BASIC QUESTIONS Part 2

1. Body image is the subjective view an individual has about his or her physical appearance including body shape, size, weight, and proportions. Which condition would put a client at risk for disturbed body image?

Urinary tract infection

Hyperlipidemia

Rheumatoid arthritis

High blood pressure

Rheumatoid arthritis is a painful, inflammatory, autoimmune condition that results in the enlargement and/or gross disproportion of the joints. Clients who have rheumatoid arthritis are at risk for disturbances in body image.

Explanation

Rheumatoid arthritis is a painful, inflammatory, autoimmune condition that results in the enlargement and/or gross disproportion of the joints. Clients who have rheumatoid arthritis are at risk for disturbances in body image.

2. The nurse is preparing to administer morphine sulfate to the client for complaints of postoperative pain. The most important nursing assessment to perform prior to administering the medication would be to

Assess respiratory rate and pattern

Assess for urinary output and edema

Assess capillary refill and skin color

Assess pain level and cranial nerve # 1

Answer a is correct because morphine sulfate is an opioid analgesic which depresses respiratory rate. Answers b, c, and d are not assessment findings which are directly related to the effects of morphine sulfate.

Explanation

Answer a is correct because morphine sulfate is an opioid analgesic which depresses respiratory rate. Answers b, c, and d are not assessment findings which are directly related to the effects of morphine sulfate.

3. The nurse is transcribing the physician orders and has difficulty reading one of the entries. The best action of the nurse is to

Clarify the order with another nurse

Call the physician who wrote the order and ask for clarification

Ask the pharmacist for clarification

Refer the matter to the Charge Nurse

Always clarify the orders with the physician who wrote the orders. Answers a, c, and d are incorrect—these people did not write the order and thus are not the best people to clarify the order.

Explanation

Always clarify the orders with the physician who wrote the orders. Answers a, c, and d are incorrect—these people did not write the order and thus are not the best people to clarify the order.

4. The client who is receiving an opioid analgesic via an epidural infusion becomes heavily sedated and has a respiratory rate of eight breaths per minute. The nurse anticipates the physician ordering which of the following medications?

Abacavir (Ziagen)

Bupivacaine (Marcaine)

Naloxone (Narcan)

Oxymorphone (Numorphan)

Answer c is correct because Narcan is an antidote for opioids and reverses CNS depression and respiratory depression related to opioid overdosage. a, b, and d are not opioid reversal agents.

Explanation

Answer c is correct because Narcan is an antidote for opioids and reverses CNS depression and respiratory depression related to opioid overdosage. a, b, and d are not opioid reversal agents.

5. Digoxin (Lanoxin) 0.125 mg by the intravenous route has been ordered for a client with atrial fibrillation. The client's potassium level is 3.1. The digoxin (Lanoxin) is available in a dose of 0.5 mg/2 ml. Which of the following actions by the nurse is appropriate?

Administer 0.5 ml and call the physician about the hyperkalemia

Administer 1 ml and call the physician about the hypokalemia

Administer 0.125 ml and call the physician about the hyperkalemia

Hold the digoxin and call the physician about the client’s hypokalemia

The potassium level is too low to administer digoxin. Hypokalemia places the client at a higher risk for digoxin toxicity.

Explanation

The potassium level is too low to administer digoxin. Hypokalemia places the client at a higher risk for digoxin toxicity.

6. Which of the following is correct about the administration of whole blood?

Administered in incidents such as acute hemorrhage where a client has lost greater than 25% of total blood volume

Volume of component for transfusion is 250–325 ml per bag

Administered to clients with bleeding due to thrombocytopenia or platelet dysfunction, platelet counts less than 20,000 (normal _ 150,000–350,000)

Administered to clients with clotting disorders who are actively bleeding or at high risk for bleeding

Answer a is correct. Answer b is incorrect because the volume is not enough. Whole blood is usually about 450–500 ml. Answer c is incorrect because it is describing the purpose of platelet administration. Answer d is incorrect because it is describing when it is appropriate to administer fresh frozen plasma.

Explanation

Answer a is correct. Answer b is incorrect because the volume is not enough. Whole blood is usually about 450–500 ml. Answer c is incorrect because it is describing the purpose of platelet administration. Answer d is incorrect because it is describing when it is appropriate to administer fresh frozen plasma.

7. The nurse should monitor the client every hour or more frequently when the client is receiving an intravenous infusion. The complication of circulatory overload may cause the following symptoms:

Less than 2 second capillary refill, headache, and hypertension

Edema, decreased urinary output, increased respiratory rate, and hypotension

Shortness of breath, increased respiratory and heart rate, hypertension, edema, and distended jugular veins

Decreased level of consciousness, edema, hypotension, and dilated pupils

Answer c is correct. It describes the symptoms associated with circulatory overload

Explanation

Answer c is correct. It describes the symptoms associated with circulatory overload

8. Coping involves all of the conscious and unconscious behaviors used by individuals to deal with stress. Coping mechanisms are effective in maintaining emotional stability. Which coping mechanism is an ineffective mechanism?

Hitting others

Crying

Yelling

Kicking a chair

Hitting others, hurting oneself, and destroying property are ineffective coping mechanisms. Crying, yelling, and kicking a chair are normative behaviors.

Explanation

Hitting others, hurting oneself, and destroying property are ineffective coping mechanisms. Crying, yelling, and kicking a chair are normative behaviors.

9. The physician orders 1000 ml D5 1⁄4 NS with Potassium 40 mEq to be administered over 8 hours. The administration set has a drop factor of 15 gtt/ml. How many milliliters per hour and drops per minute should the nurse administer this infusion?

100 ml/hr, 25 gtt/min

100 ml/hr, 31 gtt/min

125 ml/hr, 38 gtt/min

125 ml/hr, 31 gtt/min

Answer d is correct. 1000 ml/8 hr _125 ml/hr. 125 ml/60 min X 15 _ 31 gtt/min.

Explanation

Answer d is correct. 1000 ml/8 hr _125 ml/hr. 125 ml/60 min X 15 _ 31 gtt/min.

10. A nurse is planning for the discharge of an elderly client from a hospital. Which statement made by the client would indicate to the nurse that the client lacks support system at home?

“My sister and her husband are taking me home today.”

“My church members have been sending cards and letters while I have been in the hospital.”

“I am not sure how I am going to get to the grocery store after I get home.”

“My neighbor is retired. We visit and have our meals together every day.”

When the client expresses concern about getting to the grocery store after returning home from the hospital, the nurse should be aware that the client may not have a support system at home to help.

Explanation

When the client expresses concern about getting to the grocery store after returning home from the hospital, the nurse should be aware that the client may not have a support system at home to help.

11. Holistic nursing care involves addressing clients' physical, mental, emotional, and spiritual needs. Which nursing intervention assists clients and their families in meeting their spiritual needs?

Ensuring the confidentiality of the client

Notifying the physician of the family’s presence

Resolving conflicts between treatment and beliefs

Resolving conflicts between family members

Nursing interventions to assist clients and their families to meet their spiritual needs include offering support, facilitating the client’s practice of religion, praying with a client and family, contacting a spiritual counselor, and resolving conflicts between treatment and spiritual beliefs.

Explanation

Nursing interventions to assist clients and their families to meet their spiritual needs include offering support, facilitating the client’s practice of religion, praying with a client and family, contacting a spiritual counselor, and resolving conflicts between treatment and spiritual beliefs.

12. A hospice nurse is caring for the family of a client who has died 30 minutes ago. Which type of grief is the family experiencing in response to their loss?

Anticipatory grief

Acute grief

Complicated grief

Palliative grief

The family is most likely experiencing acute grief; a painful experience associated with loss that has no clear ending.

Explanation

The family is most likely experiencing acute grief; a painful experience associated with loss that has no clear ending.

13. The physician orders an infusion of 1000 ml of D5 1⁄4 NS to be infused at 50 ml/hr. The nurse begins the infusion at 0700. What time will the infusion be completed?

1100

1700

0100

0300

Answer d is because 1000 ml of solution will take 20 hours to infuse at 50 ml/hour.

Explanation

Answer d is because 1000 ml of solution will take 20 hours to infuse at 50 ml/hour.

14. The client is receiving an intravenous solution and may be experiencing a hypersensitivity reaction. Which of the following actions by the nurse is correct?

Stop the infusion, discontinue the IV, and observe the client carefully

Slow the infusion to 30 ml/hr, assess the client, and call the physician

Slow the infusion to 30 ml/hr, administer an antihistamine, and call the physician

Stop the infusion, keep the vein open with NS at 30 ml/hr, assess the client, and call the physician.

The client may be experiencing a reaction to the solution, therefore, the nurse stops that solution, but maintains intravenous access with an infusion of NS. Assessing the client and calling the physician are standard procedures for safe care.

Explanation

The client may be experiencing a reaction to the solution, therefore, the nurse stops that solution, but maintains intravenous access with an infusion of NS. Assessing the client and calling the physician are standard procedures for safe care.

15. A preoperative nurse is preparing a client for surgery. While preparing the client, the nurse informs the client of what can be expected after surgery and how the client's pain will be controlled. Which stressmanagement technique is being utilized by the nurse?

Relaxation

Guided imagery

Progressive muscle relaxation

Anticipatory guidance

Anticipatory guidance involves preparing the client for an unfamiliar or painful event, such as surgery. By informing the client of what to expect, the nurse reduces the client’s stress regarding the event.

13. Rationale
Correct answer: b.
The nurse is teaching the client to use guided imagery to help the client manage the pain of labor.

Explanation

Anticipatory guidance involves preparing the client for an unfamiliar or painful event, such as surgery. By informing the client of what to expect, the nurse reduces the client’s stress regarding the event.

13. Rationale
Correct answer: b.
The nurse is teaching the client to use guided imagery to help the client manage the pain of labor.

16. The physician orders fluconazole (Diflucan) 100 mg per mouth. The oral solution has 200 mg/5 ml. How many milliliters should the nurse administer?

2.5 ml

5 ml

7.5 ml

10 ml

The ratio of 200 mg per 5 ml yields a dose of 100 mg per 2.5 ml

Explanation

The ratio of 200 mg per 5 ml yields a dose of 100 mg per 2.5 ml

17. When preparing a client for a blood transfusion, the nurse should consider for which of the following? (Check all that apply)

Blood typing and crossmatching must be completed to a blood transfusion

Clients with type A should only receive type A blood, but may receive type O in an emergency

Clients with type B should only receive type B blood, but may receive type A in an emergency

Clients with type AB blood are “universal recipients: and should only receive type AB blood but may, in an emergency, receive all four types of blood

Answers a, b, d are correct. Answer c is incorrect because clients with type B blood may only receive types B and O.

Explanation

Answers a, b, d are correct. Answer c is incorrect because clients with type B blood may only receive types B and O.

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18. When asked why she does not take the prescribed antihypertensive medication, a client states she does not take medication to lower her blood pressure because she cannot swallow pills and they probably would not work anyway because her body was just meant to have a higher blood pressure than other people. This is an example of the use of which defense mechanism?

Sublimation

Rationalization

Reaction formation

Intellectualization

Rationalization is the use of a socially acceptable explanation to justify unpleasant consequences. Sublimation is modification of a socially unacceptable impulse into an acceptable behavior Reaction formation is the exaggerated adoption of opposite behaviors to those that are unpleasant. Intellectualization is the overuse of abstract thinking to minimize painful feelings.

Explanation

Rationalization is the use of a socially acceptable explanation to justify unpleasant consequences. Sublimation is modification of a socially unacceptable impulse into an acceptable behavior Reaction formation is the exaggerated adoption of opposite behaviors to those that are unpleasant. Intellectualization is the overuse of abstract thinking to minimize painful feelings.

19. A hemolytic transfusion reaction is caused by

Fluid volume excess and may be precipitated if blood product is infused too rapidly.

ABO or Rh incompatibility

Recipient antibodies reacting with white cell antigens in the blood component

Bacteria introduced into the component at the time of collection or during processing or storage

Answer b is correct. Answer a is the cause of circulatory overload. Answer c is the cause of febrile transfusion reaction. Answer d is the cause of bacterial transfusion reaction.

Explanation

Answer b is correct. Answer a is the cause of circulatory overload. Answer c is the cause of febrile transfusion reaction. Answer d is the cause of bacterial transfusion reaction.

20. When monitoring clients who are receiving intravenous infusions, the nurse should include which of the following interventions in the plan of care? (Check all that apply)

Monitor all clients receiving intravenous solutions for circulatory overload: assess for rapid heart rate, dyspnea, cough, restlessness, and edema

Monitor all client receiving intravenous fluids for pyrogenic reactions: chills, fever, nausea, and vomiting

Throughout the infusion, monitor client for signs of infiltration and phlebitis

Monitor vital signs every 4 hours or more frequently, noting signs of orthostatic hypotension

Assess jugular vein distention, capillary refill, and heart and lung sounds

All answers are correct. All of these assessments are important when providing care for a client receiving intravenous therapy.

Explanation

All answers are correct. All of these assessments are important when providing care for a client receiving intravenous therapy.

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21. The physician ordered an antibiotic to be administered to the client and the pharmacy prepared the medication in a solution of 50 ml NS. The medication solution should be administered over a 20-minutes period of time. The rate controlling device the nurse will be using has to be programmed in ml/hr. At how many milliliters per hour will the nurse set the rate controller device in order to administer the medication in 20 minutes?

50 ml/hr

100 ml/hr

150 ml/hr

200 ml/hr

Answer c is correct. The solution will have to infuse at a rate of 150 ml/hour to instill 50 ml over the 20 minutes

Explanation

Answer c is correct. The solution will have to infuse at a rate of 150 ml/hour to instill 50 ml over the 20 minutes

22. When providing care for a client with a tunneled central venous access device, the nurse is aware that the catheter is

Inserted through the jugular or subclavian veins, with the catheter tip located in the superior vena cava

Clients with type AB blood are “universal recipients: and should only receive type AB blood but may, in an emergency, receive all four types of blood

Answer b is correct. Answer a is location for a nontunneled central VAD. Answer c is the location for a peripherally inserted central VAD. Answer d is the location for a midline catheter.

Explanation

Answer b is correct. Answer a is location for a nontunneled central VAD. Answer c is the location for a peripherally inserted central VAD. Answer d is the location for a midline catheter.

23. The physician orders ampicillin (Ampicin) 500 mg in 100 ml D5W to infuse over 30 minutes. The nurse sets the rate controller device to deliver the medication over 30 minutes. The rate controller device must be set at how many milliliters per hour?

50 ml/hr

100 ml/hr

150 ml/hr

200 ml/hr

Answer d is correct answer. 100 ml: 30 minutes: X ml: 60 minutes

Explanation

Answer d is correct answer. 100 ml: 30 minutes: X ml: 60 minutes

24. Peripherally administered parenteral nutrition may be

Infused through a peripheral venous catheter and contain 10% dextrose solution with vitamins, minerals, trace elements, and electrolytes added

Infused through a central venous access device and contain greater than 10% dextrose solution with vitamins, minerals, trace elements, electrolytes, and insulin added

Infused through a venous access device and contain greater than 20% dextrose solution with vitamins, trace elements, and insulin added

Infused through a 20-Ga angiocath in the basilica vein and contain 5% dextrose solution and potassium 20 mEq

Answer a is the correct answer. Answer b is describing a centrally administered parenteral nutrition. Answer c contains too high of a concentration of dextrose. d is describing a solution which can be administered via a peripheral venous access device.

Explanation

Answer a is the correct answer. Answer b is describing a centrally administered parenteral nutrition. Answer c contains too high of a concentration of dextrose. d is describing a solution which can be administered via a peripheral venous access device.

25. A widow of 10 days says to the nurse from hospice who has called to invite her to a grieving support group meeting "I feel like I am losing my mind. I see my husband in the house, in the yard, sometimes even at the store. I even find myself talking to him about things that happen." Which is the best response for the nurse to make?

“If these things are still going on in 3 months then you may need to worry about losing your mind but you don’t need to worry now.”

“That is a concern. Tell me more about what is going on with you.”

“I understand you find these events very disturbing but they are normal parts of the grieving process.

“You need to relax; things will improve with time.”

Conversations with a deceased loved one and “seeing” the person in familiar places are normal manifestations of grief. By saying “I understand you find these events very disturbing”, the nurse is acknowledging and accepting the client’s distress as worthy of concern. Response “a” minimizes the client’s concern and is trite in its manner. Response “b” although therapeutic in wording, is incorrect because the events are normal and not a cause for concern. Response “d” gives advice and utilizes a cliché.

Explanation

Conversations with a deceased loved one and “seeing” the person in familiar places are normal manifestations of grief. By saying “I understand you find these events very disturbing”, the nurse is acknowledging and accepting the client’s distress as worthy of concern. Response “a” minimizes the client’s concern and is trite in its manner. Response “b” although therapeutic in wording, is incorrect because the events are normal and not a cause for concern. Response “d” gives advice and utilizes a cliché.

26. Which of the following is correct with regards to the administration of cryoprecipitate?

Administered to clients with a decreased fibrinogen level of less than 100 mg/dl

Administered to clients with hemophilia A (congenital factor VIII deficiency) or von Willebrand’s disease who are bleeding or preparing for an invasive procedure

Administered to clients with hemophilia B (Christmas disease), factor IX deficiency who are bleeding or preparing for an invasive procedure

Administered to clients with a congenital antithrombi III deficiency who have an acute risk of a venous thrombo-embolic event

Answer a is correct. Answer b is incorrect because it describes the conditions for administering Factor VIII. Answer c is incorrect because it describes conditions to
administer Factor IX, d is incorrect because it describes the conditions to administer Antithrombin III

Explanation

Answer a is correct. Answer b is incorrect because it describes the conditions for administering Factor VIII. Answer c is incorrect because it describes conditions to
administer Factor IX, d is incorrect because it describes the conditions to administer Antithrombin III

27. A labor and delivery nurse is caring for a client who is in the second stage of labor. The nurse instructs the client to create and concentrate on a mental image to help her to manage the pain of labor. Which stressmanagement technique is being taught to the client?

Relaxation

Guided imagery

Progressive muscle relaxation

Anticipatory guidance

The nurse is utilizing relaxation to help the client cope with the pain of labor. Relaxation technique utilizes rhythmic breathing, reduced muscle tension, and altered states of consciousness to help clients cope with stressors.

Explanation

The nurse is utilizing relaxation to help the client cope with the pain of labor. Relaxation technique utilizes rhythmic breathing, reduced muscle tension, and altered states of consciousness to help clients cope with stressors.

28. Loss occurs when a valued person, object, or situation is changed or removed. Grief is the painful psychological and physiological response to loss. Which phrase best describes the concept of mourning?

The emotional reaction to loss

The state of grieving

The period of acceptance of loss

The period of depression following a loss

Mourning is the period of acceptance of loss.

Explanation

Mourning is the period of acceptance of loss.

29. The nurse is preparing to insert a peripheral access device in a client's right lower arm. In order to dilate the veins of that extremity, the nurse asks the client to (Check all that apply)

Elevate his hand above his heart

Open and close his fist several times

Lower his arm below the level of his heart

Remain seated or lying in bed with warm compresses on area for 5–10 minutes

Allow the tourniquet to remain in place

These answers are interventions used to dilate veins. Answer a is incorrect because raising the hand above the heart will not dilate the veins.

Explanation

These answers are interventions used to dilate veins. Answer a is incorrect because raising the hand above the heart will not dilate the veins.

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30. A living will provides specific instructions about the kind of health care that an individual desires in particular situations. Some individuals desire that no attempt be made to resuscitate them if they stop breathing or if their heart stops beating. Which statement is true regarding a Do-Not-Resuscitate Order (DNR)?

A DNR states that an individual does not wish to be hospitalized for aggressive treatments

A DNR states that the goal of treatment is a comfortable, dignified death without implementation of life-sustaining measures

A DNR appoints an agent the client trusts to make decisions in the event of incapacity

A DNR must be written by a physician

A Do-not-Resuscitate order must be written by a physician. A Do-Not-Hospitalize order states that an individual does not wish to be hospitalized for aggressive treatments. A Comfort-Measures-Only order states that the goal of treatment is a comfortable, dignified death without implementation of life-sustaining procedures. A durable power of attorney appoints an agent the client trusts to make decisions in the event of incapacity.

Explanation

A Do-not-Resuscitate order must be written by a physician. A Do-Not-Hospitalize order states that an individual does not wish to be hospitalized for aggressive treatments. A Comfort-Measures-Only order states that the goal of treatment is a comfortable, dignified death without implementation of life-sustaining procedures. A durable power of attorney appoints an agent the client trusts to make decisions in the event of incapacity.

31. The client has had a peripheral intravenous device inthe left hand for three days. The nurse's assessment for local complications of intravenous therapy includes which of the following? (Check all that apply)

Phlebitis

Thrombosis

Circulatory overload

Allergic reaction to medications

Infiltration

Answers a, b, e, f, and g are correct. These answers are all local complications. Answers c and d are examples of systemic complications of intravenous therapy.

Explanation

Answers a, b, e, f, and g are correct. These answers are all local complications. Answers c and d are examples of systemic complications of intravenous therapy.

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32. The nurse is preparing to remove a central venous catheter and identifies which of the following interventions as appropriate care: (Check all that apply)

Position the bed in Trendelenburg or flat position, according to agency protocol and client condition

Review the Valsalva maneuver with client

Cleanse the insertion site and surrounding area with alcohol and povidone-iodine (if client is not allergic)

Carefully remove sutures

The nurse should position the bed in Trendelenburg or flat position, according to agency protocol and client condition, to prevent air embolism during the removal of the central venous catheter. Reviewing the Valsalva maneuver with the client is important to prevent the entry of air into the bloodstream. Cleansing the insertion site and surrounding area with alcohol and povidone-iodine helps to reduce the risk of infection. Carefully removing sutures ensures that the catheter is safely removed without causing any harm to the client.

Explanation

The nurse should position the bed in Trendelenburg or flat position, according to agency protocol and client condition, to prevent air embolism during the removal of the central venous catheter. Reviewing the Valsalva maneuver with the client is important to prevent the entry of air into the bloodstream. Cleansing the insertion site and surrounding area with alcohol and povidone-iodine helps to reduce the risk of infection. Carefully removing sutures ensures that the catheter is safely removed without causing any harm to the client.

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33. The physician has ordered a transfusion of packed red blood cells to your client. Which of the following actions should be included to provide safe care during the transfusion? (Check all that apply)

Use only 0.45% normal saline to prime the tubing or dilute the blood products

Assess vital signs before beginning the transfusion, 15 minutes after beginning the infusion, and every 30 minutes to 1 hour during transfusion.

Flush tubing with normal saline to administer intravenous medications throughout transfusion

Place call bell within client’s reach, instruct client to call if experiencing shortness of breath, and request that the nurse aide remain with the client during the first 15 minutes of the transfusion

Monitor client every 30 minutes throughout transfusion for adverse reactions and assessment of vital signs

Answers b and e are correct. These are appropriate interventions to use when administering blood products. Answer a is incorrect because the nurse should only use 0.9% normal saline solution when administering blood products. Answer c is incorrect because the nurse should start an additional intravenous infusion is the client needs intravenous medications throughout the administration of
blood products. Answer d is incorrect because the nurse should remain with the client during the first 15–30 minutes of the transfusion.

Explanation

Answers b and e are correct. These are appropriate interventions to use when administering blood products. Answer a is incorrect because the nurse should only use 0.9% normal saline solution when administering blood products. Answer c is incorrect because the nurse should start an additional intravenous infusion is the client needs intravenous medications throughout the administration of
blood products. Answer d is incorrect because the nurse should remain with the client during the first 15–30 minutes of the transfusion.

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Basic Questions Part 2