MSC: NCLEX Client

p. 366 | p. 370 | p. 383 OBJ: 7 TOP: Nursing Process

Needs Category: Physiological Integrity

6. The nurse instructs the patient to avoid the sudden discontinuation of beta adrenergic blockers so as to avoid which symptom? a.

Postural hypotension

Edema

Increased angina

Confusion

ANS: C Sudden discontinuation of beta adrenergic therapy has caused an exacerbation of anginal symptoms, resulting in cases of myocardial infarction. Postural hypotension occurs with the onset of treatment. Edema and confusion are not precipitated by cessation of treatment with beta blockers.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 368 OBJ:

7 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

What is mean arterial pressure (MAP)?

The difference between the systolic and diastolic pressures

An indicator of the tone of the arterial blood vessel walls

The average pressure throughout each cycle of the heartbeat

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The product of the cardiac output and the peripheral vascular resistance

ANS: C The MAP is the average pressure throughout each cycle of the heartbeat and is significant because it is the pressure that actually pushes the blood through the circulatory system. The difference between the systolic and diastolic pressures describes the pulse pressure. An indicator of the tone of the arterial blood vessel walls describes the pulse pressure. The product of the cardiac output and the peripheral vascular resistance describes the arterial blood pressure.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 357 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Which agents are preferred for the initial treatment of hypertension?

ACE inhibitors and angiotensin receptor antagonists

Calcium ion agonists and central acting alpha agonists

Thiazide diuretics and beta adrenergic blockers

Direct vasodilators and peripherally acting adrenergic antagonists

ANS: C Preferred agents include diuretics and beta adrenergic blockers. ACE inhibitors, angiotensin receptor antagonists, calcium ion agonists, and central acting alpha agonists are alternative agents. Direct vasodilators and peripherally acting adrenergic antagonists are adjunctive agents.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 367 OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

9. Prior to the administration of a beta adrenergic blocker, the nurse notes the patient to have a heart rate of 52 beats/min, peripheral edema, crackles in the bases of the lungs, and mottled skin. Which is the priority nursing action? a.

Administer the medication as ordered.

Re evaluate the patient in 20 minutes.

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Obtain a serum blood level.

Withhold the medication and notify the health care provider.

ANS: D These symptoms warrant the nurse’s withholding the dose and then notifying the health care provider. The medication should not be administered if the patient’s heart rate is low or the patient is experiencing symptoms of heart failure and poor perfusion. The patient should be assessed frequently after the medication is held and the health care provider is notified, but action needs to be taken immediately. Therapeutic blood levels for beta adrenergic medications are not typically measured.

DIF: Cognitive Level: Application Implementation

REF:

p. 367 OBJ:

3 TOP: Nursing Process Step:

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10. When displayed by the patient, which symptom would be most indicative to the nurse to withhold a recently prescribed beta adrenergic blocker? a.

Dizziness

Peripheral edema

Hyperglycemia

Wheezing

ANS: D Wheezing in a patient taking beta adrenergic blockers could indicate the adverse effect of bronchial constriction. Dizziness may indicate changes in blood pressure and safety precautions should be taken, but the medication does not have to be stopped. Peripheral edema may indicate cardiovascular problems, but the medication may have been prescribed to help these conditions. It would not warrant stopping the medication. Hyperglycemia may indicate a need for other interventions, but would not be a reason to stop the medication.

DIF: Cognitive Level: Application Implementation

REF:

p. 367 OBJ:

7 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

11. The nurse has provided information to a patient with diabetes who has been prescribed a beta adrenergic blocker. Which statement by the patient indicates a need for further teaching?

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“If I get dizzy, I will stop taking the medication.”

“I may not have my usual symptoms of low blood sugars.”

“My dosage may need adjustment if I start taking any NSAIDs.”

“I will need to be evaluated in a few weeks to see if my dosage is effective.”

ANS: A Patients should never stop taking beta adrenergic blocking agents suddenly because this can result in exacerbation of angina symptoms. Dizziness should resolve with therapy and

patients should be taught how to manage this side effect safely. The patient may not experience the usual symptoms of low blood sugar. The dosage of the beta blocker may need to be increased to compensate for the antihypertensive inhibitory effect of nonsteroidal anti inflammatory drugs (NSAIDs). The patient will need to be evaluated to see if the dosage is effective.

DIF:

Cognitive Level: Application

REF:

p. 367 OBJ:

7 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity 12. The nurse is providing instruction to a patient who was recently prescribed an ACE inhibitor for hypertension. Which is an adverse effect of this medication? a.

Constipation

Chronic cough

Hypokalemia

Nervousness

ANS: B Chronic cough may develop in as many as one third of patients receiving ACE inhibitors. Constipation, hypokalemia, and nervousness are not adverse effects of this medication.

DIF: Cognitive Level: ComprehensionREF: Implementation

pp. 368-372

OBJ:

7 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

13. The nurse is explaining to a patient how ACE inhibitors affect blood pressure. Which statement accurately describes the action of these medications?

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They increase aldosterone secretion.

They inhibit vasoconstriction.

They lower heart rate.

They promote sodium retention.

ANS: B ACE inhibitors decrease vasoconstriction and aldosterone secretion. ACE inhibitors do not increase aldosterone secretion, lower the heart rate, or promote sodium retention.

DIF: Cognitive Level: ComprehensionREF: Implementation

pp. 368-372

OBJ:

7 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

14. Which common adverse effect of an angiotensin II receptor antagonist will the nurse expect to assess in a patient? a.

Bradycardia

Headache

Hypokalemia

Insomnia

ANS: B

Headache is a common adverse effect of angiotensin II receptor antagonists. Bradycardia, hypokalemia, and insomnia are not common adverse effects of angiotensin II receptor antagonists.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 373 OBJ:

7 TOP: Nursing Process Step:

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15.

Which medication lowers blood pressure by directly inhibiting renin?

Aliskiren (Tekturna)

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Eplerenone (Inspra)

Diltiazem (Cardizem)

Reserpine

ANS: A Aliskiren is a renin angiotensin antagonist. Eplerenone blocks the action of aldosterone. Diltiazem is a calcium channel blocker. Reserpine depletes catecholamines.

DIF: Cognitive Level: Knowledge Implementation

REF:

p. 374 OBJ:

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MSC: NCLEX Client Needs Category: Physiological Integrity

16. A patient asks the nurse how amlodipine (Norvasc) works to reduce the blood pressure. Which response will the nurse provide? a.

“It causes blood vessel dilation.”

“It helps you get rid of fluid.”

“It helps your heart beat stronger.”

“It slows your heart rate.”

ANS: A The dihydropyridine group (amlodipine) are calcium channel blocking medications that work by inhibiting the vasoconstricting effects of calcium to cause vasodilation. Amlodipine does not have a diuretic effect or cause the heart to contract more forcefully. Calcium channel blockers do slow the heart rate; however, the dihydropyridines (amlodipine) have peripheral vasodilating effects.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 377 OBJ:

7 TOP: Nursing Process Step:

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17. A patient recently prescribed felodipine (Plendil) for treatment of hypertension is experiencing dizziness when rising to a standing position. Which action will the nurse take? a.

Encourage the patient to sit down if feeling faint.

Advise the patient to increase dietary sodium.

Inform the patient to discontinue the medication.

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Instruct the patient to monitor weight daily.

ANS: A If faintness or dizziness occurs, the nurse instructs the patient to sit or lie down and to change positions more slowly. Advising the patient to increase dietary sodium, informing the patient

to discontinue the medication, and instructing the patient to monitor weight are not accurate interventions.

DIF: Cognitive Level: Application Implementation

REF:

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18. Which physiologic response will the nurse expect to assess in patients taking hydralazine ( Apresoline)? a.

Pale skin

Tachycardia

Increased urinary output

Cool extremities

ANS: B With arteriolar smooth muscle relaxation, there is an increase in heart rate. Pale skin, increased urinary output , and cool extremities are not physiologic responses to hydralazine.

DIF: Cognitive Level: Application Assessment

REF:

p. 383 OBJ:

7 TOP: Nursing Process Step:

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19. Which medication is often administered with hydralazine to reduce reflex physiological responses to the drug? a.

Beta blockers

Renin inhibitor

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ACE inhibitor

Angiotensin II receptor blocker

ANS: A Beta blockers are administered with hydralazine to reduce the reflex tachycardia caused by arterial vasodilation. Diuretics may also be administered to promote water and sodium excretion. Renin inhibitors, ACE inhibitors, and angiotensin II receptor blockers are not usually administered to reduce the physiologic effects of hydralazine.

DIF: Cognitive Level: Application Assessment

REF:

p. 383 OBJ:

7 TOP: Nursing Process Step:

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20.

Hydralazine, a direct vasodilator, is used to treat hypertension associated with which condition?

Stroke

Diabetes mellitus

Myocardial infarction

Renal disease

ANS: D Hydralazine is used to treat hypertension associated with renal disease. Hydralazine is not used to treat hypertension associated with stroke, diabetes mellitus, or myocardial infarction.

DIF: Cognitive Level: Knowledge Implementation

REF:

p. 383 OBJ:

7 TOP: Nursing Process Step:

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21.

A patient’s blood pressure is 134/78 mm Hg. The nurse records the pulse pressure as: a.

212. b. 134. c. d. 56.

78.

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ANS: D 56 is the difference between the systolic and diastolic pressure and is called the pulse pressure, which is an indicator of the tone of the arterial blood vessel walls. 212 is not the pulse pressure. 134 is the systolic pressure. 78 is the diastolic pressure.

DIF:

Cognitive Level: Analysis

REF:

p. 357 OBJ:

1 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

MULTIPLE RESPONSE

22.

Which complication(s) is/are associated with uncontrolled hypertension? (Select all that apply.)

Angina

Stroke

Hyperglycemia

Renal failure

Heart failure

ANS: A, B, D, E Angina, stroke, renal failure, and heart failure are complications associated with uncontrolled hypertension. Hyperglycemia is not a complication associated with uncontrolled hypertension.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 359 OBJ:

4 TOP: Nursing Process Step:

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23. The nurse is finished conducting nutritional education with a patient about the DASH (dietary approaches to stop hypertension) diet. The patient would like to complete the breakfast menu for tomorrow. Which foods offered for breakfast would be most appropriate for the patient to choose? ( Select all that apply. ) a.

Grapefruit

Bacon

Whole milk

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Orange juice

Eggs

Oatmeal

ANS: A, D, F The DASH eating plan includes a diet rich in fruits, vegetables, and low fat dairy and other foods. Grapefruit, orange juice, and oatmeal would be appropriate choices. Bacon, whole milk, and eggs would not be appropriate for a person on the DASH diet.

DIF: Cognitive Level: Application Implementation

REF:

p. 359 OBJ:

4 TOP: Nursing Process Step:

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24. Which statement(s) concerning the use of antihypertensive therapy for the treatment of hypertension would be considered true? ( Select all that apply. ) a.

Diuretics are the most commonly prescribed antihypertensive agent.

Diuretics are not used for older adult patients.

Diuretics are the most expensive of the antihypertensive agents.

Diuretics are often prescribed in combination therapy with other antihypertensive agents.

Loop diuretics are considered potassium sparing.

ANS: A, D Diuretics are the most commonly prescribed antihypertensive used to treat all classes of hypertension. They are one of the classes of agents that have been shown to reduce cardiovascular morbidity and mortality associated with hypertension. Diuretics are prescribed in combination therapy to potentiate hypotensive activity. More potent diuretics are used for older adult patients. Diuretics are low in cost. Diuretics often cause excretion of potassium, with the exception of potassium sparing diuretics used in combination with thiazide.

DIF: Cognitive Level: Analysis Implementation

REF:

p. 360 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

5 TOP: Nursing Process Step:

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25.

Which statement(s) about diuretics is/are true? ( Select all that apply. )

A mechanism of action for the antihypertensive effects of diuretics includes volume depletion.

They have been shown to reduce cardiovascular morbidity associated with hypertension.

Thiazide diuretics are effective only if renal creatinine clearance is less than 30 mL/min.

Diuretics are sodium sparing.

Electrolytes must be evaluated periodically for patients on loop diuretics.

ANS: A, B, E Diuretics act as hypertensive agents by causing volume depletion, sodium excretion, and vasodilation of peripheral arterioles. Diuretics are often used to reduce cardiovascular morbidity and mortality rates. Potassium must be monitored in patients taking diuretics that are not potassium sparing. When creatinine clearance is higher than 30 mL/min, thiazide diuretics are most effective. Diuretics cause sodium excretion.

DIF: Cognitive Level: ComprehensionREF: Assessment

pp. 366-367

OBJ:

7 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

26. The nurse is preparing to assess blood pressure on a patient who has had two prior readings of 160/100. Physician’s notes from a prior visit indicate that the patient is suspected to have hypertension. When reassessing this patient for hypertension, the nurse will do what? (Select all that apply.) a.

Instruct patient to sit on the exam table.

Choose a cuff encircling at least 80% of the arm.

Support patients arm at heart level.

Encourage patient to sit quietly for 5 minutes before assessing blood pressure.

e. Instruct the patient that one more increased reading is required before hypertension is diagnosed. ANS: B, C, D An appropriately sized cuff bladder encircles at least 80% of the arm and is required for accuracy. The arm is supported at heart level. The individual should be seated quietly for at least 5 minutes in a chair with feet on the floor. Sitting on an exam table is not preferred.

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Feet should be on the floor. An elevated reading on two or more separate occasions after initial screening is considered hypertension.

DIF: Cognitive Level: Application Implementation

REF:

p. 358 OBJ:

1 | 3 TOP: Nursing Process Step:

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OTHER

27.

If blood pressure is 120/70, what is the MAP?

ANS: 86 86.6 86.66 MAP = ([systolic pressure – diastolic pressure] / 3) + diastolic pressure 120 – 70 = 50 50 / 3 = 16.66 16.66 + 70 = 86.66

DIF:

Cognitive Level: Analysis

REF:

p. 357 OBJ:

1 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

Chapter 23: Drugs Used to Treat Dysrhythmias Test Bank

MULTIPLE CHOICE

1. What is the action of amiodarone (Cordarone), a class III agent used to treat cardiac dysrhythmias? a.

It acts as a myocardial depressant by inhibiting sodium ion movement.

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b. It prolongs the duration of the electrical stimulation on cells and the refractory time between electrical impulses. c.

It acts as a beta adrenergic agent.

It slows the rate of electrical conduction and prolongs the time between contractions.

ANS: D Class I antidysrhythmic drugs act as a myocardial depressant by inhibiting sodium ion movement. Class II antidysrhythmic drugs act as beta adrenergic agents. Class III agents slow the rate of electrical conduction and prolong the time between contractions. Class IV antidysrhythmic drugs prolong the duration of the electrical stimulation on cells and the refractory time between electrical impulses.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 396 OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

2. How many milligrams of lidocaine will the nurse administer via intravenous (IV) bolus to a 30 year old patient with ventricular tachycardia who weighs 75 kg after a myocardial infarction? a.

ANS: D The initial lidocaine bolus is 1 to 1.5 mg/kg, decreased by half in older adults, patients with hepatic disease, and patients with heart failure. Doses of 10, 25, and 50 mg are too low for a patient of this weight.

DIF: Cognitive Level: Application Implementation

REF:

p. 393 OBJ:

4 TOP: Nursing Process Step:

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3. A patient is taking amiodarone (Cordarone) for hypertrophic cardiomyopathy and begins to complain of dizziness. What will the nurse instruct the patient to do? a.

Discontinue the medication immediately.

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Decrease the medication dosage for 1 week, and then resume the original order.

Change positions slowly.

Increase the dosage per health care provider directions.

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ANS: C Many adverse effects are dose related and resolve with reducing the dosage or discontinuing therapy. Patients should be taught to rise slowly from a supine or sitting position and sit or lie down if feeling faint. Medication should be discontinued only for serious adverse effects and with the consent of the health care provider. Changes in dose should be done only with the consent of the health care provider. Increasing the dose will likely increase the symptoms.

DIF: Cognitive Level: Application Implementation

REF:

pp. 396-397

OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

4. A patient who is started on phenytoin (Dilantin), who is also taking amiodarone (Cordarone), should be assessed for what possible effect? a.

Central nervous system depression and sedation

Decrease in effectiveness of phenytoin

Respiratory depression

Increase in serum phenytoin levels

ANS: D

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Elevation of phenytoin serum levels (200% to 300%) is observed over several weeks. The dosage of phenytoin must be gradually reduced based on patient response. The combination of phenytoin and amiodarone does not produce sedation and depression, decrease the effectiveness of either drug, or produce respiratory depression.

DIF: Cognitive Level: Knowledge Implementation

REF:

p. 398 OBJ:

6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Which lidocaine preparation is appropriate for the treatment of cardiac dysrhythmias?

0.1 % lidocaine with preservative

2 % lidocaine for topical use

Lidocaine patch

Injectable lidocaine without preservative

ANS: D Lidocaine for IV use is different from lidocaine used as a local anesthetic. The label for lidocaine for IV use should read “lidocaine for dysrhythmias” or “lidocaine without preservatives.” The 0.1% lidocaine, 2% lidocaine for topical use, and lidocaine patch are for topical anesthetic use.

DIF: Cognitive Level: Application Implementation

REF:

p. 393 OBJ:

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6. Patients who are on neuromuscular blocking agents and lidocaine must be closely observed for which complication? a.

Hyperkalemia

Respiratory depression

Neurotoxicity

Seizures

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ANS: B Lidocaine, when administered with neuromuscular blocking agents, may cause respiratory depression. Ventilator dependent patients may require additional time to be weaned when on these categories of medications. Hyperkalemia, neurotoxicity, and seizures are not adverse effects of therapy with these two drugs.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 394 OBJ:

6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

Which statement is true regarding the antidysrhythmic agent adenosine (Adenocard)?

It is synthesized from petroleum products.

It is created through recombinant DNA.

It is extracted from plants.

It is a naturally occurring chemical in the body.

ANS: D Adenosine is a naturally occurring chemical found in every cell within the body. Adenosine is not synthesized from petroleum products, is not created through recombinant DNA, and is not extracted from plants.

DIF: Cognitive Level: Knowledge Implementation

REF:

p. 395 OBJ:

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Amiodarone is contraindicated for patients with which condition?

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Pulmonary edema

Severe sinus node dysfunction causing bradycardia

Atrial fibrillation

Premature ventricular contractions (PVCs)

ANS: B Amiodarone is contraindicated for patients with severe sinus node dysfunction that causes sinus bradycardia, with second and third degree AV block, and when episodes of bradycardia have caused syncope (except in the presence of a pacemaker). Pulmonary edema is not a contraindication for amiodarone. Atrial fibrillation is an indication for the use of amiodarone. Premature ventricular contractions are not a contraindication for amiodarone, but the medication is not indicated for the treatment of PVCs.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 397 OBJ:

5 TOP: Nursing Process Step:

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The patient recently prescribed quinidine is at highest risk for which common adverse effect? a. Chills

Diarrhea

Nausea

Rash

ANS: B

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Diarrhea is common during initiation of quinidine therapy. Chills, nausea, and rash are not common adverse effects that occur during initiation of quinidine therapy. DIF: Cognitive Level: Knowledge Assessment

REF:

p. 392 OBJ:

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10. Which symptom will the nurse encourage the patient taking flecainide to report to the health care provider? a. Headache b.

Dizziness

Constipation

Weight gain

ANS: D Flecainide may induce or aggravate preexisting heart failure. Weight gain is a symptom of fluid retention; the patient should be instructed to contact the health care provider for further evaluation. Headache and constipation are not typical adverse effects. Dizziness is usually mild and tends to resolve with continued therapy.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 395 OBJ:

6 TOP: Nursing Process Step:

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11. A patient is admitted to the acute care telemetry unit with a diagnosis of atrial fibrillation. The physician orders dofetilide (Tikosyn). Before initiating this medication, the nurse will: a.

hold anticoagulant medications.

remove ECG leads.

assess potassium level.

ensure QTc interval is more than 440 to 500 msec.

ANS: C Hypokalemia must be corrected before initiation of dofetilide therapy. Before dofetilide (Tikosyn) is initiated on patients with atrial fibrillation, anticoagulation must occur. Patients with atrial fibrillation must be admitted to a unit with continuous ECG monitoring available. The QTc interval must be assessed; if it is more than 440 to 500 msec, dofetilide is contraindicated.

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DIF: Cognitive Level: Application Assessment

REF:

p. 399 OBJ:

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12. A patient is admitted to the telemetry unit with a diagnosis of cardiovascular disease. When performing the initial assessment, the nurse records blood pressure in the left arm of 142/84, blood pressure in the right arm of 138/80, temperature of 98.8° F, and radial pulse of 80 and that is weak and irregular. The nurse should notify the physician regarding: a.

both blood pressure and pulse.

blood pressure only.

pulse only.

both blood pressure and temperature.

ANS: C

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Irregular pulse rate and rhythm should be reported. A systolic pressure variance of 5 to 10 mm Hg is normal; readings reflecting a variance of more than 10 mm Hg should be reported for further evaluation. Temperature is within normal limits. DIF: Cognitive Level: Analysis Assessment

REF:

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MULTIPLE RESPONSE

5 TOP: Nursing Process Step:

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13. The nurse is assessing a patient who was recently admitted to the emergency department with dysrhythmias and shortness of breath. Which baseline nursing assessment(s) should be the priority(ies)? ( Select all that apply. ) a.

ECG monitoring

Medication history

Oxygen saturation

Presence of chest pain, dyspnea, and fatigue

Mental status

Sleep pattern

ANS: A, B, C, D, E Baseline nursing assessment of patients with dysrhythmias includes ECG monitoring, medication and medical histories, oxygen saturation, observation for the six cardinal signs of cardiovascular disease, and neurologic assessment. Sleep pattern history is not a priority for this patient.

DIF: Cognitive Level: Application Assessment

REF:

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14. The nurse is preparing to administer adenosine to a patient with supraventricular tachycardia. Which consideration(s) should the nurse take into account before administration? (Select all that apply.) a.

Constant ECG monitoring is necessary.

Initial recommended dosage is 12 mg IV bolus.

Rapid IV bolus administration is recommended.

Saline flush following bolus is necessary.

Long half life of adenosine may prolong adverse medication effects.

ANS: A, C, D Continuous cardiac monitoring is required when administering any IV medications to treat dysrhythmias. Because of the short half life of adenosine, the IV bolus should be administered rapidly. The initial dosage of adenosine is rapid IV bolus of 6 mg followed by a saline flush. Adenosine has a short half life.

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DIF: Cognitive Level: Application Implementation

REF:

p. 400 OBJ:

4 TOP: Nursing Process Step:

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This study source was downloaded by 100000761823232 from CourseHero.com on 04-12-2021 14:42:05 GMT -05:00

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15. The nurse is preparing to mix a lidocaine infusion for a patient. Which consideration(s) should the nurse take into account before administration? ( Select all that apply. ) a.

Lidocaine with preservatives should be used.

Dextrose 5% is the solution to mix with lidocaine.

Therapeutic blood levels should be 1 to 5 mg/L.

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The rate of administration is 1 to 4 mg/min.

Monitor for changes in neurologic status.

ANS:

B, C, D, E

Lidocaine for infusion should be mixed with dextrose 5% solution. Lidocaine administration rate should be 1 to 4 mg/min. Additional nursing considerations include monitoring of therapeutic blood levels (1 to 5 mg/L) and observing for adverse effects to report to the health care provider. Lidocaine for IV use for dysrhythmias is different from lidocaine used as a local anesthetic. For use with dysrhythmias, check the label carefully to be certain it says “lidocaine for dysrhythmias” or “lidocaine without preservatives.”

DIF: Cognitive Level: Application Implementation

REF:

p. 393 OBJ:

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MSC: NCLEX Client Needs Category: Physiological Integrity

16. The nurse is preparing to administer procainamide hydrochloride for the first time to a patient newly diagnosed with atrial fibrillation. Before administering this medication, the nurse will assess: (Select all that apply.) a.

cardiac rhythm.

blood pressure.

oxygen saturation.

blood glucose levels.

liver function tests.

ANS:

A, B, C

The nurse should assess cardiac rhythm, vital signs, and oxygen saturation to use as a baseline for subsequent evaluation to response. Blood glucose levels and liver function tests are not essential assessments prior to providing procainamide hydrochloride for the first time.

DIF:

Cognitive Level: Application

REF:

TOP:

Nursing Process Step: Assessment

p. 391 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

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Chapter 24: Drugs Used to Treat Angina Pectoris Test Bank

MULTIPLE CHOICE

Which medication combinations may be beneficial in treating angina pectoris?

Antidysrhythmics and platelet active agents

ACE inhibitors and statins

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Vasoconstrictors and diuretics

Analgesics and thrombolytics

ANS: B ACE inhibitors and statins are often combined to treat angina pectoris. Antidysrhythmics and platelet active agents are not used in combination to treat angina because angina does not typically result in rhythm disturbances. Vasoconstrictors would exacerbate angina and are not used with diuretics. Analgesics and thrombolytics are not used in combination to treat angina because angina is not caused by a clot, so thrombolytics are not necessary.

DIF: Cognitive Level: Knowledge Implementation

REF:

p. 405 OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

2. A patient has been diagnosed with angina pectoris and an elevated LDL cholesterol level. The health care provider has prescribed HMG CoA reductase inhibitor. What is the primary indication in using this medication? a.

Reduce coronary vessel spasm.

Simplify oxygen requirements of the cardiac cells.

Lower cholesterol levels.

Dilate the coronary arteries.

ANS: C HMG CoA reductase inhibitor, a statin, has become standard therapy to be used with elevated cholesterol levels. This medication prevents added atherosclerotic vessel build up and further narrowing of the coronary arteries. Statins do not affect vascular spasms or oxygen requirements of cells. Statins do not dilate coronary arteries.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 404 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

3. What will the nurse advise the patient to do to avoid the development of tolerance to nitroglycerin? a.

Use the sublingual form only.

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Administer subsequent doses parenterally.

Allow for a daily 8 to 12 hour nitrate free period.

Store the drug in a dark container, free from light and moisture.

ANS: C

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An 8 to 12 hour nitrate free period will eliminate the development of tolerance to nitroglycerin. Route of administration and medication storage methods do not affect tolerance. DIF: Cognitive Level: ComprehensionREF: Implementation

p. 408 OBJ:

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4. Which instruction will the nurse include for a patient prescribed sublingual nitrate PRN for angina? a.

Take a dose routinely at bedtime.

Place the tablet under the tongue and swallow immediately.

Take one tablet and then seek medical attention if the pain is not relieved within 5 minutes.

Take one tablet every 2 to 3 minutes until relief is obtained.

ANS: C The patient should seek medical attention if chest pain is not relieved by one tablet within 5 minutes. Tablets should continue to be taken every 5 minutes, for a total of three tablets in 15 minutes if pain is not relieved. Nitrates are taken at the indication of pain. Sublingual nitrates are not swallowed.

DIF: Cognitive Level: Application Implementation

REF:

p. 408 OBJ:

4 TOP: Nursing Process Step:

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MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

How frequently are nitroglycerin tablets discarded and prescriptions refilled?

Monthly

Every 3 months

Every 6 months

Yearly

ANS: C Every 6 months, the nitroglycerin prescription should be refilled and the old tablets safely discarded. Nitroglycerin has a longer shelf life than 1 or 3 months but does not have a shelf life as long as 1 year.

DIF: Cognitive Level: Knowledge Implementation

REF:

p. 408 OBJ:

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When are sustained release nitroglycerin tablets administered?

Once a day

At bedtime

When symptoms of acute angina appear

Every 8 to 12 hours

ANS: D Sustained release nitroglycerin tablets are usually taken on an empty stomach every 8 to 12 hours. If gastritis develops, it may be necessary to take these tablets with food. To be effective, sustained release nitroglycerin must be taken more often. Sustained release nitroglycerin is taken to prevent angina; waiting until symptoms occur decreases its effectiveness.

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DIF: Cognitive Level: Knowledge Implementation

REF:

p. 408 OBJ:

3 TOP: Nursing Process Step:

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7. Which instruction will the nurse include when teaching a patient about the administration of translingual nitroglycerin spray? a.

Shake the container to disperse the medication evenly.

Inhale the medication slowly over 1 to 2 minutes.

Administer the medication under the tongue.

Close the mouth and “swallow” the spray.

ANS: C Translingual nitroglycerin spray should be sprayed onto or under the tongue. The container should not be shaken because the bubbles formed may slow the release of the medication. The spray should not be inhaled or swallowed. Shaking the container can cause bubbles that will slow the release of nitroglycerin. The dose should not be inhaled or swallowed.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 408 OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Which statement is true regarding the pain associated with angina?

It does not subside until treatment is initiated.

It is highly variable in intensity and location.

It typically subsides after 1 to 3 minutes.

It is directly related to the degree of myocardial damage.

ANS: B The presentation of angina pectoris is highly variable. The sensation of discomfort may be described as squeezing, tightness, choking, pressure, burning, or heaviness. Pain or discomfort may radiate to the neck, lower jaw, shoulder, and arm. Attacks can last from 30 seconds to 30 minutes. Anginal pain usually does subside with rest. Sustained pain is usually indicative of a myocardial infarction. Although angina pain may subside in this way, in general, it is highly variable in how it is manifested. Anginal pain may or may not correlate with the amount of myocardial damage.

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DIF: Cognitive Level: ComprehensionREF: Assessment

p. 404 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

How do beta adrenergic blocking agents reduce myocardial oxygen demand?

By inhibiting the stimulation of norepinephrine and epinephrine

By increasing the production of dopamine and acetylcholine

By delaying the destruction of acetylcholinesterase and cholinesterase

By enhancing the sensitivity of alpha receptors and beta receptors

ANS: A Beta adrenergic blocking agents prevent the stimulation of epinephrine and norepinephrine, which normally increase heart rate. Dopamine and acetylcholine are not beta adrenergic neurotransmitters. Beta blockers do not delay the destruction of these enzymes. Beta blockers do not enhance the sensitivity of alpha adrenergic and beta receptor sites.

DIF:

Cognitive Level: ComprehensionREF:

p. 411 OBJ:

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TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

10. The nurse is teaching a patient about nitroglycerin prior to discharge to home. Which instruction will the nurse provide the patient? a.

“Report any headaches following self administration to your health care provider.”

“Carry the medication in a pocket directly next to the body.”

“Carry the medication with you at all times.”

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“Store nitroglycerin in a clear glass container with a tight lid.”

ANS: C Non hospitalized patients should carry nitroglycerin at all times. Headache is an expected adverse effect. Heat causes the medication to deteriorate, so being carried next to the body would cause it to become ineffective. Tablets are degraded by sunlight.

DIF: Cognitive Level: Application Implementation

REF:

p. 408 OBJ:

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11. What risk is minimized when the smallest dose of nitroglycerin is used to provide satisfactory results? a.

Allergy

Dependence

Tolerance

Nausea

ANS: C Tolerance to nitrates can develop rapidly, particularly if large doses are administered frequently. Allergy to nitrates is highly unlikely. Increasing dosages and frequency of nitrate use is more likely to reflect deterioration of cardiac function than dependence on the medication. Nausea is not a common adverse effect of nitrate treatment.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 410 OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

12. The nurse is performing pain assessment on a patient admitted for evaluation of angina. Which type of angina is precipitated by physical exertion and is relieved by rest? a. Chronic stable b.

Nocturnal

Unstable

Variant

ANS: A

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Chronic stable angina is precipitated by physical exertion or stress, lasts only a few minutes, and is relieved by rest or nitroglycerin. Nocturnal is not a designated classification. Unstable angina is unpredictable. Variant angina occurs at rest.

DIF: Cognitive Level: Knowledge Assessment

REF:

p. 404 OBJ:

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13.

What is the rationale behind administering calcium channel blockers to patients with angina?

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They decrease heart rate.

They dilate blood vessels.

They increase cardiac contractility.

They promote fluid excretion.

ANS: B By inhibiting smooth muscle contraction, the calcium channel blockers dilate blood vessels and decrease resistance to blood flow. Dilation of peripheral vessels reduces the workload of the heart. Calcium channel blockers are not given to decrease heart rate in patients with angina. Calcium channel blockers do not increase cardiac contractility or promote fluid excretion.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 411 OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

14. Which action by the nurse is most accurate when administering nitroglycerin ointment to a patient? a.

Spread the ointment on the patient’s legs in a thin, uniform layer.

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Cover the patch with a clear plastic wrap.

Rub the ointment into the skin in a circular motion.

Shave the skin prior to application.

ANS: B Covering the area where the patch is placed with a clear plastic wrap and taping it in place is appropriate. The ointment is not applied to the lower extremities, including the legs. The ointment should not be rubbed into the skin. Shaving is not recommended prior to application because of possible skin irritation.

DIF: Cognitive Level: Application Implementation

REF:

p. 410 OBJ:

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15. Which response will the nurse provide when a patient complains of a headache when using sublingual nitroglycerin? a.

“This is a common adverse effect that can be managed with acetaminophen.”

“Discontinue taking this medication.”

“Try taking this medication at night to minimize the possibility of headaches.”

“Lie down after using nitroglycerin to avoid a headache.”

ANS: A The most common adverse effect of nitrate therapy is headache. Analgesics, such as acetaminophen, may be used if needed. The medication should not be discontinued. When administered sublingually, this medication is taken as needed for chest pain. Lying down will not prevent the occurrence of a headache.

DIF: Cognitive Level: Application Implementation

REF:

p. 410 OBJ:

4 TOP: Nursing Process Step:

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16.

Which statement about ranolazine (Ranexa), a fatty oxidase enzyme inhibitor, is true?

It causes coronary artery vasodilation.

It causes no gastrointestinal (GI) side effects.

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It causes QT interval prolongation.

It elevates LDL levels.

ANS: C Baseline and follow up ECGs should be obtained to evaluate the effects on the patient’s QT incorrect interval. Increased coronary artery vasodilation is not an effect of this medication. This medication causes GI side effects such as abdominal pain. This medication does not elevate LDL levels.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 413 OBJ:

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MSC: NCLEX Client Needs Category: Physiological Integrity

17. The nurse is assisting with a patient admission to the telemetry unit. The patient is diagnosed with angina pectoris. When obtaining information for angina therapy in regard to the central nervous system (CNS), the nurse will document: a.

history of smoking.

diet.

anxiety level.

heart rate.

ANS: C Anxiety level is a component of assessing the CNS. History of smoking is included when assessing the cardiovascular system. Diet is included when assessing nutritional history. Heart rate is included when assessing the cardiovascular system.

DIF: Cognitive Level: Application Assessment

REF:

p. 406 OBJ:

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1 TOP: Nursing Process Step:

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MULTIPLE RESPONSE

18.

Which therapy(ies) is/are used in the treatment of angina pectoris? ( Select all that apply. )

ECG

Coronary artery bypass

Coronary angioplasty

Avoidance of caffeine and emotional stress

Use of nitrates

ANS: B, C, D, E Coronary artery bypass and coronary angioplasty may be standard treatment of angina pectoris, pending medical evaluation. Avoiding caffeine and emotional stress and use of nitrates is standard treatment of angina pectoris. An ECG is not a procedure for the treatment of angina.

DIF: Cognitive Level: Knowledge Implementation

REF:

pp. 404-405

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity 19. Which lifestyle modification(s) will the nurse include when educating the patient with angina pectoris? ( Select all that apply. ) a.

Weight reduction therapy

Low potassium diet

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Smoking cessation

Stress management

Independent exercise

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ANS: A, C, D Although medications can control angina attacks, lifestyle changes such as maintaining an ideal weight are important in managing the disease. Smoking cessation is a vital component to include when educating the patient with angina pectoris. Limiting potassium is not a recommendation for treatment of angina pectoris. The patient should always consult the health care provider before participating in any exercise regimen.

DIF: Cognitive Level: Application Implementation

REF:

pp. 404-405

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

20. What will the nurse include in discharge teaching for patients on nitrate therapy? (Select all that apply.) a.

Increase caffeine in diet

Relaxation techniques

Proper storage of medications

Pain assessment

Isometric exercise program

ANS: B, C, D Lifestyle modifications such as relaxation techniques are essential for many individuals with angina. Nitrates should be stored in dark, airtight containers. Pain assessment and rating is an important part of nitrate therapy. Increasing caffeine in the diet should be discouraged. Participation in a regular, moderate exercise program is essential, but exercise should not be strenuous or isometric in patients with angina.

DIF: Cognitive Level: Application Implementation

REF:

pp. 407-408

OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

21. What will the nurse include in the teaching plan for a patient with angina who is prescribed a beta adrenergic blocking agent? ( Select all that apply. ) a. Goals include reduced frequency of attacks, reduced nitrate use, and improved exercise tolerance.

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Only some beta blockers are effective in treating angina pectoris.

c. Comorbidities, such as diabetes or COPD, influence the product selection of beta blockers to treat angina. d.

Cardioselective agents minimize pulmonary and peripheral vascular adverse effects.

Stress exercise is an effective way to determine the most appropriate dosage.

f. Acebutolol, atenolol, and metoprolol must be taken in divided doses to be effective in treating angina. ANS: A, C, D, E Beta blockers are used to reduce the frequency of attacks, reduce nitrate use, and improve exercise tolerance. Comorbidities influence product selection in the angina patient. Cardioselective agents have greater affinity for beta 1 adrenergic receptors (cardiac) than beta 2 adrenergic receptors (bronchi, peripheral blood vessels), thereby reducing the possible pulmonary and vascular adverse effects. Stress exercise is an effective way to determine the

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most appropriate dosage. All beta blockers are effective in treating angina pectoris. Divided doses are not necessary to provide effective control of angina.

DIF:

Cognitive Level: Application

REF:

p. 411 OBJ:

4 TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity

22. The nurse transcribes a new order for ranolazine (Ranexa) for a patient with chronic stable angina. Before initiating this medication, the nurse will ensure that which laboratory study result(s) is/are available? ( Select all that apply. ) a.

Electrocardiography

BUN

Creatinine

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Electrolyte levels

CBC

ANS: A, B, C, D, E Premedication assessment for ranolazine (Ranexa) includes assessment of results of electrocardiography; renal function tests such as BUN, serum creatinine, and electrolyte levels; and CBC. These results will serve as a baseline for future comparison.

DIF: Cognitive Level: Application Assessment

REF:

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23. The nurse is performing a head to toe assessment on a resident in a long term care facility with a history of angina pectoris. When assessing peripheral perfusion, the nurse will perform which intervention(s)? ( Select all that apply. ) a.

Count heart rate and describe rhythm.

Note any loss of hair on lower legs.

Auscultate blood pressure.

Check pedal pulses.

Assess pupil reaction.

ANS: B, D Peripheral perfusion assessment includes noting loss of hair on lower legs, denoting decreased circulation. When assessing peripheral perfusion, the pedal pulses in the lower extremities are assessed in conjunction with skin color and temperature. Heart rate and rhythm are components of assessment of the cardiovascular system, but not associated with peripheral tissue perfusion. Pupil reaction is considered a neurologic assessment.

DIF: Cognitive Level: Application Assessment, Implementation

REF:

p. 406 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

1 TOP: Nursing Process Step:

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Chapter 26: Drugs Used to Treat Thromboembolic Disorders

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MULTIPLE CHOICE

1. A trauma patient arrives in the emergency department via EMS. He is bleeding profusely. A medical alert bracelet indicates that he is on heparin therapy. The nurse will most likely administer which medication that counteracts the action of heparin? a. Warfarin sodium (Coumadin) b.

Enoxaparin (Lovenox)

Protamine sulfate

Vitamin K

ANS: C Protamine sulfate is the antidote to heparin. With the patient’s risk of fluid volume deficit as a result of trauma, the primary intervention would be to counteract the effects of heparin to prevent hemorrhage. Warfarin is an anticoagulant and would not counteract hemorrhage. Lovenox is chemically related to heparin and would not counteract hemorrhage. Vitamin K is used to control the bleeding that results from use of warfarin (Coumadin), not heparin.

DIF: Cognitive Level: Comprehension Implementation

REF: Page 414 OBJ: 3 | 5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Perfusion; Safety

2. A patient receiving IV heparin therapy for a deep vein thrombosis (DVT) in his right calf asks why his calf remains painful, edematous, and warm to touch after 2 days of anticoagulant therapy. Which response by the nurse is most accurate? a.

“It takes at least 3 days for the symptoms to resolve once the clot dissolves.”

b. “Heparin does not dissolve blood clots but neutralizes clotting factors, preventing extension of the clot and the possibility of it traveling elsewhere in your body.” c. “I will report this to your health care provider because there may be a need to look at alternative treatments.” d. “You appear anxious. The health care provider will eventually put you on ticlopidine, which allows for an earlier discharge.”

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ANS: B Heparin is used to treat a thromboembolism and promote neutralization of activated clotting factors, preventing the extension of thrombi and the formation of emboli. Heparin will minimize tissue damage by preventing it from developing into an insoluble, stable thrombus. It is inappropriate to tell a patient how long it will take to dissolve a clot. The patient’s question does not warrant notification of the health care provider. Telling the patient that the health care provider will be starting the patient on ticlopidine is inappropriate and inaccurate.

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DIF: Cognitive Level: Analysis Implementation

REF: Pages 412-413 OBJ: 3

TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Communication; Patient Education; Perfusion; Clotting

3. A patient is receiving IV heparin therapy. The aPTT is 90; the laboratory control is 30 seconds. Which nursing intervention is most accurate? a.

Document in the nursing notes that these results are within therapeutic range.

b. Note the RBC count and wait for the health care provider to make the next round to discuss all laboratory values. c.

Stop the heparin drip.

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Assess the patient for signs and symptoms of decreased sensorium.

ANS: C Heparin dosage is considered to be in the normal therapeutic range if the aPTT is 1.5 to 2.5 times the control value. The patient’s aPTT value is above the therapeutic range, which puts her at risk for hemorrhage. The most appropriate nursing action would be to stop the heparin drip. These results cannot be documented as being within the normal therapeutic range. RBC count and mental status are not relevant in assessing therapeutic response to anticoagulation.

DIF: Cognitive Level: ApplicationREF: Page 414 OBJ: 4 | 5 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

4. Which is an accurate nursing action when administering subcutaneous enoxaparin, a lowmolecular-weight heparin product? a.

Expel the air bubble from the prefilled syringe.

Leave the needle in place for 10 seconds after injection.

Administer the medication into the deltoid muscle.

Massage the site after injection to increase absorption.

ANS: B The needle is left in place for 10 seconds after injection. Air is not expelled from the prefilled syringe. This medication is not administered intramuscularly. The site should not be massaged to increase absorption.

DIF: Cognitive Level: ApplicationREF: Page 409 OBJ: 5 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe, Effective Care Environment NOT: CONCEPT(S): Clinical Judgment; Safety

5. A patient is receiving 1400 units of heparin/hour on an IV pump. The aPTT time is 54. The laboratory control is 25. Which action by the nurse is accurate? a.

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Bolus the patient with an additional 5000 units of heparin.

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b. Stop the heparin immediately and notify the health care provider that the patient’s blood level is toxic. c.

Administer protamine sulfate stat.

Continue with the prescribed rate.

ANS: D Therapeutic heparin values are 1.5 to 2.5 times the control value. The therapeutic range of heparin with a control of 25 is 37.5 to 62.5 units/hour. A time of 54 is within the therapeutic range. An increase of heparin is not indicated because the patient is in the therapeutic range. The range is not toxic. An antidote to the anticoagulant is not indicated because the patient is within the therapeutic range.

DIF: Cognitive Level: Analysis

REF: Page 413 OBJ: 4 | 5 TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment NOT: CONCEPT(S): Clinical Judgment; Safety

6. What is the rationale for administering fibrinolytic agents, such as streptokinase, within hours of the onset of myocardial infarction? a. Enhances myocardial oxygenation b.

Lyses the blood clot

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Promotes platelet aggregation

Inhibits clotting mechanisms

ANS: B Fibrinolytic agents such as streptokinase dissolve or lyse recently formed thrombi. The goals of thrombolytic therapy are to lyse the thrombus during the early stages of clot formation, restore circulation to the areas distal to the thrombus, and reduce morbidity after thromboembolism formation. Fibrinolytic agents do not have an effect on myocardial oxygenation and do not promote platelet aggregation or inhibit clotting mechanisms.

DIF: Cognitive Level: Comprehension Step: Implementation

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TOP: Nursing Process

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment NOT: CONCEPT(S): Clinical Judgment; Safety; Perfusion

What is the mechanism of action of drugs used to treat thromboembolic disease?

Dissolving clots and preventing formation of new clots

Making platelets more flexible and preventing formation of new clots

Causing vasodilation and increased blood flow

Preventing platelet aggregation and inhibiting clot formation

ANS: D The pharmacologic agents used to treat thromboembolic disease act to prevent platelet aggregation or to inhibit a variety of steps in the fibrin clot formation cascade. Thromboembolic medications do not dissolve clots, make platelets more flexible, or cause vasodilation.

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DIF: Cognitive Level: Comprehension

REF: Page 401 OBJ: 3 TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Clotting; Perfusion

8. Dipyridamole (Persantine) has been used extensively in combination with warfarin to prevent the formation of thromboembolism after which type of event? a. Myocardial infarction b.

Transient ischemic attack

Cardiac valve replacement

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ANS:

Heart transplant C Dipyridamole has been used extensively in combination with warfarin to prevent the formation of thromboembolism after cardiac valve replacement. Heparin is used to prevent clotting after myocardial infarction. Transient ischemic attacks are often treated with aspirin. Transplant patients are treated postoperatively with immunosuppressant medications.

DIF: Cognitive Level: Comprehension Implementation

REF: Page 404 OBJ: 2 | 3 TOP: Nursing Process Step:

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MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Perfusion; Clotting

9. Which action will the nurse implement to decrease the risk of clot formation in an older patient on bed rest? a.

Assess peripheral pulses.

Encourage passive leg exercises.

Limit fluid intake.

Position pillows behind the knees.

ANS: B Using active or passive leg exercises for a patient on bed rest will prevent clot formation. Assessing pulses is not a preventive measure. Adequate hydration promotes fluidity of the blood and decreases the risk of clot formation. Placing pressure against the popliteal space will increase the risk of clot formation.

DIF: Cognitive Level: ApplicationREF: Page 402 OBJ: 2 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Perfusion; Clotting

10. The nurse is teaching a patient about dietary implications while on warfarin (Coumadin) therapy. Which salad is highest in vitamin K? a. Fruit b.

Pasta

Potato

Spinach

ANS: D Green leafy vegetables contain vitamin K.

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DIF: Cognitive Level: ApplicationREF: Page 402 OBJ: 3 | 4 | 5 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Patient Education; Nutrition

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ANS:

11. The nurse has provided instruction to a patient recently prescribed warfarin (Coumadin). Which statement by the patient indicates to the nurse the need for further teaching? a. “I will always wear a medical alert bracelet.” b.

“I will check with my health care provider before I take any OTC medications.”

“I will be careful when I use a knife or other sharp objects.”

“I will rinse my mouth with mouthwash instead of brushing my teeth.” D Soft-bristled toothbrushes are acceptable to use for oral care. Medical alert bracelets should always be worn. The health care provider needs to be consulted prior to taking any OTC medications. Caution must be used when cutting with knives or using any sharp objects.

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DIF: Cognitive Level: ApplicationREF: Page 402 OBJ: 3 | 5 TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Patient Education; Tissue Integrity

12.

Which symptom is indicative of bleeding in a patient taking warfarin (Coumadin)? a.

Bradycardia b.

Petechiae

Increased urinary output

Dry skin

ANS: B Petechiae are indicative of bleeding. These pinpoint red spots on the skin indicate intradermal hemorrhage. Bradycardia, increased urinary output, and dry skin are not indicative of bleeding.

DIF: Cognitive Level: ApplicationREF: Page 415 OBJ: 4 | 5 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

13. The nurse is caring for a 27-year-old woman on the postpartum unit one day following a Csection. To prevent clot formation, the nurse will a. position the patient with knees flexed. b.

initiate use of fitted thromboembolic disease deterrent (TED) stockings.

maintain complete bed rest.

implement deep breathing and coughing exercises.

ANS: D

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ANS: Deep breathing and coughing exercises should be part of regular postoperative nursing care to prevent clot formation. Knees should not be flexed. TED stockings require a physician’s order. Early, regular ambulation should be encouraged after surgery.

DIF: Cognitive Level: Implementation Implementation

REF: Page 402 OBJ: 2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Patient Education; Clotting; Perfusion

14. Rivaroxaban (Xarelto) is ordered on a patient following knee replacement surgery. When providing education on this medication to the patient, the nurse conveys that treatment will continue a.

only while hospitalized.

for 35 days postsurgically.

for 12 days postsurgically.

as long as creatinine clearance is less than 30. C It is recommended that patients undergoing knee replacement continue treatment with rivaroxaban for 12 days postsurgically. It is recommended that patients undergoing hip replacement surgery continue

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treatment for 35 days postsurgically. Rivaroxaban should not be administered to patients with a creatinine clearance less than 30 ml/min.

DIF: Cognitive Level: ApplicationREF: Page 411 OBJ: 3 | 5 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Patient Education MULTIPLE RESPONSE

Anticoagulant therapy may be used for which situation(s)? (Select all that apply.)

To prevent stroke in patients at high risk

Following a myocardial infarction

Following total hip or knee joint replacement surgery

With DVT

To prevent thrombosis in immobilized patients

Peptic ulcer disease

ANS: A, B, C, D, E Anticoagulant therapy is used to treat patients at high risk for stroke; patients with thromboembolic diseases, such as myocardial infarction; those at risk of developing thrombus resulting from underlying medical conditions or disease; and patients with thromboembolic diseases, such as DVT. Anticoagulant therapy is not used to treat patients with peptic ulcer disease.

DIF: Cognitive Level: Comprehension Implementation

REF: Page 401 OBJ: 1 | 2 TOP: Nursing Process Step:

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ANS:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Perfusion; Clotting

2. The nurse is preparing discharge education for a patient who will be receiving warfarin (Coumadin) at home. Which important point(s) will the nurse include? (Select all that apply.) a. “Do not make any major changes to your diet without discussing it with your health care provider.” b.

“Keep outpatient laboratory appointments for monitoring of therapy.”

“Take the medication after meals.”

d. “Report signs of bleeding to your health care provider, including observing skin for bruising; petechiae; blood in emesis, urine, or stools; bleeding gums; cold, clammy skin; faintness; or altered sensorium.” e.

“Avoid aspirin products.”

ANS: A, B, D, E

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Although patients on anticoagulant therapy should have knowledge about foods high in vitamin K (green, leafy vegetables), they should not make any major changes to their diet without consulting with their health care provider, pharmacist, and/or nutritionist. Patients receiving anticoagulant therapy should maintain regular appointments for assessment of the drug’s therapeutic effects and follow up with the health care provider for regular review of laboratory values and dosage monitoring. Regular self-assessment for signs of bleeding is necessary for patients on anticoagulant therapy. Patients on anticoagulant therapy should avoid aspirin products. Warfarin does not have to be taken after meals.

DIF: Cognitive Level: Comprehension Implementation

REF: Page 415 OBJ: 4 | 5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Patient Education; Safety

3. Which nursing intervention(s) would be accurate when administering heparin subcutaneously? (Select all that apply.) a. Assessment of recent aPTT levels b.

Massaging the site after injection of medication

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Aspirating after needle insertion

Documenting ecchymotic areas

Monitoring of vital signs

ANS: D, E Ecchymosis, or bruising, indicates bleeding below the dermis and should be assessed closely. Patients on heparin therapy are prone to bleeding, which would lead to hemorrhagic shock. Vital sign alterations would alert the nurse to internal bleeding. aPTT levels are required to be monitored for the intravenous route, but not for subcutaneous injections. The injection site should not be massaged to reduce local bleeding. Aspiration may cause bruising when administering heparin subcutaneously.

DIF: Cognitive Level: ApplicationREF: Page 413 OBJ: 5 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

The pharmacologic agents used to treat DVT may act in which way(s)? (Select all that apply.)

Prevent platelet aggregation.

Prevent the extension of existing clots.

Inhibit steps in the fibrin clot formation cascade.

Prolong bleeding time.

Lower serum triglycerides.

ANS: A, B, C, D

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Agents used to treat DVT may prevent future clotting, may prevent the extension of clots, may inhibit steps in the formation of clots, and act to prolong bleeding time. Medications used to treat DVT do not lower serum triglyceride levels.

DIF: Cognitive Level: Comprehension

REF: Page 401 OBJ: 1 | 3 TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

https://studentmagic.indiemade.com/

5. The nurse is preparing to administer dalteparin (Fragmin) to a patient in order to prevent DVT following a hip replacement. When providing this medication to the patient, the nurse will (Select all that apply.) a.

administer intramuscularly.

inject slowly.

remove needle immediately after injection.

rub injection site following administration.

alternate injection sites every 24 hours.

ANS: B, E Dalteparin (Fragmin) should be injected slowly. Injection sites should be alternated every 24 hours. Dalteparin is administered by deep subcutaneous injection, not intramuscularly. Needle should be left in place for 10 seconds after injection. To minimize bruising, do not rub the injection site after completion of the injection.

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DIF: Cognitive Level: Application Implementation

REF: Page 408 OBJ: 5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment| NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Skin Integrity

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NOT: CONCEPT(S): Clinical Judgment; Perfusion; Clotting

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Chapter 27: Drugs Used to Treat Heart Failure Test Bank

MULTIPLE CHOICE

1. Which drug will be administered to a patient being admitted with severe digoxin intoxication? a. Amiodarone (Cordarone) b.

Spironolactone (Aldactone)

Digoxin immune Fab (Digibind)

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Digitalis glycoside

ANS: C The antidote for digoxin intoxication is digoxin immune Fab (Digibind). Amiodarone is an antidysrhythmic and would not treat digoxin intoxication. Spironolactone is a diuretic and does not treat digoxin intoxication. Giving more of the same type of drug does not treat drug intoxication.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 453 OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

2. The nurse is caring for a 3-year-old girl who has a congenital heart anomaly. The patient’s current medications include digoxin and furosemide (Lasix). The apical pulse rate is 100 beats/min. Which action will the nurse take? a.

Administer the medication.

Contact the pediatric cardiologist for further orders.

Hold the digoxin.

Request that another unit nurse assess the child.

ANS: A A pulse rate of 100 beats/min in a child who is 3 years old is considered acceptable. Administration of the medication is appropriate. There is no indication for contacting the cardiologist, holding the dose, or requesting further assessment because this is within the expected range.

DIF: Cognitive Level: Application Assessment

REF:

p. 452 OBJ:

6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

3. An older adult male patient with long term heart failure has presented for an office visit. The nurse obtains information that he has recently begun taking St. John’s wort. What results with the use of this herbal supplement? a.

Digoxin toxicity

Altered potassium electrolyte balance

Reduced therapeutic benefits of digoxin

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Enhanced digoxin effectiveness without producing toxicity

ANS: C St. John’s wort is a drug that may reduce therapeutic benefits of digoxin. St. John’s wort has the opposite effect on digoxin and does not affect electrolytes.

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DIF: Cognitive Level: Application REF: p. 453 OBJ: 6 7.

Which agents stimulate the heart to increase the force of contractions, thereby increasing

TOP:

Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

4. The nurse is to administer digoxin to an 18 month old patient who weighs 16.5 lb. Guidelines for administration read as follows: 0.0075-0.010 mg/kg/day. Which is a safe medication dosage? a.

0.05 mg

0.12 mg

0.074 mg

d. 0.75 mg ANS:

16.5 lb converts to 7.5 kg; 7.5 kg

0.0075 mg = 0.05625; 7.5 kg 0.010 mg = 0.075 mg;

0.074 mg is the only answer within the safe dosage range. Values of 0.05 mg, 0.12 mg, and

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0.75 mg are too large.

DIF: Cognitive Level: Application Implementation

REF:

pp. 451-453

OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

5. The nurse monitors a patient receiving digoxin closely for toxicity when which other medication is prescribed? a.

Potassium supplements

Furosemide (Lasix)

Acetylsalicylic acid (aspirin)

Antibiotics

ANS:

Furosemide is a potassium depleting diuretic. Low potassium levels potentiate digoxin toxicity. Taking potassium supplements with a diuretic prevents digoxin toxicity. Aspirin and antibiotics do not affect digoxin levels.

DIF: Cognitive Level: Knowledge Assessment

REF:

p. 453 OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Which is the initial manifestation of digoxin toxicity in children?

Hallucinations

Weakness

Atrial dysrhythmia

Diuresis

ANS:

In children, digoxin toxicity is often first detected by the development of atrial dysrhythmias. Hallucinations, weakness, and diuresis are not initial manifestations of digoxin toxicity in children.

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DIF: Cognitive Level: Knowledge Assessment

REF:

p. 453 OBJ: TOP:

Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity cardiac output? a.

Inotropic

Chronotropic

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4 |5

Isotonic

Isopropyl

ANS: A Inotropic agents stimulate the heart to increase the force of contractions, thus boosting cardiac output. Chronotropic agents are given to increase heart rate. Isotonic agents have the same pH as body fluids. Isopropyl agents include rubbing alcohol.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 447 OBJ:

2 | 3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Which drug is used to obtain vasodilation in the treatment of chronic heart failure?

ACTH

ACE inhibitors

ARBs

ANB agents

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ANS: B Angiotensin converting enzyme (ACE) inhibitors are the mainstays of oral vasodilator therapy for treating chronic heart failure. ACTH is adrenocorticotropic hormone, secreted by the anterior pituitary to stimulate the adrenal cortex. ARBs are angiotensin reuptake blockers, used for the treatment of hypertension. ANB agents are adrenergic neuron blocking agents, such as guanethidine, given for the treatment of hypertension.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 451 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Which action of ACE inhibitors results in effective treatment of heart failure?

Increased afterload

Increased aldosterone

Increased preload

Increased cardiac output

ANS: D The therapeutic outcome of ACE inhibitors in heart failure is to improve cardiac output. ACE inhibitors reduce afterload, inhibit the secretion of aldosterone, and reduce preload.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 451 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

10. The nurse is providing teaching to a patient with heart failure who has been prescribed nifedipine, a calcium channel blocker. Which statement by the nurse is accurate? a.

“This medication dilates your coronary arteries.”

“This medication will help your kidneys get rid of fluid.”

“This medication reduces volume returning to your heart so it doesn’t overstretch.”

“This medication reduces the resistance your heart has to pump against.”

ANS: D

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This medication reduces afterload or the resistance against which the heart has to pump. This medication is not used in heart failure for this reason, does not have a diuretic effect, and does not reduce volume.

DIF: Cognitive Level: Application Implementation

REF:

p. 447 OBJ:

3 | 6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

11. Which instruction by the nurse will be included when teaching an adult patient about digoxin ( Lanoxin) for management of heart failure? a.

“Report nausea and vomiting to your health care provider.”

“Decrease the amount of high potassium foods you eat.”

“Omit your dose of digoxin if your pulse is 60 beats/min.”

“Visual disturbances are common adverse effects.”

ANS: A Nausea and vomiting is a serious adverse effect indicative of toxicity. Low potassium levels can cause toxicity; adequate intake of potassium is necessary. The dose is withheld if the pulse rate is less than 60 beats/min in adults. Visual disturbances are not common adverse effects.

DIF: Cognitive Level: Application Implementation

REF:

p. 453 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

4 TOP: Nursing Process Step:

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12. Which nursing assessment is most important to determine fluid status for a patient with heart failure? a.

Auscultation of lungs

Daily weights

Intake and output

Measurement of abdominal girth

ANS: B Daily weights are the best indicator of fluid gain or loss. Auscultation of lungs, measurement of intake and output, and measurement of abdominal girth are not the best indicators of fluid status.

DIF: Cognitive Level: Application Assessment

REF:

p. 450 OBJ:

2 | 6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

13. A patient with altered cardiac function is being assessed by the nurse. When auscultating lung sounds, the nurse will assist this patient into a position. a.

prone

supine

Sims

Fowler’s

ANS: D Lung fields are assessed in a sitting (Fowler’s) position to detect abnormal lung sounds. Prone, supine, and Sims positions are not the best positions to detect abnormal lung sounds.

DIF:

Cognitive Level: Application

REF:

p. 448 OBJ:

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TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

14. The nurse transcribes a new order for a daily diuretic on a patient diagnosed with congestive heart failure. The nurse will schedule this medication: a.

in the morning.

after lunch.

with dinner.

at bedtime.

ANS: A Diuretics should be taken in the morning to avoid night time diuresis.

DIF:

Cognitive Level: Application

REF:

p. 450 OBJ:

6 TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity

MULTIPLE RESPONSE

15. The nurse is assessing an emergency department patient who was recently discharged following a myocardial infarction (MI). Which symptom(s) would the nurse observe in this patient with left ventricular systolic failure? ( Select all that apply. ) a.

Reports of recent weight loss

Complaints of peripheral edema

Diminished exercise tolerance

Shortness of breath with activity

Blood pressure elevation

ANS: C, D Early clinical symptoms of left ventricular failure are decreased exercise tolerance and poor perfusion to peripheral tissues. Patients who develop left ventricular systolic failure as a result of MI have acute shortness of breath. Weight gain is more likely to be reported because of edema in diastolic failure.

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Patients who develop left ventricular systolic failure as a result of MI have shock with little peripheral edema and hypotension.

DIF: Cognitive Level: ComprehensionREF: Assessment

pp. 443-444

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

16. Before administering digoxin (Lanoxin), the nurse takes the adult patient’s apical pulse for 1 full minute. What additional nursing consideration(s) will be taken before administration of the medication? ( Select all that apply. ) a.

Review of the digoxin blood level

Administration of the medication with pulse less than 60 beats/min

Review of serum electrolytes, liver, and kidney function studies

Administration of the medication with a pulse of 110 beats/min

Obtaining baseline patient assessment data, including lung sounds, vital signs, and weight

ANS: A, C, E Before administering digoxin, the nurse should review digoxin levels, review baseline diagnostic data (electrolytes, liver, and kidney function tests), obtain appropriate physical

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assessments for heart failure patients, and verify that pulse rate is between 60 and 100 beats/min.

DIF: Cognitive Level: Analysis Assessment

REF:

p. 452 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

5 TOP: Nursing Process Step:

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17. Which action(s) will the nurse take when caring for a patient with heart failure? (Select all that apply.) a.

Administer diuretics at bedtime.

Assess electrolyte levels.

Report daily weight fluctuations.

Encourage sodium intake.

Maintain skin hygiene.

ANS: B, C, E Ongoing assessment of electrolyte levels is critical when caring for a patient with heart failure. Weight gains and losses are the single best indicator of fluid gain or loss. The maintenance of skin care and changing of positions are essential to prevent skin breakdown. Diuretics should be given in the morning and afternoon, not at bedtime, because this would interfere with sleep. Heart failure patients are prone to edema, which interferes with vascular return in the peripheral areas. Sodium restriction is one way of controlling edema.

DIF: Cognitive Level: Application Implementation

REF:

pp. 449-450

OBJ:

2 | 6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

18.

Which contributing factor(s) to heart failure is/are modifiable? ( Select all that apply. ) a.

Hypertension b.

Addiction to smoking

Genetic history

Exercise tolerance

Age

ANS: A, B, D Hypertension, smoking, and diminished exercise tolerance are contributing factors to atherosclerosis, which can be modified with changes in behavior and the assistance of medications. Genetic history and age are not modifiable factors.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 446 OBJ:

2 | 6 TOP: Nursing Process Step:

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MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

19. A patient with heart failure has been prescribed nesiritide (Natrecor). Which statement(s) is/are true regarding this medication? ( Select all that apply. ) a.

It increases preload.

Cardiac ventricles secrete this hormone in response to fluid overload.

It suppresses aldosterone.

It promotes norepinephrine secretion.

It causes vasodilation.

ANS: B, C, E

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Nesiritide is a hormone normally secreted by the cardiac ventricles in response to fluid and pressure overload, suppresses aldosterone, and causes vasodilation. Nesiritide does not increase preload or promote norepinephrine secretion.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 451 OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

20.

Which statements about vasodilators is/are true? ( Select all that apply. )

They reduce systemic vascular resistance.

They increase afterload.

They reduce preload.

They decrease pulmonary congestion.

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They increase tissue perfusion to muscles and organs.

They increase the volume of blood returning to the heart.

ANS: A, C, D, E Vasodilators reduce systemic vascular resistance (afterload), decrease preload, relieve pulmonary congestion, and increase tissue perfusion to muscles and vital organs. Vasodilators reduce systemic vascular resistance (afterload) and reduce preload so that the high volume of blood returning to the heart is decreased.

DIF: Cognitive Level: ComprehensionREF: Implementation

ch23

OBJ:

N/A TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

21. The nurse is providing education to a patient with altered cardiac function. When instructing this patient the nurse will encourage: ( Select all that apply. ) a.

alcohol consumed in moderation.

use of salt substitute.

regular, mild exercise.

good skin care.

stress reduction.

ANS: C, D, E Regular, mild exercise; good skin care; and stress reduction should be encouraged with a patient with altered cardiac function. Alcohol intake should be eliminated from the diet. Salt substitutes are high in potassium, so use must be limited.

DIF: Cognitive Level: Application Implementation

REF:

p. 450 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

6 TOP: Nursing Process Step:

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Chapter 28: Drugs Used for Diuresis Test Bank

MULTIPLE CHOICE

1. What would the nurse anticipate if a patient with a history of type 2 diabetes is prescribed a thiazide diuretic? a.

No change in the antidiabetic regimen

Decreased need for antidiabetic medication

Increased blood sugar levels

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Less frequent monitoring of blood sugar level

ANS: C The thiazides may induce hyperglycemia and aggravate cases of preexisting diabetes mellitus. Regular assessment for glycosuria is indicated. Dosages of oral hypoglycemics and insulin may need adjustment in patients with diabetes mellitus. Thiazides affect glucose metabolism, and the patient should change her regimen to accommodate this. Thiazides have the opposite effect on glucose metabolism. More frequent monitoring is warranted when the patient is being treated with thiazide diuretics.

DIF: Cognitive Level: Application Assessment

REF:

p. 465 OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

2. When teaching a patient who is taking thiazide diuretics, the nurse will encourage the patient to increase the intake of which electrolyte? a.

Calcium

Sodium

Potassium

Magnesium

ANS: C Thiazide diuretics cause a decrease in the level of potassium. The patient taking thiazide diuretics does not need to increase calcium or magnesium intake. Although sodium levels are altered in patients taking thiazide diuretics, patients do not need to increase sodium intake.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 459 OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

3. On admission, a patient with a history of cardiac insufficiency complains of shortness of breath. The nurse auscultates the lungs and notes bilateral crackles throughout both fields. In addition, there is bilateral +2 edema of the lower extremities. Which medication does the nurse anticipate that the health care provider will prescribe? a.

Allopurinol (Zyloprim)

Diphenhydramine (Benadryl)

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Mannitol

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Furosemide (Lasix)

ANS: D Diuretics, such as furosemide, are the mainstays of treatment in heart failure and hypertension. Allopurinol is used to treat gout. Diphenhydramine is an antihistamine and is not used for diuresis. Mannitol is used mainly to treat cerebral edema.

DIF: Cognitive Level: Application Planning

REF:

p. 461 OBJ:

4 | 6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Which medication is a potassium sparing diuretic?

Acetazolamide (Diamox)

Spironolactone (Aldactone)

Furosemide (Lasix)

Bumetanide (Bumex)

ANS: B Spironolactone is a potassium sparing diuretic that blocks the sodium retaining and potassium and magnesium excreting properties of aldosterone. This results in loss of water, with increased sodium excretion and retention of potassium. Acetazolamide is a carbonic anhydrase inhibitor and does not spare potassium. Furosemide is a loop diuretic. Bumetanide is a loop diuretic and does not spare potassium.

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DIF: Cognitive Level: Knowledge Implementation

REF:

p. 467 OBJ:

N/A TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

5. How soon will diuresis be expected to occur after the nurse has administered 20 mg of furosemide (Lasix) intravenously (IV) to a patient with heart failure? a.

As soon as injected

Within 10 minutes

After 2 hours

After 4 hours

ANS: B The onset of diuresis following IV furosemide administration is 5 to 10 minutes after administration. The diuretic effect peaks within 30 minutes and lasts approximately 2 hours.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 461 OBJ:

6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Which foods will the nurse recommend for a patient taking loop diuretics?

Protein-rich foods such as poultry, whole grains, and fish

Fiber-rich foods such as yellow vegetables, nuts, and lentils

Potassium-rich foods such as raisins, figs, and bananas

Sodium-rich foods such as canned vegetables and processed foods

ANS: C

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Loop diuretics deplete potassium. Potassium-rich foods include raisins, figs, bananas, peaches, kiwis, dates, apricots, oranges, prunes, melons, broccoli, and potatoes. Protein- and fiber-rich foods are not needed in increased amounts by patients taking loop diuretics. Because of high sodium content, canned foods are restricted for patients on diuretic therapy. DIF:

Cognitive Level: Analysis

REF:

p. 459 OBJ:

9 TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

Which condition warrants the use of acetazolamide (Diamox) as a diuretic?

Increased intracranial pressure

Increased extravascular fluid pressure

Increased intraocular pressure

Periorbital edema

ANS: C Acetazolamide is used to reduce intraocular pressure associated with glaucoma. Mannitol is an osmotic diuretic used to decrease intracranial pressure. Diuretics such as furosemide or ethacrynic acid are used to reduce fluid volume in extravascular spaces. Diuretics are not used to treat periorbital edema.

DIF:

Cognitive Level: ComprehensionREF:

p. 459 | p. 461

OBJ: 8 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

8. The nurse would expect to assess which serum potassium level in a patient who has severe vomiting and diarrhea? a.

Less than 3.5 mEq/L

Between 3.5 and 4.5 mEq/L

Between 4.6 and 5 mEq/L

Higher than 5.5 mEq/L

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ANS: A Serum potassium (K+) levels would be less than 3.5 mEq/L. Hypokalemia is especially likely to occur when a patient exhibits vomiting, diarrhea, or heavy diuresis. Between 3.5 and 4.5 mEq/L is the low end of normal range for serum potassium. Between 4.6 and 5 mEq/L is the high end of normal range for serum potassium. Serum K+ levels higher than 5.5 mEq/L indicate hyperkalemia, which occurs most commonly when a patient is given excessive amounts of potassium supplementation.

DIF:

Cognitive Level: Application

REF:

p. 459 OBJ:

5 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

9. Which medication, if administered with spironolactone (Aldactone), will alert the nurse to assess the patient for signs and symptoms of hyperkalemia? a.

Propranolol (Inderal)

Captopril (Capoten)

Furosemide (Lasix)

Ibuprofen (Motrin)

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ANS: B ACE inhibitors, such as captopril, inhibit aldosterone and thus may contribute to the development of hyperkalemia. Beta blockers, such as propranolol, do not affect potassium levels. Loop diuretics, such as furosemide, cause hypokalemia. NSAIDs, such as ibuprofen, do not affect potassium levels. DIF: Cognitive Level: Application Evaluation

REF:

p. 468 OBJ:

10 TOP: Nursing Process Step:

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MSC: NCLEX Client Needs Category: Physiological Integrity

10. The nurse has provided patient teaching about potassium sparing diuretic therapy. Which statement by the patient indicates a need for further teaching? a.

“I will take my medication in the morning.”

“I will report a weight gain of 2 pounds in 2 days.”

“I will rise slowly when I get up from a sitting position.”

“I will use a salt substitute because I limit my salt intake.”

ANS: D Salt substitutes are potentially dangerous because they are high in potassium.

DIF:

Cognitive Level: Application

REF:

p. 460 OBJ:

9 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

11.

Which patient assessment would alert the nurse to withhold a loop diuretic?

Crackles in the lung bases

b. +2 pitting peripheral edema c.

Serum potassium of 2.6 mEq/L

Weight gain of 2 pounds in 2 days

ANS: C The level indicates hypokalemia and could worsen with the administration of a loop diuretic; therefore, the dose should be withheld. Crackles, peripheral edema, and weight gain do not warrant withholding the medication.

DIF: Cognitive Level: Application REF: p. 459 | p. 463 OBJ: 5 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

12. A 37-year-old male presents at the emergency department reporting severe vomiting for the past 48 hours. When assessing skin turgor, the nurse will: a.

exert pressure against the shin.

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gently pinch the skin together over the sternum.

assess for vein distention.

inspect oral mucous membranes.

ANS: B Skin turgor is assessed by gently pinching the skin together over the sternum, on the forehead, or on the forearm. Elasticity is present and skin rapidly returns to a flat position in the well hydrated patient. Exerting pressure against the shin would assess for edema. Vein

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distention and oral mucous membranes are indicators of hydration status, but are not considered when assessing skin turgor.

DIF: Cognitive Level: Application Assessment

REF:

p. 458 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity 13. The nurse is reviewing lab work received on a patient admitted with the diagnosis of dehydration. The nurse will notify the physician of which lab value? a.

Serum sodium level: 115 mEq/L

Serum potassium level: 5.0 mEq/L

Serum sodium level: 140 mEq/L

Serum potassium level: 3.5 mEq/L

ANS: A

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A serum sodium level lower than 135 mEq/L is considered hyponatremia. A serum potassium level of 3.5 or 5.0 mEq/L, and a serum sodium level of 140 mEq/L are considered within normal limits.

DIF: Cognitive Level: Analysis Assessment, Implementation

REF:

p. 459 OBJ:

1 | 5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

MULTIPLE RESPONSE

14. A patient who has heart failure and difficulty breathing is being admitted. Which physical assessment(s) indicate(s) fluid volume excess? ( Select all that apply. ) a.

Rapid, bounding, irregular pulse rate

Clear lung sounds

3+ pitting ankle edema

Neck vein engorgement

Shortness of breath

ANS: A, C, D, E The patient with overhydration caused by heart failure often presents with a rapid and irregular pulse rate, peripheral and abdominal edema, distended neck veins, dyspnea and adventitious breath sounds of crackles and/or rhonchi in lung fields.

DIF: Cognitive Level: Application Assessment

REF:

p. 458 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

15. Which premedication assessment(s) would the nurse obtain prior to the initiation of bumetanide (Bumex)? ( Select all that apply. ) a.

Serum potassium

Bowel sounds

Lung sounds

Orientation level

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Blood pressure

ANS: A, C, D, E

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Serum potassium levels may be altered because of bumetanide therapy and therefore need to be assessed. Lung sounds, orientation level, and vital signs need to be assessed prior to initiation of therapy. Bowel sounds are not generally assessed prior to bumetanide therapy.

DIF: Cognitive Level: Application Assessment

REF:

p. 461 OBJ:

1 | 3 | 10 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity 16.

Which are common signs and symptoms of dehydration? ( Select all that apply. )

Furrowed tongue

Decreased intake and output levels

Bounding pulse rate

Mental confusion

Elastic skin turgor

ANS: A, B, D Furrowed tongue is a sign of dehydration. Signs of dehydration and hyponatremia include decreased intake and output, or output greater than intake. Signs of dehydration may also include possible mental confusion, weak pulse/weak pedal pulses, inelastic skin turgor, and delayed capillary refill.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 458 OBJ:

1 | 3 TOP: Nursing Process Step:

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MSC: NCLEX Client Needs Category: Physiological Integrity

17.

Which nursing intervention(s) would be performed for a patient who is on diuretic therapy?

( Select all that apply. ) a.

Auscultation of lung sounds

Assessment of skin turgor

Initiation of electrolyte supplements

Positioning techniques

Monitoring of intake and output

ANS: A, B, D, E Lungs should be auscultated to detect the presence of fluid as a result of heart failure. Skin turgor is directly related to the degree of hydration. Skin that is well hydrated is elastic and rapidly returns to a flat position after being pinched. In dehydrated patients, the skin remains in a peaked or pinched position and returns very slowly to the flat, normal position. Positioning techniques are essential to avoid skin breakdown resulting from edema or dehydration. Assessment of intake and output will assist in determining the effectiveness of diuretic therapy. The health care provider, not the nurse, will determine the need for electrolyte supplementation. When ordered, the nurse will administer the appropriate replacements. Maintaining the ordered diet therapy is within the role of the nurse.

DIF: Cognitive Level: Application Implementation

REF:

p. 458 OBJ:

10 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

18. Which sign(s) and/or symptom(s) of dehydration may occur as a result of a diuretic? (Select all that apply.) a.

Decreased urine specific gravity

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Skin remains peaked on turgor assessment

Bounding peripheral pulses

Neck vein engorgement

Soft, sunken eyeballs

ANS: B, E A sign of dehydration is skin that is nonelastic or does not return to normal position when pulled taut on assessment. A sign of dehydration is eyeballs that appear soft or sunken. Dehydrated patients have a urine specific gravity and weak pulses. Overhydrated patients have engorged neck veins.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 458 OBJ:

10 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

19.

Which medical condition(s) may contribute to fluid volume excess? ( Select all that apply. ) a.

Hypertension b.

Liver disease

Pregnancy

Use of corticosteroids

Skin disorders

ANS: A, B, C, D Hypertension, underlying medical diseases of the liver, pregnancy, and use of corticosteroids may contribute to fluid volume excess. Skin disorders do not contribute to fluid volume excess.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 459 OBJ:

2 TOP: Nursing Process Step:

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MSC: NCLEX Client Needs Category: Physiological Integrity

20. Individuals with which disorder(s) are particularly susceptible to the development of electrolyte disturbances during diuretic therapy? ( Select all that apply. ) a.

History of cardiac disease

History of renal disease

History of hormonal disorders

History of psychiatric illness

Massive trauma

Serious burns

Overhydration

ANS: A, B, C, E, F Patients with cardiac disease, renal disease, hormonal disorders, massive trauma, and serious burns are at risk for developing electrolyte imbalance during diuresis therapy. Psychiatric disorders do not have an effect on diuretic treatment. Although overhydration may cause an electrolyte disturbance, it is not related to diuretic treatment.

DIF: Cognitive Level: Application Assessment

REF:

p. 459 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

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21. The nurse transcribes a new order for ethacrynic acid (Edecrin) on a patient with edema resulting from cirrhosis of the liver. Which currently prescribed medication(s) should the nurse report to the ordering health care provider? ( Select all that apply. ) a.

Digoxin

Prednisone

Tobramycin

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Lipitor

Zofran

ANS:

A, B, C

Drug interactions with ethacrynic acid (Edecrin) include digoxin, corticosteroids (such as prednisone), and aminoglycosides (such as tobramycin). Lipitor (a statin drug) and Zofran (an antiemetic) are not of concern when administered with ethacrynic acid.

DIF: Cognitive Level: Analysis Assessment, Implementation

REF:

p. 464 OBJ:

10 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment; Physiological Integrity

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Chapter 29: Drugs Used to Treat Upper Respiratory Disease Test Bank

MULTIPLE CHOICE

Which is a serious adverse effect of decongestants?

Hypotension

Hypertension

Orbital edema

Facial flushing

ANS: B Sympathomimetic decongestants cause stimulation of the alpha adrenergic receptors that can increase blood pressure. Excessive use of decongestants when taking a beta adrenergic blocking agent or monoamine oxidase inhibitor can cause significant hypertension. Alpha receptor stimulation does not cause hypotension, orbital edema, or facial flushing.

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DIF: Cognitive Level: Knowledge Assessment

REF:

p. 477 OBJ:

3 | 5 | 6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

2. The nurse is teaching a patient about the administration of antihistamines. The nurse will instruct the patient to take the medication at what time of day? a.

PRN throughout the day

After contact with an allergen

45 minutes before exposure to an allergen

Once nasal congestion begins

ANS: C Allergies may be seasonal or perennial. People are commonly allergic to more than one antigen simultaneously, so seasons may overlap or occur more than once per year. Antihistamines do not prevent histamine release, but reduce the symptoms of an allergic reaction by competing with the histamines for receptor sites. Antihistamines are most effective when taken 45 to 60 minutes before anticipated exposure to the allergen or when symptoms first appear. PRN use of antihistamines, waiting until after contact with an allergen, or waiting until nasal congestion begins is not the most effective administration of antihistamines.

DIF: Cognitive Level: Knowledge Planning

REF:

p. 477 OBJ:

6 | 7 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

What can result if a patient overuses topical decongestants?

Hypertensive crisis

Allergic reaction

Secondary congestion

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Permanent olfactory damage

ANS: C Overuse of topical decongestants may lead to a rebound or increase in nasal secretions, causing a secondary congestion (known as rhinitis medicamentosa). This secondary congestion is thought to be caused by excessive vasoconstriction of blood vessels and direct irritation of the mucous membranes by the medication. As vasoconstriction wears off, the irritation triggers excessive blood flow to the passages, which in turn causes swelling and engorgement to reappear in greater intensity. Although decongestants can cause elevated blood pressure, they are not likely to cause hypertensive crisis. Allergic reaction is unlikely with decongestants. Damage to nasal tissues resulting from the use of decongestants is unlikely to be permanent.

DIF: Cognitive Level: ComprehensionREF: Step: Assessment

pp. 473-475

OBJ:

4 | 6 | 7 TOP: Nursing Process

MSC: NCLEX Client Needs Category: Physiological Integrity

4. A patient at sports camp is complaining of itchy and watery eyes, coughing, and sneezing when outdoors. The patient’s chart states that he has an allergy to grasses. Which medication will the nurse administer? a.

Antitussive

Expectorant

Antihistamine

Decongestant

ANS: C Antihistamines are used for inflammation and swelling resulting from the release of histamine during an antigen antibody reaction. A grass allergy means that the patient experiences a release of histamine (antibody reaction) when exposed to the antigen, grass. Antitussive medications are for relief of cough. Expectorants are for the loosening of mucus so the patient can expel it by coughing. Decongestants would not help these symptoms as much as antihistamines.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 474 OBJ:

2 | 6 | 7 TOP: Nursing Process Step:

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MSC: NCLEX Client Needs Category: Physiological Integrity

5. Which medication may be given to patients with allergic seasonal rhinitis who do not respond to antihistamines and sympathomimetics? a.

Leukotrienes

Mineralocorticoids

Corticosteroids

Cortisol

ANS: C Corticosteroids, whether applied topically or administered systemically, have been shown to be highly effective for the treatment of allergic rhinitis. Leukotrienes, made in the body, are mediators of the inflammatory response. Mineralocorticoids do not affect allergic responses. Cortisol is not the steroid of choice for the treatment of an allergic response.

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DIF: Cognitive Level: Knowledge Implementation

REF:

p. 474 OBJ:

3 | 7 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity 6.

What initiates the sneeze reflex?

Stimulation of the vagus nerve

Irritation of the nasal mucosa by foreign particulate matter

Stimulation of the tonsils

Enervation of the olfactory cranial nerve

ANS: B

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Sneezing is a physiological reflex used by the body to clear the nasal passages of foreign matter. Stimulation of the vagus nerve, stimulation of the tonsils, and enervation of the olfactory cranial nerve are not what initiates the sneezing reflex.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 472 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

What occurs in the nasal structures when cholinergic fibers are stimulated?

Dryness of mucous membranes in the nostrils

Bleeding in the mucous membranes in the nostrils

Production of serous and mucous secretions in the nostrils

Enhanced olfactory perception in the mucous membranes of the nostrils

ANS: C The cholinergic fibers innervate the secretory glands; when stimulated, they produce serous and mucous secretions within the nostrils. Nasal dryness is the result of treatment with anticholinergic medications. Bleeding may be a result of overtreatment with anticholinergic medications, as a result of dryness of the nasal mucous membranes. Medications tend to dull olfactory function rather than enhance it.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 471 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

What process in the antigen antibody reaction causes the symptoms of allergies?

Release of antihistamines

Production of antibodies

Suppression of histamine

Release of histamine

ANS: D

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One of the major causes of symptoms associated with an allergy is the release of histamine during the antigen antibody reaction. Antihistamines suppress the symptoms of allergic reactions. Antibodies are not responsible for the allergic symptoms. Suppressing histamine diminishes the symptoms of allergies.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 473 OBJ:

1 | 2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

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9. Which instruction will the nurse include when teaching a patient with seasonal rhinitis and blocked nasal passages about intranasal corticosteroid therapy? a.

“Clear your nasal passage after administration.”

“Anticipate a therapeutic benefit within 24 hours.”

“Use a decongestant prior to administration.”

“Report nasal burning to your health care provider.”

ANS: C Use of a decongestant just before intranasal corticosteroid administration ensures adequate penetration. The patient should clear the nasal passages before, not after, administration. The therapeutic benefit occurs after 24 hours. Nasal burning tends to resolve with continued therapy.

DIF: Cognitive Level: Application Implementation

REF:

p. 479 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

3 | 6 | 7 TOP: Nursing Process Step:

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10. The clinic nurse is assessing a patient being seen for a severe allergic reaction to environmental allergens. Which symptom should the nurse prioritize as the most important? a. Hypotension b.

Urticaria

Dyspnea

Rhinorrhea

ANS: C Dyspnea (difficulty breathing) caused by constriction and spasm of the bronchial tubes is the priority. Hypotension (low blood pressure), urticaria (severe itching), and rhinorrhea (running nose) can occur during a severe allergic reaction, but are not the priority.

DIF: Cognitive Level: Analysis Assessment

REF:

p. 473 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment; Physiological Integrity

11. A college student is being seen at an outpatient clinic with reports of allergic rhinitis and conjunctivitis. The health care provider orders fexofenadine. When providing information regarding this medication, the nurse will include statements indicating that: a.

fexofenadine is one of the least sedating antihistamines.

tolerance will not develop.

antihistamines are more effective if taken after histamine is released.

histamine release will be prevented by this medication.

ANS: A Fexofenadine is one of the least sedating antihistamines. Occasionally, a tolerance to antihistaminic effects will develop. Antihistamines are more effective if taken before histamine is released. Histamine release is not prevented by this medication. Symptoms are reduced.

DIF: Cognitive Level: Application Implementation

REF:

p. 477 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

6 | 7 TOP: Nursing Process Step:

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MULTIPLE RESPONSE

12.

When does allergic rhinitis occur? ( Select all that apply. )

Nasal mucosa become inflamed.

Exposure as a result of an allergen produces inflammation.

Histamine is released following allergen exposure.

The weather is cold during the winter.

A person has an initial exposure to an antigen.

ANS: A, B, C Allergic rhinitis is inflammation resulting from an allergic reaction. Following allergen exposure, and with subsequent inhalation of the allergen, an antigen antibody reaction occurs, causing inflammation and swelling of the nasal passages. Histamine is released during the allergic reaction. Allergic rhinitis can occur during any season, depending on when the allergen is most abundant in the air. Allergic rhinitis occurs in patients who have experienced previous exposure to one or more allergens and have developed antibodies.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 473 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

13.

Which action(s) is/are true of antihistamines? ( Select all that apply. )

Reduce inflammation locally

Antagonize H1 receptors

May be administered orally

Are systemically distributed

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Reduce nasal congestion

ANS: A, B, C, D Antihistamines reduce the symptoms of nasal itching, sneezing, rhinorrhea, lacrimation, and conjunctival itching through local and systemic actions. Antihistamines are H1 antagonists or blockers, may be administered orally, are distributed systemically, and do not reduce nasal congestion.

DIF: Cognitive Level: Knowledge Implementation

REF:

p. 477 OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

14. The nurse is preparing education for a patient who has developed rebound nasal congestion resulting from use of topical decongestants. What information will the nurse include? (Select all that apply.) a.

For future topical decongestant use, follow the dosage directions daily. Do not overuse.

Stop the topical decongestant at once.

A decrease in congestion will occur immediately.

d. Nasal steroid solutions can be used but may take several days to reduce inflammation and congestion. e.

Use nasal saline spray to moisturize irritated mucosa.

ANS: A, B, D, E

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The best treatment for rebound nasal congestion caused by use of topical decongestants is prevention. Further use of the medication will exacerbate the nasal congestion. Nasal steroid solutions may help gradually reduce the congestion without exacerbating the symptoms.

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Nasal saline spray will bring comfort to the irritated nasal mucosa by moisturizing them. A decrease in the nasal congestion will occur gradually. DIF: Cognitive Level: Application Implementation

REF:

p. 473 OBJ:

6 | 7 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

15. Which patient(s) would be able to take an alpha adrenergic decongestant safely? (Select all that apply.) a.

24- year-old woman with allergic rhinitis

18- year-old man with cold symptoms

64- year-old woman with a history of heart disease

70- year-old woman with glaucoma

56- year-old man with prostatic hypertrophy

ANS: A, B A 24-year-old woman with allergic rhinitis and an 18-year-old man with cold symptoms should be able to take an alpha adrenergic decongestant safely. Alpha adrenergic decongestants will stimulate alpha receptors throughout the body. Therefore, oral therapy should be prescribed with caution in patients with a history of cardiac disease, intraocular pressure, or prostatic hypertrophy.

DIF: Cognitive Level: Analysis REF: p. 474 | p. 476 OBJ: 5|6|7 Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

TOP: Nursing Process

16. Which principle(s) will the nurse include in a teaching plan for antihistamine therapy? (Select all that apply.) a.

It is typical to experience an increase in energy.

Dietary fiber and fluids should be increased.

Do not take with prescription medications unless approved by a physician.

Blurred vision is an expected adverse effect.

e. Over the counter (OTC) medications are safe to use with any currently prescribed prescription medications. ANS: B, C, D

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All histamines cause anticholinergic adverse effects such as dry mouth, constipation, and urinary retention. Therefore, fluids and fiber should be increased in the diet when taking antihistamines. It is important to seek approval from the health care provider if currently using other scheduled medications with antihistamines. Blurred vision is an adverse effect of antihistamine use; patients should be urged to use caution because their cognitive and sensory abilities are impaired. Because of the sedative effect of most antihistamines, patients feel a decrease in energy. OTC medications must be approved by the health care provider to prevent drug interactions.

DIF: Cognitive Level: Application Planning

REF:

p. 475 OBJ:

6 | 7 TOP: Nursing Process Step:

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MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

17. Which topically active aerosol steroids are highly effective for reducing sneezing, nasal itching, stuffiness, and rhinorrhea? ( Select all that apply. ) a.

Beclomethasone (Beconase AQ)

Prednisone (Deltasone)

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Fluticasone (Flonase)

Flunisolide (Nasarel)

Budesonide (Rhinocort Aqua)

ANS:

A, C, D, E

Beclomethasone, fluticasone, flunisolide, and budesonide are drugs used to reduce sneezing, nasal itching, stuffiness, and rhinorrhea. Prednisone is not used to treat these symptoms.

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DIF: Cognitive Level: ComprehensionREF: Implementation

p. 480 OBJ: TOP:

Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

3 | 6 |7

18. The nurse is providing counseling to a patient on cromolyn sodium (Nasalcrom) nasal spray. Information relayed to the patient will include that:(Select all that apply.) a.

cromolyn must be taken immediately following exposure to the stimulus.

the patient should blow the nose before nasal instillation.

therapeutic effects are immediate.

inhalation will cause coughing.

the maximum is six sprays in each nostril daily.

ANS:

B, E

Patients should blow their noses before nasal instillation. The maximum is six sprays in each nostril daily. Cromolyn must be taken before exposure to the stimulus that initiates an attack or allergic rhinitis. Therapeutic effects require regular use and are usually evident within 2 to 4 weeks. Coughing is not an expected adverse effect. The health care provider should be notified if inhalation causes coughing.

DIF:

Cognitive Level: Application

REF:

TOP:

Nursing Process Step: Implementation

pp. 480-481

MSC: NCLEX Client Needs Category: Physiological Integrity

OBJ:

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Chapter 30: Drugs Used to Treat Oral Disorders

MULTIPLE CHOICE

1. A patient with chronic obstructive pulmonary disease (COPD) uses a corticosteroid inhaler bid. Which adverse effect is associated with this medication? a.

Mucositis

Plaque

Xerostomia

Candidiasis

ANS: D Medications that predispose a patient to candidiasis are those that suppress the immune system, including immunosuppressants, corticosteroids, cytotoxics, and broad spectrum antibiotics. Educating patients on the importance of oral hygiene following prescribed inhalation dosages will assist in decreasing this complication. Mucositis, plaque, and xerostomia are not associated with steroid inhaler use.

DIF: Cognitive Level: Application Assessment

REF:

Page 485

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Infection

2. The nurse is assessing a patient’s mouth and notes white, milk curd-appearing plaques attached to the oral mucosa. Which condition is present? a.Thrush b.

Canker sores

Cold sores

Mucositis

ANS: A

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Thrush is characterized by white, milk curd-appearing plaques that are attached to the oral mucosa. Canker sores can appear as ulcers 0.5 to 2 cm in diameter on surfaces that are not attached to bone, such as the tongue, gums, or inner lining of the cheeks and lips. Cold sores (“fever blisters”) are most commonly found at the junction of the mucous membrane and the skin of the lips or nostrils, although they can occur inside the mouth, especially affecting the gums and roof of the mouth. Mucositis is a general term used to describe a painful inflammation of the mucous membranes of the mouth.

DIF: Cognitive Level: Knowledge Assessment

REF:

Page 485

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance NOT: CONCEPT(S): Clinical Judgment; Infection

What is the primary pharmacologic therapy for Candida albicans?

Steroids

Antifungal agents

Topical anesthetics

Topical anti-inflammatory agents

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Candida albicans is the most common oral infection appearing in extremely debilitated patients. Medications that predispose a person to C. albicans infections are those that depress the immune system and those that cause xerostomia. C. albicans is a fungus and therefore is treated with antifungal agents such as nystatin (Mycostatin). Steroids, topical anesthetics, and topical anti-inflammatory agents are not used to treat C. albicans.

DIF: Cognitive Level: Knowledge Implementation

REF:

Page 485

OBJ:

1 | 2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance NOT: CONCEPT(S): Clinical Judgment; Infection

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Which condition is treated by saliva substitutes?

Caries

Mucositis

Xerostomia

Halitosis

ANS: C Xerostomia, or lack of saliva, originates from nonoral causes. Xerostomia is treated by discontinuing medications that dry the mucous membranes or by artificial saliva products. Dentifrices are used to treat caries. Saliva substitutes are not used to treat mucositis. Mouthwash is used to treat halitosis, along with dentifrices.

DIF: Cognitive Level: Knowledge Implementation

REF:

Page 486

OBJ:

1 | 2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance NOT: CONCEPT(S): Clinical Judgment; Nutrition

Which information will the nurse include when teaching a patient about cold sores?

Use of drying agents prevents the spread of secretions.

Erupted lesions are not contagious.

Eruptions are related to breaks in personal hygiene.

Pus-filled lesions indicate a secondary bacterial infection.

ANS: D Cold sore lesions first become visible as small red papules that later develop into 1- to 3-mm diameter fluid-filled blisters. Over the following 10 to 14 days, a crust develops as the vesicles that burst coalesce into larger lesions. The liquid from the vesicles contains the live virus that can be transferred to other people by direct contact. The base of the lesions is erythematous. If pus develops in the vesicles or under the crust of a cold sore, a secondary bacterial infection may be present and the patient should seek medical attention. Drying agents are not used to treat cold sores. Cold sores are contagious. Eruptions are not necessarily related to poor personal hygiene.

DIF: Cognitive Level: Application Assessment

REF:

Page 484

OBJ:

1 TOP: Nursing Process Step:

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MSC: NCLEX Client Needs Category: Health Promotion and Maintenance NOT: CONCEPT(S): Clinical Judgment; Infection

Which local anesthetic is used for inflammation of oral mucous membranes?

Chlorhexidine (Peridex)

2 % viscous lidocaine

Nystatin (Mycostatin)

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Hydrogen peroxide

ANS: B Two percent viscous lidocaine is used as a topical anesthetic for pain associated with oral inflammation. Care must be taken so that the patient does not accidentally burn himself or herself because the drug anesthetizes the entire mouth and throat. Chlorhexidine, nystatin, and hydrogen peroxide are not local anesthetics.

DIF: Cognitive Level: Knowledge Implementation

REF:

Page 486

OBJ:

1 | 2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Inflammation

7. Which medication helps prevent or reduce mucositis in patients undergoing chemotherapy or radiation treatment? a.

Amlexanox paste (Aphthasol)

Palifermin (Kepivance)

Docosanol (Abreva)

Nystatin (Mycostatin)

ANS: B

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Palifermin is a recombinant human keratinocyte growth factor approved specifically for preventing and treating the mucositis that develops in leukemia or lymphoma patients undergoing chemotherapy before bone marrow transplantation. Amlexanox paste is used to treat canker sores. Docosanol is used to treat cold sores. Nystatin is used to treat thrush.

DIF: Cognitive Level: Knowledge Planning

REF:

Page 487

OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Inflammation; Health Promotion

8. Which infection is often called the “disease of the diseased” because it appears in debilitated patients? a.

Aspergillosis

Candidiasis

Trichomoniasis

Brucellosis

ANS: B Candidiasis is a fungal infection caused by Candida albicans, the most common organism associated with oral infections. It is often called the “disease of the diseased” because it appears in debilitated patients and patients taking a variety of medicines. Aspergillosis is caused by the fungus Aspergillus, which is commonly found growing on dead leaves, stored grain, or compost piles, or in other decaying vegetation. Although it is similar to candidiasis in its occurrence in debilitated patients, it is not as common. Trichomoniasis is a common parasitic sexually transmitted disease. Brucellosis is a zoonotic infection transmitted from animals to humans by the ingestion of infected food products, direct contact with an infected animal, or inhalation of aerosols.

DIF: Cognitive Level: ComprehensionREF: Assessment

Page 485

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Infection

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What is the most common cause of most tooth, gum, and periodontal disease?

Sugar

Halitosis

Plaque

Smoking

ANS: C Plaque is the primary cause of most tooth, gum (gingiva), and periodontal disease. Plaque, the whitish yellow substance that builds up on teeth and gum lines, is thought to originate from saliva. Plaque forms a sticky meshwork that traps bacteria and food particles. If not removed regularly, it thickens, and bacteria proliferate. Sugar is not a cause of dental disease as such but becomes a problem when poor oral hygiene allows it to collect in the oral cavity. Halitosis is a symptom of poor oral hygiene but is not a cause of dental disease. Although smoking can contribute to periodontal disease through vasoconstriction, it is not a cause of dental disease.

DIF: Cognitive Level: ComprehensionREF: Assessment

Page 487

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Inflammation

10. Which instruction by the nurse is most important when educating a patient about using viscous lidocaine (Xylocaine) for mucositis? a.

“Cleanse the oral cavity after using.”

“This medication can be used as a gargle.”

“After using, wait for 30 minutes before eating.”

“Your sense of taste will be diminished.”

ANS: C Caution the patient not to take food or drink for approximately 30 minutes after the medication because of the risk of aspiration from the absence of the gag reflex. The oral cavity is cleansed before administration. The medication can be used as a gargle and the sense of taste is diminished, but these are not the most important instructions.

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DIF: Cognitive Level: Application Implementation

REF:

Page 487

OBJ:

2 | 3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Inflammation; Safety; Patient Education

11. A patient is being treated with topical amlexanox paste 5% (Zilactin). Which statement by the patient indicates a knowledge deficit? a.

“This medicine will help control discomfort.”

“I will apply the paste before meals.”

“The paste will be applied to each lesion.”

“Healing will be promoted.”

ANS: B It is best to apply amlexanox paste 5% (Zilactin) after meals. Discomfort is controlled with this medication; it is applied to each lesion and promotes healing. DIF: Cognitive Level: Analysis Evaluation

REF:

Page 486

OBJ:

2 | 3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Patient Education

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12. A patient using carbamide peroxide (Gly-Oxide) to treat multiple canker sores develops tissue irritation and black hairy tongue. The patient asks the nurse what can be done to soothe the pain. The nurse will first encourage use of a.

Milk of Magnesia.

viscous lidocaine 2%.

Salivart.

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saline rinses.

ANS: D Saline rinses may be soothing and can be used before topical application of carbamide peroxide (GlyOxide). They would be encouraged prior to other measures. Milk of Magnesia, viscous lidocaine 2%, and Salivart are not used to soothe this side effect.

DIF: Cognitive Level: Application Implementation

REF:

Page 488

OBJ:

1 | 2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Inflammation; Patient Education

13.

The nurse is assisting with care of a patient on chemotherapy with severe mucositis. The

patient reports mucous membrane pain level to be “8” on the pain scale. The priority nursing diagnosis for this patient is a.

altered nutrition: less than body requirements.

risk for aspiration.

fluid volume deficit.

pain.

ANS: D Pain is the nursing priority. A score of “8” indicates severe pain and comfort measures would take priority. Altered nutrition: less than body requirements, risk for aspiration, and fluid volume deficit are not the priorities at this time.

DIF: Cognitive Level: Analysis Diagnosis

REF:

Page 487

OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment| NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Pain

MULTIPLE RESPONSE

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1. The nurse is completing education for a patient who will be undergoing chemotherapy next week. In anticipation of adverse effects associated with oral mucositis resulting from chemotherapy, which information will the nurse include in the teaching plan? (Select all that apply.) a.

Avoid acidic and spicy foods.

Using docosanol (Abreva) will decrease the pain.

Milk of Magnesia can be used to rinse the mouth and coat mucous membranes.

Nystatin liquid can be taken orally to eliminate fungal infections.

Cleanse the oral cavity before applying topical agents.

Rinse the mouth with an over-the-counter (OTC) mouthwash.

ANS: A, C, D, E Spicy and acidic foods should be avoided to prevent irritation to mucous membranes. Viscous lidocaine 2%, Milk of Magnesia, diluted bismuth subsalicylate (Kaopectate), and sucralfate

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suspensions may be used for topical application. Oral candidal infections are often adverse effects of chemotherapy, and nystatin liquid, an antifungal agent, may be prescribed. Directions for using this agent include swishing the medication in the oral cavity for approximately 1 minute before swallowing or sucking on lozenges (troches) to reduce candidal oral infections. Pain medication applied topically must come into contact with mucous membranes to be effective. Therefore, it is advisable to clean the oral cavity before application. This medication is not used in the treatment of oral mucositis. OTC mouthwashes are usually not recommended for treatment of mucositis.

DIF: Cognitive Level: Application Implementation

REF:

Page 488

OBJ:

1 | 3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Inflammation; Safety; Patient Education

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What will the nurse include when educating a 12-year-old patient about care of a cold sore?

(Select all that apply.) a.

“Keep the cold sore clean with mild soap.”

“Use an astringent to assist in drying the cold sore and promote rapid healing.”

“Keep the cold sore moist to prevent cracking.”

d. “Note signs of infection, including the presence of pus. Contact the health care provider if this occurs.” e.

“Oral analgesics may help alleviate pain.”

ANS: A, C, D, E To reduce the possibility of further infection with bacteria, the area should be kept clean. Cold sores should be kept moist to prevent cracking and the development of secondary bacterial infection. With secondary infection, application of antibiotic ointment would be indicated. Application of docosanol, local anesthetics, and UV blockers or oral analgesics may be prescribed. Astringents should be avoided to prevent drying, delayed healing, and increased discomfort.

DIF: Cognitive Level: Application Process Step: Implementation

REF:

Page 484 | Page 486 OBJ:

1|2

TOP: Nursing

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Infection; Tissue Integrity; Patient Education

Which assessment information is pertinent to oral health? (Select all that apply.)

Medication history

Dental history, visit frequency

Presence of halitosis

Amount of saliva present

Bowel sounds

ANS: A, B, C, D Pertinent history for oral health includes current drug therapy and dental history and frequency. Halitosis may indicate poor oral hygiene or the presence of infection in the oral cavity. Reduced amount of saliva is a risk factor for injury and infection in the oral cavity. Bowel sounds are not pertinent information to oral health.

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DIF: Cognitive Level: Application Assessment

REF:

Page 487

OBJ:

1 | 3 TOP: Nursing Process Step:

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MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Health Promotion

A patient who is undergoing bone marrow transplantation has developed severe mucositis.

Which treatment option(s) may promote comfort? (Select all that apply.) a.

2 % viscous lidocaine (Xylocaine) before meals

Acetylcysteine (Mucomyst) therapy as needed

Commercially prepared mouthwashes

Docosanol (Abreva) therapy

Milk of Magnesia mouth rinses

ANS: A, E The pain with mucositis can be extremely severe. Viscous lidocaine 2% anesthetizes the entire mouth and throat. Used before meals, it facilitates patient eating. Care must be taken that the patient does not burn himself or herself because sensation is diminished. Milk of Magnesia can also be used as a mouth rinse to coat the mucous membranes. Acetylcysteine does not treat mucositis. Commercial mouthwashes contain alcohol, which is detrimental to the healing of mucositis. Docosanol is used to treat topical herpes infections, not mucositis.

DIF: Cognitive Level: Application Step: Implementation

REF:

Page 487

OBJ:

1 | 2 | 3 TOP: Nursing Process

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Inflammation; Pain; Patient Education

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In addition to discomfort, which are adverse effects of xerostomia? (Select all that apply.)

Reduced taste and appetite

Excessive salivation

Difficulty chewing and swallowing food

Increase in dental caries

Difficulty with speech

Improved taste and enjoyment of food

ANS: A, C, D, E Xerostomia increases tooth decay and causes loss of taste, difficulty in chewing and swallowing food, and difficulty talking. Xerostomia does not cause excessive salivation or food to taste better.

DIF: Cognitive Level: ComprehensionREF: Assessment

Page 486

OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Nutrition; Safety; Communication

1 TOP: Nursing Process Step:

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Chapter 32: Drugs Used to Treat Gastroesophageal Reflux and Peptic Ulcer Diseases Test Bank

MULTIPLE CHOICE

1. Which medication is used in the treatment of gastric reflux esophagitis and diabetic gastroparesis? a.

Metoclopramide

Misoprostol

Pantoprazole

Ranitidine

ANS:

Metoclopramide is a gastric stimulant used to relieve the symptoms of gastric reflux esophagitis and diabetic gastroparesis, aid in small bowel intubation, and stimulate gastric emptying and intestinal transit of barium after radiologic examination of the upper gastrointestinal (GI) tract. Misoprostol is used to prevent and treat gastric ulcers caused by NSAIDs, including aspirin. Pantoprazole and ranitidine do not treat gastroparesis.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 530 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

4 TOP: Nursing Process Step:

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2. The nurse is preparing to administer medications and notes that a patient has sucralfate ordered qid. When is the best time to administer this medication? a.

1 hour before meals

With meals

1 hour after meals

With a bedtime snack

ANS:

This medication should be administered on an empty stomach. Taking the medication with meals, 1 hour after meals, or with a bedtime snack does not allow the medication to form its protective coat of the gastric mucosa.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 529 OBJ: TOP:

Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

4 |5

Which is a common adverse effect of magnesium based antacid preparations?

Heartburn

Rebound indigestion

Constipation

Diarrhea

ANS:

Magnesium oxide, magnesium hydroxide, and magnesium trisilicate are used in antacid preparations. All magnesium products can cause diarrhea. Milk of Magnesia is often taken for

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constipation. Antacids are given to relieve heartburn. Calcium based antacids are likely to cause rebound indigestion. Magnesium is often given as a laxative, in antacid form or as magnesium sulfate.

DIF: Cognitive Level: Knowledge Implementation

REF:

p. 523 OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Cimetidine (Tagamet) is an example of which class of drug?

Protokinetic agent

Proton pump inhibitor

Histamine (H2) receptor antagonist

Coating agent

ANS: C All H2 receptor antagonists end in “ dine.” Examples in this category include cimetidine, ranitidine, famotidine, and nizatidine. An example of a protokinetic agent is metoclopramide. An example of a proton pump inhibitor is omeprazole. An example of a coating agent is sucralfate.

DIF: Cognitive Level: Knowledge Implementation

REF:

p. 524 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

4 TOP: Nursing Process Step:

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5. A postoperative appendectomy patient has a nasogastric tube and wonders why the previous nurse told him that he was receiving an IV “ulcer preventing” medication called ranitidine. The patient states that he has never had any stomach problems in his life. Which is the best response by the nurse? a.

“This medication will cause the pH in your stomach to drop.”

“This medication helps coat your stomach while the nasogastric tube is in place.”

c. “Because you are not eating after surgery, this medication will help reduce the hydrochloric acid your stomach is still secreting.” d.

“The nasogastric tube will cause peptic ulcer disease. This medication will help prevent that.”

ANS: C Patients who are not eating still secrete hydrochloric acid from the stomach’s parietal cells. H2 receptor antagonists block the H2 receptors, resulting in a decrease in the amount of acid secreted. The pH of the stomach contents then becomes less acidic, which reduces the stress of the mucosal lining of the stomach. Ranitidine causes the stomach contents to become less acidic as the amount of acid secreted decreases; consequently, the pH of the stomach rises. This is not a coating agent, and giving it parenterally will not work to coat the stomach. Increased gastric acid, not nasogastric tubes, causes peptic ulcer disease (PUD).

DIF: Cognitive Level: Application Implementation

REF:

pp. 524-525

OBJ:

3 | 5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance 6. Which explanation by the nurse is accurate to include when teaching a patient who is beginning therapy for gastroesophageal reflux disease (GERD) with metoclopramide?

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“This medication decreases esophageal muscle tone to reduce reflux.”

“Peristalsis is increased, so food is digested more quickly.”

“Gastric emptying is delayed, so you may feel full for longer intervals.”

“This medication is an antikinetic agent, so you may have difficulty with motor skills.”

ANS: B Prokinetic agents increase the lower esophageal sphincter muscle pressure and peristalsis, hastening emptying of the stomach to reduce reflux. Metoclopramide increases lower esophageal sphincter pressure. Metoclopramide hastens gastric emptying. Metoclopramide is a prokinetic agent and does not affect motor function.

DIF:

Cognitive Level: Application

REF:

p. 530 OBJ:

5 TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

7. A patient who is taking NSAIDs to treat arthritis asks the nurse why misoprostol has also been prescribed. Which explanation by the nurse is accurate? a.

NSAIDs often cause GI irritation that can result in peptic ulcers.

NSAIDs promote the production of prostaglandins and reduce the incidence of gastric irritation.

Antiulcer medications eradicate the presence of bacteria in the stomach that cause ulcers.

d. Drug interactions are prevented when antiulcer medications are used in combination with NSAIDs. ANS: A Misoprostol, a GI prostaglandin, is used to prevent and treat gastric ulcers caused by NSAIDs. Prostaglandin inhibition is effective in reducing pain and inflammation, especially in arthritis, but makes the patient more predisposed to peptic ulcers. Prostaglandins are normally present in the GI tract to inhibit gastric acid and pepsin secretion to protect the stomach and duodenal lining against ulceration. NSAIDs inhibit prostaglandin production. Bismuth subsalicylate, metronidazole, and tetracycline combination (Helidac), as well as lansoprazole, clarithromycin, and amoxicillin combination (Prevpac), are used to treat infections caused by Helicobacter pylori. Drug interactions are not prevented by the presence of antiulcer medications.

DIF: Cognitive Level: ComprehensionREF: Assessment

pp. 526-527

MSC: NCLEX Client Needs Category: Physiological Integrity

OBJ:

4 | 5 TOP: Nursing Process Step:

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Which organism or disorder is responsible for many cases of PUD?

H. pylori

Candida albicans

Escherichia coli

Herpes zoster

ANS: A Various combinations of antibiotics (e.g., amoxicillin, tetracycline, metronidazole, clarithromycin), bismuth, and antisecretory agents (e.g., H2 antagonists, proton pump

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inhibitors) are used to eradicate H. pylori. C. albicans is the causative agent of candidiasis. E. coli is a normal bowel flora. Herpes zoster is also known as shingles.

DIF: Cognitive Level: Knowledge Implementation

REF:

p. 520 OBJ:

2 | 3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

9. A patient with PUD asks the nurse about the action of prokinetic medications. Which explanation by the nurse is accurate? a.

It blocks the formation of hydrochloric acid, reducing irritation of the gastric mucosa.

It increases the lower esophageal sphincter muscle pressure and peristalsis.

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It reduces the secretion of saliva, hydrochloric acid, pepsin, bile, and other enzymatic fluids.

It decreases the volume of hydrochloric acid produced, increasing the gastric pH.

ANS: B Prokinetic agents increase the lower esophageal sphincter muscle pressure and peristalsis, hastening emptying of the stomach to reduce reflux. Proton pump inhibitors block the formation of hydrochloric acid, reducing irritation of the gastric mucosa. Antispasmodic agents reduce the secretion of saliva, hydrochloric acid, pepsin, bile, and other enzymatic fluids necessary for digestion and decrease GI motility and secretions. H2 antagonists decrease the volume of hydrochloric acid produced, increasing the gastric pH, which results in decreased irritation to the gastric mucosa.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 521 OBJ:

4 | 5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

10. Which is considered an acceptable time frame for a patient with gastric distress to self medicate with over the counter antacids? a.

Hours

Days

Weeks

Months

ANS: C For indigestion, antacids should not be administered for more than 2 weeks. If after this time the patient is still experiencing discomfort, a health care provider should be contacted. A time frame of hours or days is less than the acceptable time interval. A time frame of months is greater than the acceptable time interval.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 523 OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

11. The nurse is instructing a patient recently diagnosed with GERD. Which statement by the patient indicates a need for further teaching? a.

“I will avoid foods high in fat.”

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“I will eat small frequent meals and have a snack at bedtime.”

“Orange juice may aggravate my symptoms.”

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“I will wait 2 hours after eating lunch before lying down for a nap.”

ANS: B Late night snacks need to be avoided to reduce increased gastric secretions. The patient with GERD needs to avoid foods high in fat and should wait 2 hours after eating before lying down. Orange juice may aggravate the symptoms of a patient with GERD.

DIF: Cognitive Level: Application Evaluation

REF:

pp. 521-522

OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

12. The nurse is planning to administer an antacid to a patient diagnosed with PUD who will receive an H2 antagonist at 8:00 AM. When is the most appropriate time for the nurse to provide the antacid to this patient? a.

With the H2 antagonist

30 minutes prior to the H2 antagonist

2 hours after the H2 antagonist

Within an hour after the H2 antagonist

ANS: C Because antacid therapy is often continued during early therapy of PUD, administer 1 hour before or 2 hours after H2 antagonist dose.

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DIF: Cognitive Level: Analysis Implementation

REF:

p. 525 OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

13. A patient taking misoprostol (Cytotec) to treat a gastric ulcer reports recurrent diarrhea. The nurse should encourage this patient to: a.

immediately discontinue misoprostol (Cytotec).

take with a magnesium containing antacid.

omit fresh fruits from diet.

take medication with meals.

ANS: D Taking medication with meals may lessen diarrhea. Diarrhea associated with misoprostol therapy is dose related. The patient should not discontinue therapy without first consulting with the health care provider. Magnesium containing antacids should be avoided. Fresh fruits are considered roughage and should be encouraged.

DIF: Cognitive Level: Application Implementation

REF:

p. 527 OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

MULTIPLE RESPONSE

14. Which factor(s) prevent(s) breakdown of the body’s normal defense barriers that protect against ulcer formation? ( Select all that apply. ) a.

Stomach pH

Prostaglandins

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Intrinsic factor

Mucous cells

Hydrochloric acid

ANS: B, D Prostaglandins play a major role in protecting the stomach walls from injury by stomach acids and enzymes. They inhibit gastric acid secretion, maintain blood flow, and stimulate mucous and bicarbonate production. Mucous cells secrete mucus that coats the stomach wall and protects the stomach wall from hydrochloric acid and the digestive enzyme pepsin. For decades, ulcer treatment focused on reducing acid secretions (anticholinergic agents, H2 antagonists, proton pump inhibitors), neutralizing acid (antacids), or coating ulcer craters to hasten healing (sucralfate). Major changes in therapy have come about because the FDA has approved antibiotics to eradicate H. pylori. Intrinsic factor is a glycoprotein secreted by parietal cells of the gastric mucosa. It has an important role in the absorption of vitamin B12 (cobalamin) in the intestine, and failure to produce or use intrinsic factor results in the condition termed pernicious anemia.

DIF: Cognitive Level: ComprehensionREF: Implementation

pp. 519-520

OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

15. Which are important nursing considerations when administering prokinetic agents? ( Select all that apply.) a.

These agents are used to treat esophagitis associated with gastric reflux.

They are used to treat GERD when lifestyle changes and diet are ineffective.

They may be useful in treating nausea associated with chemotherapy treatment.

They may be administered intravenously.

Administer the medication to diabetic patients after meals.

ANS: A, B, C, D Metoclopramide is used to relieve the symptoms of gastric reflux esophagitis. This agent is used to treat GERD when lifestyle and diet modifications are ineffective. Metoclopramide is used as an antiemetic in

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conjunction with chemotherapy. Prokinetic agents may be administered intravenously and should be administered before meals.

DIF: Cognitive Level: Application Process Step: Assessment MSC:

REF:

p. 521 | pp. 529-530 OBJ:

4|5

TOP: Nursing

NCLEX Client Needs Category: Physiological Integrity

16.

Which factor(s) contribute(s) to the development of PUD? ( Select all that apply. )

Cigarette smoking

Stress

Genetics

Excessive ingestion of milk products

H. pylori

ANS: A, C, E Cigarette smoking increases acid secretion and alters blood flow to the stomach. In addition, cigarette smoking interferes with prostaglandin synthesis, which compromises defense mechanisms. A genetic predisposition seems to exist for the development of PUD. Infection

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by H. pylori is thought to be associated with as many as 90% of duodenal and 70% of gastric ulcers. Chronic emotional stress was previously believed to cause stress ulcer, and physicians suggested that patients with this condition reduce their stress levels. However, patients who took steps to reduce the stress in their lives saw no improvement. It is now known that emotional stress does not cause ulcers, but it may make them worse. Bacteria have been shown to cause a stress ulcer, which can be treated simply by taking a dose of antibiotics.

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Dairy products do not contribute to the development of ulcers.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 520 OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

17.

Which drug therapy is aimed at reducing gastric acid secretions? ( Select all that apply. ) a.

Prokinetic agents b.

Antacids

H2 antagonists

Proton pump inhibitors

Coating agents

ANS: C, D H2 antagonists and proton pump inhibitors are used to reduce gastric acid secretion. Prokinetic agents are used to hasten emptying of the stomach to reduce reflux. Antacids neutralize gastric acid. Coating agents are given to form a barrier in the stomach.

DIF:

Cognitive Level: ComprehensionREF:

p. 521 OBJ:

4 TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity

18. Which information will the nurse include when teaching a patient with renal failure about antacid therapy for treatment of heartburn? ( Select all that apply. ) a.

Taking magnesium-based antacids prevents diarrhea.

Magnesium-based antacids are preferred for patients with renal failure.

Aluminum hydroxide antacids exacerbate constipation.

d. If the patient has coffee ground emesis or bloody stools, the frequency of antacids should be doubled. e.

Antacids neutralize gastric acid.

ANS: C, E Constipation is an adverse effect of aluminum based antacids. Antacids lower the acidity of gastric secretions by neutralizing the acid. Magnesium has a laxative effect. Patients with renal failure should

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not use antacids containing magnesium. Hematemesis or hematochezia should be reported to the health care provider immediately.

DIF: Cognitive Level: Application Implementation

REF:

pp. 522-523

OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

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19.

The nurse is discussing dietary and lifestyle changes with a patient diagnosed with GERD.

When reviewing necessary modifications, the nurse will include information regarding: (Select all that apply.) a.

limiting coffee intake to 2 cups/day.

smoking cessation.

avoiding NSAIDs.

decreasing protein foods.

using nonfat milk

ANS:

B, C, E

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Interventions to help relieve symptoms associated with GERD include cessation of smoking, avoidance of NSAIDs, and use of nonfat milk. Coffee should be avoided completely. Protein foods should be increased.

DIF:

Cognitive Level: Application

REF:

TOP:

Nursing Process Step: Implementation

p. 522 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

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Chapter 34: Drugs Used to Treat Constipation and Diarrhea Test Bank

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MULTIPLE CHOICE

1. When the nurse assesses bowel habits in a patient, which is the best example of normal bowel elimination? a.

Daily bowel movements

Multiple soft stools daily

Daily liquid stools

Regular bowel elimination pattern of soft stool

ANS:

Normal bowel habits are stools that are soft and occur on a regular schedule of elimination for that particular patient. Although this may be routine for some people, it is not normal for everyone. Liquid stools are not considered normal.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 551 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

2. Which drug would be most effective for an obstetric patient who is complaining of constipation as a result of her enlarging uterus and use of prenatal vitamins? a.

Saline laxative

Lubricant laxative

Stimulant laxative

Mineral oil

ANS:

Lubricant and bulk forming laxatives may be used in the pregnant patient because little cramping accompanies their use. Saline laxatives are not safe for a pregnant woman because of the bowel distention and possible electrolyte imbalance they may cause. Stimulant laxatives are too harsh for a pregnant woman because they may cause cramping. Mineral oil is not a good laxative to use on a regular basis because it can cause malabsorption of vitamins.

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DIF: Cognitive Level: Application Implementation

REF:

p. 555 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

The nurse is performing a premedication assessment. For which patient would laxative use be

contraindicated? a.

Patient with quadriplegia

Patient with appendicitis

Geriatric patient

Patient with fractured femur

ANS:

Patients who have a history of an inflammation of the gastrointestinal (GI) tract, including gastritis, colitis, Crohn’s disease, ulcerative colitis, and appendicitis, should not take laxatives and should be referred to a health care provider. Quadriplegic and geriatric patients as well as patients with fractures may generally take laxatives and stool softeners on a regular basis. This study source was downloaded by 100000761823232 from CourseHero.com on 04-12-2021 14:51:47 GMT -05:00

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DIF: Cognitive Level: Application REF: p. 552 | p. 555 OBJ: 2 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

4. Which is the laxative of choice for an older patient who is in the end stage of Alzheimer’s disease and requires a daily laxative? a.

Emollient

Stimulant

Fecal softener

Bulk forming

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ANS: D Bulk forming laxatives are considered the safest laxative for routine use because they cause water to be retained within the stool, which increases bulk, and stimulates peristalsis. Emollient laxatives reduce muscle tone and decrease peristalsis over time. Stimulant laxatives can cause cramping and should not be used on a regular basis. Fecal softeners are not laxatives.

DIF:

Cognitive Level: Analysis

REF:

p. 555 OBJ:

2 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

A friend reports using loperamide (Imodium) for continual diarrhea for a week since

returning home from a vacation outside the country. Which is the nurse’s best response? a. “There are some other over the counter products available for diarrhea, such as Kaopectate (bismuth subsalicylate).” b. “I’d stop taking the Imodium and go in to see a health care provider immediately. You may have an infection in your intestinal tract.” c. “If you’re not running a temperature, I wouldn’t worry. That happens to many people when they travel.” d. “As long as you can drink plenty of fluids, I’m sure the diarrhea will go away once you’re back in a normal routine.” ANS: B Diarrhea may be a defense mechanism to rid the body of infecting organisms or irritants. Diarrhea is usually self limiting and should not be suppressed with over the counter products. It is safest for people who are suffering from diarrhea after traveling outside the country to visit their health care provider, who can determine whether an infection is present.

DIF: Cognitive Level: Application Evaluation

REF:

pp. 551-552

OBJ:

6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

6. A patient who has had a myocardial infarction is advised to avoid straining with defecation. Which medication would be prescribed to this patient? a.

Stool softeners

Bulk forming laxatives

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Stimulants

Emollients

ANS: A Stool softeners are routinely used for the prevention of constipation or to prevent straining with defecation (e.g., in patients recovering from myocardial infarction or abdominal This study source was downloaded by 100000761823232 from CourseHero.com on 04-12-2021 14:51:47 GMT -05:00

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surgery). Bulk forming laxatives and emollients can cause straining. Stimulants can cause cramping and straining.

DIF:

Cognitive Level: Analysis

REF:

p. 555 OBJ:

2 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

7. An older adult is admitted through the emergency department with complaints of nausea, abdominal tenderness, and continual stooling. On assessment, the nurse notes abdominal distention, smearing of stool on undergarments, and hypoactive bowel sounds LUQ and LLQ. The patient is unable to determine when the last bowel movement was. What is the nurse’s priority assessment? a.

Signs and symptoms of an infection

An impaction

A pattern of laxative abuse

History of GI disease

ANS: B A nursing priority is to determine basic needs such as last bowel movement, constipation, and pain control. The symptoms presented do not indicate an infection as a priority. Frequent stooling indicated by the history and smearing on the undergarments is a sign of an impaction, or an area of hardened stool. Laxative abuse or a history of GI disease may be contributing factors that the health care provider will review. Although the patient may have an infection or history of GI disease, checking for an impaction is a higher priority because it is done more quickly and is more likely to yield results. These symptoms are not characteristic of laxative abuse.

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DIF:

Cognitive Level: Application

REF:

p. 556 OBJ:

1 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

Which symptom is the patient with a lactase deficiency most likely to exhibit?

Constipation

Excessive salivation

Diarrhea

Vomiting

ANS: C Patients with deficiencies of digestive enzymes such as lactase or amylase have difficulty digesting certain foods. Diarrhea usually develops because of irritation from undigested food. Constipation, excessive salivation, and vomiting do not result from enzyme deficiencies.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 552 OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity 9. A patient is receiving morphine for pain control. What will the nurse emphasize about preventing constipation? a.

Adequate hydration consists of four full glasses of water every day.

Laxatives should be given on a daily basis.

Stool softeners are taken on a regular basis during opioid use.

Enemas should be given on a weekly basis.

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When codeine or morphine is used regularly for pain control in cancer patients, it is imperative that the individual know that stool softeners should be initiated and continued as long as constipating medicines are being taken. Although adequate hydration is important in the prevention of constipation, individual needs vary, and hydration alone cannot prevent constipation related to opioid use. Laxatives are too harsh to be given regularly unless specifically ordered by the health care provider. Enemas are not a preventive measure but an intervention intended to produce a more positive outcome.

DIF: Cognitive Level: Application Implementation

REF:

p. 554 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

10.

What is the mechanism of action of a stimulant laxative?

Draws water into the bowel to facilitate the passage of feces

Lubricates the intestinal wall and soften stool

Increases bulk and stimulate peristalsis

Irritates the intestine directly, promoting peristalsis and evacuation

ANS: D Stimulant laxatives act directly on the intestine, causing an irritation that promotes peristalsis and evacuation. Saline laxatives draw water into the bowel to facilitate the passage of feces. Lubricant laxatives lubricate the intestinal wall and soften the stool, allowing a smooth passage of fecal contents. Bulk producing laxatives must be administered with a full glass of water. The laxative causes water to be retained within the stool. This increases bulk, which stimulates peristalsis.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 554 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

11.

Which effect will the nurse expect when a patient is taking psyllium while on digoxin?

Decreased effectiveness of the laxative

Increased laxative effect

Increased absorption of the digoxin

Decreased absorption of the digoxin

ANS: D

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Do not administer products containing psyllium (e.g., Metamucil) at the same time as salicylates, nitrofurantoin, or digoxin glycosides. The psyllium may inhibit absorption. Administer these medications at least 1 hour before or 2 hours after psyllium. Digoxin does not affect laxatives.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 556 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

12.

Which instruction will the nurse include in the discharge teaching of a patient taking psyllium?

“Administer with a full glass of water.”

“Limit the intake of high fiber foods.”

“Avoid mixing in juice.”

“Fat soluble vitamin deficiency is common.”

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ANS: A It is important that bulk forming laxatives be dispersed in a full glass of water or juice before administration. High fiber foods should not be limited. Psyllium may be mixed in juice for administration. Fat soluble vitamin deficiency is not a common adverse effect.

DIF: Cognitive Level: Application Implementation

REF:

p. 555 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

13. Which instruction by the nurse will assist in the patient’s understanding of lactulose, an osmotic laxative? a.

“This medication draws water into the intestine and stimulates defecation.”

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“There is increased irritability directly on the intestinal wall.”

“There is lubrication of the intestinal wall that softens the stool.”

“There is an effect on the nerves to increase the peristalsis of the intestinal smooth muscle.”

ANS: A Osmotic laxatives (e.g., magnesium hydroxide, magnesium sulfate, magnesium citrate, sodium phosphate, lactulose, polyethylene glycol) are hypertonic compounds that draw water into the intestine from surrounding tissues.

DIF: Cognitive Level: Application Implementation

REF:

p. 555 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

14. The nurse is caring for a patient receiving palliative care with opioid induced constipation. Laxative therapy has been unsuccessful in treating this patient. Which PRN medication should the nurse provide to best alleviate this type of constipation? a.

Methylnaltrexone

Bisacodyl

Mineral oil

Docusate

ANS: A Methylnaltrexone is used for the treatment of opioid induced constipation in patients with advanced illness who are receiving palliative care when their response to laxative therapy has not been adequate. Bisacodyl, mineral oil, and docusate are not the treatment of choice for this situation.

DIF: Cognitive Level: Application Implementation

REF:

p. 555 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

15. The nurse is assessing a patient taking lactulose to treat chronic constipation. Which adverse effect should the nurse immediately report to the health care provider? a.

Nausea

Abdominal spasms

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Flatulence

Abdominal tenderness

ANS: D

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Abdominal tenderness is considered a serious adverse effect and can indicate acute abdomen. Nausea, abdominal spasms, and flatulence is a common adverse effect.

DIF: Cognitive Level: Analysis Assessment

REF:

p. 556 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

MULTIPLE RESPONSE

16. The nurse is assessing a patient with constipation. Which situation(s) would cause constipation? ( Select all that apply. ) a.

Diet low in fiber and/or residue

Excessive fluid intake

Diet low in cheese and yogurt

Iron supplements

Use of morphine

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intake helps prevent constipation. Constipation can be caused by excessive intake of constipating foods such as cheese or yogurt.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 551 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

17.

Which sign(s) and symptom(s) are consistent with dehydration? ( Select all that apply. )

Increased hemoglobin and hematocrit

Decreased urine specific gravity

Mental confusion and excessive thirst

Periorbital edema and increased blood pressure

Nonelastic skin turgor and delayed capillary filling

ANS: A, C, E Blood work of dehydrated patients will show falsely elevated hemoglobin and hematocrit levels as a result of decreased capillary fluid. Dehydrated patients may become confused as a result of electrolyte imbalances and often complain of thirst. Older patients may not complain of thirst as a result of perceptual changes. Dehydration is evident by nonelastic skin turgor and delayed capillary filling. DIF: Cognitive Level: Analysis Assessment

REF:

p. 553 OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

18. Which treatment(s) would be considered safe for an infant? ( Select all that apply. ) a. Saline laxatives b.

Bulk forming laxatives

Malt soup extract

Stimulant laxatives

ANS: B, C Constipation in infants can be treated with a bulk forming laxative and malt soup extract.

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Saline laxatives are not appropriate for infants because of the risk of electrolyte imbalances. Stimulant laxatives are not appropriate for infants.

DIF:

Cognitive Level: Analysis

REF:

p. 555 OBJ:

2 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

19. The nurse in a long term care facility is preparing to pass medications to the residents. To which of the following residents should the nurse administer an antidiarrheal? (Select all that apply.) a.

An 80-year-old woman with diarrhea of sudden onset that has lasted 3 days

A 76-year-old man with infectious diarrhea

A 92-year-old man with diarrhea secondary to inflammatory bowel disease

A 70-year-old woman with a history chronic diarrhea from GI surgery

An 88-year-old man that has had two episodes of stress induced diarrhea

ANS: A, C, D Diarrhea of sudden onset lasting more than 2 or 3 days can cause significant fluid and water loss; therefore, an antidiarrheal is indicated. Patients with inflammatory bowel disease develop diarrhea. Rapid treatment shortens the course of the incapacitating diarrhea and allows the patient to live a more normal lifestyle. Postoperative GI surgery patients develop diarrhea. These patients may require chronic antidiarrheal therapy to allow adequate absorption of fluids and electrolytes. Antidiarrheals should not be given to patients known to have infectious diarrhea. Two bouts of diarrhea would not indicate a need for an antidiarrheal.

DIF: Cognitive Level: Analysis Step: Assessment

REF:

p. 553 | p. 557 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

TOP: Nursing Process

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Chapter 34: Drugs Used to Treat Constipation and Diarrhea Test Bank

MULTIPLE CHOICE

1. When the nurse assesses bowel habits in a patient, which is the best example of normal bowel elimination? a.

Daily bowel movements

Multiple soft stools daily

Daily liquid stools

Regular bowel elimination pattern of soft stool

ANS:

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 551 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

2. Which drug would be most effective for an obstetric patient who is complaining of constipation as a result of her enlarging uterus and use of prenatal vitamins? a.

Saline laxative

Lubricant laxative

Stimulant laxative

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Mineral oil

ANS:

DIF: Cognitive Level: Application Implementation

REF:

p. 555 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

The nurse is performing a premedication assessment. For which patient would laxative use be

contraindicated? a.

Patient with quadriplegia

Patient with appendicitis

Geriatric patient

Patient with fractured femur

ANS:

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DIF: Cognitive Level: Application REF: p. 552 | p. 555 OBJ: 2 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

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4. Which is the laxative of choice for an older patient who is in the end stage of Alzheimer’s disease and requires a daily laxative? a.

Emollient

Stimulant

Fecal softener

Bulk forming

DIF:

Cognitive Level: Analysis

REF:

p. 555 OBJ:

2 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

A friend reports using loperamide (Imodium) for continual diarrhea for a week since

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DIF: Cognitive Level: Application Evaluation

REF:

pp. 551-552

OBJ:

6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

6. A patient who has had a myocardial infarction is advised to avoid straining with defecation. Which medication would be prescribed to this patient? a.

Stool softeners

Bulk forming laxatives

Stimulants

Emollients

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surgery). Bulk forming laxatives and emollients can cause straining. Stimulants can cause cramping and straining.

DIF:

Cognitive Level: Analysis

REF:

p. 555 OBJ:

2 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

Signs and symptoms of an infection

An impaction

A pattern of laxative abuse

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History of GI disease

DIF:

Cognitive Level: Application

REF:

p. 556 OBJ:

1 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

Which symptom is the patient with a lactase deficiency most likely to exhibit?

Constipation

Excessive salivation

Diarrhea

Vomiting

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 552 OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity 9. A patient is receiving morphine for pain control. What will the nurse emphasize about preventing constipation? a.

Adequate hydration consists of four full glasses of water every day.

Laxatives should be given on a daily basis.

Stool softeners are taken on a regular basis during opioid use.

Enemas should be given on a weekly basis.

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ANS: C This study source was downloaded by 100000761823232 from CourseHero.com on 04-12-2021 14:51:47 GMT -05:00

https://www.coursehero.com/file/19255130/ch35/

DIF: Cognitive Level: Application Implementation

REF:

p. 554 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

10.

What is the mechanism of action of a stimulant laxative?

Draws water into the bowel to facilitate the passage of feces

Lubricates the intestinal wall and soften stool

Increases bulk and stimulate peristalsis

Irritates the intestine directly, promoting peristalsis and evacuation

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 554 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

2 TOP: Nursing Process Step:

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11.

Which effect will the nurse expect when a patient is taking psyllium while on digoxin?

Decreased effectiveness of the laxative

Increased laxative effect

Increased absorption of the digoxin

Decreased absorption of the digoxin

ANS: D Do not administer products containing psyllium (e.g., Metamucil) at the same time as salicylates, nitrofurantoin, or digoxin glycosides. The psyllium may inhibit absorption. Administer these medications at least 1 hour before or 2 hours after psyllium. Digoxin does not affect laxatives.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 556 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

12.

Which instruction will the nurse include in the discharge teaching of a patient taking psyllium?

“Administer with a full glass of water.”

“Limit the intake of high fiber foods.”

“Avoid mixing in juice.”

“Fat soluble vitamin deficiency is common.”

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DIF: Cognitive Level: Application Implementation

REF:

p. 555 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

13. Which instruction by the nurse will assist in the patient’s understanding of lactulose, an osmotic laxative? a.

“This medication draws water into the intestine and stimulates defecation.”

“There is increased irritability directly on the intestinal wall.”

“There is lubrication of the intestinal wall that softens the stool.”

“There is an effect on the nerves to increase the peristalsis of the intestinal smooth muscle.”

DIF: Cognitive Level: Application Implementation

REF:

p. 555 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Methylnaltrexone

Bisacodyl

Mineral oil

Docusate

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DIF: Cognitive Level: Application Implementation

REF:

p. 555 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

15. The nurse is assessing a patient taking lactulose to treat chronic constipation. Which adverse effect should the nurse immediately report to the health care provider? a.

Nausea

Abdominal spasms

Flatulence

Abdominal tenderness

ANS: D

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Abdominal tenderness is considered a serious adverse effect and can indicate acute abdomen. Nausea, abdominal spasms, and flatulence is a common adverse effect.

DIF: Cognitive Level: Analysis Assessment

REF:

p. 556 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

MULTIPLE RESPONSE

16. The nurse is assessing a patient with constipation. Which situation(s) would cause constipation? ( Select all that apply. ) a.

Diet low in fiber and/or residue

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Excessive fluid intake

Diet low in cheese and yogurt

Iron supplements

Use of morphine

ANS: A, D, E Constipation can be caused by diets lacking in adequate residue and/or fiber and fluids or the use of constipating medicines (morphine, codeine, anticholinergic agents). Iron has a constipating effect. Fluid intake helps prevent constipation. Constipation can be caused by excessive intake of constipating foods such as cheese or yogurt.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 551 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

17.

Which sign(s) and symptom(s) are consistent with dehydration? ( Select all that apply. )

Increased hemoglobin and hematocrit

Decreased urine specific gravity

Mental confusion and excessive thirst

Periorbital edema and increased blood pressure

Nonelastic skin turgor and delayed capillary filling

REF:

p. 553 OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

18. Which treatment(s) would be considered safe for an infant? ( Select all that apply. ) a. Saline laxatives b.

Bulk forming laxatives

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Malt soup extract

Stimulant laxatives

ANS: B, C Constipation in infants can be treated with a bulk forming laxative and malt soup extract.

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Saline laxatives are not appropriate for infants because of the risk of electrolyte imbalances. Stimulant laxatives are not appropriate for infants.

DIF:

Cognitive Level: Analysis

REF:

p. 555 OBJ:

2 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

An 80-year-old woman with diarrhea of sudden onset that has lasted 3 days

A 76-year-old man with infectious diarrhea

A 92-year-old man with diarrhea secondary to inflammatory bowel disease

A 70-year-old woman with a history chronic diarrhea from GI surgery

An 88-year-old man that has had two episodes of stress induced diarrhea

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DIF: Cognitive Level: Analysis Step: Assessment

REF:

p. 553 | p. 557 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

TOP: Nursing Process

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Chapter 35: Drugs Used to Treat Diabetes Mellitus Test Bank

MULTIPLE CHOICE

1. A patient received the evening dose of Lispro subcutaneously at 1630. What time will symptoms of hypoglycemia likely occur? a. 1900 b. 1830 c.

0130

d. 0600 ANS: B The most rapid-acting insulin, Lispro, peaks within 1 to 2 hours after administration. The peak time of insulin is when patients would most likely exhibit symptoms of hypoglycemia, particularly if they have inadequate dietary intake. The time of 1900 would be past the peak of action and after signs of hypoglycemia would have appeared. The times of 0130 and 0600 are long after the peak of action and the time when signs of hypoglycemia would have appeared.

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DIF: Cognitive Level: Application Assessment

REF:

p. 574 OBJ:

4 | 6 | 7 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

2. It is 2:00 PM and a patient who has been NPO since 12 AM for a bronchoscopy is complaining of a headache and shakiness, and is extremely irritable. Vital signs are within normal limits, and a one touch glucose reads 50 mg/dL. Which action is most important for the nurse to take? a.

Have the patient eat a snack and drink milk.

Administer glucagon subcutaneously.

Call the bronchoscopy room to follow up with the delay.

Obtain an A1c test.

ANS: B Irritability, nervousness, headache, tremors, dizziness, apprehension, sweating, cold and clammy skin, and hunger are symptoms of hypoglycemia. The patient has not eaten since the prior day. A blood glucose of 50 mg/dL is true hypoglycemia and needs to be dealt with immediately. Glucagon is preferred over PO intake, given that an endoscopy is scheduled. Having the patient eat a snack and drink milk, calling the bronchoscopy room, and obtaining an A1c test are not appropriate responses.

DIF: Cognitive Level: Analysis Diagnosis

REF:

p. 571 OBJ:

2 | 6 | 7 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

3. After a blood glucose reading, it is determined that the patient should receive 4 units of Lispro and 8 units of NPH. Which action will the nurse take to administer these medications?

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Draw up each insulin in separate syringes and administer two injections.

Draw up the NPH first and then the Lispro using the same syringe.

Administer the Lispro before the meal and the NPH after the meal.

Draw up the Lispro first and then the NPH using the same syringe.

ANS: D Lispro, an insulin analogue, is the most rapid-acting insulin. Insulin analogues are compatible with intermediate (NPH) or long-acting insulin. When combining two types of insulin, the short acting insulin is drawn up before the intermediate acting insulin. There is no reason to administer a second injection. The long-acting insulin is drawn up last when mixing. Insulin is to be administered before meals.

DIF: Cognitive Level: Application Implementation

REF:

p. 578 OBJ:

4 | 6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

4. A patient with type 2 diabetes mellitus, which was previously controlled with an oral antidiabetic agent, is hospitalized for treatment of a leg ulcer. The health care provider has ordered sliding scale insulin coverage with regular insulin for hyperglycemia. The nurse brings the injection into the room, and the patient becomes upset, stating “I don’t want to start taking that drug! I’ll need it the rest of my life.” What is the nurse’s best response? a. “This is the same drug as the oral medication you were taking. It’s a stronger dose while you are in the hospital.” b. “Don’t worry. You shouldn’t need this too often. As you feel better, your blood glucose level will drop.” c. “Your body is under stress right now, which raises your blood glucose level. This does not mean you will be on this drug permanently. Once you’re feeling better, your provider will determine if your oral medication is all you will need.” d. “Your disease is progressing and your pancreas is producing less insulin. I know this is a hard time for you. Do you want to talk about it?” ANS: C Type 2 diabetes mellitus patients normally controlled with oral hypoglycemics may require insulin during situations of increased physiologic and psychological stress. The stress response stimulates epinephrine

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and norepinephrine, which raises the blood glucose level. Examples of stressors include pregnancy, surgery, and infections.

DIF: Cognitive Level: Application Implementation

REF:

p. 562 OBJ:

4 | 6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Psychological Integrity

What test determines glycemic control over the previous 8 to 10 weeks?

24 hour glucose clearance test (GTT )

Fructosamine test

Fasting blood sugar (FBS)

A1c test

ANS: D The A1c test measures the percentage of hemoglobin that has been irreversibly glycosylated because of high blood sugar levels. This test reflects the average blood sugar level attained

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over the past 8 to 10 weeks. The GTT is never conducted over an interval this long. The fructosamine test measures the amount of glucose bonded to a protein, fructosamine. This reflects the average blood glucose level attained over the past 1 to 3 weeks. The FBS measures the amount of glucose in the blood before eating.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 572 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

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When is the best time for the nurse to administer Lispro?

After the patient has started eating

Within 10 to 15 minutes of eating

30 minutes before a meal

45 to 60 minutes before a meal

ANS: B Insulin analogues, such as Lispro and Aspart, are the most rapid-acting insulins. The onset of these insulins is within 10 minutes of the injection, they peak within 1 to 2 hours, and their duration is 3 to 5 hours. Patients should be eating their meal within 10 to 15 minutes of the injection.

DIF: Cognitive Level: Application Implementation

REF:

p. 574 OBJ:

7 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

Which is the most important for the successful management of diabetes mellitus?

A network of community resources

The level of self management

Preventative education

Frequent follow up with the health care provider

ANS: B Teaching patients to self manage all aspects of their disease, including treatment modalities and preventing complications, is critical to patient success. Patients must be proficient in the entire therapeutic regimen—diet, activity level, blood or urine testing, medication, self injection techniques, prevention of complications, and effective management of hypoglycemia or hyperglycemia. No outside source can overcome the failure of the patient to participate. Teaching the patient to prevent complications of his or her disease is important, but patient participation in managing the disease is crucial. No health care provider can overcome the failure of the patient to participate.

DIF:

Cognitive Level: Application

REF:

p. 563 OBJ:

1 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

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8. What laboratory test is the preferred screening test for diabetes in children and nonpregnant adults? a.

FPG

ECG

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GTT

A1 c

ANS: A The fasting plasma glucose (FPG) is the preferred test used to screen for diabetes in children and nonpregnant adults. Electrocardiograms (ECGs) are used to monitor electrical activity of the heart. The GTT is not recommended for routine clinical use, but may be required in the evaluation of patients with impaired fasting glucose or when diabetes is still suspected, despite a normal FPG, as with the postpartum evaluation of women with gestational diabetes mellitus. The A1c test is used to monitor diabetes management over 90 day intervals, the life of a red blood cell.

DIF: Cognitive Level: Knowledge Assessment

REF:

p. 566 OBJ:

2 | 6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

9. The patient asks the nurse how sulfonylureas normalize glucose levels. Which response by the nurse is correct? a.

By stimulating pancreatic secretion of insulin

By inhibiting secretion of insulin by the pancreas

By increasing glucose production in the liver

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By increasing insulin metabolism in the liver

ANS: A Sulfonylureas stimulate the pancreas to secrete more insulin. They also diminish glucose production and metabolism of insulin by the liver. The net effect is a normalization of insulin and glucose levels. Sulfonylureas decrease glucose production and hepatic metabolism of insulin.

DIF: Cognitive Level: Application Implementation

REF:

p. 564 OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

10. The nurse is instructing a patient about insulin administration. Which statement by the patient indicates a need for further teaching? a.

“I may need more insulin if I have surgery.”

“Once I open my insulin, I will store it in the refrigerator.”

“I will date the insulin bottle when I open it.”

“I will keep a spare bottle of insulin on hand.”

ANS: B Once insulin is opened and being used, it can be stored at room temperature for up to 1 month. The patient may need more insulin if undergoing surgery, should date the insulin bottle after opening, and should keep a spare bottle of insulin on hand.

DIF:

Cognitive Level: Application

REF:

p. 570 | p. 577

OBJ: 6 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

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11. Which instruction by the nurse is accurate to include when providing teaching to a patient recently diagnosed with diabetes who has been prescribed insulin? a.

Beta blockers can mask symptoms of hypoglycemia.

Lipodystrophy increases the absorption of insulin.

Infection will decrease the need for insulin.

Excessive exercise will increase the need for insulin.

ANS: A Beta adrenergic blocking agents (e.g., propranolol, timolol, nadolol, pindolol) may mask many symptoms of hypoglycemia. Lipodystrophy does not increase the absorption of insulin. Infection does not decrease the need for insulin. Excessive exercise does not increase the need for insulin.

DIF: Cognitive Level: Application Implementation

REF:

p. 578 OBJ:

4 | 6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

12. Which instruction is most important for the nurse to teach a patient with diabetes who is receiving metformin? a.

Take the medication before meals.

This medication will cause the pancreas to secrete more insulin.

Stop taking the drug 24 to 48 hours prior to radiopaque dye procedures.

There may be an increase in the triglyceride level.

ANS: C Radiopaque dyes often induce temporary renal insufficiency, so metformin should be discontinued 24 to 48 hours before procedures in which radiopaque dye will be administered. Metformin is not administered before meals. The pancreas does not secrete more insulin as a result of taking this medication. Metformin does not increase triglyceride levels.

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DIF: Cognitive Level: Application Implementation

REF:

p. 579 OBJ:

5 | 6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

13. The nurse is caring for a patient with a new diagnosis of type 1 diabetes mellitus. When assisting with the plan of care, which goal set by the patient will require revision? a.

Patient will participate in 20 minutes of cardiovascular exercise 5 days a week.

Patient will discontinue insulin use within 1 year.

Patient will consume 20% of caloric intake from fat.

Patient will demonstrate accurate self glucose testing skills.

ANS: B Type 1 diabetes mellitus requires the administration of insulin injections to replace the insulin that the body is no longer able to make. Participation in a regular exercise program is a realistic goal. A diabetic diet includes 20% to 35% of calories from fat. A person diagnosed with diabetes should be able to perform glucose testing.

DIF: Cognitive Level: Analysis Step: Planning

REF:

p. 562 | p. 567 OBJ:

1|6

TOP: Nursing Process

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MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

14. The nurse is administering sulfonylurea drugs to four different patients diagnosed with type 2 diabetes. Which patient should not receive the medication as ordered? a.

A 42-year-old man with hypertension

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A 50-year-old woman with shingles

An 80-year-old woman with an allergy to sulfa

A 37-year-old man with a blood glucose level of 140

ANS: C In general, sulfonylureas should not be administered to patients who are allergic to sulfonamides. These patients may also be allergic to sulfonylureas. There is no contraindication for administering sulfonylurea drugs to a 42-year-old man with hypertension, a 50-year-old woman with shingles, or a 37year-old man with a blood glucose level of 140.

DIF: Cognitive Level: Analysis Assessment, Implementation

REF:

p. 581 OBJ:

6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity; Safe, Effective Care Environment

MULTIPLE RESPONSE

15. A third subclass of diabetes mellitus includes additional types of diabetes that are part of other diseases having features not generally associated with the diabetic state. Which disorder(s) may have an associated diabetic component? ( Select all that apply. ) a.

Patients receiving high dose corticosteroid therapy for disease maintenance

Cushing’s syndrome

Alzheimer’s disease

Acromegaly

Malnutrition

ANS: A, B, D, E Drugs and chemicals that induce hyperglycemia are included in the third subclass of diabetes mellitus. Cushing’s syndrome, acromegaly, and malnutrition are included in the third subclass of diabetes mellitus. Alzheimer’s disease is not included in the third subclass of diabetes mellitus.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 562 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

1 TOP: Nursing Process Step:

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16. A 65-year-old man is diagnosed with type 2 diabetes mellitus. Which patient symptom(s) would indicate type 1 diabetes mellitus, and not type 2? ( Select all that apply. ) a.

Impotence

Increased thirst over the past week

A 10-pound weight loss within the past month

Polyphagia

Ketoacidosis

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ANS: B, C, D, E Diabetes type 2 symptoms are insidious and patients present when symptoms may have been apparent for a prolonged time. Polydipsia, a 10-pound weight loss over this short period (1 month), polyphagia, and ketoacidosis are associated with type 1 diabetes. Onset of diabetes type 2 symptoms is usually in the fourth decade of life. Impotence is a symptom associated with type 2 diabetes mellitus.

DIF: Cognitive Level: Application Assessment

REF:

p. 562 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

17. Which dietary control measures are used in the management of diabetes mellitus? (Select all that apply.) a.

Specific daily caloric requirements

Consistent carbohydrate diabetes meal plan

50 % intake of carbohydrates daily

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d. Adjustments to daily meals according to age, metabolic stress, pregnancy, and advanced age and/or older adults e.

20 % intake of proteins daily

ANS: B, C, D, E Meal planning systems are used with the diabetic patient. The consistent carbohydrate diabetes meal plan is used, with an emphasis on consistency of timing of meals and snacks. Daily meals and snacks provide 1500 to 2000 calories, with 50% of the calories from carbohydrates, 20% from protein, and 30% from fat. Individualized adjustments may be required with children, adolescents, metabolically stressed patients, pregnant women, and geriatric patients. Specific daily caloric requirement is not a primary consideration in calculating calorie requirements for a diabetic patient.

DIF: Cognitive Level: ComprehensionREF: p. 563 | pp. 568-569 OBJ: 3 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

18.

Which statement(s) regarding type 2 diabetes mellitus would be correct? (Select all that apply.)

Type 2 diabetes is more prevalent in overweight people older than 45 years.

A genetic predisposition exists for the development of type 2 diabetes mellitus.

Type 2 diabetes requires lifelong insulin replacement.

Type 2 diabetes is often diagnosed after complications have resulted.

Women have a higher incidence of type 2 diabetes.

ANS: A, B, D, E Contributing factors to the development of type 2 diabetes mellitus include being older than 45 years, being overweight, and having a family predisposition to the disease. The early symptoms of this type of diabetes are minimal; therefore, many patients do not seek medical assistance until the complications have appeared. Contributing factors to the development of type 2 diabetes mellitus include being female. In type 2 diabetes mellitus, the pancreas continues to secrete insulin. Patients may be diet controlled or regulated with oral hypoglycemics. Insulin is only used if the other treatments are not effective.

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DIF: Cognitive Level: Application Assessment

REF:

p. 562 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

19.

Which statement(s) regarding gestational diabetes would be true? ( Select all that apply. )

It is diagnosed in about 2% of all pregnancies in the United States.

It includes diabetic women who become pregnant.

Fetal development may be complicated as a result of gestational diabetes.

The risk of developing diabetes after pregnancy is increased.

Most women with gestational diabetes have normal glucose tolerance postpartum.

f. Women need to be re evaluated postpartum to determine their classification with respect to glucose tolerance. ANS: C, D, E, F

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Gestational diabetic individuals are put into a separate category because of the special clinical features of diabetes that develop during pregnancy and the complications associated with fetal involvement. These women are also at a greater risk of developing diabetes 5 to 10 years after pregnancy. The majority of individuals with gestational diabetes have normal glucose tolerance postpartum. Gestational diabetes patients must be reclassified 6 weeks after delivery into one of the following categories: diabetes mellitus, impaired fasting glucose, impaired glucose tolerance, or normoglycemia. Gestational diabetes is diagnosed in about 4% of all pregnancies in the United States. Gestational diabetes does not include diabetic women who become pregnant.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 562 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

20. The nurse is educating a patient with diabetes mellitus regarding urine testing for ketones. Information provided will include that ketone testing should be done:(Select all that apply.) a.

when illness occurs.

during pregnancy.

before and after physical exercise.

when blood glucose is above usual range.

every morning upon awakening.

ANS:

A, B, D

Ketone testing should be done when illness occurs, during pregnancy, and whenever blood glucose is elevated above the individual’s usual range. It is not necessary to test urine for ketones before and after physical exercise or every morning upon awakening.

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DIF:

Cognitive Level: Application

REF:

TOP:

Nursing Process Step: Implementation

p. 572 OBJ:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

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Chapter 36: Drugs Used to Treat Thyroid Disease Test Bank

MULTIPLE CHOICE

Which medication is used to treat hyperthyroidism?

Levothyroxine (Synthroid)

Liotrix (Thyrolar)

Propylthiouracil (Propacil)

Liothyronine (Cytomel)

ANS:

Propylthiouracil is an antithyroid agent used in the treatment of hyperthyroidism. Levothyroxine, liotrix, and liothyronine are used to treat hypothyroidism.

DIF: Cognitive Level: Knowledge Implementation

REF:

p. 601 OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

2. A patient with a history of heart failure has been diagnosed with hypothyroidism. The drug interaction with glycosides and thyroid replacement therapy will most likely require which change in therapy?

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Decrease in the daily digoxin dosage

Gradual increase in the daily glycoside dosage

Inability to begin thyroid replacement therapy because of the underlying heart condition

Increased thyroid replacement dosage

ANS:

If thyroid replacement therapy is started while receiving digoxin, a gradual increase in the glycoside will also be necessary to maintain adequate therapeutic activity. Decreasing the digoxin would put the patient at risk for cardiovascular complications. The two treatments can be coordinated. The thyroid medication does not need to be increased.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 600 OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Which nursing diagnosis may be identified for a patient with hyperthyroidism?

Imbalanced nutrition: more than body requirements

Constipation

Disturbed sleep pattern

Ineffective airway clearance

ANS:

Hyperthyroidism is caused by an excess amount of thyroid hormones. Patients typically exhibit the following symptoms: rapid, bounding pulse (even during sleep); cardiac enlargement; palpitations; and dysrhythmias. Patients are nervous and easily agitated. Reflexes are hyperactive and the patient typically experiences insomnia. A nursing diagnosis of “Disturbed sleep pattern” would be a common problem. The patient with hyperthyroidism is likely to consume less than body requirements and is not likely to be constipated as a result of the disease. Ineffective airway clearance is not a common problem of patients with hyperthyroidism.

DIF:

Cognitive Level: Analysis

REF:

p. 596 OBJ:

4 TOP: Nursing Process Step: Diagnosis

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

The nurse is providing instruction to a patient recently prescribed a radioactive iodine isotope.

Which is the correct action of this medication? a.

Stimulates the synthesis of T3 and T4 hormones

https://studentmagic.indiemade.com/ b.

Increases the storage of thyroxine before thyroid surgery

Destroys hyperactive thyroid tissue

Replaces deficient thyroid hormone

ANS: C The thyroid gland absorbs high concentrations of radioactive iodine, which destroys the hyperactive thyroid tissue with essentially no damage to other tissues in the body. Radioactive iodine does not stimulate hormone synthesis, increase hormone storage, or replace deficient hormones.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 600 OBJ:

6 | 8 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Which patient would be a candidate for radioactive iodine therapy?

A 17-year-old woman with Graves’ disease

A 64-year-old woman with hypothyroidism

A 46-year-old man with heart disease and thyroid cancer

An 82-year-old man with myxedema crisis

ANS: C

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Patients typically treated with radioactive iodine therapy are those who are beyond childbearing years, those with severe complicating diseases (e.g., heart disease), those with recurrent hyperthyroidism after previous thyroid surgery, those who are poor surgical risks, and those who have unusually small thyroid glands. Women of childbearing age should not be treated with radioactive iodine. Hypothyroidism and myxedema are not treated with radioactive iodine.

DIF:

Cognitive Level: Application

REF:

p. 600 OBJ:

8 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

Which medication is used in the treatment of hypothyroidism?

Levothyroxine (Synthroid)

Radioactive iodine

Propylthiouracil (Propacil)

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Methimazole (Tapazole)

ANS: A Levothyroxine (T4) is one of the two primary hormones secreted by the thyroid gland. This hormone is partially metabolized to liothyronine (T3), so therapy with levothyroxine (Synthroid) replaces both hormones. Levothyroxine is considered the drug of choice for hormone replacement in hypothyroidism. Radioactive iodine, propylthiouracil, and methimazole are used to treat hyperthyroidism.

DIF: Cognitive Level: Knowledge Implementation

REF:

p. 599 OBJ:

3 | 5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

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7. A patient with myxedema complains to the nurse that he has a “hangover” the next morning after taking a pain medication at night. Which explanation by the nurse is the most accurate? a.

“You have increased sensitivity to the medicine because of your thyroid condition.”

b. “Because you haven’t been sleeping, you have increased fatigue and should increase the analgesic.” c.

“You are not taking enough thyroid medication and you should increase the dosage.”

d. “The pain medication is incompatible with your thyroid medication and you should find another analgesic to take.” ANS: A Myxedema patients are sensitive to small doses of sedative hypnotics, anesthetics, and narcotics. Increasing the analgesic would only make the patient feel more lethargic in the morning. The patient should not change the dose of his thyroid medication without consulting his primary health care provider. Any pain medication is likely to have this effect because of the patient’s thyroid condition.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 595 OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Which condition can occur if congenital hypothyroidism is not treated?

Diabetes

Impaired vision

Periorbital edema

Cretinism

ANS: D Cretinism is a condition resulting from congenital hypothyroidism. Diabetes is not a complication of congenital hypothyroidism. Periorbital edema and impaired vision are complications of hyperthyroidism.

DIF: Cognitive Level: Knowledge Assessment

REF:

p. 595 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

3 TOP: Nursing Process Step:

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What is the mechanism of action of propylthiouracil?

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Blocks reuptake of thyroid hormone in the liver

Destroys hormone in the thyroid gland

Increases synthesis of hormone in the thyroid gland

Blocks synthesis of hormone in the thyroid gland

ANS: D Propylthiouracil and methimazole are antithyroid agents that act by blocking the synthesis of T3 and T4 in the thyroid gland. They do not destroy any T3 or T4 already produced, so there is usually a latent period of a few days to 3 weeks before symptoms improve once therapy is started. Antithyroid medications do not block reuptake of hormones, destroy hormones, or increase synthesis of hormone.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 601 OBJ:

6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

10.

When assisting with the care of a patient with hyperthyroidism, the nurse will:

provide a cool environment.

anticipate ordering a low calorie diet.

limit daily caffeine intake.

encourage intake of bran products.

ANS: A For the hyperthyroid individual, the nurse should plan to provide a cool, quiet, structured environment because the patient lacks the ability to respond to change and anxiety producing situations and has

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intolerance to heat. The individual with hyperthyroidism is usually ordered on a high calorie diet of 4000 to 5000 calories per day with balanced nutrients. The individual with hyperthyroidism is to have no caffeine products. Because of the risk for diarrhea, bran products should not be encouraged.

DIF: Cognitive Level: Application Implementation

REF:

p. 597 OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

11. The nurse transcribes a new order for liothyronine for a patient diagnosed with hypothyroidism. When educating the patient about this medication, the nurse will include that: a.

the onset of action is slower than that of levothyroxine.

it is safe for patients with cardiovascular disease to take.

adverse effects may occur up to 3 weeks after changes in therapy have been initiated.

symptoms of adverse effects include tachycardia and weight gain.

ANS: C Adverse effects may occur 1 to 3 weeks after changes in therapy have been initiated. Onset of action is more rapid than that of levothyroxine. It is not recommended for patients with cardiovascular disease. Symptoms of adverse effects include bradycardia and weight loss.

DIF: Cognitive Level: Application Implementation

REF:

p. 599 OBJ:

5 TOP: Nursing Process Step:

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https://www.coursehero.com/file/19255117/ch37/

MSC: NCLEX Client Needs Category: Physiological Integrity

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12. Medications ordered on a patient with hypothyroidism include liotrix and cholestyramine. The nurse administers the dose of liotrix at 0800. When is the best time for the nurse to administer the cholestyramine? a. 0700 b. 0800 c.

1000

d. 1200 ANS: D To prevent binding of thyroid hormones by cholestyramine, administer doses at least 4 hours apart.

DIF: Cognitive Level: Analysis Assessment, Implementation

REF:

p. 600 OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment; Physiological Integrity

MULTIPLE RESPONSE

13. A patient recently completed radiation treatment for throat cancer and presents to the health care provider’s office with symptoms indicating possible hypothyroidism. Which symptom(s) would most likely be exhibited and/or reported? ( Select all that apply. ) a.

Inability to sleep

Weight gain

Lethargy

Nervousness

Cold intolerance

ANS: B, C, E Symptoms associated with hypothyroidism include weight gain, lethargy, and cold intolerance. Inability to sleep and nervousness are not symptoms associated with hypothyroidism.

DIF: Cognitive Level: ComprehensionREF: Assessment

pp. 595-596

MSC: NCLEX Client Needs Category: Physiological Integrity

OBJ:

3 TOP: Nursing Process Step:

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14.

What is characteristic of antithyroid drugs that act on the thyroid gland? (Select all that apply.)

They are a physiologic hormone replacement.

They block synthesis of T3 and T4 in the thyroid gland.

They destroy T3 and T4.

Immediate improvement is observed.

They may be used before subtotal thyroidectomy.

ANS: B, E Antithyroid drugs act by blocking the synthesis of T3 and T4. They are prescribed long term for patients with hyperthyroidism and may be used for short term treatment before subtotal

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thyroidectomy. Antithyroid drugs are not related to synthetic or physiologic hormone replacement. Antithyroid drugs act by blocking the synthesis of, not destroying, T3 and T4. There is a latency period of a few days to 3 weeks before symptoms improve. DIF: Cognitive Level: ComprehensionREF: Implementation

p. 601 OBJ:

6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

15. A postoperative total thyroidectomy patient is started on levothyroxine (Synthroid) daily. What information will the nurse include in discharge teaching? ( Select all that apply. ) a.

“Close follow up with your health care provider is important.”

“Notify your health care provider if you experience any palpitations or tachycardia.”

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“A variation in emotions and personality is normal during this adjustment period.”

“Synthroid may be stopped as soon as the thyroid gland resumes functioning.”

“When energy levels have returned, Synthroid will be gradually tapered.”

ANS: A, B, C Early intervention in correcting complications from the surgery or the hormone replacement therapy is crucial for a timely and positive outcome. Adverse effects such as tachycardia, anxiety, weight loss, abdominal cramping, and diarrhea are common, but should be reported to the health care provider. After surgery, the goal is to return the patient to a euthyroid state with the use of replacement therapy. During this time of adjustment, patients will experience symptoms related to fluctuations in hormonal levels. Variation in emotions and personality may occur. The total thyroidectomy patient no longer has a thyroid gland and will not have hormone secretion. Synthroid is indicated for lifelong use in the patient who has had a total thyroidectomy.

DIF: Cognitive Level: Application Implementation

REF:

p. 599 OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

16.

Which clinical manifestation(s) would the nurse assess in a patient with hypothyroidism?

( Select all that apply. ) a.

Cold intolerance, weight gain

Nervousness, agitation

Increased susceptibility to infection

Exophthalmos, fatigue

Hypoactive reflexes

ANS: A, C, E Hypothyroid patients have a lower basal metabolic rate. This may be characterized by intolerance to cold, subnormal body temperature, weight gain, and slowness in motion, speech, and mental processes. Patients with hypothyroidism may become susceptible to infection. Nervousness and agitation are not manifestations of hypothyroidism. Exophthalmos and fatigue are not manifestations of hypothyroidism.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 595 OBJ:

3 TOP: Nursing Process Step:

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MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

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17. Which clinical symptom(s) would the nurse observe in a patient with thyrotoxicosis? (Select all that apply.) a.

Decreased metabolic rate

Decreased heart rate

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Decreased body temperature

Muscle tremors

Restlessness

Anxiety

Sweating

ANS:

D, E, F, G

Thyrotoxicosis symptoms include muscle weakness and tremors, restlessness and nervousness, anxiety, sweating, increased metabolic rate, increased pulse rate (to perhaps 140 beats/min), and increased body temperature and a sensation of feeling too warm.

DIF:

Cognitive Level: ComprehensionREF:

TOP:

Nursing Process Step: Assessment

p. 596 OBJ:

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MSC: NCLEX Client Needs Category: Physiological Integrity

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Chapter 37: Corticosteroids Test Bank

MULTIPLE CHOICE

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1. A patient has been on high dose corticosteroid therapy for the treatment of lupus erythematosus. In addition to monitoring electrolyte levels, which laboratory studies will the nurse monitor? a.

Complete blood count

Partial thromboplastin time

Liver function panel

Blood glucose levels

ANS: D Corticosteroid therapy may induce hyperglycemia, particularly in prediabetic or diabetic patients. All patients must be monitored for the development of hyperglycemia, particularly during the early weeks of therapy. Steroids do not affect blood count, bleeding time, or liver function.

DIF: Cognitive Level: Application Assessment

REF:

p. 606 OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

2. A patient who has been taking glucocorticoids over the past 3 months for Crohn’s disease comes in for a follow up visit. On assessment, the nurse notes facial edema, thinning extremities, and a fatty deposition (buffalo hump) on the scapular area. The patient reports the symptoms of the Crohn’s disease are “somewhat better.” What will the nurse expect the treatment to be? a.

Decrease the steroid dosage by one half.

Increase the steroid dosage.

Maintain the steroid dosage.

Immediately stop the steroid dosage.

ANS: C Glucocorticoids are primarily used as anti inflammatory agents. Because the symptoms are improving, the physician will most likely maintain the steroid dosage. Adverse effects are anticipated with corticosteroid therapy. Decreasing the dose will not help the condition. Increasing the dose will exacerbate the adverse effects, and the condition is improving with the current dosage. Stopping the dosage will not help the condition or the adverse effects.

DIF:

Cognitive Level: Application

REF:

p. 608 OBJ:

5 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

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3. What is the rationale for administering glucocorticoid therapy as an adjunct to chemotherapeutic agents? a.

Assists with pain control

Raises blood sugar to meet the increased metabolic needs

Produces immunosuppression effects

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Reduces mucositis

ANS: C Glucocorticoids have an anti inflammatory and antiallergenic action. Suppression of inflammation resulting from cancer enhances the effectiveness of the chemotherapeutic agents. Glucocorticoids do not have an analgesic effect. Glucocorticoids increase blood glucose, but it is an adverse effect, not a primary effect. Glucocorticoids do not reduce mucositis.

DIF: Cognitive Level: ComprehensionREF: Evaluation

p. 608 OBJ:

2 | 5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

4. A patient with type 1 diabetes was prescribed a glucocorticoid for chronic obstructive pulmonary disease. Which will the nurse expect in the treatment plan? a.

A decrease in the amount of insulin needed

No change in the amount of insulin needed

An increase in the need for carbohydrates

An increase in the insulin needed

ANS: D

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Glucocorticoids may elevate blood glucose levels and induce hyperglycemia, particularly in prediabetic or diabetic patients. Insulin needs increase with an increase in blood glucose levels. Carbohydrate needs will not increase.

DIF:

Cognitive Level: Application

REF:

p. 610 OBJ:

4 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

Which condition would require mineralocorticoid replacement?

Addison’s disease

Diabetes insipidus

Myxedema

Glomerulonephritis

ANS: A Addison’s disease is a result of failure of the adrenal cortex to produce mineralocorticoids, glucocorticoids, and sex hormones. Replacement therapy of all hormones is essential for the patient to lead a healthy life. Diabetes insipidus is treated with vasopressin. Myxedema is treated with thyroid hormone. Glomerulonephritis is treated with antibiotics.

DIF:

Cognitive Level: ComprehensionREF:

p. 607 OBJ:

5 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

Which fluid replacement method will the nurse identify for a patient on a fluid restriction?

Freely throughout the day and evening shift

One third of the allowed volume on each shift

Half the volume with meals and the remainder divided among shifts

As the patient desires

ANS: C

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When fluid restrictions are prescribed, one half of fluid volume is generally given with meals. The other half is given on a per shift basis. When allowed the opportunity to take fluids freely, most patients will use all of their allotment early in the day and not have enough left for meals and medications later. Because most patients are asleep on the night shift, the fluid requirement is less.

DIF: Cognitive Level: Application Implementation

REF:

p. 606 OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

7. Which will the nurse include in the teaching plan for a patient asking about the use of salt substitutes while on a sodium restricted diet? a.

Salt substitutes may be high in potassium and should be used sparingly.

Salt substitutes are safe for unlimited use.

The salty flavor is reduced, so additional amounts are needed for desired flavor.

Salt substitutes may interact with the patient’s medications.

ANS: A Potassium restrictions may be indicated if the patient is taking a potassium sparing diuretic. Salt substitutes may be high in potassium; therefore, their use must be limited. Salt substitutes tend to have a more salty taste than sodium chloride, so reduced amounts are needed to provide desired flavor. It is unlikely that salt substitute will interact with patients’ medications.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 606 OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

8. A patient on a high dosage of corticosteroids over a period of time may develop which type of psychiatric complication? a.

Lethargy

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Psychotic behaviors

Manic phases

Anxiety attacks

ANS: B A patient receiving a higher dosage of corticosteroids is susceptible to psychotic behavioral changes. The most susceptible patient is one with previous histories of mental dysfunction. Perform a baseline assessment of the patient’s ability to respond rationally to the environment and the diagnosis of the underlying disease. Lethargy, mania, and anxiety are not common complications of treatment with corticosteroids.

DIF:

Cognitive Level: ComprehensionREF:

p. 610 OBJ:

5 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

What is the rationale for monitoring vital signs of patients receiving corticosteroids?

Orthostatic hypotension

Malignant hyperthermia

Infection

Hyperglycemia

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ANS: C Patients receiving corticosteroids are more susceptible to infection, and fever is often an early indicator of infection. Glucocorticoids, however, sometimes suppress a febrile response to infection. Orthostatic hypotension is not a common adverse effect of treatment with corticosteroids. Malignant hyperthermia is an anesthetic related complication. Hyperglycemia is a common adverse effect of treatment with corticosteroids, but it is not assessed by vital signs

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DIF: Cognitive Level: ComprehensionREF: p. 604 | p. 610 OBJ: 4 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

10. The nurse is assessing a patient for adverse effects of long term glucocorticoid therapy. Which condition would most likely be present? a.

Dehydration

Hypotension

Osteoporosis

Thrombocytopenia

ANS: C Long term glucocorticoid therapy may produce osteoporosis. Dehydration, hypotension, and thrombocytopenia are not adverse effects of long term glucocorticoid therapy.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 610 OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

11. The nurse transcribes a new order for a patient for a fludrocortisone. When planning the time of administration, the nurse will schedule this medication to be given: a.

with breakfast and dinner.

once daily in the evening.

before meals.

with lunch.

ANS: B Mineralocorticoids are usually given once daily in the evening. Glucocorticoids are usually ordered twice daily with breakfast and with dinner.

DIF: Cognitive Level: Analysis Assessment

REF:

p. 606 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

4 TOP: Nursing Process Step:

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12. Which statement(s) made by a patient on a corticosteroid medication show(s) a need for further education? a.

“I should increase my potassium intake.”

“I may have to decrease my fluid intake.”

“I will avoid weight bearing measures.”

“I will change position frequently.”

ANS: C Weight bearing measures should be encouraged for the patient taking corticosteroids to prevent calcium loss. An increase in potassium is often necessary when on corticosteroids.

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Fluid restrictions may be imposed when taking corticosteroids. Position should be changed at least every 2 hours for the patient taking corticosteroids.

DIF: Cognitive Level: Analysis Assessment

REF:

p. 607 OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance; Physiological Integrity

MULTIPLE RESPONSE

13.

The nurse is instructing a patient about adverse effects associated with corticosteroid therapy.

What information would be important to include? ( Select all that apply. ) a.

Avoid crowds or people with an infection.

Monitor and care for your skin daily; change positions frequently.

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Take medication on an empty stomach.

d. During periods of physical or psychological stress, higher doses of corticosteroids are necessary. Contact your health care provider. e.

Follow a diet low in sodium.

ANS: A, B, D, E Corticosteroid therapy patients should avoid large crowds or people with an infection. Patients taking corticosteroid drugs should monitor for signs of edema, skin breakdown, and weight daily. During periods of physical or psychological stress, increased dosing may be necessary. Patients taking corticosteroid drugs should follow a low sodium diet that is also high in potassium, if not contraindicated. Corticosteroids should be taken with food to avoid gastrointestinal upset.

DIF: Cognitive Level: Application Implementation

REF:

pp. 606-607

OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

14.

What are functions of glucocorticoids? ( Select all that apply. )

Maintain fluid and electrolyte balance

Have anti inflammatory activities

Regulate protein, carbohydrate, and fat metabolism

Provide relief of rheumatoid arthritis

Include aldosterone

ANS: B, C, D Glucocorticoids have anti inflammatory and antiallergenic activities. Glucocorticoids (cortisone, hydrocortisone, prednisone, and others) regulate carbohydrate, protein, and fat metabolism. Glucocorticoids are effective for immunosuppression in the treatment of certain cancers, organ transplantation, autoimmune diseases (e.g., lupus erythematosus, dermatomyositis, rheumatoid arthritis), relief of allergic manifestations (e.g., serum sickness, severe hay fever, status asthmaticus), and treatment of shock. In addition, they may be used to treat nausea and vomiting resulting from chemotherapy. Glucocorticoids do not maintain fluid and electrolyte imbalance. Glucocorticoids do not include aldosterone.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 608 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

2 TOP: Nursing Process Step:

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15. A patient has been diagnosed with rheumatoid arthritis and will begin daily oral corticosteroid treatment. Which baseline assessment(s) would be important for a patient receiving corticosteroids? ( Select all that apply. ) a.

Baseline weight

Blood pressure

Complete blood cell count (CBC)

Electrolyte studies

Hydration status

ANS: A, B, D, E Baseline assessments for patients receiving corticosteroid therapy include weight, blood pressure, electrolyte studies, intake and output, and diet and hydration status. A baseline CBC is not needed for patients taking corticosteroids.

DIF: Cognitive Level: Application Assessment

REF:

pp. 604-605

OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

16. Which measure(s) for monitoring hydration and fluid balance would be inappropriate for the patient on steroid therapy? ( Select all that apply. ) a.

Daily weights

Abdominal girth measurements

Reports of thirst

Neurologic assessment

Assessment for alteration in skin integrity

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ANS: A, B Perform daily weights using the same scale, in clothing of approximately the same weight, at the same time, usually before breakfast. Record and report significant weight changes. (Weight gains and losses are the best indicators of fluid gain or loss.) As appropriate to the patient’s condition, obtain and record abdominal girth measurements. Thirst, altered mental status, and alteration of skin integrity are late signs of dehydration and therefore not a good way to monitor fluid balance.

DIF: Cognitive Level: Application Assessment

REF:

p. 605 OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

17. What would be primary therapeutic outcome(s) expected from fludrocortisone (Florinef) therapy? ( Select all that apply. ) a.

Reduced inflammation

Pain relief

Blood pressure control

Restored fluid and electrolyte balance

ANS: C, D Fludrocortisone is used in combination with glucocorticoids to treat salt losing adrenogenital syndrome for blood pressure control and to restore fluid and electrolyte balance. Because fludrocortisone has mineralocorticoid and glucocorticoid effects, it has an anti inflammatory action. However, this is not one of the primary therapeutic outcomes expected from fludrocortisone therapy. Fludrocortisone does not relieve pain.

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DIF: Cognitive Level: ComprehensionREF: Implementation

pp. 607-608

MSC: NCLEX Client Needs Category: Physiological Integrity

OBJ:

2 | 5 TOP: Nursing Process Step:

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18. A patient with type 2 diabetes is being discharged on glucocorticoid (prednisone) therapy for rheumatoid arthritis. Which information will the nurse include in discharge teaching? (Select all that apply.) a.

“Daily, single dose therapy should be taken in the morning.”

“The metabolic needs of your body will be increased.”

“Steroids should never be discontinued abruptly.”

“Signs and symptoms of infections may not be evident.”

“Blood glucose levels will be elevated on corticosteroid therapy.”

ANS: A, C, D, E During steroid replacement therapy, the drugs should mimic the body’s circadian rhythm. Steroids ordered once a day are given early in the morning. Steroid replacement therapy is gradually tapered in small increments before discontinuation to ensure that the patient’s adrenal glands are able to start secreting steroids to compensate for the reduced drug dosage. Glucocorticoids have an anti inflammatory action and therefore suppress the signs and symptoms of an infection. An adverse effect of glucocorticoid therapy is increased blood sugar levels. Glucocorticoids do not increase the body’s metabolic needs.

DIF: Cognitive Level: Application Step: Planning

REF:

pp. 608-610

OBJ:

2 | 4 | 5 TOP: Nursing Process

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

19. A patient has just received a new prescription for a corticosteroid medication. The nurse is educating a patient on symptoms to report to the health care provider. When providing this education, the nurse will inform the patient to report: ( Select all that apply. ) a. productive cough. b.

dyspnea.

confusion.

chest pain.

weight gain.

ANS: A, B, C, D, E Symptoms to be reported when on a corticosteroid include productive cough, dyspnea, confusion, chest pain, and weight gain.

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DIF: Cognitive Level: Application Implementation

REF:

p. 606 OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance; Physiological Integrity

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Chapter 38: Gonadal Hormones Test Bank

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MULTIPLE CHOICE

1. A female patient with a history of endometriosis presents with bilateral lower quadrant pain reportedly at midcycle. Which gonadal drug is indicated for treating symptoms of endometriosis? a.

Estrogen

Progesterone

Androgens

Gonadotropins

ANS: B Progesterones are used to treat secondary amenorrhea, breakthrough uterine bleeding, and endometriosis. They may be combined with estrogens as contraceptives. Estrogen products are used for relieving the hot flash symptoms of menopause; for contraception; for hormone replacement therapy after an oophorectomy; in conjunction with appropriate diet, calcium, and physical therapy in the treatment of osteoporosis; for treatment of severe acne in females; and to slow the disease progress (and minimize discomfort) in patients with advanced prostatic cancer and certain types of breast cancer. Androgens are used to treat hypogonadism, eunuchism, androgen deficiency, and palliation of breast cancer in postmenopausal women with certain cell types of cancer. When androgens are used for palliation of cancer in women, they suppress cancer cell growth. Gonadotropin is a hormone secreted in the pituitary; it regulates the release of the gonadal hormones.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 616 OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

What is the rationale for using an androgen as part of breast cancer treatment?

For maintenance of fat stores

To promote nutrition

To prevent wasting resulting from cancer growth

For palliative treatment to suppress cancer cell growth

ANS: D When androgens are used for palliation of breast cancer in women, they suppress cancer cell growth. Androgens affect muscle growth, not fat stores. Estrogen affects fat stores. Although androgens may be

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used to stimulate appetite and improve nutrition, this is not the indication in this case. Although androgens may be used to prevent wasting, this is not the indication in this case.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 617 OBJ:

2 | 4 TOP: Nursing Process Step:

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3. The health of a patient receiving androgen therapy for breast cancer declines and she becomes bed bound. Which condition will this patient be at risk of developing? This study source was downloaded by 100000761823232 from CourseHero.com on 04-12-2021 14:52:17 GMT -05:00

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Electrolyte imbalances

Hypercalcemia

Hyperglycemia

Fluid overload

ANS: B Immobilized patients receiving androgens for palliative breast cancer treatment are at risk for hypercalcemia. The nurse should monitor patients for nausea, vomiting, constipation, poor muscle tone, and lethargy. Immobilization does not affect electrolyte balance, blood glucose, or fluid balance in this case.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 617 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Which patient on oral contraceptive therapy will be at greatest risk for heart attack?

A 34-year-old woman with a history of osteoporosis

A 28-year-old woman with a history of eczema

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A 36-year-old woman who smokes half a pack per day

A 36-year-old woman who has a history of abnormal Pap smears

ANS: C The incidence of fatal heart attacks is increased for women older than 35 years of age who use gonadal hormones and smoke. Osteoporosis, eczema, and cervical dysplasia do not increase risk for heart attack.

DIF: Cognitive Level: Application Assessment

REF:

p. 613 OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

5. Which is most important for the nurse to remember when instructing the patient about treatment with gonadal hormones? a.

Dosage, schedule, and adverse effects

Cost, storage, and route of administration

Drug interactions and food interactions

Scheduling follow up appointments and lab studies

ANS: A Most gonadal hormones are prescribed to patients for prolonged self administration. Therefore, planning should stress patient education specific to the type of gonadal hormone prescribed and its intended actions, including monitoring of adverse effects to expect and report. Cost, storage, and route of administration are lesser concerns. There are few, if any, interactions between gonadal hormones and food or other drugs. Follow up appointments and lab studies are lesser concerns.

DIF: Cognitive Level: Application Evaluation

REF:

p. 613 OBJ:

2 | 4 | 5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

6. The nurse is teaching a young woman about birth control pills. For which situation will the patient need to seek immediate follow up with the health care provider? a.

Breakthrough bleeding

Nausea

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Missed dose

Light menstrual flow

ANS: A Breakthrough bleeding is not an expected adverse effect and should be reported to a health care provider immediately to consider alternatives in therapy. Nausea is an expected adverse effect of contraceptive therapy. Missed doses are common and do not require notification of the provider. Light menstrual flow is common with contraceptive therapy.

DIF: Cognitive Level: Application Implementation

REF:

p. 614 OBJ:

5 TOP: Nursing Process Step:

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Which statement is true regarding androgen therapy?

Androgen use may cause hyperglycemia.

Androgen should be administered with food or milk to avoid gastric irritation.

Signs of masculinization will appear and are reversible.

Electrolyte imbalances are extremely rare.

ANS: B Androgens may cause gastric irritation and therefore can be given with food or milk. Androgens cause hypoglycemia. Treatment is often stopped once signs of masculinization appear, because these may not be reversible. Androgens cause electrolyte imbalances.

DIF:

Cognitive Level: ComprehensionREF:

p. 617 OBJ:

2 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

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Which is the most potent of the natural estrogenic hormones produced in the ovaries? a.

Estradiol b.

Estrone

Estriol

Estrogen

ANS: A The natural estrogenic hormone released from the ovaries comprises several closely related chemical compounds: estradiol, estrone, and estriol. The most potent is estradiol. Estradiol is metabolized to estrone, which is half as potent. Estrone is metabolized to estriol, which is considerably less potent. Estrogens are a group of steroid compounds named for their importance in the estrus cycle, functioning as the primary female sex hormone.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 613 OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

9. Which information will the nurse include when teaching a patient with seizures about estrogen therapy? a.

Phenytoin reduces the effectiveness of estrogen.

Estrogen reduces the effectiveness of phenytoin.

Phenytoin may inhibit the metabolism of estrogen.

Estrogen may inhibit the metabolism of phenytoin.

ANS: D

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Estrogens may inhibit the metabolism of phenytoin, resulting in phenytoin toxicity. Phenytoin does not reduce the effectiveness of estrogen. Estrogen does not reduce the effectiveness of phenytoin. Phenytoin does not inhibit the metabolism of estrogen.

DIF: Cognitive Level: Application Implementation

REF:

p. 614 OBJ:

4 | 5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

10. When preparing a female patient for the endocrine changes that may occur as a result of androgen changes, the nurse will include information regarding: a.

priapism.

voice changes.

gynecomastia.

fluid retention.

ANS: B Women should be monitored for signs of masculinization, such as deepening of the voice. Males should be carefully monitored for priapism and development of gynecomastia. Fluid retention is a metabolic effect, not an endocrine change, that may occur.

DIF: Cognitive Level: Application Implementation

REF:

pp. 617-618

OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

MULTIPLE RESPONSE

11.

What is progestin therapy used for? ( Select all that apply. )

Contraception

Endometriosis

Amenorrhea

Abnormal uterine bleeding

Cancer

2 TOP: Nursing Process Step:

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ANS: A, B, C, D Progestin therapy is used in combination with estrogens as a contraceptive, to relieve symptoms of endometriosis, for hormonal balance to relieve amenorrhea, and for hormonal balance to relieve abnormal uterine bleeding. Progestin is not used in cancer treatment.

DIF: Cognitive Level: Application Assessment

REF:

p. 616 OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

12. The nurse is completing discharge teaching to a new mother who will begin oral contraceptives. Which common adverse effect(s) should be expected? ( Select all that apply. ) a.

Elevated blood pressure

Breast tenderness

Weight gain

Edema

Increased thirst

ANS: B, C, D

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Breast tenderness, weight gain, and edema are adverse effects to expect when beginning oral contraceptives. Elevated blood pressure and increased thirst are not adverse effects to expect from oral contraceptives.

DIF: Cognitive Level: Application Implementation

REF:

p. 614 OBJ:

4 | 5 TOP: Nursing Process Step:

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MSC: NCLEX Client Needs Category: Physiological Integrity

13.

Why is estrogen therapy used in postmenopausal women? ( Select all that apply. )

To meet contraceptive needs

To treat acne

To prevent osteoporosis

To treat hot flashes

To maintain hormonal balance

ANS: C, E Estrogen therapy is used in conjunction with diet, calcium, and physical therapy in the prevention and treatment of osteoporosis and to slow the disease progression in patients with advanced prostate cancer and certain types of breast cancer. Postmenopausal females would take estrogen to maintain hormonal balance. Women of childbearing age use estrogen to meet contraceptive needs. Women who use estrogen to treat acne are not postmenopausal. Estrogen therapy is used to reduce the frequency of hot flashes of menopausal (not postmenopausal) women.

DIF: Cognitive Level: Analysis Evaluation

REF:

pp. 613-614

OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

14. Which condition(s) would be of special concern when evaluating a patient for treatment with gonadal hormones? ( Select all that apply. ) a.

Sexually transmitted disease

Hypertension

Liver disease

Cancer of the reproductive organs

Smoking

ANS: B, C, D, E Hypertension, liver disease, and cancer of the reproductive organs may be contraindications for treatment with gonadal hormones. Smoking increases the risk of heart attacks, stroke, and embolic disorders in patients taking gonadal hormones. Sexually transmitted diseases are not affected by treatment with gonadal hormones.

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DIF:

Cognitive Level: Application

REF:

p. 612 OBJ:

2 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

15. When teaching a patient about estrogen therapy, which drug(s) will the nurse identify as causing drug interactions? ( Select all that apply. ) a.

Diazepam (Valium)

Warfarin (Coumadin)

Thyroid hormones

Phenytoin (Dilantin)

Acetaminophen (Tylenol)

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ANS: B, C, D Estrogen may diminish the anticoagulant effects of warfarin. Monitor the prothrombin time and increase the dosage of warfarin, if necessary. Patients who have no thyroid function and who start estrogen therapy may require an increase in thyroid hormone dosage. Estrogens increase thyroid binding globulin levels, which reduce the level of circulating free T4. The total level of T4 is either normal or increased. Do not adjust the thyroid dosage until the patient shows clinical signs of hypothyroidism. Estrogens may inhibit the metabolism of phenytoin, resulting in phenytoin toxicity. Monitor patients with concurrent therapy for signs of phenytoin toxicity (e.g., nystagmus, sedation, lethargy). Serum levels may be ordered, and a reduced dosage of phenytoin may be required. There are no drug interactions with estrogen and diazepam or acetaminophen.

DIF: Cognitive Level: Application Implementation

REF:

p. 614 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

4 TOP: Nursing Process Step:

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16. The nurse is discussing estrogen therapy with a patient education group. When relaying information, the nurse may explain that therapeutic outcomes of estrogen therapy include: ( Select all that apply. ) a.

contraception.

hormonal balance.

treatment of severe facial acne.

appetite suppression.

prevention of heart disease.

ANS: A, B, C The primary therapeutic outcomes expected from estrogen therapy include contraception, hormonal balance, prevention of osteoporosis, palliative treatment of prostate and breast cancer, and treatment of severe acne in females. Appetite suppression and prevention of heart disease are not expected therapeutic outcomes of estrogen therapy.

DIF: Cognitive Level: Application Implementation

REF:

p. 614 OBJ:

3 | 4 | 5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

17. The nurse is preparing to administer an estrogen containing medication to a patient. This medication will be held if the nurse assesses that the patient: ( Select all that apply. ) a. may be pregnant. b.

has a blood pressure of 130/70.

has a history of phlebitis.

reports breast tenderness.

is taking thyroid hormones.

ANS: A, C The nurse must determine whether the patient is pregnant before starting estrogen therapy and

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the medication withheld if there is a possibility of pregnancy. Estrogen should be held and the health care provider contacted if the patient has a history of thromboembolitic disorders. A blood pressure of 130/70 is considered within normal limits. Breast tenderness is not a contraindication of estrogen administration. Thyroid hormones may need adjustment, but a patient taking estrogen can take thyroid hormones.

DIF: Cognitive Level: Analysis REF: Assessment, Implementation, Evaluation

p. 614 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

2 |5 TOP:

Nursing Process Step:

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Chapter 39: Drugs Used in Obstetrics Test Bank

MULTIPLE CHOICE

1. Which drug will the health care provider prescribe to soften the cervix of a woman who is at 42 weeks of gestation? a.

Methylergonovine (Methergine)

Dinoprostone (Prepidil)

Betamethasone (Celestone)

Terbutaline (Brethine)

ANS: B

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Dinoprostone is a natural chemical in the body that causes uterine and gastrointestinal smooth muscle stimulation. It plays a role in cervical softening and dilation unrelated to uterine muscle stimulation. It is used to start and continue cervical ripening at term. Methergine is used to treat postpartum bleeding. Betamethasone is used to enhance fetal lung development. Terbutaline is used to treat premature labor.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 631 OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

For which reason will betamethasone IM be administered to the mother in premature labor?

To stop uterine contractions

To prevent precipitous labor

To stimulate lung maturity in the fetus

To stimulate prolactin to enhance breastfeeding

ANS: C Glucocorticoids may be administered IM to accelerate fetal lung maturation to minimize respiratory distress syndrome. Tocolytic drugs are given to stop uterine contractions. Prolactin production and release are triggered by pituitary hormone, estrogen, and progesterone.

DIF: Cognitive Level: Application Implementation

REF:

p. 626 OBJ:

4 | 6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

3. A 26-year-old patient with preeclampsia is receiving IV magnesium sulfate. The 1400 assessment includes blood pressure, 100/70 mm Hg; respiration, 10; fetal heart tone, 100/min; urine output, 20 mL/hr; and absent patellar reflex. Which is the priority nursing action? a. Decrease IV magnesium sulfate to half the dose and reassess the patient and fetus in 15 minutes. b.

Stop the IV magnesium sulfate and contact the health care provider.

Place the patient on her left side and administer oxygen.

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Stop the IV magnesium sulfate and administer calcium gluconate 5 mEq IV over 3 minutes.

ANS: D The patient is exhibiting signs of magnesium sulfate toxicity, including respiratory depression. The infusion should be stopped at once. The antidote, calcium gluconate, should be administered.

DIF: Cognitive Level: Application Evaluation

REF:

pp. 635-636

OBJ:

4 | 6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

4. Which drug is administered after delivery to reduce the risk of postpartum hemorrhage after the placenta has been delivered? a.

Oxytocin (Pitocin)

Magnesium sulfate

Vitamin K

Dopamine

ANS: A Uterine stimulants, primarily oxytocin, given in low dose infusions after delivery of the fetus and placenta, help stimulate firm uterine contractions to reduce the risk of postpartum hemorrhage from an atonic uterus. Magnesium sulfate is given to treat eclampsia and preeclampsia. Vitamin K is given to prevent hemorrhage. Dopamine is given to treat hypotension.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 633 OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

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5. A 36-week primigravida patient has been admitted to the unit with a blood pressure of 200/120 mm Hg, severe headache, and edema. Which medication does the nurse anticipate that the health care provider will order? a.

Nifedipine (Procardia)

Furosemide (Lasix)

Magnesium sulfate

Terbutaline (Brethine)

ANS: C Magnesium sulfate depresses the central nervous system and blocks peripheral nerve transmission, which produces anticonvulsant effects and smooth muscle relaxation. In cases of preeclampsia or eclampsia, magnesium sulfate is used to control seizure activity. Hypertension, headache, and edema are signs of preeclampsia in a pregnant woman. Calcium channel blockers, such as nifedipine, are sometimes given as tocolytic agents. Furosemide is given for diuresis; it may be used in the treatment of hypertension, but not eclampsia. Terbutaline is given as a tocolytic agent.

DIF: Cognitive Level: Application Evaluation

REF:

pp. 635-636

OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

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Which drug is administered when a patient is experiencing premature labor?

Magnesium sulfate

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Oxytocin (Pitocin)

Levonorgestrel (Mirena)

Terbutaline (Brethine)

ANS: D Terbutaline is a beta adrenergic receptor stimulant, which acts primarily on the beta2 receptors. Stimulation of beta1 receptors produces uterine relaxation and relaxation of the bronchial and vascular smooth muscle. In higher doses, terbutaline will stimulate the beta1 receptors, which raises heart rate. Magnesium sulfate is given to treat eclampsia. Oxytocin is given to produce uterine contractions. Levonorgestrel is a progestin given for contraception.

DIF: Cognitive Level: ComprehensionREF: Implementation

pp. 625-626

OBJ:

4 | 6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

7. A patient is a gravida 1, Rh-negative woman at a 28 weeks’ gestation. The father of her child is Rh positive. The mother is asking the nurse about the effect on her unborn child of RhoGAM that has been ordered. What is the nurse’s best reply? a.

“Your child will do well after birth once transfusions are administered.”

“If the baby is Rh negative at birth, he or she will need RhoGAM also.”

“RhoGAM kills antibodies you make, so your child will be protected.”

d. “Your baby may be Rh positive and cause you to make antibodies. These won’t affect this baby, but could affect future children if RhoGAM isn’t given.” ANS: D An Rh-negative mother and an Rh-positive father have the potential for an Rh-positive baby. At birth or during any time that the uterus ruptures, fetal blood circulation can mix with maternal circulation, causing the mother to produce antibodies (active immunity) against Rhpositive blood. This would cause Rh hemolytic disease in children of future pregnancies. Rho( D) immune globulin suppresses the stimulation of active immunity by Rh-positive foreign red blood cells that enter maternal circulation at the time of delivery, at the termination of pregnancy, or during a transfusion of inadequately typed blood. Transfusions may cause further problems. Immune globulin is given to the mother. The drug does not kill antibodies; it suppresses production.

DIF: Cognitive Level: Application Implementation

REF:

p. 638 OBJ:

7 TOP: Nursing Process Step:

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Which drug will the nurse administer to prevent neonatal conjunctivitis in the newborn? a.

Silver nitrate b.

Dexamethasone

Erythromycin

Vitamin K

ANS: C Erythromycin or tetracyclines are the drugs of choice because they prevent neonatal conjunctivitis from Neisseria gonorrhoeae and chlamydial ophthalmia neonatorum from Chlamydia trachomatis. Silver nitrate is an outdated treatment for neonatal ocular infections.

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Dexamethasone is given for lung development. Vitamin K is given for treatment of hemorrhage.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 639 OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

9. Which emergency drug must be available when caring for a patient receiving magnesium sulfate? a.

Naloxone

Calcium gluconate

Dextrose

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Dopamine

ANS: B Calcium gluconate is the antidote for magnesium sulfate and should always be available when magnesium sulfate is administered. Naloxone is an antidote for opioid drugs. Dextrose is given to treat hypoglycemia. Dopamine is given to treat hypotension.

DIF: Cognitive Level: Knowledge Implementation

REF:

p. 637 OBJ:

4 | 6 TOP: Nursing Process Step:

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10. Which test would the nurse anticipate to be done to determine if preterm labor is present in a patient whose symptoms are questionable? a. Sonogram b.

Fetal fibronectin test

Amniocentesis

Doppler study

ANS: B A fetal fibronectin test may be ordered to assess the presence of preterm labor in patients whose presenting symptoms are questionable, so that early intervention (e.g., tocolytic therapy, corticosteroids, transport to a tertiary center) can be initiated when indicated. Sonograms determine the presence and viability of a fetus. Amniocentesis determines genetic problems in a fetus. Doppler determines circulation in the vascular system of the mother or the baby.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 623 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

11.

Which is characterized by seizures?

Pregnancy induced hypertension

Preeclampsia

Eclampsia

Premature rupture of membranes

ANS: C

6 TOP: Nursing Process Step:

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Eclampsia (convulsions accompanying preeclampsia) is characterized by seizures. Pregnancy induced hypertension is characterized by sudden hypertension (an elevation of systolic pressure 30 mm Hg or more than prior readings, systolic blood pressure of 140 mm Hg or

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more, or diastolic pressure of 90 mm Hg or more). Preeclampsia is characterized by elevated blood pressure and proteinuria. Premature rupture of membranes is characterized by leakage of amniotic fluid from the vagina.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 623 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

12.

Which medication is used to treat a patient with atonic uterus?

Estradiol

Ergonovine

Ergotamine

Egophony

ANS: B Continued intravenous infusions of low dose oxytocin or intramuscular injections of ergonovine or methylergonovine may be used to stimulate firm uterine contractions to reduce the risk of postpartum hemorrhage from an atonic uterus. Estradiol is an estrogen and is not used to treat atonic uterus. Ergotamine is used to treat migraine headaches. Egophony is a change in lung sounds characteristic of plural effusion.

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DIF: Cognitive Level: ComprehensionREF: Implementation

pp. 632-633

OBJ:

4 | 5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

13.

A woman is 32 weeks pregnant and has been examined by the health care provider on June

1. She is scheduling her next appointment. The most appropriate day for the nurse to schedule the appointment is: a.

June 9.

June 16.

June 30.

July 7.

ANS: B The pregnant woman who does not experience complications is usually examined monthly for the first 6 months, every 2 weeks in the seventh and eighth months, and weekly during the last month.

DIF: Cognitive Level: Analysis Implementation

REF:

p. 622 OBJ:

1 TOP: Nursing Process Step: Planning,

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

14. The nurse administers hydralazine IV to control the blood pressure of a woman diagnosed with preeclampsia. If the nurse administered this medication at 0800, the next assessment of blood pressure should occur at: a. 0803. b. 0815. c.

0830.

d. 1000. ANS: A

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The vasodilator hydralazine is usually administered to control blood pressure. If IV has been given, monitor the maternal and fetal heart rates and the mother’s blood pressure every 2 to 3 minutes after the initial dose and every 10 to 15 minutes thereafter.

DIF: Cognitive Level: Analysis Assessment, Implementation

REF:

p. 626 OBJ:

4 TOP: Nursing Process Step:

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15. be:

When caring for the neonate immediately following delivery, the priority nursing diagnosis will

risk for bleeding.

altered body temperature.

ineffective airway clearance.

risk for infection.

ANS: C Ensuring that the airway remains open is the priority because if the airway does not remain patent, oxygenation will be impaired. Risk for bleeding, altered body temperature, and risk for infection are relevant but not priorities at this time.

DIF:

Cognitive Level: Analysis

REF:

p. 627 OBJ:

3 TOP: Nursing Process Step: Diagnosis

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment; Physiological Integrity

MULTIPLE RESPONSE

16. Which assessment(s) will the nurse complete during routine pregnancy visits? (Select all that apply.)

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Blood pressure

Hemoglobin

Weight

Fetal heart sounds

Glucose tolerance test (GTT)

ANS: A, C, D Assessments during routine pregnancy visits include blood pressure, weight, and fetal heart sounds. Assessments during routine pregnancy visits do not include hemoglobin or GTT.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 621 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

17. A patient at 33 weeks’ gestation is admitted to the obstetric unit in active labor with symptoms associated with pregnancy induced hypertension (PIH). Which action(s) will the nurse implement? ( Select all that apply. ) a.

Vital signs hourly

Administration of IV pitocin

Administration of magnesium sulfate IV

Fetal stress test

Assessment of deep tendon reflexes

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ANS: A, C, D, E

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Important nursing assessments and/or interventions include monitoring of vital signs and level of consciousness continuously, continuous fetal monitoring with stress tests and external or internal fetal monitoring, and deep tendon reflexes. IV magnesium sulfate is often prescribed for patients with PIH. Oxytocin increases uterine contractions and is contraindicated in preterm labor.

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DIF:

Cognitive Level: Application

REF:

TOP:

Nursing Process Step: Implementation

p. 626 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

18. What will the nurse include when teaching a postpartum patient about expected adverse effects of Rho(D) immune globulin? (Select all that apply.) a.

Nausea

Constipation

Fever

Insomnia

Aches

Diarrhea

Anorexia

ANS:

C, E

Fever as well as generalized aches and pains are common adverse effects of treatment with this drug. Nausea, constipation, insomnia, diarrhea, and anorexia are not adverse effects of Rh o(D) immune globulin.

DIF:

Cognitive Level: ComprehensionREF:

TOP:

Nursing Process Step: Assessment

p. 638 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

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Chapter 40: Drugs Used in Men’s and Women’s Health Test Bank

MULTIPLE CHOICE

1. A female patient has developed leukorrhea since being on oral broad spectrum antibiotics for the past week for a lower respiratory infection. Which organism causes leukorrhea? a. Herpes simplex b.

Mycoplasma hominis

Human papillomavirus (HPV)

Candida albicans

ANS: D Candida albicans infections of the mouth, gastrointestinal tract, or vagina may develop as secondary infections during the use of broad spectrum antibiotics, such as penicillins, tetracyclines, and cephalosporins. Herpes simplex, Mycoplasma hominis, and HPV do not cause leukorrhea.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 642 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

1 TOP: Nursing Process Step:

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2. A patient states that she has a difficult time remembering when to resume her triphasic contraceptive pills following her menses. Which alternative plan will the nurse suggest that she discuss with her health care provider? a.

Changing to the 28-day packet

Using the inert pills every other month

Changing her prescription to the mini pill

Calling the health care provider whenever she forgets to get appropriate instruction

ANS: A Using the 28-day packet would allow her to continue with the same type of combination oral contraception. The 28-day packet would allow her to continue daily pills and eliminate the need to recall. Using the inert pills on alternate months will alter her menstrual schedule. Changing to the mini pill might not meet her contraceptive needs. It is unnecessary and inappropriate to contact the provider for missed doses.

DIF: Cognitive Level: Application Process Step: Implementation

REF:

pp. 652-653 | p. 647 OBJ:

3|4

TOP: Nursing

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

Which is more likely to be experienced by women taking the mini pill as an oral contraceptive?

Ovulation, dysmenorrhea, and break-through bleeding

Excessive weight gain and breast tenderness

Increased estrogen related adverse effects

Difficulty breastfeeding after pregnancy

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ANS: A The mini pill is made up of progestin, which inhibits ovulation. This form of contraception is an alternative for women particularly susceptible to adverse effects caused by estrogen therapy. Between 30% and 40% of women continue to ovulate with this form of contraception, however, and there is a slightly higher incidence of uterine and tubal pregnancies. Dysmenorrhea, manifested by irregular or infrequent menses and spotting between cycles, is common in women taking the mini pill. The mini pill has a reduced chance for weight gain and breast tenderness, does not contain estrogen, and does not cause difficulty with breastfeeding.

DIF:

Cognitive Level: ComprehensionREF:

p. 653 OBJ:

4 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

4. The nurse is obtaining a history on a patient who is seeking oral contraceptives. Which condition would contraindicate the use of oral contraceptives? a.

Sexually transmitted diseases (STDs)

Hypothyroidism

Varicose veins

Thromboembolic disease

ANS: D Women who have a history of thromboembolic disease must consult with a health care provider before obtaining a prescription for an oral contraceptive. Serious adverse effects include embolisms and thrombus formation, cardiac abnormalities, seizures, and severe depression. STDs, hypothyroidism, and varicose veins do not pose a problem with contraceptive therapy.

DIF:

Cognitive Level: ComprehensionREF:

p. 652 OBJ:

4 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

5. A patient diagnosed with benign prostatic hypertrophy asks why tamsulosin (Flomax), an alpha1 adrenergic blocking agent, has been prescribed. Which explanation by the nurse is most accurate? a.

It inhibits the action of testosterone.

It improves sexual function.

It reduces the size of the prostate.

It increases urinary flow.

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ANS: D Alpha 1 adrenergic blocking agents are used to relax the smooth muscle of the bladder and prostate. Tamsulosin specifically blocks alpha1 receptors on the prostate gland and certain areas of the bladder neck, causing muscle relaxation and increased urine flow in men with enlarged prostate glands. Adrenergic blocking agents do not affect hormone production, directly affect sexual function, or affect prostate size.

DIF: Cognitive Level: ComprehensionREF: Evaluation

pp. 659-660

OBJ:

6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

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Which type of drug is most effective in the treatment of erectile dysfunction (ED)?

Phosphodiesterase inhibitors

Antiandrogen agents

Sympathomimetic agents

Alpha 1 adrenergic blocking agents

ANS: A Sildenafil (Viagra), a phosphodiesterase inhibitor, increases cyclic guanosine monophosphate concentrations in the corpus cavernosum, which results in smooth muscle relaxation and greater blood flow into the corpus cavernosum, producing an erection. Antiandrogen agents, sympathomimetic agents, and adrenergic blocking agents are not effective in treating ED.

DIF:

Cognitive Level: ComprehensionREF:

p. 662 OBJ:

7 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

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7. The nurse is teaching a patient beginning therapy with dutasteride (Avodart). How long will it take before the patient can expect results? a.

24 hours

2 weeks

1 month

6 months

ANS: D Longer than 6 to 12 months of treatment may be necessary to assess whether a therapeutic response has been achieved.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 660 OBJ:

6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

8. Why must caution be used when taking a phosphodiesterase inhibitor to enhance male sexual function? a.

It can become habit forming.

Life-threatening consequences can occur with cardiovascular disorders.

It is an ineffective treatment.

It is expensive and available only by special prescription.

ANS: B The patient must consult with a health care provider before using a phosphodiesterase inhibitor. People with cardiovascular disorders are particularly susceptible to life-threatening consequences with its use. It is unlikely that a patient will develop physiologic dependence on the medication, although psychological dependence may occur. Phosphodiesterase inhibitors can be a very effective treatment for ED. Phosphodiesterase inhibitors are readily available online and are not expensive.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 663 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

7 TOP: Nursing Process Step:

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What is the mechanism whereby estrogen functions as a contraceptive?

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Inhibiting luteinizing hormone (LH), blocking release of ovum from a follicle

Thinning cervical mucus, which inhibits sperm migration

Trapping the ovum in the endometrial wall, preventing its growth

Blocking follicle-stimulating hormone (FSH), thereby preventing release of ovum

ANS: D Estrogens block pituitary release of FSH, preventing the ovaries from developing a follicle from which the ovum is released. Progestins inhibit pituitary release of LH, the hormone responsible for releasing an ovum from a follicle. Estrogens and progestins alter cervical mucus by making it thick and viscous, inhibiting sperm migration. Hormones also change the endometrial wall, impairing implantation of the fertilized ovum.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 647 OBJ:

N/A TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

10. The nurse is instructing a patient on use of a transdermal contraceptive. When evaluating the patient’s understanding of the information provided, the nurse identifies a need for further education when the patient states: a.

“Apply the first patch during the first 24 hours of the menstrual period.”

“Use a backup contraceptive concurrently for the first 7 days of the first cycle.”

“Fold the used patch over on itself before discarding.”

“Trim the patch carefully prior to application.”

ANS: D

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Patches should not be cut. The first patch should be applied during the first 24 hours of the menstrual period. A backup contraceptive should be used concurrently for the first 7 days of the first cycle. When removing the patch, it should be folded over on itself and placed in a sturdy container.

DIF:

Cognitive Level: Analysis

REF:

p. 655 OBJ:

5 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance; Physiological Integrity

11. A woman using the NuvaRing vaginal ring informs the nurse that the ring was accidentally expelled a day ago. The nurse will instruct this patient to: a.

rinse the ring in cool water and reinsert as soon as possible.

rinse the ring in hot water and reinsert as soon as possible.

rinse the ring in lukewarm water, reinsert, and use a nonhormonal back up contraceptive.

insert a new ring.

ANS: C If the ring is expelled for longer than 3 hours, the patient should be instructed to rinse it in cool or lukewarm water, reinsert, and use a nonhormonal back up contraceptive for the next 7 consecutive days of continuous ring use. It is not necessary to insert a new ring after a day.

DIF: Cognitive Level: Application Implementation

REF:

p. 657 OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance; Physiological Integrity

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MULTIPLE RESPONSE 12. The health care provider has instructed a patient to use over the counter miconazole ( Monistat) cream to treat her vaginal yeast infection. What information is important to include in patient education? ( Select all that apply. ) a.

Wash the genital area thoroughly before inserting the vaginal cream.

Wash the applicator before usage.

Wear a minipad to catch remaining discharge following vaginal administration.

Wash hands before and after administration.

The sexual partner may require treatment as well.

ANS: A, C, D, E It is imperative that proper cleansing of the genital area be done regularly using soap and water; rinse and dry well. A minipad should be worn to catch remaining discharge. Hands should be washed before and after medication insertion and before and after toileting. Both partners in a sexual relationship require treatment. The male partner may require oral anti infectives. The vaginal applicator should be thoroughly washed with soap and water after each use and then dried.

DIF: Cognitive Level: Application Implementation

REF:

pp. 645-646

OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

13. A nurse working at the community health clinic receives a call from a teen patient who reports that she has missed one of her birth control pills. Which response by the nurse is accurate? ( Select all that apply. ) a.

Take the missed pill now.

Take the next pill at the regularly scheduled time.

Come into the clinic for a pregnancy test.

Start with the next month’s pill packet at day 1.

Take the missed pill and the next pill together at the next regularly scheduled time.

ANS: A, B If a patient misses one pill, she should take the missed pill immediately. Even if a patient misses one pill, she should take the next pill for that day on time after taking the missed pill immediately. A pregnancy

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test is not necessary. Starting the next month’s pill packet at day 1 is not the appropriate action to take. Taking both the missed pill and the next pill at the next scheduled time is not the appropriate action to take.

DIF: Cognitive Level: Application Implementation

REF:

pp. 652-653

OBJ:

3 | 4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

14. The nurse is completing a female reproductive history on a 16 year old. What important assessment(s) should be included? ( Select all that apply. ) a.

Breast self-examination (BSE) routine

Age of menarche and pattern of menses

c. Smoking and blood pressure history when seeking a prescription for oral contraceptive pills (OCPs) d.

Sexual orientation and number of partners

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Number of pregnancies, live births, miscarriages, and abortions

Nutritional intake of carbohydrates

ANS: A, B, C, D, E All women of reproductive age should perform regular BSEs. Onset and pattern of menses provide baseline assessments for future comparison. OCPs are contraindicated in women who smoke or have hypertension. Sexual orientation and number of partners provide a baseline assessment for future STD assessments. Gestational history provides baseline information for future pregnancies. Nutritional intake of carbohydrates is not included when obtaining a female reproductive history.

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DIF: Cognitive Level: Application REF: pp. 642-643 | p. 645 OBJ: 2 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

15. The nurse is giving instructions to a young female at an outpatient clinic regarding combination OCP therapy. What information will the nurse include? ( Select all that apply. ) a.

Medication should be taken at approximately the same time daily.

A back up birth control method should be used for the first 6 months.

Medication should be discontinued 1 year before attempting pregnancy.

Headaches, dizziness, and chest or abdominal pain should be reported immediately.

If a pill is missed, take it immediately and remain on schedule for the next dosage.

ANS: A, D, E Medications should be taken at approximately the same time daily. Headaches, dizziness, and chest or abdominal pain should be reported immediately to the health care provider because these may be symptoms of a serious adverse effect. If one pill is missed, patients are directed to take it as soon as possible and continue with their normal schedule. If more than one pill is missed and a period is skipped, patients should return to their health care provider for a pregnancy test before restarting contraception. A back up contraceptive method is recommended at any point with OCP therapy. Because of a possibility of birth defects, the pill should be discontinued 3 months before attempting pregnancy.

DIF: Cognitive Level: Application Implementation

REF:

pp. 652-653

OBJ:

3 | 4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

16. The nurse will teach the patient beginning therapy with alfuzosin, an alpha 1 adrenergic blocking agent, to expect which common (and usually self limiting) adverse effect(s)? (Select all that apply.) a.

Nausea

Insomnia

Dizziness

Headache

Lethargy

Anorexia

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ANS: C, D, E Dizziness, headache, and lethargy are adverse effects of treatment with alfuzosin. Nausea, insomnia, and anorexia are not adverse effects of treatment with alfuzosin.

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DIF: Cognitive Level: ComprehensionREF: Implementation

pp. 659-660

MSC: NCLEX Client Needs Category: Physiological Integrity

OBJ:

6 TOP: Nursing Process Step:

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17.

The nurse at an outpatient clinic is educating a group of young adults regarding prevention of

the spread of sexually transmitted infections. Information will include:(Select all that apply.) a.

the use of hormonal contraceptives.

the use of latex condoms when infection is present.

abstinence.

frequent use of nonoxynol 9.

the importance of “partner services.”

ANS:

C, E

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Abstinence will prevent sexually transmitted infections, and use of sexual abstinence during the communicable phase of any disease will prevent reinfection. All sexual partners need to understand the importance of “partner services,” the documentation of all sexual partners for the purpose of providing evaluation and treatment. Hormonal contraceptives do not prevent sexually transmitted infections. When infections are present, abstain from sexual intercourse. A recent study indicates that frequent use of nonoxynol 9 may actually increase the risk of HIV infection during vaginal intercourse because of irritation of vaginal tissues.

DIF: Cognitive Level: Application Implementation

REF:

pp. 645-647

OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance; Physiological Integrity

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Chapter 41: Drugs Used to Treat Disorders of the Urinary System Test Bank

MULTIPLE CHOICE

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What is the action of urinary antimicrobial agents?

Reduce pain associated with bladder spasms caused by the infection

Enhance output enough to flush out the infection from the urinary tract

Eliminate urinary retention

Have an antiseptic effect on the urine and the urinary tract

ANS:

Urinary antimicrobial agents have an antiseptic effect on the urine and the urinary tract. Pyridium reduces pain associated with bladder spasms related to urinary tract infection (UTI). Antimicrobial agents do not enhance output or eliminate urinary retention.

DIF: Cognitive Level: ComprehensionREF: Assessment

pp. 669-670

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

2. A patient is complaining of moderate bladder pain and spasms secondary to a UTI. Which drug would assist in relieving symptoms? a.

Tolterodine (Detrol)

Nitrofurantoin (Furadantin)

Phenazopyridine hydrochloride (Pyridium)

Oxybutynin chloride (Ditropan)

ANS:

Phenazopyridine relieves burning pain, urgency, and frequency associated with UTIs. Tolterodine is given for treatment of overactive bladder (OAB). Nitrofurantoin is given for treatment of UTIs, but does not treat bladder pain or spasms. Oxybutynin is given for treatment of OAB.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 676 OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

3. A 42-year-old woman is admitted with complaints of dysuria, frequency, and lower back pain. The urinalysis report is positive for red blood cells, and the blood work shows an elevated white blood cell count. Which medication will the nurse anticipate that the health care provider will order?

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Meperidine (Demerol)

Bethanechol chloride (Urecholine)

Ciprofloxacin (Cipro)

Metronidazole (Flagyl)

ANS:

Dysuria, frequency, lower back pain, hematuria, and leukocytosis are indicators of a UTI. A variety of antimicrobial agents, including ciprofloxacin, are used to treat UTIs. Meperidine

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masks symptoms of pain that could lead to a more specific diagnosis and will not treat the underlying problem. Bethanechol is given for treatment of nonobstructive urinary retention. Metronidazole is given for treatment of vaginal infections.

DIF:

Cognitive Level: Application

REF:

p. 669 OBJ:

1 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

4. How often is fosfomycin (Monurol) usually administered when used in the treatment of UTIs? a. In a one-time dose b.

Once per day

Once per week

Monthly

ANS: A

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Fosfomycin is the first antibiotic to be approved for administration in a single treatment dose for the treatment of UTIs. Fosfomycin is used to treat females with uncomplicated acute cystitis caused by susceptible strains of Escherichia coli and Enterococcus faecalis. Fosfomycin is not used in the treatment of kidney infections.

DIF: Cognitive Level: Knowledge Implementation

REF:

p. 670 OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

5. After undergoing prostate surgery, a patient is discharged on the medication phenazopyridine hydrochloride (Pyridium) to assist with urinary catheter discomfort. What information will the nurse include in the discharge teaching? a.

Urine will have a foul smell while taking this medication.

Diarrhea and abdominal cramping are expected adverse effects.

The sclera of the eye is yellow while on therapy.

Urine will appear reddish orange.

ANS: D Phenazopyridine hydrochloride is used to produce a local anesthetic effect on the mucosa of the ureters and bladder. Patients should be instructed that phenazopyridine causes urine to become reddish orange, which is not a cause for alarm. Other secretions may also be reddish orange and contact lenses may become stained. Phenazopyridine does not cause a foul odor in the urine. Diarrhea is not a common adverse effect of phenazopyridine. Icterus is a sign of hepatic damage and should be reported to the health care provider.

DIF: Cognitive Level: Application Implementation

REF:

p. 676 OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

A 14-year-old male is taking tolterodine (Detrol). What is the action of this drug?

Restores bladder tone and function

Decreases the urge to void

Prevents urinary retention

Acidifies urine

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ANS: B

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Tolterodine is used to reduce the urgency and frequency of bladder contractions and delay the initial desire to void in patients with an OAB. Tolterodine does not restore bladder tone and function, prevent urinary retention, or acidify urine.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 674 OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Which condition will neostigmine be used to treat?

OAB

UTI

Postoperative or postdelivery urinary retention

Benign prostatic hypertrophy

ANS: C Neostigmine is an anticholinesterase agent that binds to cholinesterase, preventing the destruction of acetylcholine. The acetylcholine accumulates at cholinergic synapses, and its effects become prolonged and exaggerated. This produces a general cholinergic response manifested by miosis; increased tone of intestinal, skeletal, and bladder muscles; bradycardia; stimulation of secretions of the salivary and sweat glands; and constriction of the bronchi and ureters. An OAB is treated with anticholinergic agents. Anticholinergic agents with more selective action on the bladder are darifenacin, oxybutynin, solifenacin, tolterodine, and trospium. UTIs are treated with anti infectives. Benign prostatic hyperplasia– related urinary problems are treated with anticholinergic medications.

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DIF:

Cognitive Level: Knowledge

REF:

p. 674 OBJ:

1 TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity

Which organism causes most UTIs?

Proteus mirabilis

Klebsiella pneumoniae

Escherichia coli

Pseudomonas aeruginosa

ANS: C Gram negative aerobic bacilli from the gastrointestinal (GI) tract cause most UTIs. E. coli accounts for about 80% of noninstitutionally-acquired uncomplicated UTIs. Although common, P. mirabilis and K. pneumoniae are not responsible for most UTIs. P. aeruginosa is not the most common cause of UTIs.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 666 OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

What may become discolored by phenazopyridine (Pyridium) in addition to the urine? a.

Feces b.

Sclera

Sputum

Saliva

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ANS: B The urinary analgesic phenazopyridine hydrochloride will commonly turn the urine reddish orange. It may also affect the skin or sclera, in which case the health care provider should be contacted. Phenazopyridine does not discolor feces, sputum, or saliva.

DIF: Cognitive Level: Knowledge Assessment

REF:

p. 676 OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

10.

The nurse is teaching a patient about the anticholinergic agent prescribed for urinary retention.

Which statement by the patient indicates a need for further teaching? a.

“I will chew gum to relieve dry mouth.”

“I will limit my fluid intake.”

“I will eat fresh fruits.”

“I will not drive if I develop blurred vision.”

ANS: B Adequate fluid intake will help prevent constipation, which is a common adverse effect of urinary retention. Dry mouth can be relieved by chewing gum. Fresh fruits will help prevent constipation. Caution patients not to drive until they have adjusted to blurred vision.

DIF: Cognitive Level: Application Evaluation

REF:

p. 674

OBJ:

4 | 5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

11. The nurse is preparing to administer a single dose packet of fosfomycin to a patient diagnosed with a UTI. When preparing this medication, the nurse will: a.

pour contents into a souffle cup and administer by mouth.

mix with 3 mL of normal saline and inject subcutaneously.

pour contents into 90 mL of juice, stir, and administer by mouth.

mix contents with 120 mL of water and administer by mouth.

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ANS: D Fosfomycin is administered by pouring the entire contents of a single dose packet into 90 120 mL of water. Fosfomycin is not injected. Hot water should not be used.

DIF: Cognitive Level: Application Implementation

REF:

p. 670 OBJ:

1 | 3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity; Safe, Effective Care Environment

12. When obtaining urine for analysis on a patient in the labor and birth unit, the nurse assesses the urine to appear frothy. The nurse interprets this as a sign of possible: a.

gestational diabetes.

infection.

preeclampsia (toxemia).

dehydration.

ANS: C Foamy or frothy urine may indicate protein; proteinuria is associated with kidney disease, toxemia of pregnancy (also found in leukemia), lupus erythematosus, and cardiac disease.

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Foamy or frothy urine does not indicate gestational diabetes, infection, or dehydration. DIF: Cognitive Level: Analysis Assessment, Evaluation

REF:

p. 668 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

3 TOP: Nursing Process Step:

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MULTIPLE RESPONSE

13. A patient has been taking an antimicrobial agent prescribed to treat a UTI for 2 days. She contacts the health care provider’s office to report persistence of symptoms. In evaluating the medication effectiveness, which assessment(s) would be important? ( Select all that apply. ) a.

Complete emptying of the bladder

Amount of pain with urination as well as frequency

Amount of daily fluid intake and output

GI symptom complaints

Bleeding with urination

Persistence of nocturia

ANS: A, B, C, D, E Focused assessment of UTI symptoms includes assessing for urinary retention, pain and/or burning with urination, intake and output, GI symptoms, and bleeding with urination. Nocturia is common with OAB syndrome, not a UTI.

DIF: Cognitive Level: Application Implementation

REF:

p. 670 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

14. The nurse is assisting with postpartum care for a mother who has given birth to her fourth child. She reports a moderate amount of urinary incontinence since the birth of the third child and is concerned that this problem will worsen. Which instruction(s) may facilitate management of incontinence? ( Select all that apply. ) a.

Instruction of proper wiping techniques to prevent bacterial infection

Education on bladder training and Kegel exercises

Information on personal hygiene measures to prevent perianal breakdown

Information of incontinence products and appliances

Importance of establishing a regular toileting schedule

Importance of increasing fluid intake

ANS: A, B, C, D, E

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Patient education for incontinence includes teaching about proper wiping technique to prevent infection, Kegel and bladder training exercises, personal hygiene measures to prevent perianal breakdown, incontinence products and appliances for personal use, and the importance of responding to the urge to void and maintaining a regular toilet schedule. Patient education for incontinence does not include increasing fluid intake.

DIF: Cognitive Level: Application Implementation

REF:

p. 669 OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

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15. The nurse is reviewing the urinalysis results of an older adult patient admitted with elevated temperature and incontinence. Which urinalysis properties are indicative of an infection? ( Select all that apply. ) a.

Straw color

Foul odor

Trace glucose

pH of 8.2

Specific gravity of 1.014

ANS: B, D Urinalysis properties indicating infection include a foul odor and pH > 8.0. Urine the color of straw, clear yellow, or amber is a normal finding. A trace amount of glucose in the urine is a normal finding. The normal range of specific gravity is 1.003 to 1.029.

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DIF: Cognitive Level: Application Assessment

REF:

p. 668 OBJ:

2 | 6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

16. Which intervention(s) will help stimulate urination when a patient is experiencing postoperative urinary retention? ( Select all that apply. ) a.

Reinforcing Kegel exercises

Administration of bethanechol chloride (Urecholine)

Pouring warm water over the perineum

Increasing IV fluids

Urinary catheterization

ANS: B, C Administration of bethanechol chloride stimulates the parasympathetic nerve, causing contraction of the detrusor urinae muscle in the bladder, usually resulting in urination. Placing the patient in the proper position to void, pouring warm water over the perineum, and running water in the sink are techniques used to assist with voiding. Although Kegel exercises may help patients with incontinence, it will not help in postoperative urinary retention. Increasing IV fluids and catheterization will not help stimulate urination.

DIF: Cognitive Level: Application Implementation

REF:

p. 669 OBJ:

1 | 3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

17. Fluoxetine, erythromycin, clarithromycin, ketoconazole, itraconazole, miconazole, vinblastine, ritonavir, and nefazodone may inhibit the metabolism of which drugs? (Select all that apply.) a.

Warfarin

Tolterodine

Phenytoin

Darifenacin

Heparin

Solifenacin

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ANS: B, D, F

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These agents inhibit the metabolism of tolterodine, darifenacin, and solifenacin. Warfarin, phenytoin, and heparin are not influenced by these drugs.

DIF: Cognitive Level: ComprehensionREF: Implementation

pp. 669-670

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity 18.

The nurse is caring for a patient taking Pyridium for the diagnosis of UTI. What should the

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Chapter 42: Drugs Used to Treat Glaucoma and Other Eye Disorders Test Bank

MULTIPLE CHOICE

1. The nurse is preparing a patient for an ophthalmic examination. Which action occurs when the nurse instills eye drops to produce mydriasis? a.

Drying of tears in the eyes

Extreme dilation of the pupil

Opening of the canal of Schlemm

Paralysis of the ciliary muscle

ANS:

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Dilating the eye before eye examinations allows for better visualization of the interior of the globe. Anticholinergic drugs may produce drying of tears in the eye as an adverse effect of use. Obstruction of the canal of Schlemm results in glaucoma. Paralysis of the ciliary muscle is cycloplegia.

DIF: Cognitive Level: Application Implementation

REF:

p. 678 OBJ:

6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Which type of medication would be used to dilate the pupils before an eye examination?

Osmotics

Adrenergic agent

Beta adrenergic agent

Corticosteroid

ANS:

Adrenergic agents are sympathomimetic. They cause pupil dilation, increased outflow of aqueous humor, vasoconstriction, relaxation of ciliary muscle, and a decrease in the formation of aqueous humor. Adrenergic agents are used to lower intraocular pressure (IOP) in open angle glaucoma, relieve congestion and hyperemia, and produce mydriasis for ocular examinations. Osmotics are given to reduce IOP. Beta adrenergics are given for the treatment of asthma. Corticosteroids are given for acute allergic reactions in the eye.

DIF: Cognitive Level: ComprehensionREF: Evaluation

p. 688 OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Which medication is used to produce miosis following a diagnostic procedure?

Pilocarpine (Pilocar)

Mannitol (Osmitrol)

Atropine (Isopto Atropine)

Epinephrine (EpiPen)

ANS:

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Pilocarpine is a direct acting cholinergic agent that is used to counter the effects of mydriatic and cycloplegic agents after surgery or eye ophthalmoscopic examinations. Cholinergic

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agents also reduce IOP in glaucoma patients by widening the filtration angle that permits outflow of aqueous humor. Mannitol is an osmotic diuretic given to decrease ocular pressure by drawing aqueous humor from the eye. Atropine is a mydriatic agent given to dilate the pupil. Epinephrine may be used to treat certain types of glaucoma.

DIF:

Cognitive Level: ComprehensionREF:

p. 687 OBJ:

6 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

4. Which discharge instruction will the nurse include for a patient sent home from the clinic who is taking an adrenergic ophthalmic solution for an acute inflammation? a. Headaches and eye pain are adverse effects to be reported to the health care provider immediately. b.

Mouth dryness should be reported immediately.

Avoid driving or operating machinery until blurring subsides.

“Halos” or yellow rings around objects will be seen while taking this medication.

ANS: C Adrenergic agents cause the smooth muscle of the ciliary body and iris to relax, producing mydriasis. Blurred vision will temporarily occur until the patient can adjust to the increased light coming into the eyes. Activities such as driving or operating machinery should be avoided until vision stabilizes. Sunglasses help reduce the brightness. These are common, mild adverse effects and usually resolve with continued therapy. Mouth dryness is a common adverse effect. Halos are a sign of acute closed angle glaucoma.

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DIF: Cognitive Level: Application Implementation

REF:

pp. 688-689

OBJ:

4 | 6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

What is the action of timolol maleate (Timoptic), a beta adrenergic blocking agent?

Draws aqueous humor from the eye into the circulatory network

Increases the production of aqueous humor

Increases the outflow of aqueous humor

Decreases the production of aqueous humor

ANS: D Timolol maleate is a beta adrenergic blocking agent used to reduce increased intraocular pressure. The exact mechanism of action of these medications is unknown, but they are believed to reduce the production of aqueous humor. Timolol is believed to decrease production of aqueous humor.

DIF:

Cognitive Level: ComprehensionREF:

p. 689 OBJ:

6 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

What is the mechanism of action of osmotic agents when used to decrease IOP?

Promoting outflow of the aqueous humor into the tear ducts

Increasing plasma osmolarity and drawing extracellular fluid into the blood

Blocking production of aqueous humor

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Decreasing viscosity of the tears and allowing fluid to drain away from the eye

ANS: B Osmotic agents elevate the osmotic pressure of the plasma, causing fluid from the extravascular spaces to be drawn into the blood. The effect on the eye is reduction of volume of intraocular fluid, which produces a decrease in IOP. Osmotic agents do not promote flow of aqueous humor into tear ducts, block production of aqueous humor, or decrease viscosity of tears.

DIF: Cognitive Level: ComprehensionREF: Implementation

pp. 683-684

OBJ:

6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

Which is a potential serious adverse effect associated with mannitol (Osmitrol)?

Bradycardia

Fluid overload

Anaphylaxis

Fever

ANS: B Mannitol, an osmotic agent, acts on blood volume by pulling fluid from the tissue spaces into the general circulation (blood). Patients should be assessed at regularly scheduled intervals for signs and symptoms of fluid overload, pulmonary edema, or heart failure. Osmotic agents are not likely to cause bradycardia, anaphylaxis, or fever.

DIF:

Cognitive Level: Knowledge

REF:

p. 684 OBJ:

6 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

8. The nurse is caring for a patient immediately following a right sided trabeculectomy. When positioning this patient, the nurse will encourage a position. a.

prone

right side lying

left side lying

Trendelenburg

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ANS: C Following right sided trabeculectomy, the patient is usually positioned on the back or on the unoperated side. Prone position, right side lying, and Trendelenburg positions are not recommended after a trabeculectomy.

DIF: Cognitive Level: Application Implementation

REF:

p. 682 OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

9. The nurse is assisting with applanation tonometry on a patient at the ophthalmologist’s office. The results indicate the patient’s reading to be 15 mm Hg. The nurse interprets this result as IOP. a.

decreased

normal

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slightly increased

severely increased

ANS: B Normal IOP using an applanation tonometer is 10 to 21 mm Hg.

DIF: Cognitive Level: Analysis Evaluation

REF:

p. 682 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

2 | 4 TOP: Nursing Process Step:

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MULTIPLE RESPONSE

10.

Which statement(s) about aqueous humor is/are true? ( Select all that apply. )

Bathes and feeds the lens, posterior surface of the cornea, and iris

Maintains the iris color

c. Drains out of the eye through drainage channels located near the junction of the cornea and sclera d.

Manufactures fluid for tear production

Flows out of the canal of Schlemm into the venous system of the eye

ANS: A, C, E Aqueous humor bathes and feeds the lens, posterior surface of the cornea, and iris. After it is formed, the fluid flows forward between the lens and the iris into the anterior chamber. Aqueous humor drains out of the eye through drainage channels located near the junction of the cornea and sclera. Aqueous humor drains into a meshwork leading into the canal of Schlemm and into the venous system of the eye. Eye color is not dependent on the aqueous humor. Tears are produced by the lacrimal glands in the upper and lower eyelids.

DIF: Cognitive Level: ComprehensionREF: Assessment

pp. 678-679

OBJ:

1 | 2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

11. A factory worker had a chemical inadvertently splashed into his right eye. An eyewash was used at the work site. Which nursing assessment(s) would be important to include? (Select all that apply.) a.

Visual acuity

Presence of pain, blurred or halo vision, or lack of vision

Type of chemical

Presence of nystagmus

Presence of contacts or use of eyeglasses

ANS: A, B, C, E Important nursing assessments would include visual acuity and baseline vital signs. These assessments would also include subjective data such as pain, clarity, and acuity of vision; observation of any physical abnormalities of the eye or lid; pupil characteristics; drainage or excessive tearing; edema or redness;

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and interventions completed before arrival. Important nursing assessments would include the type and cause of injury and whether contacts or eyeglasses are worn. Nystagmus is involuntary, rhythmic, repeated oscillations of one or both eyes. The cause is unknown. It would be unrelated to chemical eye injury.

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DIF: Cognitive Level: Application Assessment

REF:

p. 681 OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment 12. What information will the nurse include when instructing a patient on the correct method of instilling eye drops? ( Select all that apply. ) a. With an infection, prevent cross contamination and use a separate source of medication and droppers for each eye. b.

Wash hands before and after administration.

Place the lid on the surface area as instructed to avoid contamination.

Never touch the tip of the dropper or opening of the ointment container.

Wipe eye from the outer to inner canthus.

ANS: A, B, C, D Separate medication sources should be used when an eye infection is present to avoid cross contamination. Washing of hands before and after instillation will prevent infection. The medication lid should not lie with the opening down on any surface. Any medications instilled into the eye should be sterile. The medication tip should not touch anything, including the eye, face, or fingers. Wipe the eye from the inner canthus outward.

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DIF: Cognitive Level: Application Implementation

REF:

pp. 679-680

OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

13. A patient recently diagnosed with glaucoma is to begin drug therapy with carbonic anhydrase inhibitors. For which assessment(s) would the nurse need to contact the health care provider? ( Select all that apply. ) a.

Electrolyte levels

Any signs of gastric symptoms before initiating drug therapy

Allergy to sulfonamides

Patient history of menopause

Elevated IOP levels

ANS: A, C Baseline electrolyte studies, weight, hydration data, vital signs, and mental status should be obtained before beginning drug therapy. Carbonic anhydrase inhibitors should be held and the health care provider notified if the patient is pregnant or allergic to sulfonamides. If the patient is experiencing gastrointestinal symptoms, the medication should be administered with milk or food. Menopause is unrelated to the condition of glaucoma or its treatment. Elevated IOP levels are associated with glaucoma and are an expected condition. They do not need to be reported to the health care provider.

DIF: Cognitive Level: Application Implementation

REF:

pp. 685-686

OBJ:

4 | 5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

14.

What is the purpose of administering a cycloplegic agent? ( Select all that apply. )

Facilitate examination of the eye

Facilitate surgery on the eye

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Cause pupillary dilation

Paralyze the ciliary muscle

Decrease the production of aqueous humor

ANS: A, B, D The eye is easier to examine in some cases if the ciliary muscle is paralyzed. Surgery on the eye is easier when the ciliary muscle is paralyzed. Cycloplegic agents are used to paralyze the ciliary muscle in preparation for examination or surgery. Drugs that cause pupillary dilation are called mydriatic agents. Cycloplegic agents do not decrease the production of aqueous humor.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 691 OBJ:

6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

15. Which are important teaching points for the nurse to review with a patient recently diagnosed with open angle glaucoma? ( Select all that apply. ) a.

The disease will cause damage to the optic disc if left untreated.

Symptoms are sudden and painful when the disease begins.

Loss of peripheral vision is a common trigger for diagnosis.

Total blindness may result if the glaucoma is not treated.

Glaucoma is not a serious disease and will cause only mild inconvenience to the patient.

Treatment is only necessary when symptoms are bothersome.

ANS: A, C, D IOP builds up and, if not treated, will damage the optic disc. Initially, the patient has no symptoms, but over the years, peripheral vision is gradually lost. If glaucoma is left untreated, total blindness may result. Patients with glaucoma are initially asymptomatic. Glaucoma is a serious disease that, if left

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untreated, may result in total blindness. If glaucoma is not treated, IOP builds up and will damage the optic disc.

DIF: Cognitive Level: ComprehensionREF: Implementation

pp. 680-681

OBJ:

3 | 4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

16. What information will the nurse include when teaching the patient and family about postoperative care for a trabeculectomy? ( Select all that apply. ) a.

Use aseptic technique for all dressing changes and medication administration.

Place the patient on the operated side.

Avoid heavy lifting.

Redness in the eye, pain, and swelling are common occurrences after surgery.

Avoid straining on defecation.

ANS: A, C, D, E Teach the patient and family proper hygiene and eye care techniques to ensure that medications, dressings, and/or surgical wounds are not contaminated during necessary eye care. Explain and enforce activity and exercise restrictions. To prevent an increase in IOP, instruct the patient to avoid heavy lifting, straining on defecation, coughing, or bending and placing the head in a dependent position. Teach the patient and family about signs and

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symptoms of infections and when and how to report them to allow early recognition and treatment of possible infection. Straining increases IOP and should be avoided. The patient is positioned on the unoperated side or the back.

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DIF: Cognitive Level: Application Implementation

REF:

pp. 682-683

OBJ:

4 TOP: Nursing Process Step:

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MSC: NCLEX Client Needs Category: Physiological Integrity

17. The nurse is educating a patient about a newly prescribed cholinergic agent. When relaying common adverse effects of this type of medication, the nurse will include information about: (Select all that apply.) a.

conjunctival irritation.

headache.

salivation.

hypotension.

bradycardia.

ANS:

A, B

Conjunctival irritation and headache are common adverse effects of cholinergic agents. Salivation, hypotension, and bradycardia are systemic adverse effects of cholinergic agents and may indicate toxicity.

DIF: Cognitive Level: Application Implementation

REF:

pp. 686-687

OBJ:

6 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity; Health Promotion and Maintenance

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Chapter 43: Drugs Used to Treat Cancer

MULTIPLE CHOICE

1. The nurse is educating a patient with cancer about combination chemotherapy. Which is an accurate statement? a. “Combination chemotherapy is the administration of an antineoplastic drug that will be toxic during a specific phase of cellular growth.” b. “Combination chemotherapy is the administration of an antineoplastic drug that is active throughout the cell cycle.” c. “Combination chemotherapy is the administration of antineoplastic drugs that change the way the body responds to cancer or strengthens the immune system.” d. “Combination chemotherapy is the administration of antineoplastic drugs, which results in cell death during different phases of the cell cycle.”

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ANS: D Use of combination drug therapy is superior in therapeutic effect to the use of single agent chemotherapy.

DIF: Cognitive Level: ComprehensionREF: Implementation

Page 669

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Patient Education

2. The cell cycle-specific agent vincristine sulphate (Oncovin) acts in which phase of the cell’s life cycle? a.

S phase

Mitotic phase

Phase G1

Phase G0

ANS: B Vinca alkaloids block the formation of the mitotic spindle during mitosis, thus inhibiting cell division. The S phase is the stage of active synthesis of two sets of DNA. Phase G1 is considered a presynthetic phase in which the cell prepares for DNA synthesis by manufacturing necessary enzymes. G0 is the largest variable in the cell cycle and, during this resting phase, the cell is not actively replicating.

DIF: Cognitive Level: Knowledge Process Step: Implementation

REF:

Page 667 | Page 668 OBJ:

TOP: Nursing

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MSC:

NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment

What is the importance of correlating the dosage schedule with cell cycle-specific drug therapy?

Ongoing proliferation of neoplastic tissue

Combination therapy is far superior to the use of single agent therapy. The use of a cell cyclespecific and cell cycle-nonspecific agents together facilitates cell death during different phases of the cell cycle. Combination therapy is not more economical or faster. Combination therapy is not less toxic because it exposes patients and nurses to additional medications. The use of combination drug therapy allows for cell death during different phases of the cell cycle, but the agents often have toxic effects on different organs at different time intervals after administration.

DIF: Cognitive Level: ComprehensionREF: Evaluation

Page 669

OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment

Why is a patient with prostate cancer prescribed an estrogen?

To achieve hormonal balance

To decrease the rate of production for malignant cells

To soften prostatic tissue

To suppress prostate gland function

2 TOP: Nursing Process Step:

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ANS: B Estrogen therapy is used during the treatment of prostate cancer to decrease the rate of production of malignant cells. The use of female hormones decreases the amount of male hormones available for use by the cancer cells. Estrogen is not given for hormonal balance, does not soften prostatic tissue, and does not suppress prostate gland function.

DIF: Cognitive Level: ComprehensionREF: Evaluation

Page 669

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment

Which assessment by the nurse would be a sign of neurotoxicity related to chemotherapy?

Paresthesia

Euphoria

Nausea

Hallucinations

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ANS: A Signs and symptoms of neurotoxicity include numbness and tingling in extremities, confusion, changes in gait, and motor weakness. Euphoria, nausea, and hallucinations are not signs of neurotoxicity related to chemotherapy.

DIF: Cognitive Level: Knowledge Evaluation

REF:

Page 674

OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

8. Which symptom is the patient who is receiving bleomycin (Blenoxane) therapy most likely to exhibit? a.

Increased respiratory rate and cough

Weight gain and peripheral edema

Numbness and tingling of hands and feet

Lethargy and orthostatic hypotension

ANS: A Compromised respiratory function may occur in patients receiving bleomycin therapy. Increased respiratory rate and cough can be signs that further problems are developing, such as heart failure. Bleomycin does not cause weight gain, peripheral edema, numbness and tingling of hands and feet, lethargy, or orthostatic hypotension.

DIF: Cognitive Level: ComprehensionREF: Assessment

Page 672

OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

9. What is the purpose of administering filgrastim (Neupogen) to a patient who is post-bowel resection resulting from cancer? a.

Decrease the gastrointestinal (GI) toxicity resulting from chemotherapeutic agents

Suppress the immune response

Work as an antiemetic and stimulate his appetite

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Increase the white blood cell (WBC) counts

ANS: D Filgrastim works to stimulate WBC production and decrease the incidence of infection. Filgrastim is a colony stimulating factor, which stimulates WBC proliferation and maturation. It is particularly helpful for patients prone to neutropenia resulting from cancer therapy. Filgrastim does not affect GI toxicity, suppress immune response (it works to enhance it), or affect appetite or nausea.

DIF: Cognitive Level: Application Implementation

REF:

Page 671

OBJ:

3 TOP: Nursing Process Step:

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MSC: NCLEX Client Needs Category: Health Promotion and Maintenance NOT: CONCEPT(S): Clinical Judgment

10.

What is the intended outcome of the chemoprotective drug amifostine (Ethyol)?

Decreased nausea and vomiting

Increased effectiveness of the chemotherapy

Maintenance of body weight

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Decreased renal toxicity

ANS: D Amifostine is used to reduce the cumulative renal toxicity associated with the repeated administration of cisplatin in patients with advanced ovarian cancer. Chemoprotective drugs do not decrease nausea and vomiting, enhance the effectiveness of chemotherapy treatment, or help prevent weight loss. DIF: Cognitive Level: ComprehensionREF: Implementation

Page 670

OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment

11.

Why are bone marrow stimulants used in the treatment of cancer?

To increase uptake of the chemotherapy from the interior of the bones

To strengthen bones weakened by pathologic processes

To enhance the patient’s immune system during treatment

To protect the bone marrow from destructive actions from the cancer treatment

ANS: C Bone marrow stimulants trigger the recovery of bone marrow cells several days earlier than would be the natural course of recovery. The major benefit to this earlier recovery is that patients’ immune systems are able to respond to and stop infections from being so pathologic, and patients can be released from the isolation room several days earlier. Bone marrow stimulants do not increase uptake of drugs, strengthen bones, or protect the bone marrow from destructive effects of chemotherapy or radiation.

DIF: Cognitive Level: ComprehensionREF: Process Step: Implementation

Page 670 | Page 671 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment

TOP: Nursing

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12. The nurse is providing education about chemotherapy to a patient who is being discharged. Which statement by the patient indicates a need for further teaching? a.

“I will shave with an electric razor.”

“I will take aspirin for a headache.”

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“I will wash my laundry separate from other family members.”

“I will flush the toilet twice after using.”

ANS: B Patients should not take any aspirin or aspirin-containing products. Shaving with an electric razor is preferable for a patient undergoing chemotherapy because of the decreased risk of bleeding. The clothing of the chemotherapy patient should be washed separately from other household linens. Because most chemotherapeutic agents are excreted in the urine and feces, it is best to flush the toilet two or three times.

DIF: Cognitive Level: Application Process Step: Evaluation

REF:

Page 672 | Page 674 OBJ:

TOP: Nursing

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Patient Teaching; Safety

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13. The nurse is caring for a patient diagnosed with breast cancer. The patient reports that she has been experiencing frequent watery stools following chemotherapy treatment. When educating the patient regarding dietary guidelines to help relieve symptoms the nurse will encourage a. eliminating spicy foods.

Alkylating agents, antineoplastic antibiotics, hormones, and antimetabolites are considered major chemotherapeutic agents. Antinuclear antibodies are antibodies produced by the immune system that attack the body’s own tissues instead of foreign toxins. They are frequently present in people with systemic lupus erythematosus and, less commonly, in other diseases. Chelating agents are used to detoxify a patient from heavy metal poisoning.

DIF: Cognitive Level: ComprehensionREF: Process Step: Implementation

Page 669 | Page 670 OBJ:

TOP: Nursing

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment

2. Which nursing consideration(s) would be taken into account prior to the administration of cisplatin IV? (Select all that apply.) a.

Review of laboratory data for presence of myelosuppression and hepatic and renal parameters

Administration of IV hydration as prescribed

Administration of epoetin alfa (Epogen)

Administration of prechemotherapy mesna (Mesnex)

Assessment for dermatologic conditions

ANS: A, B, D Premedication nursing considerations regarding cisplatin, an alkylating agent, include checking laboratory reports for baseline data reflecting hepatic and renal function and

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baseline hematologic studies that reflect the degree of myelosuppression present before initiating chemotherapy, assessing patient hydration and the health care provider’s orders for oral and IV hydration instructions before drug therapy, and administering prechemotherapy drugs including mesna, ondansetron, and antianxiety drugs. Epogen is given to treat anemia associated with chemotherapy; it is not given before administration of chemotherapy. Dermatologic assessment is not necessary before administering cisplatin.

DIF: Cognitive Level: Application Implementation

REF:

Page 673

OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

3. Which sign(s) and symptom(s) assessed by the nurse would indicate thrombocytopenia? (Select all that apply.) a.

Pinpoint red rash

Casts in urine

Brown, fatty stools

Increase in menstrual flow

Coffee-ground emesis

ANS: A, D, E

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Pinpoint red rash, an increase in menstrual flow, and coffee-ground emesis indicate thrombocytopenia, which causes an increased tendency to bleed. Thrombocytopenia may cause hematuria and dark, tarry stools.

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Chapter 44: Drugs Used to Treat the Musculoskeletal System

MULTIPLE CHOICE

1. A patient who has undergone a lengthy surgical procedure under general anesthesia is unable to breathe on his own following the procedure. Which drug will the nurse expect to be administered as an antidote to the neuromuscular-blocking agent?

Dantrolene (Dantrium)

Neostigmine methylsulfate (Prostigmin)

Ether

Baclofen (Lioresal)

ANS: B

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Neostigmine methylsulfate is an antidote to neuromuscular-blocking agents. Additional measures to implement include artificial respirations with oxygen and atropine sulfate for bradycardia and hypotension. Dantrolene is a direct-acting skeletal muscle relaxant given for the treatment of neuroleptic malignant syndrome associated with the use of antipsychotic agents. Ether is a general anesthetic. Baclofen is a skeletal muscle relaxant.

DIF: Cognitive Level: Application Implementation

REF:

Page 684

OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Gas Exchange

What is the reason for a paraplegic patient to receive baclofen (Lioresal)?

It interrupts reflexes at the level of the spinal cord.

of reflex muscle contractions.

ANS: A Baclofen is a gamma aminobutyric acid derivative that interrupts polysynaptic reflexes at the level of the spinal cord. Baclofen does not appear to act directly on the skeletal muscles. Interrupting transmission of impulses from motor nerves to muscles at the skeletal neuromuscular junction is the mechanism of action of neuromuscular-blocking agents. Producing generalized mild weakness of skeletal muscles and decreasing the force of reflex muscle contractions is the mechanism of action of dantrolene.

DIF: Cognitive Level: ComprehensionREF: Implementation

Page 682

OBJ:

2 | 3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment

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3. A patient taking antipsychotic medication for schizophrenia is admitted with a temperature of 106° F. The admitting diagnosis is neuroleptic malignant syndrome resulting from antipsychotic medication. Which drug is indicated in treatment of this condition?

ANS: B Dantrolene, a direct-acting skeletal muscle relaxant, is used to treat neuroleptic malignant syndrome associated with the use of antipsychotic agents. Edrophonium is an antidote for neuromuscular-blocking agents. Baclofen is a skeletal muscle relaxant used for the treatment of muscle spasticity resulting from multiple sclerosis (MS) and cerebral palsy. Metaxalone is used for muscle spasms.

DIF: Cognitive Level: ComprehensionREF: Implementation

Page 683

OBJ:

2 | 3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

In the intensive care unit, the nurse is taking care of a patient who is on a ventilator and is

nt? a.

d. Self-care deficit

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ANS: A Pain is the highest priority, according to Maslow’s hierarchy of needs. Succinylcholine, a neuromuscularblocking agent, is used to paralyze muscles while a patient is on a ventilator. Neuromuscular-blocking agents do not relieve pain. Disturbed body image is not a priority for this situation, although it does apply. Risk for injury and self-care deficit are not as great of priorities for this situation.

DIF: Cognitive Level: Application Process Step: Diagnosis

REF:

Page 684 | Page 685 OBJ:

1|4

TOP: Nursing

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Pain

“They decrease intracranial pressure resulting from therapy.”

“They reduce the risk of injury during therapy.”

ANS: D

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Neuromuscular-blocking agents are used before electroconvulsive therapy to paralyze the skeletal muscles and reduce the risk of fractures during therapy. Neuromuscular-blocking agents do not stimulate respiration, prevent aspiration, or affect intracranial pressure.

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DIF: Cognitive Level: Application Implementation

REF:

Page 684

OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment NOT: CONCEPT(S): Clinical Judgment

6. Which laboratory values will the nurse review prior to beginning medication therapy for skeletal and muscle disorders?

ANS: B Examine laboratory reports associated with the disease process present (e.g., calcium, phosphorus, lupus testing, rheumatoid factor, uric acid level, CRP, HLA, aldolase, aspartate, creatine kinase). Electrolytes, trace minerals, ABGs, CBC, electrolytes, glucose, HDL, and PT are not associated with this disease process.

DIF: Cognitive Level: Application Assessment

REF:

Page 679

OBJ:

1 | 2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment

Which medication will be prescribed for a patient complaining of muscle spasms resulting

fro

m a back injury?

Acetaminophen (Tylenol)

Morphine sulfate

Bethanechol (Urecholine)

d. Cyclobenzaprine (Flexeril)

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ANS: D Cyclobenzaprine is a centrally acting skeletal muscle relaxant, which is a group of drugs used to relieve acute muscle spasms. Their exact mechanism of action is unknown, except that they depress central nervous system (CNS) function. All the centrally acting skeletal muscle relaxants produce some degree of relaxation, and health care providers maintain that the benefits from the sedative effects may exceed the benefits from actual muscle relaxation. Acetaminophen, morphine, and bethanechol do not relieve skeletal muscle spasms.

DIF: Cognitive Level: ComprehensionREF: Process Step: Evaluation

Page 681 | Page 682 OBJ:

TOP: Nursing

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Pain

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8. Which symptoms will be most important for the nurse to assess for early signs of respiratory distress in the patient who has been given a neuromuscular-blocking agent? a.

Nasal flaring and retraction of intercostal muscles

Dyspnea, increased respiratory rate, and cyanosis

Restlessness, anxiety, and lethargy

Pallor, stridor, and diaphoresis

ANS:

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The signs of restlessness, anxiety, lethargy, decreased mental alertness, and headache are early, subtle clues to respiratory distress. Retractions, flaring, dyspnea, hyperventilation, cyanosis, pallor, stridor, and diaphoresis are not early signs of respiratory distress.

DIF

Cognitive Level: Application

REF:

Page 679

OBJ:

TOP

Nursing Process Step: Assessment

MSC

: NCLEX Client Needs Category: Safe, Effective Care Environment

NOT

: CONCEPT(S): Clinical Judgment; Gas Exchange

Which common adverse effects occur with neuromuscular-blocking agents?

Fever

Flushing

Nausea

Ataxia

ANS:

Neuromuscular-blocking agents cause histamine release, which may cause bronchospasm, bronchial and salivary secretions, flushing, edema, and urticaria. Ensure that the airway is patent and that secretions are suctioned regularly to prevent obstruction. Report evidence of bronchospasm, edema, and urticaria immediately. Neuromuscular-blocking agents do not commonly cause fever, nausea, or ataxia.

DIF

Cognitive Level: ComprehensionREF:

Page 685

Nursing Process Step: Implementation

MSC

: NCLEX Client Needs Category: Physiological Integrity

NOT

: CONCEPT(S): Clinical Judgment; Safety

OBJ:

10. Which assessment is most important for the nurse to obtain when a patient is being treated with a neuromuscular-blocking agent? a.

Skin assessment for rash and urticaria

Blood pressure assessment for orthostatic hypotension

Respiratory assessment for patent airway

Assessment for fluid volume overload

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ANS:

Histamine release caused by these drugs may produce increased salivation. In patients who are paralyzed or who have incomplete return of control over swallowing, coughing, and deep breathing, these secretions may obstruct the airway. Histamines are not likely to produce

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rash or urticaria related to the administration of neuromuscular-blocking agents. Patients on neuromuscular-blocking agents are generally kept on bed rest and not subject to orthostatic hypotension. Neuromuscular-blocking agents do not cause fluid volume overload.

DIF: Cognitive Level: Application Assessment

REF:

Page 684

OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Gas Exchange

11. Which drug interaction may occur when an aminoglycoside or tetracycline is given in conjunction with neuromuscular-blocking agents? a.

Deep sedation

Decreased effectiveness of antibiotics

Increased neuromuscular-blocking activity

Sensitivity to antibiotics and possible allergic reaction

ANS: C

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Question antibiotic orders that prescribe aminoglycosides or tetracycline when neuromuscular blockers have been used. These drugs may potentiate the neuromuscular- blocking activity. This combination of medications would not cause deep sedation. Neuromuscular-blocking agents do not decrease the effectiveness of antibiotics or increase sensitivity to antibiotics.

DIF: Cognitive Level: ComprehensionREF: Implementation

Page 685

OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

12. A patient taking a neuromuscular-blocking agent is assessed to have a heart rate of 120 and blood pressure of 80/50. The nurse will anticipate the physician writing an order for a.

ABGs.

blood glucose level.

CBC.

liver function tests.

ANS: A Patients taking neuromuscular-blocking agents should be monitored closely for clinical signs of hypoxia and hypercapnia (tachycardia, hypotension, cyanosis). ABG levels may be determined to confirm the clinical observations. Blood glucose levels, CBC, and liver function tests would not be indicated with these symptoms.

DIF: Cognitive Level: Analysis REF: Page 679 OBJ: 4 TOP: Nursing Process Step: Assessment | Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Gas Exchange

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13. The nurse receives a conscious patient from the postoperative unit after administration of a neuromuscular blocker. Once the patient’s vital signs are stable, the best position for the nurse to assist the patient into is position. a.

Sims

semi-Fowler’s

supine

prone

ANS: B Patients can usually cough better in a semi-Fowler’s or high Fowler’s position; therefore, depending on the situation and stability of the patient’s vital signs, elevating the head of the bed may assist coughing and breathing. Sims, supine, and prone are not the best positions for a patient postoperatively.

DIF: Cognitive Level: Application Implementation

REF:

Page 680

OBJ:

1 | 4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment| NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

MULTIPLE RESPONSE

Patients with which conditions must be carefully assessed to determine whether they would

tol

erate treatment with a neuromuscular-blocking agent? (Select all that apply.)

Pregnancy

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Hepatic disease

Pulmonary disease

Renal disease

Neurologic disorders

Psychiatric disorders

ANS: B, C, D, E Patients with hepatic disease, pulmonary disease, renal disease, and neurologic disorders such as myasthenia gravis, spinal cord injury, or MS must be fully evaluated to assess their ability to tolerate neuromuscular-blocking agents. Neuromuscular-blocking agents can usually be used safely with the pregnant patient and the psychiatric patient.

DIF: Cognitive Level: Application Assessment

REF:

Page 684

OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety

The nurse is examining a patient in the emergency department whose chief complaint is a

ct all

Degree of impairment

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Pain level

d. Inspection of the affected part for swelling, capillary refill, bruising, redness, localized tenderness, deformities, and paresthesia e.

Elevation of the affected extremity

ANS: A, B, C, D Important nursing assessment of a musculoskeletal injury includes mechanism of injury, degree of impairment, pain level, and obvious deformity and neurovascular assessment. Elevating the affected extremity would exacerbate the pain and deformity of the injury.

DIF: Cognitive Level: Application Step: Assessment

REF:

Pages 678-681 OBJ:

TOP: Nursing Process

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Mobility; Pain; Safety

3. An employee at a factory has not been to work because of low back muscle spasms. His wife contacts the occupational health nurse to report that her spouse is on a centrally acting skeletal muscle relaxant and is having problems with sleepiness. Based on the medication action, what will the nurse tell her? (Select all that apply.) a.

“The health care provider should be notified because these drugs are

’s

ANS: B, C, D, E

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Patients should be instructed to avoid activities that require alertness, such as driving or operating heavy machinery, for safety. When obtaining patient information regarding adverse effects, additional information may be needed to fully assess the degree of adverse effects the patient may be experiencing. Review of baseline liver and kidney function and CBC laboratory data is necessary. Centrally acting skeletal muscle relaxants are used to relieve acute muscle spasm. They act on the CNS, and sedation may be an adverse effect associated with usage. This tends to be mild and will resolve with continued use. These drugs are indicated for the treatment of low back pain.

DIF: Cognitive Level: Application Step: Assessment

REF:

Page 681

OBJ:

1 | 2 | 3 TOP: Nursing Process

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance NOT: CONCEPT(S): Clinical Judgment; Safety; Patient Education; Communication

Why are neuromuscular-blocking agents used? (Select all that apply.)

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Alleviation of pain

Reducing the use and adverse effects of general anesthetics

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Easing endotracheal intubation and prevent laryngospasm

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Producing amnesia during painful procedures

Decreasing muscular activity in electroshock therapy

ANS:

B, C, E

Neuromuscular-blocking agents are used to produce adequate muscle relaxation during anesthesia to reduce the use (and adverse effects) of general anesthesia, ease endotracheal intubation and prevent laryngospasm, and decrease muscular activity in electroshock therapy. Neuromuscular-blocking agents have no effect on the pain threshold, memory, or consciousness.

DIF: Cognitive Level: Application Implementation

REF:

Page 684

OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment

5. When assessing a patient for signs and symptoms of early respiratory depression immediately after leaving the postoperative area, the nurse will be alert for signs of what?S(elect all that apply.) a.

Restlessness

Anxiety

Lethargy

Increased mental alertness

Cyanosis

ANS:

A, B, C

Early signs of diminished ventilation include restlessness, anxiety, lethargy, decreased mental alertness, and headache. Increased mental alertness is not an early sign of respiratory depression. Cyanosis is a late sign of respiratory complications.

DIF:

Cognitive Level: Application

REF:

TOP:

Nursing Process Step: Assessment

Page 679

OBJ:

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MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Gas Exchange; Safety

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Chapter 46: Nutrition

MULTIPLE CHOICE

Which meal contains the best sources of dietary fiber?

Eggs, bacon, orange juice

Salad, whole wheat toast, sliced peach

Roast beef, mashed potatoes with gravy, corn, milk

Grilled hamburger on a bun, fresh carrot sticks, potato chips

ANS: B Good dietary sources of fiber include fresh fruits, vegetables, and whole grain foods. There is little fiber in eggs, bacon, and orange juice and much fat and sugar. Although there is fiber in the menu of roast beef, mashed potatoes, corn, and milk as well as a hamburger on a bun, carrot sticks, and potato chips, these are not the best sources of dietary fiber.

DIF: Cognitive Level: Application Evaluation

REF:

Page 741

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Nutrition

2. A patient who is 8 weeks’ postpartum would like to begin a moderate intensity exercise program to lose the remaining 20 lb she gained during her pregnancy. Which exercise regimen will the nurse recommend to accomplish this goal best? a.

Walking 2 miles daily in 1 hour, four times weekly

Jogging 4 miles in 20 minutes, three times weekly

Walking 4 miles in 1 hour daily

Jogging 2 miles in 20 minutes, twice weekly

ANS: C According to the National Academy of Sciences, a moderate intensity physical activity would include walking at a rate of 4 to 5 miles/hour four to seven times weekly. Walking 2 miles daily in 1 hour four times weekly is below a moderate level of activity. Jogging 4 miles in 20 minutes three times weekly and jogging 2 miles in 20 minutes twice weekly is beyond a moderate level of activity.

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DIF: Cognitive Level: Application Implementation

REF:

Page 745

OBJ:

N/A TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Patient Education

Which food is a good source of vitamin A?

Sweet potatoes

Apples

Bananas

Whole grain bread

ANS: A Vegetables and fruits that are orange (sweet potatoes, cantaloupe, carrots) are concentrated with carotene and are a good source of vitamin A. Apples are a good source of soluble and insoluble fiber. Bananas are a good source of fiber, potassium, and vitamin C. Whole grain bread is a good source of vitamin E and fiber.

DIF: Cognitive Level: ComprehensionREF: Assessment

Page 743

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Nutrition; Health Promotion

OBJ:

3 TOP: Nursing Process Step:

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Which dietary fats are cardioprotective?

Monounsaturated

Polyunsaturated

Saturated

Trans

ANS: A Monounsaturated fats decrease low-density lipoprotein (LDL) and increase high-density lipoprotein (HDL) and are considered to be cardioprotective. Polyunsaturated fats also lower LDL and raise HDL but are not considered to be cardioprotective. Saturated fats raise both LDL and HDL and are thought to increase atherosclerotic plaque formation in the arteries. Trans fats may induce more heart disease than saturated fats because in addition to raising LDL cholesterol, trans fats decrease HDL cholesterol and increase triglycerides, as well as another undesirable blood fat, lipoprotein.

DIF: Cognitive Level: Knowledge Evaluation

REF:

Page 742

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance NOT: CONCEPT(S): Clinical Judgment; Nutrition; Health Promotion

5. A patient is receiving continuous tube feedings at 100 mL/hr. At 1400, the nurse determines that there is 175 mL of residual volume. Which action will the nurse take? a.

Continue the feedings as ordered.

Reduce the feeding by 50%.

Stop the feeding and notify the health care provider.

Aspirate and dispose of the residual and restart the feeding.

ANS: C When the residual volume of a tube feeding exceeds 100 mL (or the limit set by the health care provider), the tube feeding is stopped and the residual volume is rechecked within 1 hour. When the residual volume has returned to the limits set by the health care provider, it is restarted. Because the residual amount already exceeds the recommended amount, the feeding should not continue. Infusion rate should not be changed without an order from the health care provider.

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DIF: Cognitive Level: Application Implementation

REF:

Page 747

OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment NOT: CONCEPT(S): Clinical Judgment; Nutrition; Safety

6. What is the average daily dietary intake level sufficient to meet the nutrient requirements of most healthy individuals in a group? a.

Dietary Reference Intake (DRI)

Tolerable Upper Intake Level (UL)

Estimated Average Requirements (EAR)

Adequate Intake (AI)

ANS: A The Recommended Dietary Allowance (RDA) table lists the average daily dietary intake level that is sufficient to meet the nutrient requirements of almost all (97% to 98%) healthy individuals in a group. RDAs are goals in meeting nutritional needs. The UL is the highest level of daily nutrient intake that is likely to pose no risk of adverse health effects to almost all individuals in the general population. The EAR is a nutrient intake value that is estimated to meet the requirement of half of the healthy individuals in a group. The AI is a value based on observed or experimentally determined approximations of nutrient intake by a group of healthy people. The AI is used when the RDA cannot be determined.

DIF: Cognitive Level: Knowledge Planning

REF:

Page 739

OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Nutrition; Health Promotion

1 TOP: Nursing Process Step:

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7. Which is a macronutrient that is a separate factor necessary for complete nutrition and wellness? a.

A phytochemical

A trace mineral

Fiber

A vitamin

ANS: C Macronutrients are essential chemical elements needed by all life in large quantities for normal function. Dietary fiber is derived from plant sources and consists of indigestible carbohydrates and lignin and digestible macronutrients (carbohydrates, proteins), such as cereal brans, sweet potatoes, and legumes, which contribute to overall nutrition. Another category of fiber is functional fiber, which consists of indigestible carbohydrates that have a beneficial physiologic effect on humans. Phytochemicals, minerals, and vitamins are micronutrients.

DIF: Cognitive Level: ComprehensionREF: Planning

Page 741

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Nutrition; Health Promotion

8. A newly admitted patient asks the nurse why the physician has ordered the DASH diet for him. The nurse informs the patient that this diet is ordered to encourage healthy eating specifically for the diagnosis of a.

diabetes.

hypertension.

arthritis.

seizure disorder.

ANS: B DASH stands for Dietary Approaches to Stop Hypertension. DIF: Cognitive Level: Application Implementation

REF:

Page 736

OBJ:

N/A TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance NOT: CONCEPT(S): Clinical Judgment; Nutrition; Health Promotion; Patient Education

https://studentmagic.indiemade.com/ 9. A patient presents at the physician’s office with reports of frequent nosebleeds and delayed clotting. The physician diagnoses this patient with a vitamin deficiency. To treat this type of deficiency, the nurse will encourage the patient to consume foods high in vitamin a.

ANS: C Symptoms of bleeding and/or delayed clotting implicate a vitamin K deficiency.

DIF: Cognitive Level: Application Planning

REF:

Page 743

OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance NOT: CONCEPT(S): Clinical Judgment; Nutrition; Health Promotion; Clotting; Patient Education

MULTIPLE RESPONSE

1. Protein

What provide(s) energy sources for body activities and metabolism? (Select all that apply.) a.

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Fat

Carbohydrate

Minerals

Vitamins

ANS: A, B, C The macronutrients protein, fat, and carbohydrate are primary energy sources required for balanced metabolism. Minerals and vitamins are not primary sources of energy for the body.

DIF: Cognitive Level: ComprehensionREF: Assessment

Page 741

OBJ:

N/A TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Nutrition; Health Promotion

2. A patient is receiving total parenteral nutrition. Which action(s) will the nurse perform? (Select all that apply.) a.

Assess for electrolyte imbalance.

Check residual volume qid.

Position the patient in a high Fowler’s position.

Monitor blood glucose levels.

Discard the solution every 24 hours.

ANS: A, D, E

Electrolytes are monitored during parenteral nutrition. Hyperglycemia may develop and therefore should be monitored. Solutions are discarded every 24 hours. Checking residual volume qid is not an accurate nursing action. Positioning the patient in a high Fowler’s position is not necessary for parenteral nutrition. DIF: Cognitive Level: Application Implementation

REF:

Page 752

OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Nutrition; Safety

A patient is being discharged on psyllium (Metamucil). Which explanation(s) by the nurse would

https://studentmagic.indiemade.com/ be accurate regarding fiber intake? (Select all that apply.) a.

It adds bulk to fecal content.

It enhances gastric emptying.

It decreases blood cholesterol concentration.

It decreases postprandial blood glucose concentration.

It stimulates the appetite.

ANS: A, C, D Functional fibers such as psyllium add bulk to fecal contents. Fibers can reduce the absorption of dietary fat and cholesterol as well as enterohepatic recirculation of cholesterol and bile acids. This may reduce blood cholesterol concentration. In addition, functional fibers delay gastric emptying, which reduces postprandial blood concentration, potentially preventing excessive insulin secretion and insulin sensitivity. Fibers delay gastric emptying. Functional fibers assist with weight control because they provide a sense of fullness and satiety.

DIF: Cognitive Level: ComprehensionREF: Implementation

Page 741

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance NOT: CONCEPT(S): Clinical Judgment; Nutrition; Health Promotion; Patient Education

What can be directly absorbed from the GI tract into the bloodstream? (Select all that apply.)

Glucose

Sucrose

Fructose

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Galactose

Lactose

Maltose

ANS: A, C, D Monosaccharides, such as glucose (also known as dextrose), fructose, and galactose, are the only sugars that can be absorbed directly from the gastrointestinal tract into the blood. Disaccharides, such as sucrose (common table sugar), lactose, and maltose, are the most common sugars in foods but must be metabolized to monosaccharides before being absorbed into the bloodstream.

DIF: Cognitive Level: Knowledge Planning

REF:

Page 741

OBJ:

N/A TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Nutrition; Health Promotion

How are essential fatty acids used in the body? (Select all that apply.)

Building cell membranes

Energy production

Prostaglandin production

Catalyzing metabolic reactions

https://studentmagic.indiemade.com/ e.

Eicosanoid production

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Stimulation of growth hormone

ANS:

A, C, E

Essential fatty acids are required for cell membrane structure, prostaglandin production, and eicosanoid production. Essential fatty acids are not a source of energy, do not catalyze metabolic reactions, and do not stimulate growth hormone.

DIF: Cognitive Level: ComprehensionREF: Planning

Page 742

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Nutrition; Health Promotion

6. A patient is being treated for symptoms of alcohol withdrawal and has been identified to have a thiamine deficiency. When performing physical assessment on this patient specific to thiamine deficiency, the nurse will focus on (Select all that apply.) a.

level of consciousness.

cardiac status.

sensitivity to light.

risk for diarrhea.

nutrition status.

ANS:

A, B, E

Signs and symptoms of thiamine deficiency include anorexia, constipation, indigestion, confusion, edema, muscle weakness, cardiomegaly, and heart failure. Assessment will focus on level of consciousness, cardiac status, and nutrition status. Photophobia and diarrhea are not symptoms related to thiamine deficiency.

DIF:

Cognitive Level: Application

REF:

TOP:

Nursing Process Step: Assessment

Page 753

OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Nutrition; Safety; Addiction

https://studentmagic.indiemade.com/

Chapter 47: Herbal and Dietary Supplement Therapy

MULTIPLE CHOICE

What is black cohosh used for?

Preventing miscarriage during the first trimester

Reducing symptoms of premenstrual syndrome

Providing antispasmodic activity of the gastrointestinal (GI) system

Controlling migraine headaches

ANS:

Black cohosh is used to reduce symptoms of premenstrual syndrome, dysmenorrhea, and menopause. Therapy is not recommended for longer than 6 months. Because of its effect of relaxing the uterus, black cohosh is not used in pregnant women. Black cohosh does not affect the GI system or relieve migraines.

DIF: Cognitive Level: ComprehensionREF: Implementation

Page 758

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Health Promotion

Which herbal medicine may improve a patient’s short-term memory loss and cognitive function?

Ginger

Green tea

Feverfew

Ginkgo biloba extract

ANS:

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Ginkgo biloba extract is used primarily for increasing cerebral blood flow, particularly in geriatric patients. Conditions treated are short-term memory loss, headache, dizziness, tinnitus, and emotional instability with anxiety. Ginger is used to relieve nausea. Green tea has antioxidant effects. Feverfew is used to relieve migraines.

DIF: Cognitive Level: Knowledge Implementation

REF:

Page 762

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Health Promotion; Cognition; Perfusion

Which statement about dietary supplements is true?

Dietary supplements are considered safe and effective.

Dietary supplements have not been tested for safety or efficacy.

There are no serious adverse effects to taking dietary supplements.

Dietary supplements have full FDA and USP approval.

ANS:

Labels and advertisements of dietary supplements must contain a statement that the product has not yet been evaluated by the FDA for the treatment, cure, or prevention of disease. Legally, dietary supplements are not required to be safe and effective, and unfounded claims of therapeutic benefits abound. There can be serious adverse effects when taking dietary

supplements. Dietary supplements are not fully approved by the FDA or the United States Pharmacopeia (USP).

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DIF: Cognitive Level: ComprehensionREF: Evaluation

Page 755

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment NOT: CONCEPT(S): Clinical Judgment; Safety

4. Which dietary supplement should be used with extreme caution if the patient is on a platelet inhibitor? a.

Aloe

Ephedra

Green tea

Garlic

ANS: D Garlic reduces platelet aggregation and should be used with extreme caution in patients receiving platelet inhibitors (e.g., aspirin, ticlopidine, dipyridamole, clopidogrel).

DIF: Cognitive Level: ComprehensionREF: Process Step: Evaluation

Page 761 | Page 762 OBJ:

TOP: Nursing

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance NOT: CONCEPT(S): Clinical Judgment; Safety; Clotting

What is St. John’s wort used to treat?

Rheumatoid arthritis

Asthma

Depression

Viral infections

ANS: C St. John’s wort is used to treat mild depression and heal wounds. The action of St. John’s wort is unknown. Studies have shown a prolonged effect of serotonin, dopamine, and norepinephrine as a result of decreased reuptake. Aloe is used to treat arthritis. Ephedra is used to treat asthma. Goldenseal is used to treat viral infections.

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DIF: Cognitive Level: Knowledge Evaluation

REF:

Page 765

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Psychological Integrity NOT: CONCEPT(S): Clinical Judgment; Health Promotion; Mood and Affect

Which is a therapeutic effect of valerian?

Lower high-density lipoproteins (HDLs) and raise low-density lipoprotein (LDLs) b.

Prevent infection c.

Promote relaxation and sleep

Elevate mood

ANS: C Valerian has been used for more than 1000 years as a mild tranquilizer. Valerian is used for restlessness and may promote sleep. Valerian does not affect cholesterol levels, prevent infection, or affect mood.

DIF: Cognitive Level: ComprehensionREF: Planning

Page 765

OBJ:

MSC: NCLEX Client Needs Category: Psychological Integrity NOT: CONCEPT(S): Clinical Judgment; Health Promotion; Sleep

Which herb is used to stimulate the innate immune system?

Aloe

Echinacea

Chamomile

Ginger

1 TOP: Nursing Process Step:

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ANS: B Echinacea is a nonspecific stimulator of the innate (nonspecific) immune system. It stimulates phagocytosis and effector cell activity. There is an increased release of tumor necrosis factors and interferons from macrophages and T lymphocytes, which increases the body’s resistance to bacterial and viral infection. It may have anti-inflammatory effects by inhibiting hyaluronidase, a potent inflammatory. Aloe gel has been marketed for topical use to treat pain, inflammation, and itching and as a healing agent for sunburn, skin ulcers, psoriasis, and frostbite. Chamomile is used as a digestive aid for bloating and as an antispasmodic and antiinflammatory in the GI tract, an antispasmodic for menstrual cramps, an anti- inflammatory for skin irritation, and a mouthwash for minor mouth irritation or gum infections. Ginger has been used for centuries to alleviate nausea and vomiting from a variety of causes. It is thought to act as an antiemetic by increasing gastroduodenal motility and by blocking serotonin receptors that, when stimulated, may trigger nausea and vomiting.

DIF: Cognitive Level: ComprehensionREF: Implementation

Page 759

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Health Promotion; Immunity

8. The use of which medication would alert the nurse to educate the patient about using ginkgo biloba cautiously? a.

Antiemetics

Anti-inflammatories

Anticoagulants

Antibiotics

ANS: C Ginkgolides inhibit platelet activating factor, inhibiting platelet aggregation. Ginkgo does not interact with antiemetics, anti-inflammatories, or antibiotics.

DIF: Cognitive Level: Application Process Step: Implementation

REF:

Page 762 | Page 763 OBJ:

TOP: Nursing

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Health Promotion; Safety; Clotting; Patient Education 9. A patient diagnosed with diabetes, hypertension, chronic obstructive pulmonary disease, and angina reports to the nurse that she is taking an aloe juice drink to treat constipation.

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When assessing this patient for adverse interactions, the nurse will prioritize a.

pulse rate.

blood pressure.

lung sounds.

blood glucose monitoring.

ANS: D

Blood glucose would be the priority because when aloe is taken orally, it may have hypoglycemic effects.

DIF: Cognitive Level: Analysis Assessment

REF:

Page 758

OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Health Promotion; Safety; Glucose Regulation

10. The nurse is caring for a 36-year-old male patient newly diagnosed with multiple sclerosis (MS). The patient asks if he can continue to take echinacea to help boost his immune system. The nurse’s best response is a.

“Limit use to no more than 8 weeks at a time.”

“Echinacea use is not recommended for patients with autoimmune diseases.”

“What other medications are you taking?”

“That is a decision that you will need to make independently.”

ANS: B Because echinacea appears to be an immunomodulator, it is not recommended for patients with autoimmune diseases, such as MS.

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DIF: Cognitive Level: Application Implementation

REF:

Page 760

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Immunity; Patient Education

MULTIPLE RESPONSE

Aloe gel for topical use has been marketed to treat which conditions? (Select all that apply.)

Sunburn

Psoriasis

Migraine headaches

Pain and inflammation

Itching

ANS: A, B, D, E Aloe gel may be used topically as a healing agent for sunburn and frostbite; for treatment of psoriasis, skin ulcers, pain, and inflammation; and for topical use to relieve itching. Aloe gel is not used to treat migraine headaches.

DIF: Cognitive Level: Application Implementation

REF:

Page 758

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Health Promotion; Tissue Integrity; Pain 2. Which symptom(s) would be consistent with a paradoxical response associated with melatonin use? (Select all that apply.) a.

Drowsiness

Agitation

Insomnia

Poor concentration

Jet lag

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ANS: B, C This study source was downloaded by 100000761823232 from CourseHero.com on 04-12-2021 14:55:24 GMT -05:00

https://www.coursehero.com/file/40907024/c47rtf/

Paradoxical, or opposite, responses would include agitation and insomnia. Melatonin causes drowsiness and poor concentration, which are not paradoxical. Melatonin is best known as a sleep aid and treatment for jet lag.

DIF: Cognitive Level: ComprehensionREF: Evaluation

Page 768

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Sleep; Mood and Affect

3. A high school male athlete reports that he is taking creatine supplements to enhance his athletic performance and bulk up his muscles. Which important teaching point(s) and/or recommendation(s) should be made for this supplement? (Select all that apply.) a.

Adverse effects may include muscle cramping, dehydration, GI bloating, and diarrhea.

Inform the health care provider of usage, should future nephrotoxic medicines be prescribed.

It is important to limit fluid.

Creatine causes a weight gain of 3 to 6 lb because of water retention.

Recommended dosage is 5 to 6 g four times daily for 5 to 7 days, followed by doses of 2 g/day.

ANS: A, B, D, E Adverse effects of creatine may include muscle cramping, dehydration, GI bloating, and diarrhea. Because creatine is nephrotoxic, the addition of another drug with this effect could produce serious renal complications. Cell volumization occurs because of a process linked to increased muscle protein synthesis. Recommended dosages are a loading dose of 5 to 6 g four times daily for 5 to 7 days, followed by doses of 2 g/day to maintain elevated creatine concentrations in the muscle. Restricting fluids is not recommended.

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DIF: Cognitive Level: Application Process Step: Implementation

REF:

Page 766 | Page 767 OBJ:

1|2

TOP: Nursing

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Health Promotion; Nutrition; Safety; Fluid and Electrolytes; Patient Education

4. A patient calls inquiring about herbal treatment of hypercholesterolemia and other nonpharmaceutical measures to lower his cholesterol level. Which important concept(s) should be included in the response to this patient? (Select all that apply.) a.

Maintain daily dose of black cohosh.

Drink one to four cups of green tea daily.

Ingest one fresh clove of garlic daily.

Maintain daily aspirin dose.

Avoid concurrent use of garlic with ginkgo, ginger, feverfew, and ginseng.

ANS: B, C, E Green tea has been shown to lower cholesterol, triglycerides, and low-density lipoprotein ( LDL) and to raise high-density lipoprotein (HDL); moderate consumption of one to four cups daily appears to provide therapeutic benefits. One fresh clove of garlic daily, or a daily dose of 8 mg of Allium, is the current dosage recommendation to treat hypercholesterolemia. Garlic reduces platelet aggregation and should be used with caution in patients receiving platelet inhibitors, anticoagulants, and herbal medicines (e.g., ginkgo, ginger, feverfew, ginseng). Black cohosh is used to reduce symptoms of premenstrual syndrome, dysmenorrhea, and menopause. Aspirin is not taken for control of hyperlipidemia;

discontinuation of aspirin therapy for other indications should be only with the direction of the health care provider.

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DIF: Cognitive Level: Application REF: Nursing Process Step: Implementation

Page 761 | Page 762 | Page 764 OBJ:

TOP:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Health Promotion; Nutrition; Patient Education

Which effect(s) can be attributed to green tea? (Select all that apply.)

Lower cholesterol

Lower triglycerides and LDLs

Raise HDLs

Lower blood glucose

Preventing calcium loss

Preventing viral infection

ANS: A, B, C Green tea has been shown to lower cholesterol, triglycerides, and LDL and to raise HDL. Green tea does not affect blood glucose or prevent loss of calcium or viral infections.

DIF: Cognitive Level: ComprehensionREF: Planning

Page 764

OBJ:

1 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Health Promotion; Nutrition

6. The nurse at a health care clinic is educating a patient regarding the use of the supplement ginseng. What information should be conveyed by the nurse? (Select all that apply.) a.

Research has confirmed that ginseng increases the body’s resistance to stress.

Ginseng is available in tablet form.

Insomnia can result from ginseng intake.

Ginseng is an aphrodisiac.

Ginseng may affect blood coagulation.

ANS: B, C, E

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Ginseng is available in tablet form. Insomnia can result from ginseng intake. Ginseng may affect blood coagulation. Very few scientific studies have been completed on ginseng. Research has not confirmed that it increases the body’s resistance to stress. There is no scientific basis ginseng is an aphrodisiac.

https://studentmagic.indiemade.com/

DIF: Cognitive Level: Application Implementation

REF:

Page 763

OBJ:

1 | 2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

NOT: CONCEPT(S): Clinical Judgment; Health Promotion; Safety; Patient Education; Clotting

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Chapter 48: Substance Abuse Test Bank

MULTIPLE CHOICE

1. A 16-year-old male has been referred to the community mental health center following legal charges of driving under the influence. Which screening tests would be appropriate to use on this patient? a.

Drug Abuse Screening Test (DAST)

Adolescent Alcohol Involvement Scale (AAIS)

Adolescent Drug Abuse Diagnosis (ADAD)

Minnesota Multiphasic Personality Inventory (MMPI 2)

ANS: B The adolescent patient has legal problems associated with alcohol use. The AAIS screening instrument would be appropriate to use. DAST is a comprehensive screening and assessment instrument. ADAD is an adolescent drug abuse diagnosis instrument. MMPI is a personality inventory.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 834 OBJ:

MSC: NCLEX Client Needs Category: Psychosocial Integrity

N/A TOP: Nursing Process Step:

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2. A patient admitted 48 hours ago has a diagnosis of gastrointestinal (GI) bleeding and is receiving IV hydration and transfusions. When making rounds, the nurse observes the patient to be having a tonic clonic seizure. What may be the cause of the seizure? a.

Low blood counts as a result of bleeding

Alcohol withdrawal

Alkalosis

Inadequate nutrition

ANS: B Alcohol withdrawal symptoms can begin within a few hours of discontinuation of drinking and may continue for 3 to 10 days. Withdrawal symptoms may be severe and include visual and auditory hallucinations and tonic clonic seizures. The patient’s admitting diagnosis, GI bleeding, may be associated with alcohol abuse. Denial is a common symptom associated with alcoholism, and the patient may not have been honest about alcohol intake when the health care provider took the history on admission. History may be obtained from the patient’s family or significant other. It is unlikely that the blood loss is significant enough to induce seizures. Alkalosis is not likely the cause of seizures in this case; the patient is more likely to be acidotic from the combined dehydration and withdrawal. Common causes in the setting of alcohol withdrawal include alcoholic ketoacidosis and ingestion of alcohols or

medications that result in metabolic acidosis (e.g., methanol, ethylene glycol, salicylate). Inadequate nutrition is not likely to cause seizures in this patient. DIF:

Cognitive Level: Application

REF:

p. 837 OBJ:

MSC: NCLEX Client Needs Category: Psychosocial Integrity

5 TOP: Nursing Process Step: Evaluation

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3. Which theory views addiction as a maladaptive habit that can be examined and changed the same way as other habits? a.

Psychoanalytic theory

Behavior theory

Cognitive theory

Family system theory

ANS: B Behavior or learning theories view addictive behaviors as overlearned maladaptive habits that can be examined and changed in the same way as other habits. Psychoanalytic theory bases substance abuse on fixation with oral issues. Cognitive theories suggest that addiction is based on a distorted way of thinking about substance use. Family system theory emphasizes the pattern of relationships among family members through the generations as an explanation of substance abuse.

DIF:

Cognitive Level: ComprehensionREF:

p. 829 OBJ:

2 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Psychosocial Integrity

4. A nurse working the night shift suspects that a colleague is abusing alcohol. Which action by the nurse is most important? a.

“Good faith” reporting is unfaithful to a colleague.

Reporting will result in loss of the colleague’s license.

It is not of concern, and the nurse won’t be penalized for refusing to get involved.

State guidelines may mandate to report substance abuse.

ANS: D In some states, when substance abuse of a colleague is suspected, reporting is mandatory. Professionals must be loyal to their patients and protect them from harm. “Good faith” reporting should not be viewed as disloyalty to a colleague. Licenses are often not revoked when a colleague self reports or is reported for substance abuse. Health professionals may be named in a civil lawsuit if they fail to report suspected impairment of another professional.

DIF: Cognitive Level: Analysis Planning

REF:

pp. 834-835

OBJ:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

3 TOP: Nursing Process Step:

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What does a urinalysis that is positive for the drug tested indicate?

It indicates illegal drug use.

It verifies drug dependency.

It is a violation of the individual’s constitutional rights.

It verifies whether the drug is present in the specimen.

ANS: D Positive urinalysis simply indicates the presence of the drug being tested for in the urine specimen. The person may have a prescription for a substance found in the urine or may have been accidentally dosed with it. Presence of the substance in the urine does not indicate dependence because the person may only be an episodic user of the substance. Asking for the person’s permission to collect a specimen and examine it does not violate the person’s constitutional rights. The Supreme Court has ruled that drug screening does not violate one’s constitutional right to privacy or represent an unreasonable search.

DIF: Cognitive Level: ComprehensionREF: Evaluation

p. 835 OBJ:

N/A TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

What will the nurse instruct patients who are on daily disulfiram (Antabuse) to avoid?

All forms of cough syrup

Alcohol

Benzodiazepines

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Aspirin products

ANS: B Disulfiram is used to reduce the desire for alcohol by inducing severe nausea and vomiting when a patient ingests alcohol while on this drug. Reactions can be quite severe, and patients must understand the need to avoid all forms of alcohol while taking this medication. Not all cough syrups contain alcohol. Benzodiazepines and aspirin do not react with disulfiram.

DIF: Cognitive Level: ComprehensionREF: Implementation

pp. 847-848

OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

7. Which protects individuals who have been successfully rehabilitated from substance abuse from discrimination related to past addiction? a.

Americans with Disabilities Act (ADA)

National Council on Alcoholism and Drug Dependence

Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF)

American Medical Association (AMA)

ANS: A Persons dependent on drugs, but who are no longer using drugs illegally and are receiving treatment for chemical dependence, or who have been rehabilitated successfully, are protected by the ADA from discrimination on the basis of past drug addiction. The National Council on Alcoholism and Drug Dependence is a voluntary health agency dedicated to educating the public about alcoholism. The ATF is a principal law enforcement agency in the

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U.S. Department of Justice dedicated to preventing terrorism, reducing violent crime, and protecting the United States. The AMA is a professional organization for physicians. DIF:

Cognitive Level: ComprehensionREF:

p. 835 OBJ:

1 TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity

8. What must be administered before glucose infusions for a patient in alcohol withdrawal to prevent Wernicke’s encephalopathy? a.

Chlordiazepoxide (Librium)

Thiamine

Diazepam (Valium)

Bromocriptine (Parlodel)

ANS: B Thiamine and multiple vitamins should be administered routinely to patients in alcohol withdrawal. Intravenous fluid therapy for rehydration may be necessary, but thiamine must be administered before glucose infusion to prevent Wernicke’s encephalopathy. Benzodiazepines are given for treatment of anxiety and seizures associated with alcohol withdrawal. Bromocriptine is not used to prevent Wernicke’s encephalopathy.

DIF: Cognitive Level: ComprehensionREF: Implementation

p. 837 OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

9. What effect will occur if a patient being treated with naltrexone (ReVia) for substance abuse ingests opioids or alcohol? a.

Increased euphoria

Nausea, vomiting, and diarrhea

Deep sedation

An absence of the “high” associated with drugs

ANS: D

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Naltrexone is an opioid antagonist prescribed to block the pharmacologic effects of the “high” associated with opioids and alcohol. Studies report less alcohol craving and fewer drinking days, especially when naltrexone is combined with psychosocial treatment. Naltrexone prevents the euphoria associated with taking drugs like opioids and alcohol. These are symptoms of taking alcohol in combination with disulfiram (Antabuse). Naltrexone is not sedating.

DIF:

Cognitive Level: ComprehensionREF:

p. 838 OBJ:

5 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

10.

A patient is admitted into a substance abuse treatment center and is withdrawing from alcohol.

Which statement made by the patient’s family member shows a need for further education?

“Withdrawal symptoms can begin within a few hours of discontinuation of drinking.”

“Withdrawal symptoms will improve within 24 hours.”

“Less than 1% of patients develop delirium tremens.”

“Benzodiazepines are commonly used for detoxification.”

ANS: B Withdrawal symptoms may continue for 3 to 10 days. Withdrawal symptoms can begin within a few hours of discontinuation of drinking. Less than 1% of patients develop delirium tremens. Benzodiazepines are commonly used for detoxification.

DIF:

Cognitive Level: Analysis

REF:

p. 837 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

5 TOP: Nursing Process Step: Evaluation

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11. The nurse is assisting with the development of care plan for a patient withdrawing from cocaine. What would be the first nursing diagnosis priority for this patient? a.

Altered nutrition; less than body requirements

Risk for altered peripheral tissue perfusion

Risk for fluid volume deficit

High risk for self directed violence

ANS: D Depression with suicidal ideation is generally the most serious problem associated with cocaine withdrawal. Altered nutrition, risk for altered peripheral tissue perfusion, and risk for fluid volume deficit are not the priorities for a patient withdrawing from cocaine.

DIF:

Cognitive Level: Analysis

REF:

p. 841 OBJ:

5 TOP: Nursing Process Step: Diagnosis

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

12. The nurse is transcribing an order for disulfiram on a patient in alcohol rehabilitation. When planning the time of day to administer this medication the nurse will document that disulfiram be given: a.

before breakfast.

with lunch.

before dinner.

at bedtime.

ANS: D Disulfiram should be administered at bedtime to avoid the complications of sedative effects.

DIF: Cognitive Level: Application Implementation

REF:

pp. 847-848

OBJ:

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

5 TOP: Nursing Process Step:

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13. Which patient assessment will the nurse expect to observe when a patient has ingested alcohol while on disulfiram (Antabuse)? a.

Unconsciousness

Hypertension

GI bleeding

Severe vomiting

ANS: D Severe vomiting occurs when alcohol is ingested while a patient is on disulfiram therapy. Disulfiram blocks the metabolism of acetaldehyde, a metabolite of alcohol. Elevated levels of acetaldehyde produce a reaction causing nausea, severe vomiting, sweating, throbbing headache, dizziness, blurred vision, and confusion. Disulfiram will not generally cause unconsciousness when alcohol is ingested with it, does not cause hypertension when taken in combination with alcohol, and does not cause GI bleeding.

DIF:

Cognitive Level: Application

REF:

p. 847 OBJ:

5 TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Psychosocial Integrity

14.

What is the rationale for administering acamprosate (Campral)?

Withdrawal from alcohol addiction

Maintenance of sobriety

Improvement of renal function

Correction of electrolyte imbalances

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ANS: B Acamprosate is used in alcohol rehabilitation programs for chronic alcoholics who want to maintain sobriety. Drugs likely to be given during withdrawal from alcohol addiction include anticonvulsants, thiamine, benzodiazepines, and beta blockers. Acamprosate does not improve renal function. Acamprosate does not correct electrolyte imbalances.

DIF: Cognitive Level: ComprehensionREF: pp. 846-847 OBJ: N/A TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

MULTIPLE RESPONSE

15. What important point(s) of patient education should be included about disulfiram (Antabuse) therapy? ( Select all that apply. ) a.

The patient should return for liver function tests in 10 to 14 days following initiation of therapy.

Headache, fatigue, and a metallic taste are common adverse effects that usually resolve.

Avoid alcohol ingestion to prevent a reaction.

d. Carefully read all labels for possible alcohol content, including perfumes, and over the counter (OTC) medications such as cough syrups. e.

Report to the health care provider any allergic symptoms, such as hives or pruritus.

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ANS: A, B, C, D Baseline laboratory data include liver function tests and alcohol screening. Headache, fatigue, and a metallic taste are common adverse effects of disulfiram. Disulfiram is a drug used to treat chronic

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alcoholism that produces a very unpleasant reaction to alcohol. Patients should be instructed to read all labels of topical substances and OTC drugs for alcohol content, as well as avoiding any foods that may be prepared with alcohol. Disulfiram is unlikely to cause allergic reactions.

DIF: Cognitive Level: Application Implementation

REF:

pp. 847-848

OBJ:

5 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Physiological Integrity

16.

What does the biologic model theory of substance abuse hypothesize? ( Select all that apply.

) a.

A predisposition to substance abuse based on a hereditary condition

b. Alcoholic individuals as fixated at the oral stage of development, needing satisfaction through oral behaviors such as drinking c. Genetic aberrations that block feelings of well being, resulting in anxiety, anger, low self esteem, and other negative feelings, leaving a craving for a substance that will suppress the bad feelings d. That genes may play a role in alteration of metabolic enzyme systems in the body that enhance or detract from pleasurable responses to chemical substances e. That it is a person’s choice of whether to use drugs, which drugs to use, how much to use, and to seek treatment for substance abuse ANS: A, C, D The biologic model hypothesizes that substance abuse is caused by a person’s genetic profile, making a predisposition to substance abuse a hereditary condition. Genes may play a role in altering metabolic enzyme systems in the body that enhance or detract from pleasurable responses to chemical substances. Psychoanalytic theories see alcoholics as fixated at the oral stage of development. Sociocultural factors play a role in a person’s choice of whether to use drugs, which drugs to use, how much to use, and treatment for substance abuse.

DIF: Cognitive Level: ComprehensionREF: Assessment

p. 829 OBJ:

2 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Psychosocial Integrity

17. A health professional colleague is suspected of having a substance abuse problem because of the person’s frequent absenteeism, mood swings when at work, diminished alertness, and poor patient care. Which action(s) will the nurse take? ( Select all that apply. )

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Confront the individual.

Document specific examples of inappropriate actions.

Avoid assigning this individual to patients with narcotic medication orders or high acuities.

Notify law enforcement of the suspicions.

Submit a confidential report to an appropriate supervisor.

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ANS: B, E Observation and documentation are crucial to building a record of repeat instances over time to support the suspicion of impairment. Examples of inappropriate actions need to be well documented over time. An accurate record can also be useful in helping the impaired individual to recognize the problems and submit voluntarily to treatment. If a health professional suspects that a colleague is impaired, a confidential report should be made to an appropriate supervisor familiar with institutional policy. Confronting the individual, avoiding assigning this individual to patients with narcotic medication orders or high acuities, and notifying law enforcement of the suspicions are not appropriate actions to take.

DIF: Cognitive Level: Application Implementation

REF:

pp. 833-835

OBJ:

3 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Psychosocial Integrity

18. A patient has completed substance abuse treatment for alcoholism. What will assist in longterm goal attainment and promote abstinence? ( Select all that apply. ) a.

Naltrexone therapy

Regular attendance at NA

Regular contact with his program sponsor

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Following the 12 step program of AA

Diazepam therapy to reduce the likelihood of DTs

ANS: A, C, D Treatment may require pharmacologic treatment, such as disulfiram or naltrexone therapy. Regular contact with a sponsor provides support and continuity in the process of maintaining sobriety. Treatment requires lifelong effort with a combination of psychosocial support; use of the 12-step program will assist the patient in maintaining recovery. NA stands for Narcotics Anonymous; this patient should attend meetings of AA, or Alcoholics Anonymous. Diazepam has a high potential for abuse and should not be used with recovering addicts.

DIF: Cognitive Level: Application Implementation

REF:

p. 839 OBJ:

4 TOP: Nursing Process Step:

MSC: NCLEX Client Needs Category: Psychosocial Integrity

19.

Which psychological trait(s) is/are linked to substance abuse? ( Select all that apply. )

Dependent personality

Ability to relax

Depression

Anxiety

Autonomy

Social personality

Optimism

ANS: A, C, D Substance abuse has been linked to a dependent personality, depression, and anxiety.

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Stress is one reason given for substance abuse. Antisocial personality is linked with substance abuse. Substance abusers tend to be depressed and pessimistic.

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DIF:

Cognitive Level: ComprehensionREF:

TOP:

Nursing Process Step: Evaluation

p. 829 OBJ:

MSC: NCLEX Client Needs Category: Psychosocial Integrity

20. Clonidine (Catapres) is used in treating which opioid withdrawal symptom(s)? (Select all that apply.) a.

Hypertension

Tremors

Agitation

Depression

Sweating

Nausea

ANS: B, C, E Clonidine is useful in decreasing tremors, agitation, and sweating associated with opioid withdrawal. Clonidine does not have a hypotensive effect, treat depression, or alleviate nausea.

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DIF: Cognitive Level: ComprehensionREF: Implementation

p. 839 OBJ:

MSC: NCLEX Client Needs Category: Physiological Integrity

5 TOP: Nursing Process Step:

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