1-Enalapril maleate (Vasotec) is prescribed for a client who is hospitalized. The nurse's
priority assessment before administering this medication is to:
A. Check the client's blood pressure
B. Check the client's peripheral pulses
C. Check the client's latest potassium level
D. Check the client's intake-and-output record for the previous 24 hours - ANSWER A.
Check the client's blood pressure
Checking the client's blood pressure
Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor. Indicated for the
treatment of hypertension, a frequent side effect associated with this medication is
postural hypotension. Thus, the nurse would check the client's blood pressure
immediately before administering each dose. The nurse would not specifically check the
client's peripheral pulses, the results of the most recent potassium level, and the intake
and output for the previous 24 hours when this mediation is administered.
2-A client is scheduled to have an upper gastrointestinal series. The nurse teaches the
client about the examination. Which of the following statements by the client indicates a
need for further teaching?
A. "The test will take about 30 minutes."
B. "I need to fast for 8 hours before the test."
C. "I should drink citrate of magnesia the night before the test and take a Fleet enema in
the morning of the test."
D. "I have to take a laxative after the test is completed, because the liquid that I'll need
to drink for the test can be constipating." ANSWER C. "I will need to drink citrate of
magnesia the night before the test and give myself a Fleet enema on the morning of the
test."
,An upper GI series is visualization of the esophagus, duodenum, and upper jejunum by
means of the use of a contrast medium. The test requires swallowing a contrast
medium-usually barium-administered in a flavored milkshake. Films are taken at
intervals during the course of approximately 30 minutes. No preparation is necessary
prior to a GI series, except NPO status for 8 hours before the test. After an upper GI
series, the client is ordered a laxative to hasten the elimination of the barium. Barium
that remains in the colon can become hard and form a solid mass that is difficult to expel
and can cause fecal impaction.
3-A nurse working the evening shift has reviewed a physician's prescriptions and has
determined that the dose of a prescribed medication is higher than the normal dosage.
The nurse phones the physician's answering service and learns that the physician is off
for the night and will be available in the morning. The nurse should:
A. Call the nursing supervisor
B. Ask the answering service to contact the on-call physician
C. Withhold the medication until the physician can be reached in the morning
D. Administer the medication but consult the physician when he becomes available -
ANSWER B. Ask the answering service to contact the on-call physician
4. An ED nurse is caring for a client suspected of experiencing acute MI and is preparing
the client for transfer to the coronary intensive care unit. The nurse notices the sudden
appearance of PVCs on the monitor, a radial pulse that is weaker than normal, checks
the carotid pulse and assesses that the PVCs are not perfusing. The appropriate action
by the nurse is:
A. Documenting the findings
B. Notify the ED physician to examine the client
C. Continue to monitor the client's cardiac status
D. Inform the client that PVCs are a normal occurrence after an MI - ANSWER B. Notify
the ED physician to examine the client
,5. NPO status is ordered 8 hours prior to the procedure for a client who is to undergo
ECT at 1 p.m. The nurse reviews the client's chart the morning of the procedure and
notes that the client usually takes an oral antihypertensive in the morning. The nurse
should:
A. Administer the antihypertensive with a small sip of water
B. Withhold the antihypertensive and give it at bedtime
C. Administer the medication through the intravenous (IV) route
D. Omit the antihypertensive and resume its administration on the day after the ECT -
ANSWER A. Administer the antihypertensive with a small sip of water
6 A client who has had coronary artery bypass graft surgery comes to the physician's
office for a follow-up visit. While assessing this client, the client tells the nurse that he is
feeling depressed. Which response by the nurse is therapeutic?
A. "Tell me more about what you're feeling."
B. "That's a normal response after this type of surgery."
C. "It will take time, but, I promise you, you will get over this depression."
D. "Every client who has this surgery feels the same way for about a month." ANSWER
A. "Tell me more about what you're feeling."
7 A laboring client experiences a spontaneous rupture of membranes. The nurse
immediately initiates a fetal heart rate count for a full minute and then assesses the
amniotic fluid. The nurse notes that the fluid is yellow and that it has an unpleasant odor.
Which of the following is the nurse's first action?
A. Call the physician
B. Record the findings
C. Lab test the fluid for presence of protein
D. Continue to monitor client and FHR - ANSWER A. Notify physician Correct
8 A nurse has cared for a physician who has just placed a central venous access device
, into a client who has been diagnosed with severe malnutrition and will be receiving
parenteral nutrition (PN). The priority nursing action immediately after the catheter has
been placed is to:
A. Notify radiography to come and take a chest x-ray
B. The client's blood glucose level should be checked for a baseline measurement
C. PN prescribed bag should be hanged, and the infusion is started at the prescribed
rate
D. The normal saline solution in the catheter should be infused at a rate of 100 mL/hr to
maintain patency - ANSWER A. Call the radiography department to obtain a chest x-ray
9 A rape victim being treated in the emergency department says to the nurse, "I'm really
worried that I've got HIV now." Which is the best response by the nurse?
A. "HIV is rarely an issue in rape victims."
B. "Every rape victim is concerned about HIV."
C. "You're more likely to get pregnant than to contract HIV."
D. "Let's talk about the information you need to assess your risk of acquiring HIV
infection." - ANSWER D. "Let's talk about the information you need to assess your risk of
acquiring HIV infection."
10 A patient is taking ordered ibuprofen (Motrin), 300 mg po qid, for joint pain
associated with rheumatoid arthritis. The patient tells the nurse that the medication is
giving him nausea and heartburn. The nurse should teach the patient to:
A. Call the doctor
B. Stop taking the medication
C. Take the medication with food
D. Take the medication twice a day instead of four times - ANSWER C. Take the
medication with food
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