1) A client who had a stroke is receiving clopidogrel.

Which adverse effect does the nurse

monitor for in this client?
Select one:
a. Repeated syncope Not a symptom of clopidogrel.
b. Spontaneous ecchymosis Clopidogrel is a anti-platelet medication that can cause
bruising. The nurse should monitor for signs of abnormal bleeding, such as spontaneous
bruising.
c. New-onset confusion - Not a symptom of clopidogrel.
d. Abdominal distention - Not a symptom of clopidogrel.
2) A client with aphasia presents to the emergency department with a suspected brain attack.
Which clinical manifestation leads the nurse to suspect that this client has had a thrombotic
stroke?
Select one:
a. A grand mal seizure 2 months ago Seizures are commonly associated with hemorrhagic
strokes.
b. Sudden loss of motor coordination Thrombotic strokes are not characterized by sudden
onsets of symptoms. This particular symptom would relate to an embolic stroke due to its
immediate appearance.
c. Chest pain and nuchal rigidity Meningitis is generally characterized by nuchal rigidity,
as well as chest pain in some situations.
d. Two episodes of speech difficulties in the last month Thrombotic strokes have a gradual
onset of symptoms, preceded by a TIA. Two episodes of speech difficulties would
correlate with a TIA.
3) The nurse is caring for a client with a pulmonary embolus who also has right-sided heart
failure. Which symptom will the nurse need to intervene for immediately?
Select one:
a. Heart rate of 100 beats/minute An increased heart rate is an expected symptom of a PE.
b. Dry cough A dry cough is an expected symptom of a PE.
c. Respiratory rate of 28 breaths/minute An increased respiratory rate is an expected
symptom of a PE.
d. Urinary output of 10 mL/hour Decreased urinary output is not an expected symptom of
a PE. It can potentially be indicative of decreased cardiac output.
4) The nurse is preparing a client who has multiple sclerosis (MS) for discharge home from a
rehabilitation center. The client has been prescribed cyclophosphamide and methylprednisolone.
Which instruction does the nurse include in the teaching plan for the client?

Select one:
a. Stop using these medications when your symptoms improve. Prescribed medications
should not suddenly be discontinued. For example: methylprednisolon is a corticosteroid
that needs to be gradually discontinued to avoid any detrimental effects.
b. Take warm baths to promote muscle relaxation. Patients with MS lose sensation to
temperature after a certain point. Suggesting the individual takes a warm bath may be
harmful due to their lack of sensation.
c. Avoid crowds and people with colds. Corticosteroids decrease immune responses,
therefore large crowds should be avoided since they place an individual at risk for
infection or further complications.
d. Use physical aids such as walkers as little as possible. In the late stages of MS,
physical aids can assist the individual with balance and ambulation. If physical aids are
necessary, then they should be utilized.
5) The nurse is teaching a client about different medications for asthma. Which medication does
the nurse teach the client to administer to control the prolonged inflammatory response?
Select one:
a. Prednisolone Prednisolone is a corticosteroid that blocks late-phase reactions to
allergens, reduces airway obstruction, and decreases inflammatory response.
b. Aspirin Aspirin is an NSAID that is used to treat mild to moderate pain and
inflammation. It is contraindicated in asthmatics, since it may cause irritation within the
airway and lungs.
c. Diphenhydramine Diphenhydramine is an antihistamine that is used to treat allergy
related symptoms.
d. Bitolterol Bitolterol is a short acting beta-2 adrenergic drug used for asthma patients,
however it is utilized as a rescue drug. This drug is not used for long term treatments for
asthmatics.
6) The nurse is teaching a client with pneumonia ways to clear secretions. Which intervention is
the most effective?
Select one:
a. Administering an antiemetic medication Antiemetic drugs prevent nausea and vomiting.
They do not help to clear secretions.
b. Having the client cough and deep breathe hourly Having the client cough and deep
breathe each hour would be effective in assisting them to clear some of their secretions,
however it is not the best answer.
c. Administering an antitussive medication Antitussive medications suppress coughs,
therefore not allowing for the proper clearance of the airway and the secretions.
d. Increasing fluids to 2 L/day if tolerated Fluids decrease the patency of mucus. The
increased fluid intake promotes thinning of the mucus.
7) Which response is an example of compensation for an acid-base imbalance.

Select one:
a. Increased release of acids from kidneys during exacerbation of chronic obstructive
pulmonary disease (COPD) Increased release of acid from the kidneys would not be a
compensatory mechanisms. This would place the individual in a more acidic state.
b. Increased thirst when spending time in an excessively dry environment Increased thirst
when spending time in a dry environment is an expected correlation that does not relate
to any compensatory mechanism.
c. Increase in the rate and depth of respirations when exercising Respiratory rates increase
with activity, blowing off excess carbon dioxide. If lactic acid is present within skeletal
muscles respirations increase due to blood flow and oxygen being insufficient in regards
to meeting the high demand for oxygen.
d. Increased urinary output when blood pressure increases during exercise When
someones blood pressure is elevated, their blood volume decreases. As the their blood
volume decreases the plasma becomes more concentrated, released ADH. This helps to
minimize urination through fluid retention.
8) The nurse is caring for a client who has myasthenia gravis. Which nursing intervention does
the nurse implement to reduce muscle weakness in this client?
Select one:
a. Administer a therapeutic massage Massages are not the best intervention to reduce
muscle weakness, since it will relax the muscles more.
b. Perform passive range-of-motion exercises Passive range-of-motion will encourage the
client to attempt exercises while the nurse assists. Allowing the nurse to help with
exercises will not reduce muscle weakness. It is a preventative measure in regards to
muscle weakness.
c. Collaborative with the physical therapist The hallmark symptom for myasthenia gravia
is muscle weakness. Collaboration with a PT to teach the client how to conserve energy
to prevent fatigue and muscle weakness will aide in the symptoms.
d. Reposition the client every 2 hours Repositioning the client promotes the individual to
be sedentary. Repositioning assists with blood flow and circulation, but it does not help to
decrease muscle weakness in a client.
9) The nurse is caring for a client receiving heparin and warfarin therapy for a pulmonary
embolus. The clients international normalized ratio (INR) is 2.3. What is the nurses best action?
Select one:
a. Discontinue the heparin Heparin can be discontinued once the warfarin therapy has
reached a therapeutic range. Heparin is utilized as additional coverage until the warfarin
therapy is deemed effective or therapeutic.
b. Increase the warfarin dose If the patient is within the therapeutic range, then the current
warfarin dose is effective. An increase in the dose is not necessary.

c. Continue the current therapy The heparin was only utilized alongside the warfarin until
a therapeutic range was achieved. Once the range is achieved the heparin therapy is not
necessary for additional coverage for the patient.
d. Increase the heparin dose Heparin is only being used as supplemental coverage. An
increase in heparin is not necessary, because the therapeutic range of the warfarin therapy
is desired.
10) A client has respiratory acidosis. The nurse evaluates that treatment is being effective with
which arterial blood gas values?
Select one:
a. pH 7.28, HCO3- 12 mEq/L, PCO2 45 mm Hg, PO2 96 mm Hg The pH is acidic,
indicating that treatment has not yet been effective.
b. pH 7.32, HCO3- 17 mEq/L, PCO2 25 mm Hg, PO2 98 mm Hg The pH is normal,
however the bicarbonate and CO2 levels are both abnormal. The two levels do not
correlate with effective treatment.
c. pH 7.35, HCO3- 36 mEq/L, PCO2 65 mm Hg, PO2 78 mm Hg The pH is normal,
indicating acid-base balance with full compensation.
d. pH 7.48, HCO3- 12 mEq/L, PCO2 35 mm Hg, PO2 85 mm Hg The pH is basic,
indicating that acid-base balance has not yet been achieved.