1. A 2 year-old child is receiving temporary total parental nutrition (TPN) through a central venous line. This is the first day of TPN therapy. Although all of the following nursing actions must be included in the plan of care of this child, which one would be a priority at this time?
- Use aseptic technique during dressing changes
- Maintain central line catheter integrity
- Monitor serum glucose levels
- Check results of liver function tests
2. Nurse Jamie is administering the initial total parenteral nutrition solution to a client. Which of the following assessments requires the nurse’s immediate attention?
- Temperature of 37.5 degrees Celsius
- Urine output of 300 cc in 4 hours
- Poor skin turgor
- Blood glucose of 350 mg/dl
3. Nurse Susan administered intravenous gamma globulin to an 18 month-old child with AIDS. The parent asks why this medication is being given. What is the nurse’s best response?
- “It will slow down the replication of the virus.”
- “This medication will improve your child’s overall health status.”
- “This medication is used to prevent bacterial infections.”
- “It will increase the effectiveness of the other medications your child receives.”
4. When caring for a client with total parenteral nutrition (TPN), what is the most important action on the part of the nurse?
- Record the number of stools per day
- Maintain strict intake and output records
- Sterile technique for dressing change at IV site
- Monitor for cardiac arrhythmias
5. The nurse is administering an intravenous vesicant chemotherapeutic agent to a client. Which assessment would require the nurse’s immediate action?
- Stomatitis lesion in the mouth
- Severe nausea and vomiting
- Complaints of pain at site of infusion
- A rash on the client’s extremities
6. Nurse Celine is caring for a client with clinical depression who is receiving a MAO inhibitor. When providing instructions about precautions with this medication, the nurse should instruct the client to:
- Avoid chocolate and cheese
- Take frequent naps
- Take the medication with milk
- Avoid walking without assistance
7. While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. The BEST response to this client should be:
- “As you urinate more, you will need less medication to control fluid.”
- “You will have to take this medication for about a year.”
- “The medication must be continued so the fluid problem is controlled.”
- “Please talk to your physician about medications and treatments.”
8. George, age 8, is admitted with rheumatic fever. Which clinical finding indicates to the nurse that George needs to continue taking the salicylates he had received at home?
- Chorea.
- Polyarthritis.
- Subcutaneous nodules.
- Erythema marginatum.
9. An order is written to start an IV on a 74-year-old client who is getting ready to go to the operating room for a total hip replacement. What gauge of catheter would best meet the needs of this client?
- 18
- 20
- 21 butterfly
- 25
10. A client with an acute exacerbation of rheumatoid arthritis is admitted to the hospital for treatment. Which drug, used to treat clients with rheumatoid arthritis, has both an anti-inflammatory and immunosuppressive effect?
- Gold sodium thiomalate (Myochrysine)
- Azathioprine (Imuran)
- Prednisone (Deltasone)
- Naproxen (Naprosyn)
11. Which of the following is least likely to influence the potential for a client to comply with lithium therapy after discharge?
- The impact of lithium on the client’s energy level and life-style.
- The need for consistent blood level monitoring.
- The potential side effects of lithium.
- What the client’s friends think of his need to take medication
12. Which of the following is least likely to influence the potential for a client to comply with lithium therapy after discharge?
- The impact of lithium on the client’s energy level and life-style.
- The need for consistent blood level monitoring.
- The potential side effects of lithium.
- What the client’s friends think of his need to take medication.
13. The nurse is caring for an elderly client who has been diagnosed as having sundown syndrome. He is alert and oriented during the day but becomes disoriented and disruptive around dinnertime. He is hospitalized for evaluation. The nurse asks the client and his family to list all of the medications, prescription and nonprescription, he is currently taking. What is the primary reason for this action?
- Multiple medications can lead to dementia
- The medications can provide clues regarding his medical background
- Ability to recall medications is a good assessment of the client’s level of orientation.
- Medications taken by a client are part of every nursing assessment.
14. A 25-year-old woman is in her fifth month of pregnancy. She has been taking 20 units of NPH insulin for diabetes mellitus daily for six years. Her diabetes has been well controlled with this dosage. She has been coming for routine prenatal visits, during which diabetic teaching has been implemented. Which of the following statements indicates that the woman understands the teaching regarding her insulin needs during her pregnancy?
- “Are you sure all this insulin won’t hurt my baby?”
- “I’ll probably need my daily insulin dose raised.”
- “I will continue to take my regular dose of insulin.”
- “These finger sticks make my hand sore. Can I do them less frequently?”
15. Mrs. Johanson.’s physician has prescribed tetracycline 500 mg po q6h. While assessing Mrs. Johanson’s nursing history for allergies, the nurse notes that Mrs. Johanson’s is also taking oral contraceptives. What is the most appropriate initial nursing intervention?
- Administer the dose of tetracycline.
- Notify the physician that Mrs. Johanson is taking oral contraceptives.
- Tell Mrs. Johanson, she should stop taking oral contraceptives since they are inactivated by tetracycline.
- Tell Mrs. Johanson, to use another form of birth control for at least two months.
16. An adult client’s insulin dosage is 10 units of regular insulin and 15 units of NPH insulin in the morning. The client should be taught to expect the first insulin peak:
- as soon as food is ingested.
- in two to four hours.
- in six hours.
- in ten to twelve hours.
17. An adult is hospitalized for treatment of deep electrical burns. Burn wound sepsis develops and mafenide acetate 10% (Sulfamylon) is ordered bid. While applying the Sulfamylon to the wound, it is important for the nurse to prepare the client for expected responses to the topical application, which include:
- severe burning pain for a few minutes following application.
- possible severe metabolic alkalosis with continued use.
- black discoloration of everything that comes in contact with this drug.
- chilling due to evaporation of solution from the moistened dressings.
18. Ms.Clark has hyperthyroidism and is scheduled for a thyroidectomy. The physician has ordered Lugol’s solution for the client. The nurse understands that the primary reason for giving Lugol’s solution preoperatively is to:
- decrease the risk of agranulocytosis postoperatively.
- prevent tetany while the client is under general anesthesia.
- reduce the size and vascularity of the thyroid and prevent hemorrhage.
- potentiate the effect of the other preoperative medication so less medicine can be given while the client is under anesthesia.
19. A two-year-old child with congestive heart failure has been receiving digoxin for one week. The nurse needs to recognize that an early sign of digitalis toxicity is:
- bradypnea.
- failure to thrive.
- tachycardia.
- vomiting.
20. Mr. Bates is admitted to the surgical ICU following a left adrenalectomy. He is sleepy but easily aroused. An IV containing hydrocortisone is running. The nurse planning care for Mr. Bates knows it is essential to include which of the following nursing interventions at this time?
- Monitor blood glucose levels every shift to detect development of hypo- or hyperglycemia.
- Keep flat on back with minimal movement to reduce risk of hemorrhage following surgery.
- Administer hydrocortisone until vital signs stabilize, then discontinue the IV.
- Teach Mr. Bates how to care for his wound since he is at high risk for developing postoperative infection.
Answers and Rationales
- Answer C. Monitor serum glucose levels. Hyperglycemia may occur during the first day or 2 as the child adapts to the high-glucose load of the TPN solution. Thus, a chief nursing responsibility is blood glucose testing.
- Answer D. Total parenteral nutrition formulas contain dextrose in concentrations of 10% or greater to supply 20% to 50% of the total calories. Blood glucose levels should be checked every 4 to 6 hours. A sliding scale dose of insulin may be ordered to maintain the blood glucose level below 200mg/dl.
- Answer C. Intravenous gamma globulin is given to help prevent as well as to fight bacterial infections in young children with AIDS.
- Answer C. Clients receiving TPN are very susceptible to infection. The concentrated glucose solutions are a good medium for bacterial growth. Strict sterile
technique is crucial in preventing infection at IV infusion site.
- Answer C. A vesicant is a chemotherapeutic agent capable of causing blistering of tissues and possible tissue necrosis if there is extravasation. These agents are irritants which cause pain along the vein wall, with or without inflammation.
- Answer A. Foods high in tryptophan, tyramine and caffeine, such as chocolate and cheese may precipitate hypertensive crisis.
- Answer C. This is the most therapeutic response and gives the client accurate information.
- Answer B. Chorea is the restless and sudden aimless and irregular movements of the extremities suddenly seen in persons with rheumatic fever, especially girls. Polyarthritis is characterized by swollen, painful, hot joints that respond to salicylates. Subcutaneous nodules are nontender swellings over bony prominences sometimes seen in persons with rheumatic fever. Erythema marginatum is a skin condition characterized by nonpruritic rash, affecting trunk and proximal extremities, seen in persons with rheumatic fever.
- Answer A. Clients going to the operating room ideally should have an 18- gauge catheter. This is large enough to handle blood products safely and to allow rapid administration of large amounts of fluid if indicated during the perioperative period. An 18-gauge catheter is recommended. A 20-gauge catheter is a second choice. A 21-gauge needle is too small and a butterfly too unstable for a client going to surgery. A 25-gauge needle is too small.
- Answer C. Gold sodium thiomalate is usually used in combination with aspirin and nonsteroidal anti-inflammatory drugs to relieve pain. Gold has an immunosuppressive affect. Azathioprine is used for clients with life-threatening rheumatoid arthritis for its immunosuppressive effects. Prednisone is used to treat persons with acute exacerbations of rheumatoid arthritis. This medication is given for its anti-inflammatory and immunosuppressive effects. Naproxen is a nonsteroidal anti-inflammatory drug. Immunosuppression does not occur.
- Answer D. The impact of lithium on the client’s energy level and life style are great determinants to compliance. The frequent blood level monitoring required is difficult for clients to follow for a long period of time. Potential side effects such as fine tremor, drowsiness, diarrhea, polyuria, thirst, weight gain, and fatigue can be disturbing to the client. While the client’s social network can influence the client in terms of compliance, the influence is typically secondary to that of the other factors listed.
- Answer D. The impact of lithium on the client’s energy level and life style are great determinants to compliance. The frequent blood level monitoring required is difficult for clients to follow for a long period of time. Potential side effects such as fine tremor, drowsiness, diarrhea, polyuria, thirst, weight gain, and fatigue can be disturbing to the client. While the client’s social network can influence the client in terms of compliance, the influence is typically secondary to that of the other factors listed.
- Answer A. Drugs commonly used by elderly people, especially in combination, can lead to dementia. Assessment of the medication taken may or may not provide information on the client’s medical background. However, this is not the primary reason for assessing medications in a client who is exhibiting sundown syndrome. Ability to recall medications may indicate short-term memory and recall. However, that is not the primary reason for assessing medications in a client with sundown syndrome. Medication history should be a part of the nursing assessment. In this client there is an even more important reason for evaluating the medications taken.
- Answer B. The client starts to need increased insulin in the second trimester. This statement indicates a lack of understanding. As a result of placental maturation and placental production of lactogen, insulin requirements begin increasing in the second trimester and may double or quadruple by the end of pregnancy. The client starts to need increased insulin in the second trimester. This statement indicates a lack of understanding. Insulin doses depend on blood glucose levels. Finger sticks for glucose levels must be continued.
- Answer B. The nurse should be aware that tetracyclines decrease the effectiveness of oral contraceptives. The physician should be notified. The physician should be notified. Tetracycline decreases the effectiveness of oral contraceptives. There may be an equally effective antibiotic available that can be prescribed. Note on the client’s chart that the physician was notified. The nurse should be aware that tetracyclines decrease the effectiveness of oral contraceptives. The nurse should not tell the client to stop taking oral contraceptives unless the physician orders this. The nurse should be aware that tetracyclines decrease the effectiveness of oral contraceptives. If the physician chooses to keep the client on tetracycline, the client should be encouraged to use another form of birth control. The first intervention is to notify the physician.
- Answer B. The first insulin peak will occur two to four hours after administration of regular insulin. Regular insulin is classified as rapid acting and will peak two to four hours after administration. The second peak will be eight to twelve hours after the administration of NPH insulin. This is why a snack must be eaten mid-morning and also three to four hours after the evening meal. The first insulin peak will occur two to four hours after administration of regular insulin. The first insulin peak will occur two to four hours after administration of regular insulin. The second peak will occur eight to twelve hours after the administration of NPH insulin.
- Answer A. Mafenide acetate 10% (Sulfamylon) does cause burning on application. An analgesic may be required before the ointment is applied. Mafenide acetate 10% (Sulfamylon) is a strong carbonic anhydrase inhibitor that affects the renal tubular buffering system, resulting in metabolic acidosis. Mafenide acetate 10% (Sulfamylon) does not cause discoloration. Silver nitrate solution, another topical antibiotic used to treat burn sepsis, has the disadvantage of turning everything it touches black. Mafenide acetate 10% (Sulfamylon) is an ointment that is applied directly to the wound. It has the ability to diffuse rapidly through the eschar. The wound may be left open or dry dressing may be applied. Silver nitrate solution is applied by soaking the wound dressings and keeping them constantly wet, which may cause chilling and hypotension.
- Answer C. Doses of over 30 mg/day may increase the risk of agranulocytosis. Lugol’s solution does not act to prevent tetany. Calcium is used to treat tetany. The client may receive iodine solution (Lugol’s solution) for 10 to 14 days before surgery to decrease vascularity of the thyroid and thus prevent excess bleeding. Lugol’s solution does not potentiate any other preoperative medication.
- Answer D. Bradypnea (slow breathing) is not associated with digitalis toxicity. Bradycardia is associated with digitalis toxicity. Although children with congestive heart failure often have a related condition of failure to thrive, it is not directly related to digitalis administration. It is more related to chronic hypoxia. Tachycardia is not a sign of digitalis toxicity. Bradycardia is a sign of digitalis toxicity. The earliest sign of digitalis toxicity is vomiting, although one episode does not warrant discontinuing medication.
- Answer A. Hydrocortisone promotes gluconeogenesis and elevates blood glucose levels. Following adrenalectomy the normal supply of hydrocortisone is interrupted and must be replaced to maintain the blood glucose at normal levels. Care for the client following adrenalectomy is similar to that for any abdominal operation. The client is encouraged to change position, cough, and deep breathe to prevent postoperative complications such as pneumonia or thrombophlebitis. Maintenance doses of hydrocortisone will be administered IV until the client is able to take it by mouth and will be necessary for six months to two years or until the remaining gland recovers. The client undergoing an adrenalectomy is at increased risk for infection and delayed wound healing and will need to learn about wound care, but not at this time while he is in the ICU.