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Walter, teenage patient is admitted to the hospital because of acetaminophen (Tylenol)

overdose. Overdoses of acetaminophen can precipitate life-threatening abnormalities in which of the following organs? a. b. c. d. 2. a. b. c. d. 3. a. b. c. d. 4. a. b. c. d. 5. a. b. c. d. 6. Lungs Liver Kidney Adrenal Glands A contraindication for topical corticosteroid usage in a male patient with atopic dermatitis Parasite infection. Viral infection. Bacterial infection. Spirochete infection. In infants and children, the side effects of first generation over-the-counter (OTC) Reye’s syndrome. Cholinergic effects. Paradoxical CNS stimulation. Nausea and diarrhea. Reye’s syndrome, a potentially fatal illness associated with liver failure and encephalopathy acetaminophen (Tylenol) ibuprofen (Motrin) aspirin brompheniramine/psudoephedrine (Dimetapp) The nurse is aware that the patients who are allergic to intravenous contrast media are Eggs Shellfish Soy acidic fruits A 13-month-old child recently arrived in the United States from a foreign country with his

(eczema) is:

antihistamines, such as diphenhydramine (Benadryl) and hydroxyzine (Atarax) include:

is associated with the administration of which over-the-counter (OTC) medication?

usually also allergic to which of the following products?

parents and needs childhood immunizations. His mother reports that he is allergic to eggs. Upon further questioning, you determine that the allergy to eggs is anaphylaxis. Which of the following vaccines should he not receive? a. b. Hepatitis B inactivated polio

c. d. 7.

diphtheria, acellular pertussis, tetanus (DTaP) mumps, measles, rubella (MMR) The cell and Coombs classification system categorizes allergic reactions and is useful in

describing and classifying patient reactions to drugs. Type I reactions are immediate hypersensitivity reactions and are mediated by: a. b. c. d. 8. a. b. c. d. 9. a. b. c. d. 10. a. b. c. d. 11. a. b. c. d. 12. a. b. c. d. immunoglobulin E (IgE). immunoglobulin G (IgG). immunoglobulin A (IgA). immunoglobulin M (IgM). Drugs can cause adverse events in a patient. Bone marrow toxicity is one of the most aplastic anemia. thrombocytosis. leukocytosis. granulocytosis. Serious adverse effects of oral contraceptives include: Increase in skin oil followed by acne. Headache and dizziness. Early or mid-cycle bleeding. Thromboembolic complications. The most serious adverse effect of Alprostadil (Prostin VR pediatric injection) Apnea. Bleeding tendencies. Hypotension. Pyrexia. Mandy, a patient calls the clinic today because he is taking atrovastatin (Lipitor) to treat his Stop taking the drug and make an appointment to be seen next week. Continue taking the drug and make an appointment to be seen next week. Stop taking the drug and come to the clinic to be seen today. Walk for at least 30 minutes and call if symptoms continue. Which of the following adverse effects is associated with levothyroxine (Synthroid) Tachycardia Bradycardia Hypotension Constipation

frequent types of drug-induced toxicity. The most serious form of bone marrow toxicity is:

administration in neonates is:

high cholesterol and is having pain in both of his legs. You instruct him to:

therapy?

liver abnormalities. a. He says he is here to donate platelets Directed donation. Metabolic acidosis. 16. d. c. b. Jonas comes into the local blood donation center. c. and diarrhea. a. 18. d. c. Autologous donation. a. Myelosuppression. Which of the following adverse effects is specific to the biguanide diabetic drug metformin Hypoglycemia GI distress Lactic acidosis Somulence The most serious adverse effect of tricyclic antidepressant (TCA) overdose is: Seizures. c. An allergic response to a recent medication. b. d. a rash. 19. Allogenic donation. Apheresis. d. Nothing related to the blood transfusion.9 percent sodium chloride 5 percent dextrose in water solution Sterile water Heparin sodium Cris asks the nurse whether all donor blood products are cross-matched with the recipient packed red blood cells platelets plasma granulocytes (Glucophage) therapy? before and after the administration of blood to a patient is: to prevent a transfusion reaction. only today. The nurse knows this process is called: products is: . a. a. b. c. Cardiac arrhythmias. b.13. Hyperpyrexia. a. b. c. A month after receiving a blood transfusion an immunocompromised male patient develops fever. 14. The nurse would suspect this patient has: a. Which of the following always require cross-matching? 17. b. 15. d. The nurse is aware that the following solutions is routinely used to flush an IV device 0. d. Nurse Bryan knows that the age group that uses the most units of blood and blood Premature infants. Graft-versus-host disease (GVHD).

The transfusion to be administered slowly over several hours. Rh factor positive needs a blood transfusion. 22. A child is admitted with a serious infection.” “Granulocyte transfusions replenish the low white blood cells until the body can produce its A neighbor tells nurse Maureen he has to have surgery and is reluctant to have any blood own. 23. An autologous product. c. He asks the nurse what are his options. b.” “The physician will have to explain his rationale to you. Irradiation of the donor blood. The physician orders granulocyte transfusions for the next four days. d. Hepatitis C infection. This donor blood is incompatible with the patient’s blood. 21.000 patients contract: a.” “This therapy is fast and reliable in treating infections in children. acetaminophen (Tylenol) will prevent any transfusion reactions or side effects. Adults ages 21-64 years. c. a. b. d. c. d. Hepatitis B infection. Acetaminophen (Tylenol). Children ages 1-20 years. 20. To prevent Diphenhydramine hydrochloride (Benadryl). d. c. An allogenic product. b. A cross-matched product. Premedicating the patient with diphenhydramine hydrochloride (Benadryl) and This is a compatible match. b.b. c. The mother asks the nurse why? The nurse responds: a. the physician will order: of infection he could receive from the transfusion. Human immunodeficiency disease (HIV).” product transfusions because of a fear of contracting an infection. Rh factor negative blood to the unit for the nurse to infuse into this patient. he is severely neutropenic. The nurse teaches him that approximately 1 in 250. A male patient with blood type AB. The nurse knows that: a. The nurse teaches the person that the safest blood product is: a. A directed donation product. A severely immunocompromised female patient requires a blood transfusion. “This is the only treatment left to offer the child. The Transfusion Service (blood bank) sends type O. c. . Louie who is to receive a blood transfusion asks the nurse what is the most common type GVHD. d. 24. West Nile viral disease. The elderly above age 65 years. After two days of antibiotics. b.

26. c. Once a week administration is possible. which worked well A large bore catheter The type of device the physician prefers Dr. The nurse should use the entire 50 milliliter vial. A blood culture and sensitivity. A blood type and antibody screen. The patient is at minimal risk receiving this product since it is the first time he has been Dr. 28. A female patient needs a whole blood transfusion. Caustic agents in small veins can be avoided. What type of intravenous (IV) A small catheter to decrease patient discomfort The type of IV device the patient has had in the past. d. a. 25. c. 29. Rodriguez orders 250 milliliters of packed red blood cells (RBC) for a patient. therapy is administered for treatment of: blood bank) to prepare the correct product a sample of the patient’s blood must be obtained for: device should the nurse consider starting? available in a 50 milliliter vial with a concentration of 25 percent. Central venous access devices (CVADs) are frequently utilized to administer chemotherapy. Why would the physician order antibiotics to be given through the line rather than through a peripheral IV . Anemia. b. d. b. The product is transfused with type O. A blood type and cross-match. a. A female patient’s central venous access device (CVAD) becomes infected. The nurse will administer 4 milliliters. To prevent infiltration of the peripheral line CVADs are less expensive than a peripheral IV. line? a. b.d. This concentration of product should not be used. 30. A male patient needs to receive a unit of whole blood. What is a distinct advantage of using the CVAD for chemotherapeutic agent administration? a. a. b. This Thrombocytopenia. Rh negative blood. Hypoalbuminemia. d. b. Smith orders a gram of human salt poor albumin product for a patient. c. What dosage will the nurse administer? a. Leukopenia. The patient or his family can administer the drug at home. d. 27. d. The nurse should determine the volume to administer from the physician. c. c. In order for transfusion services (the A complete blood count and differential.

For this reason. Educate the patient using topical corticosteroids to avoid crowds or people known to have infections and to report even minor signs of an infection. First generation OTC antihistamines do not exhibit a cholinergic effect. present a risk of disseminated infection. in some individuals. Viruses. rather than systemic effect. Answer C. Brompheniramine/psudoephedrine contains a first generation OTC antihistamine and a decongestant. Answer B. Reye’s syndrome is a systemic response to a virus. However. 3. or adrenal glands. use of first generation OTC antihistamines has declined. renal system. and second generation product usage has increased. Topical corticosteroid usage results in little danger of concurrent infection with these agents. d. fever. Typically. However. 5. Answer B. c. When treating atopic dermatitis with a steroidal preparation. Toxic doses of acetaminophen deplete hepatic glutathione. Answer B. euphoria. and inflammation are at an increased risk of developing Reye’s syndrome. Prolonged use of acetaminophen may result in an increased risk of renal dysfunction. but a single overdose does not precipitate life-threatening problems in the respiratory system. Therefore. Use of acetaminophen has not been associated with Reye’s syndrome and can be safely given to patients with fever due to viral illnesses. ibuprofen has not been associated with the onset of Reye’s disease. 2. Acetaminophen is extensively metabolized by pathways in the liver. both renal and hepatic failure are reported. Topical agents produce a localized. the site is vulnerable to invasion by organisms. first generation OTC antihistamines have a sedating effect because of passage into the CNS.b. Nausea and diarrhea are uncommon when first generation OTC antihistamines are taken. 4. Some types of contrast media contain iodine as an ingredient. which leads to hepatic necrosis. such as herpes simplex or varicella-zoster. paradoxical CNS stimulation occurs and is manifested by excitement. Virus-infected children who are given aspirin to manage pain. resulting in accumulation of the intermediate agent. especially infants and children. Shellfish also contain significant amounts of iodine. To reduce the pain and discomfort associated with antibiotic administration in a small vein To lessen the chance of an allergic reaction to the antibiotic To attempt to sterilize the catheter and prevent having to remove it 1. Answer C. Ibuprofen adverse effects include GI irritation and bleeding. and in toxic doses. quinine. Neither agent has been associated with the development of Reye’s syndrome. and confusion. restlessness. a patient who is allergic to iodine will exhibit .

IgG is the only class of Ig that crosses the placenta. and deep vein thrombosis. IgA. 8. colostrum. Treatment for mild cases is supportive. Aplastic anemia is the result of a hypersensitivity reaction and is often irreversible. is the first Ig to be made by the fetus and the first Ig to be made by a virgin B cell when it is stimulated by antigen. white blood cells. 7. However. The vaccines in options a. However. Option 2 is an elevated platelet count. the second most common serum Ig is found in secretions (tears. and mucus). Binding of the allergen to the IgE on the cells results in the release of various pharmacological mediators that result in allergic symptoms. Answer A. And. In some institutions. and platelets. Answer A. Answer A. 9. Severe cases require a bone marrow transplant. These products do not contain iodine. Oral contraceptives have been associated with an increased risk of stroke. Early or mid-cycle bleeding are effects of estrogen deficiency. a severe decrease in all cell types: red blood cells. Headache and dizziness are effects of estrogen excess. 10. Careful monitoring for apnea or respiratory depression is mandatory. a substance that enhances phagocytosis. Clinicians deciding to utilize alprostadil must be prepared to intubate and mechanically ventilate the infant. . apnea appearing during the first hour of drug infusion occurs in 10-12 percent of neonates with congenital heart defects.b and c do not contain egg protein. It leads to pancytopenia. and even children with dramatic egg allergies are extremely unlikely to have an anaphylactic reaction. IgE.an allergic response to both iodine containing contrast media and shellfish. The measles portion of the MMR vaccine is grown in chick embryo cells. saliva. These risks are increased in women who smoke. the least common serum immunoglobulin (Ig) binds very tightly to receptors on basophils and mast cells and is involved in allergic reactions. Most versatile Ig because it is capable of carrying out all of the functions of Ig molecules. a reduced number of platelets cause the blood not to clot as easily. Transfusions may be necessary. Answer D. Option 4 is an elevated granulocyte count. patients that do respond to egg contact with anaphylaxis should be in a medically controlled setting where full resuscitation efforts can be administered if anaphylaxis results. myocardial infarction. IgG is the major Ig (75 percent of serum Ig is IgG). Increased skin oil and acne are effects of progestin excess. IgM. elective intubation occurs prior to initiation of the medication. It is an opsonin. A granulocyte is a type of white blood cell. It is important in local (mucosal) immunity. Option 3 is an elevated white count. All items are adverse reactions of the drug. 6. the third most common serum Ig. The current MMR vaccine does not contain a significant amount of egg proteins. IgM antibodies are very efficient in leading to the lysis of microorganisms. A reduced number of red blood cells causes hemoglobin to drop. Answer D. A reduced number of white blood cells make the patientsusceptible to infection.

Muscle aches. but the donor is known to the recipient and is usually a family member or friend. This patient will need an immediate evaluation to rule out myopathy. 17. TCA overdose can induce seizures. Answer C. Allogenic donation is collected from a blood donor other than the recipient. 0. 13. Metformin does not induce insulin production. especially in higher doses. This process can occur within a month of the transfusion. Autologous donation is the collection and reinfusion of the patient’s own blood. The process of apheresis involves removal of whole blood from a donor. Answer A. TCAs do not cause an elevation in body temperature. One of the separated portions is then withdrawn. Excessive ingestion of TCAs result in life-threatening wide QRS complex tachycardia. 16. Answer A. Its use prevents red cell lysis. Additional doses may exacerbate the problem. and weakness may be early signs of myopathy such as rhabdomyolysis associated with the HMG-CoA reducatase class of antilipemic agents. but the nurse must remember that immunocompromised transfusion recipients are at risk for GVHD. Red blood cells contain antigens and antibodies that must be matched between donor and recipient. Answer D. they require no cross-match.9 percent sodium chloride is normal saline. administration does not result in hypoglycemic events. NVD is not specific for metformin. Options 1 and 4 may be a thought. Within an instrument that is essentially designed as a centrifuge. Hypotension would be a side effect of bradycardia. Answer A. Constipation is a symptom of hypothyroid disease. Answer D. 18. 14. An agent that increases the basal metabolic rate would not be expected to induce a slow heart rate. the components of whole blood are separated. . Answer C. Metformin does not induce sleepiness. Levothyroxine. This solution has the same osmolarity as blood. thus. Directed donation is collected from a blood donor other than the recipient. GVHD occurs when white blood cells in donor blood attack the tissues of an immunocompromised recipient. The solutions given in options 2 and 3 are hypotonic solutions and can cause red cell lysis. Lactic acidosis is the most dangerous adverse effect of metformin administration with death resulting in approximately 50 percent of individuals who develop lactic acidosis while on this drug. but they are typically not life-threatening. vomiting. Thus. Some nausea. can induce hyperthyroid-like symptoms including tachycardia. and diarrhea may develop but is usually not severe. soreness. 15. Exercise will not reverse myopathy and delays diagnosis. TCAs do not cause metabolic acidosis.11. Answer B. and the remaining components are retransfused into the donor. The solution in option 4 may anticoagulate the patient and result in bleeding. 12. The blood products in options 2-4 do not contain red cells.

The treatment in option 2 takes days and is not always able to prevent morbidity and mortality. 22. It is also known as the universal donor. only a small amount of albumin. Answer B. RBC transfusion will not correct a low white blood cell count. The incidence of West Nile viral transmission is unknown. Answer C. The product in option 1 is collected from a blood donor other than the recipient. Answer B. and chills. RBC transfusion will not correct a low platelet count. Incompatible matches would result in severe adverse events and possible death. The risk of infection with the agents in options 2 and 3 has decreased to approximately 1 in 2 million secondary to donor questioning and donor blood testing. This is needed to utilize the correct type of donor blood and to match the donor product with the patient. The test in option 4 is utilized to determine the patient’s blood type and presence of antibodies to blood antigens. but the donor is known to the recipient and is usually a family member or friend. Answer C. The process in option 2 is also collected from a blood donor other than the recipient. Options 1 and 3 are not therapeutic responses. Option 2 will not prevent GVHD. Use of acetaminophen prevents and treats the common side effects of blood administration caused by the presence of white blood cells in the transfusion product: fever. A red blood cell transfusion is used to correct anemia in patients in which the low red blood cell count must be rapidly corrected. Answer D. This amount will not correct low albumin levels. Answer C. Hepatitis B is the most common infection spread via blood transfusion. People older than 65 years use 43 percent of donated blood. Packed RBCs contain very little plasma and. preventing GVHD.19. The tests in options 1 and 3 are unnecessary. It is recommended by the American Medical Association’s Council on Scientific Affairs as the safest product since it eliminates recipient incompatibility and infection. 23. thus. headache. This process eliminates white blood cell functioning. Cross-matching significantly enhances compatibility. Donors are screened by a questionnaire that includes symptoms. . Rh negative blood has none of the major antigens and is safely administered to patients of all blood types. Answer C. Premedicating with these agents will not prevent a major transfusion reaction if the blood type and Rh factors of the donor blood are incompatible with the recipient’s blood. 26. 24. It does not detect infection. Type O. Diphenhydramine HCl is an antihistamine. 21. It’s use prior to a blood transfusion decreases the likelihood of a transfusion reaction. Granulocyte (neutrophil) replacement therapy is given until the patient’s blood values are normal and he is able to fight the infection himself. This process is the collection and reinfusion of the patient’s own blood. Answer D. This number is expected to increase as the population ages. thus. The donated blood is also tested for infection. 20. It does not determine donor blood compatibility with the patient. but donor infection is still relatively rare. 25.

A 25 percent solution is an acceptable product and can safely be used. b. The third option would not occur. d. 29. a. c. c.5 grams of albumin. 30. Which of the following should the geriatric patient to have difficulty retaining knowledge about prescribed medications? nurse document as subjective data? . 28. It is unnecessary to seek the answer from the physician. The nurse should determine the correct device without asking the patient what type has been used before or asking the physician which type he prefers and start the IV. Extravasations of a vesicant can result in significant tissue necrosis. Thus. CVAD use lessens the need for peripheral IV lines and. but in this case. If unsuccessful in eliminating the microorganism. The nurse should determine the volume. Large bore catheters prevent damage to blood components and are less likely to develop clotting problems than a small bore catheter. 2. d. the CVAD must be removed. the risk of infiltration. which can be eliminated by antibiotic administration through the catheter. Answer D. The volume in option 1 would provide 12. Nurse Brenda is teaching a patient about a newly prescribed drug. a. 1. the antibiotics are given to eradicate microorganisms from the CVAD. What could cause a Decreased plasma drug levels Sensory deficits Lack of family support History of Tourette syndrome When examining a patient with abdominal pain the nurse in charge should assess: Any quadrant first The symptomatic quadrant first The symptomatic quadrant last The symptomatic quadrant either second or third The nurse is assessing a postoperative adult patient. Microorganisms that infect CVADs are often coagulase-negative staphylococci. thus. b. 3. Many chemotherapeutic drugs are vesicants (highly active corrosive materials that can produce tissue damage even in low concentrations). Administration into a large vein is optimal. Answer C. CVAD use has this effect. Answer D. the nurse will administer 4 milliliters to provide a complete gram of albumin. IV chemotherapeutic agents are not administered at home. A 25 percent solution contains one quarter of a gram per milliliter. CVADs are more expensive than a peripheral IV. the antibiotics are given through the CVAD to eliminate the infective agent. They are given in an outpatient or clinic setting if not given during hospitalization.27. Answer C. In this case however. Dosing depends on the drug.

d. Which action does the Position the head of the bed flat Helps the patient dangle the legs Stands behind the patient Places the chair facing away from the bed A female patient who speaks a little English has emergency gallbladder surgery. 5. c.a. d. Discard the syringe to avoid a medication error . a. b. c. b. Vital signs Laboratory test result Patient’s description of pain Electrocardiographic (ECG) waveforms A male patient has a soft wrist-safety device. which nursing action would best help this patient understand wound care instruction? a. b. Indicators of denial include: Shock dismay Numbness Stoicism Preparatory grief The nurse in charge is transferring a patient from the bed to a chair. 4. Asking frequently if the patient understands the instruction Asking an interpreter to replay the instructions to the patient. pale fingers Pink nail beds Which of the following planes divides the body longitudinally into anterior and posterior Frontal plane Sagittal plane Midsagittal plane Transverse plane A female patient with a terminal illness is in denial. c. Which assessment finding should the nurse A palpable radial pulse A palpable ulnar pulse Cool. during consider abnormal? regions? nurse take during this patient transfer? discharge preparation. d. a. 6. 7. d. b. b. Writing out the instructions and having a family member read them to the patient Demonstrating the procedure and having the patient return the demonstration Before administering the evening dose of a prescribed medication. the nurse on the evening shift finds an unlabeled. a. 9. a. 8. d. What should the nurse in charge do? a. filled syringe in the patient’s medication drawer. b. d. c. c. c.

b. a.” A scrub nurse in the operating room has which responsibility? Positioning the patient Assisting with gowning and gloving Handling surgical instruments to the surgeon Applying surgical drapes A patient is in the bathroom when the nurse enters to give a prescribed medication. c. d.” “Read this manual and then ask me any questions you may have. d. Manager Educator Caregiver Patient advocate A female patient exhibits signs of heightened anxiety. the nurse must stay prepared to give especially alert for adverse effects. a. b. Obtain a label for the syringe from the pharmacy Use the syringe because it looks like it contains the same medication the nurse was Call the day nurse to verify the contents of the syringe When administering drug therapy to a male geriatric patient. 7. b. After providing medication teaching. Faster drug clearance Aging-related physiological changes Increased amount of neurons Enhanced blood flow to the GI tract A female patient is being discharged after cataract surgery. d.000 units per milliliter. What Leave the medication at the patient’s bedside Tell the patient to be sure to take the medication. d. a. 13. 15. Don’t worry. c.500 units. 11. And then leave it at the bedside Return shortly to the patient’s room and remain there until the patient takes the medication Wait for the patient to return to bed. 12.b. b. The nurse is performing which professional role? a. 14. and then leave the medication at the bedside The physician orders heparin. d. d. c. Which factor makes geriatric patients to adverse drug effects? a. the nurse asks the patient to repeat the instructions. c. c.” “Why don’t you listen to the radio?” “Let’s talk about what’s bothering you. to be administered subcutaneously every 6 most likely to reduce the patient’s anxiety? should the nurse in charge do? hours. The vial reads 10. 10. The nurse should anticipate giving how much heparin for each dose? . c. Which response by the nurse is “Everything will be fine. b.

a. b. d. During discharge teaching. Within 1 month Within 3 months Within 6 months Within 12 months Which human element considered by the nurse in charge during assessmentcan affect The patient’s ability to recover The patient’s occupational hazards The patient’s socioeconomic status The patient’s cognitive abilities An employer establishes a physical exercise area in the workplace and encourages all Primary prevention drug administration? employees to use it. c. b. ¼ ml ½ ml ¾ ml 1 ¼ ml The nurse in charge measures a patient’s temperature at 102 degrees F. Which statement The bell detects high-pitched sounds best The diaphragm detects high-pitched sounds best The bell detects thrills best The diaphragm detects low-pitched sounds best A male patient is to be discharged with a prescription for an analgesic that is a controlled equivalent Centigrade temperature? test? a. b.a. d. the physician is most likely to order which laboratory Red blood cell count Sputum culture Total hemoglobin Arterial blood gas (ABG) analysis The nurse uses a stethoscope to auscultate a male patient’s chest. c. This is an example of which level of health promotion? . a. the nurse should explain that the patient must fill this prescription how soon after the date on which it was written? a. b. 19. about a stethoscope with a bell and diaphragm is true? substance. c.9 degrees C 40. a. what is the 39 degrees C 47 degrees C 38. d.1 degrees C To evaluate a patient for hypoxia. a. 16. 18. d. b. b. c. d. 21. 17. c. 20. d. c.

Secondary prevention Tertiary prevention Passive prevention What does the nurse in charge do when making a surgical bed? Leaves the bed in the high position when finished Places the pillow at the head of the bed Rolls the patient to the far side of the bed Tucks the top sheet and blanket under the bottom of the bed The physician prescribes 250 mg of a drug. c. 22. b. c. d. 23. d. d. c. c. Prolonged half-life Poor absorption Potential for drug dependence Potential for hepatotoxicity Which nursing action is essential when providing continuous enteral feeding? Elevating the head of the bed Positioning the patient on the left side Warming the formula before administering it Hanging a full day’s worth of formula at one time When teaching a female patient how to take a sublingual tablet. 25. The drug vial reads 500 mg/ml. b. a. c.b. how much of 2 ml 1 ml ½ ml ¼ ml Nurse Mackey is monitoring a patient for adverse reactions during barbiturate therapy. 26. a. 24. a. d. b. d. a. 27. a. b. c. d. a. b. b. d. c. the nurse should Top of the tongue Roof of the mouth Floor of the mouth Inside of the cheek Which action by the nurse in charge is essential when cleaning the area around a Cleaning from the center outward in a circular motion Removing the drain before cleaning the skin Cleaning briskly around the site with alcohol Wearing sterile gloves and a mask the drug should the nurse give? What is the major disadvantage of barbiturate use? instruct the patient to place the table on the: Jackson-Pratt wound drain? .

Answer C. the nurse may elicit pain in the symptomatic area. b. d. . a. A lack of family support may affect compliance. Toilette syndrome is unrelated to knowledge retention. causing the muscles in other areas to tighten. 3. c. Answer C. 29.28. Answer B. The doctor orders dextrose 5% in water. The I. 1. Sensory deficits could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications. c. d. concluding with the symptomatic area. 4. The nurse in charge should run the I. d. b. Therefore. This would interfere with further assessment. 2. c. 30. A safety device on the wrist may impair circulation and restrict blood supply to body tissues.000 ml to be infused over 8 hours. Otherwise. the nurse should assess the patient for signs of impaired circulation. Decreased plasma drug levels do not alter the patient’s knowledge about the drug.V. and ECG waveforms are examples of objective data. Answer C. When assessing the patient 10 Restlessness Pale. Subjective data come directly from the patient and usually are recorded as direct quotations that reflect the patient’s opinions or feelings about a situation. b. if time and the patient’s condition permit. Vital signs. tubing delivers 15 drops per milliliter. pale fingers. A palpable radial or lunar pulse and pink nail beds are normal findings. not knowledge retention. warm. infusion at a rate 15 drop per minute 21 drop per minute 32 drop per minute 125 drops per minute A male patient undergoes a total abdominal hysterectomy. The nurse should systematically assess all areas of the abdomen. of: a. a. dry skin Heart rate of 110 beats/minute Urine output of 30 ml/hour Which pulse should the nurse palpate during rapid assessment of an unconscious male Radial Brachial Femoral Carotid hours later.V. the nurse identifies which finding as an early sign of shock? adult? 1. such as cool. laboratory test result.

. Frontal or coronal plane runs longitudinally at a right angle to a sagittal plane dividing the body in anterior and posterior regions. When teaching a patient about medications before discharge.5. neurons are lost and blood flow to the GI tract decreases. The nurse acts as a patient advocate when making the patient’s wishes known to the doctor. As a safety precaution. Anxiety may result from feeling of helplessness. The other options are considered unsafe because they promote error. A sagittal plane runs longitudinally dividing the body into right and left regions. 9. Answer A. 10. Answer A. isolation. The circulating nurse assists the surgeon and scrub nurse. The other options are associated with depression—a later stage of grief. positions the patient. Answer D. accounting for all gauze. Demonstrating by the nurse with a return demonstration by the patientensures that the patient can perform wound care correctly. The nurse performs the care giving role when providing direct care. 6. With increasing age. Answer B. dividing the structure into superior and inferior regions. After placing the patient in high Fowler’s position and moving the patient to the side of the bed. Answer B. the nurse then faces the patient and places the chair next to and facing the head of the bed. Shock and dismay are early signs of denial-the first stage of grief. A transverse plane runs horizontally at a right angle to the vertical axis. 7. needles. Aging-related physiological changes account for the increased frequency of adverse drug reactions in geriatric patients. the nurse helps the patient sit on the edge of the bed and dangle the legs. Answer B. Answer D. Patients may claim to understand discharge instruction when they do not. assists with gowning and gloving. applies appropriate equipment and surgical drapes. 12. and instruments. they would not reduce anxiety. 11. Because the other options ignore the patient’s feeling and block communication. Answer A. The nurse acts as a manager when performing such activities as scheduling and making patient care assignments. sponges. 13. Answer C. including bathing patients and administering medications and prescribed treatments. An interpreter of family member may communicate verbal or written instructions inaccurately. and provides the surgeon and scrub nurse with supplies. if exactly midline. This response helps reduce anxiety by encouraging the patient to express feelings. Renal and hepatic changes cause drugs to clear more slowly in these patients. the nurse is acting as an educator. or insecurity. with the circulating nurse. it is called a midsagittal plane. The nurse should be supportive and develop goals together withthe patient to give the patient some control over an anxiety-inducing situation. 8. maintaining strict surgical asepsis and. the nurse should discard an unlabeled syringe that contains medication. The scrub nurse assist the surgeon by providing appropriate surgical instruments and supplies.

Palpation detects thrills best. The patient’s ability to recover. Answer C. 15. 18. Answer D. 19. Answer D.500/10. In most cases. .000 or ¾ ml 16. an outpatient must fill a prescription for a controlled substance within 6 months of the date on which the prescription was written. Answer B. use this formula: C degrees = (F degrees – 32) x 5/9 C degrees = (102 – 32) 5/9 + 70 x 5/9 38. the nurse must find a family member or significant other to take on the responsibility of administering medications in the home setting. To convert Fahrenheit degrees to centigrade.9 degrees C 17. The diaphragm of a stethoscope detects high-pitched sound best.500 X= 7. Answer C. Answer C.000 X = 7. and socioeconomic status do not affect drug administration. All of these test help evaluate a patient with respiratory problems. However. ABG analysis is the only test evaluates gas exchange in the lungs. If not. The nurse solves the problem as follows: 10.500 units = 1 ml/X 10. the bell detects low pitched sounds best. The nurse should never leave medication at the patient’s bedside unless specifically requested to do so.000 units/7. occupational hazards. Answer C. The nurse must consider the patient’s cognitive abilities to understand drug instructions. 20.14. providing information about patient’s oxygenation status. The nurse should return shortly to the patient’s room and remain there until the patient takes the medication to verify that it was taken as directed.

Primary prevention precedes disease and applies to health patients. no correlation exists between duration of action and half-life. the nurse places the pillow at the head of the bed and tucks the top sheet and blanket under the bottom of the bed. bypassing the GI and hepatic systems. the nurse leaves the bed in the high position when finished. The nurse should give ½ ml of the drug. Sublingual medications are absorbed directly into the bloodstream form the oral mucosa. When making an occupied bed or unoccupied bed. the patient should be positioned on the right side. the nurse rolls the patient to the far side of the bed. Answer A. The nurse should give enteral feeding at room temperature to minimize GI distress. Answer A. All these actions promote transfer of the postoperative patient from the stretcher to the bed. The dosage is calculated as follows: 250 mg/X=500 mg/1 ml 500x=250 X=1/2 ml 24. Patients can become dependent on barbiturates. Tertiary prevention enables patients to gain health from others’ activities without doing anything themselves. . Barbiturates are absorbed well and do not cause hepatotoxicity. Secondary prevention focuses on patients who have health problems and are at risk for developing complications. No drug is administered on top of the tongue or on the roof of the mouth. the nurse fanfolds these linens to the side opposite from where the patientwill enter and places the pillow on the bedside chair. 26. 22. 25. With the buccal route. Answer A. To limit microbial growth. Answer C. Because of the rapid distribution of some barbiturates. Answer C. When making an occupied bed.21. 23. the nurse should hang only the amount of formula that can be infused in 3 hours. especially with prolonged use. The nurse should instruct the patient to touch the tip of the tongue to the roof of the mouth and then place the sublingual tablet on the floor of the mouth. Answer C. When such elevation is contraindicated. the tablet is placed between the gum and the cheek. Elevating the head of the bed during enteral feeding minimizes the risk of aspiration and allows the formula to flow in the patient’s intestines. although existing hepatic damage does require cautions use of the drug because barbiturates are metabolized in the liver. When making a surgical bed. After placing the top linens on the bed without pouching them.

1 ml/minute To find the number of drops/minute: 2. The brachial pulse is palpated during rapid assessment of an infant. it may irritate the skin and has no lasting effect on bacteria because it evaporates. moving from center outward in ever-larger circles. because the skin near the drain site is more contaminated than the site itself. Answer A. hyperactivity of the sympathetic nervous system causes increased epinephrine secretion. Alcohol should never be used to clean around a drain. An above-normal heart rate is a late sign of shock. Answer C. 30. This is done by checking his skin color. 28. and irritable. It also decreases tissue perfusion to the skin. During a rapid assessment. nervous.000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes) to find the number of milliliters per minute: 125/60 min = X/1 minute 60X = 125X = 2. The nurse should use the carotid artery to check a patient’s circulation. and circulation. the nurse’s first priority is to check the patient’s vital functions by assessing his airway. anxious. most importantly. Giving 1. In a patient with a circulatory problems or a history of compromised circulation. mental status and. temperature. To check a patient’s circulation. Answer A. . but a mask is not necessary. Answer D. The nurse always should clean around a wound drain. his pulse. the radial pulse may not be palpable. cool clammy skin. The nurse should never remove the drain before cleaning the skin. Early in shock. or 32 drops/minute 29. causing pale. breathing. the nurse must assess his heart and vascular network function.1 ml/X gtts = 1 ml/15 gtts X = 32 gtts/minute. A urine output of 30 ml/hour is within normal limits. The nurse should wear sterile gloves to prevent contamination. which typically makes the patient restless.27.

He recently visited his health care provider and was put on an antibiotic for pneumonia.B besides high blood pressure values. tympanic An 82-year-old widower brought via ambulance is admitted to the emergency department with complaints of shortness of breath. asks to get out of bed to go to the bathroom. and malaise. and nosebleed C) Dizziness. the nurse checks the early morning temperature of a client." Which vital sign value would take priority in initiating care? A) Respiration rate = 20 breaths per minute B) Oxygen saturation by pulse oximetry = 92% C) Blood pressure = 138/84 D) Temperature = 39° C (102° F). anorexia. flushing of the face. mental confusion. what other signs and symptoms may the nurse observe if hypertension is present? A) Unexplained pain and hyperactivity B) Headache. which helps his "high blood. The client's remaining vital signs are in the normally acceptable range. tympanic The client. The client indicates that he also takes a diuretic and a beta blocker. and mottled extremities D) Restlessness and dusky or cyanotic skin that is cool to the touch Which of the following vlues for vital signs would the nurse address first? A) Heart rate = 72 beats per minute B) Respiration rate = 28 breaths per minute C) Blood pressure = 160/86 D) Oxygen saturation by pulse oximetry = 89% E) Temperature = 37. The client's temperature is 36. D) Tell him it is not a good idea and provide a urinal. Using an oral electronic thermometer. D D C A . What should the nurse do next? A) Check the client's temperature history.1° C (97° F). He has new orders for "up ad lib." What action should the nurse take? A) Give him some slippers and tell him where the bathroom is located. B) Ask the nursing assistant to assist him to the bathroom.2° C (99° F). C) Obtain orthostatic blood pressure measurements. who has been on bed rest for 2 days.

C) Tell the client it is very important to end the conversation so the nurse can count respirations. How should the nurse handle measuring the rate of respiration? A) Count respirations during the time the client is not talking to the visitor. C) The client underwent surgery 18 hours earlier. B The nurse decides to take an apical pulse instead of a radial pulse. Which of the following client conditions influenced the nurse's decision? A) The client is in shock. B) The client has an arrhythmia. For which of the following clients would it be most appropriate for unlicensed assistive personnel to measure the client's vital signs? A) A client who recently started taking an antiarrhythmic medication B) A client with a history of transfusion reactions who is receiving a blood transfusion C) A client who has frequently been admitted to the unit with asthma attacks D) A client who is being admitted for elective surgery who has a history of stable hypertension The client has an oral temperature of 39. temperature is normal.2° C (102.6° F). D D D . Delegation of some tasks may become one of the decisions the nurse will make while on duty. D) The client showed a response to orthostatic changes.B) Document the results. the temperature is obviously an error. since the talking client is obviously not in respiratory distress. D) Document the respiration rate as "deferred" and measure the rate later. D) Get another thermometer. B) Wait at the client's bedside until the visit is over and then count respirations. The client is talking with a visiting pastor. C) Recheck the temperature every 15 minutes until it is normal. The nurse is to measure vital signs as part of the preparation for a test. What are the most appropriate nursing interventions? A) Provide an alcohol sponge bath and monitor laboratory results.

Which statement best describes the Cheyne-Stokes pattern? A) Respirations cease for several seconds. The pulse deficit is measured by: A) Subtracting 60 (bradycardia) from the client's pulse rate and reporting the difference B) Subtracting the client's pulse rate from 100 (tachycardia) and reporting the difference C) Assessing the apical pulse and the radial pulse for the same minute and subtracting the difference D) Assessing the apical pulse and 30 minutes later assessing the carotid pulse and subtracting the difference The nurse observes that a client's breathing pattern represents CheyneStokes respiration. with an increase in depth and rate (more than 20 breaths per minute). D) Reduce external coverings and keep clothing and bed linens dry. with alternating periods of apnea and hyperventilation. B) Respirations are abnormally shallow for two to three breaths followed by irregular periods of apnea. the condition occurs normally during exercise. administer antipyretics as ordered. and redistribution of blood to surface vessels C) Vasoconstriction. and reduction of blood flow to extremities D) Vasoconstriction. keep the client's room warm. vasodilation. the cycle begins with slow breaths and C D . and administer an analgesic.B) Remove excess clothing. and the posterior hypothalamus controls heat production. provide a tepid sponge bath. D) Respiration rate and depth are irregular. and administer an analgesic. C) Respirations are labored. The anterior hypothalamus controls heat loss. D The hypothalamus controls body temperature. sweating. C) Provide fluids and nutrition. reduction of blood flow to extremities. and shivering The nurse's documentation indicates that a client has a pulse deficit of 14 beats. What heat conservation mechanisms will the posterior hypothalamus initiate when it senses that the client's body temperature is lower than comfortable? A) Vasodilation and redistribution of blood to surface vessels B) Sweating.

B) Recheck the blood pressure and give the client orange juice.4) 4) HR= 72 BPM 5) RR= 28 BrPM C 1. 3 1. 2. 7 antibiotic for pneumonia. Skin turgor 3. Allergies to antibiotics 5. HR 2. 2. 52 year old woman admitted with dyspnea and discomfort in her left chest with deep breaths. What are the appropriate nursing interventions? A) Check other vital signs. 82 yr old admitted via ambulance to ER with shortness of breath. and report the findings. Recent BM's 6. He recently visited the health care center and is on 4.2 (100. BP in right arm .climaxes in apnea.3 (99. Smoking history 4. What vital sign should not be delegated to a nursing assistant: a) temperature b) radial pulse c) respiratory rate d) oxygen saturation Place the vital signs in order of priority for your nursing interventions: 1) SpO2= 89% 2) BP= 160/86 mmHG 3) Temperature= 37. 5. which helps his "high blood". beta-adrergic blocker. 4. He is also on a diuretic. D The nurse finds that the systolic blood pressure of an adult client is 88 mm Hg. SHe smoked for 35 years and recently lost over 10 pounds.8) via temporal artery. What additional assessment data is needed in planning intervention for the patients infection ? (choose all that apply) 1. C) Recheck the blood pressure after ambulating the client safely. anorexia. and malaise. He has a temperature of 38. make sure the client is safe. D) Recheck the blood pressure.

BP in distal extremity . Client's normal temperature 8.7.