Exam (elaborations)

CPNRE Practice exam 2024 with 100% correct answers

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Course
CPNRE

Institution
CPNRE

The nurse is administering heparin via the subcutaneous route. Which intervention should the nurse implement? a. Prepare the medication using a 25-gauge, ½ inch needle b. After injecting the needle, aspirate and observe for blood c. After removing the needle, massage the area gently d. Admin...

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CPNRE Practice exam 2024 with 100%
correct answers

The nurse is administering heparin via the subcutaneous route. Which intervention should the nurse
implement?

a. Prepare the medication using a 25-gauge, ½ inch needle

b. After injecting the needle, aspirate and observe for blood

c. After removing the needle, massage the area gently

d. Administer the medication in the client's "love handles" - correct answer Prepare the medication
using a 25-gauge, ½ inch needle

Knowledge: The nurse should NOT aspirate for blood when administering heparin because this can
damage surrounding tissue and cause bruising. The nurse should not massage after injecting heparin
because this may cause bruising or bleeding. Heparin is administered in the abdomen at least 2 inches
from umbilicus-best practice.

The nurse is administering morning medications on a medical floor. Which medication should the nurse
administer first?

a. Regular insulin sliding scale to an elderly client diagnosed with Type 1 diabetes mellitus

b. Methylprednisolone, a glucocorticoid, to a client diagnosed with lupus erythematosus

c. Morphine, a narcotic analgesic, to a client diagnosed with AIDS

d. Lasix, a diuretic, to a client with hypertension - correct answer a. Regular insulin sliding scale to an
elderly client diagnosed with Type 1 diabetes mellitus

b. Methylprednisolone, a glucocorticoid, to a client diagnosed with lupus erythematosus (can be
administered within the 30-minute acceptable time frame)

c. Morphine, a narcotic analgesic, to a client diagnosed with AIDS -pain medication is a priority, but it
can be administered after the sliding scale

d. Lasix, a diuretic, to a client with hypertension- can be administered within the 30-minute acceptable
time frame

,Regular insulin is administered prior to meals; therefore, this medication should be administered.
Critical Thinking

Which data would indicate that the antibiotic therapy has been successful for a client diagnosed with
bacterial pneumonia?

a. The client's hematocrit is within normal range

b. The client is expectorating thick green sputum

c. The client's lung sounds are clear to ausculatation

d. The client has complaints of pleuritic chest pain. - correct answer a. The client's hematocrit is within
normal range- does not indicate client response

b. The client is expectorating thick green sputum- symptom of pneumonia

c. The client's lung sounds are clear to ausculatation

d. The client has complaints of pleuritic chest pain.— symptom of pneumonia

The symptoms of pneumonia includes crackles and wheezes, rhonchi in the lung fields. Clear lungs
indicate an improvement in the pneumonia and that the medication is effective. Application

The nurse is administering Humalog at 0730 to a client diagnosed with Type 1 diabetes. Which
intervention should the nurse implement?

a. Ensure the client eats at least 90% of the lunch tray

b. Do not administer unless the breakfast tray is in the client's room

c. Check the client's blood glucose level 1 hour after receiving the insulin

d. Have 50% dextrose in water at the bedside for emergency use. - correct answer a. Ensure the client
eats at least 90% of the lunch tray—insulin will not be working 4-5 hours after being administered

b. Do not administer unless the breakfast tray is in the client's room

c. Check the client's blood glucose level 1 hour after receiving the insulin—glucose level should be
checked prior to administering

d. Have 50% dextrose in water at the bedside for emergency use.—this is administered when a client is
unconscious secondary to hypoglycemia, and should not be kept at the bedside. Orange juice or some
form of simple glucose can be kept at the bedside.

,Application: The insulin peaks in 15-20 minutes after being administered; therefore, the meal should be
at the bedside prior to administering this medication

The client has a severe anaphylactic reaction to insect bites. What priority discharge intervention should
the nurse discuss with the client?

a. Wear an insect repellent on exposed skin

b. Keep prescribed antihistamines on their person

c. Keep an EpiPen in the refrigerator at all times

d. Wear a MedicAlert identification bracelet - correct answer a. Wear an insect repellent on exposed
skin —appropriate intervention, but if the client has an insect bite, the repellent will not prevent
anaphylaxis, therefore, not priority intervention

b. Keep prescribed antihistamines on their person —used with anaphylaxis, but it takes at least 30
minutes to work, therefore not a priority medication

c. Keep an EpiPen in the refrigerator at all times —keeping medication in the refrigerator does not allow
it to be available to the client at all times.

d. Wear a MedicAlert identification bracelet

Application: Bracelet indicates the client is at risk for an anaphylactic reaction; therefore, this is the
priority intervention.

The client's mother contacts the clinic regarding medication administration stating, "My daughter
cannot swallow this capsule. It's too large." Investigation reveals that the medication is a capsule
marked SR. The nurse should instruct the mother to:

a. Open the capsule and mix the medication with apple sauce

b. Crush the medication and administer it with a glass of liquid

c. Call the pharmacist and request a change to a different medication

d. Stop the medication and inform the physician - correct answer d. Stop the medication and inform
the physician

, Application: SR means sustained released. These medications cannot be altered. In answers A and B,
crushing or opening the capsule is not allowed. The best response would be to inform the prescriber
(the doctor) immediately

The client calls the nursing station and requests pain medication. When the nurse enters the room with
the narcotic medication, the nurse finds the client laughing and talking with visitors. Which action
should the nurse administer first?

a. Administer the client's prescribed pain medication

b. Assess the client's perception of pain on a 1-10 scale

c. Wait until the visitors leave to administer any medication

d. Check the MAR to see if there is a nonnarcotic medication ordered - correct answer a. Administer
the client's prescribed pain medication —should not administer pain medication until after assessing the
client's pain

b. Assess the client's perception of pain on a 1-10 scale

c. Wait until the visitors leave to administer any medication —should assess client whether the client
has visitors or not

d. Check the MAR to see if there is a nonnarcotic medication ordered —nurse should assess the client's
pain first

Application: first action is to always assess the client in pain to determine if client is having a
complication that requires medical intervention rather than PRN medication.

The client in hypovolemic shock is receiving normal saline by rapid intravenous infusion. Which
assessment data would warrant immediate intervention by the nurse?

a. The client's blood pressure is 89/48

b. The client's pulse oximeter reading is 95%

c. The client's lung sounds are clear bilaterally

d. The client's urine output is 120 mL in 3 hours - correct answer a. The client's blood pressure is 89/48

b. The client's pulse oximeter reading is 95% --normal finding

c. The client's lung sounds are clear bilaterally—normal finding

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