Correct Answers & Rationales
Question 1
The client presents to the clinic with a serum cholesterol of 275mg/dL and is placed
on rosuvastatin (Crestor). Which instruction should be given to the client?
Report muscle weakness to the physician.
Allow six months for the drug to take effect.
Take the medication with fruit juice.
Ask the doctor to perform a complete blood count before starting the medication.
Correct Answer
Report muscle weakness to the physician.
The client taking antilipidemics should be encouraged to report muscle weakness
because this is a sign of rhabdomyositis. The medication takes effect within 1 month
of beginning therapy, so answer B is incorrect. The medication should be taken with
water because fruit juice, particularly grapefruit, can decrease the effectiveness,
making answer C incorrect. Liver function studies should be checked before
beginning the medication, not after the fact
Question 2
The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which
information obtained on the visit would cause the most concern? The client:
Likes to play football
Drinks several carbonated drinks per day
Has two sisters with sickle cell tract
Is taking acetaminophen to control pain
Correct Answer
Likes to play football.
The client with osteogenesis imperfecta is at risk for pathological fractures and is
likely to experience these fractures if he participates in contact sports. The client
might experience symptoms of hypoxia if he becomes dehydrated or deoxygenated;
extreme exercise, especially in warm weather, can exacerbate the condition.
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,Question 3
During a home visit, a client with AIDS tells the nurse that he has been exposed to
measles. Which action by the nurse is most appropriate?
Administer an antibiotic
Contact the physician for an order for immune globulin
Administer an antiviral
Tell the client that he should remain in isolation for 2 weeks
Correct Answer
Contact the physician for an order for immune globulin.
Question 4
The nurse is measuring the duration of the client's contractions. Which statement is
true regarding the measurement of the duration of contractions?
Duration is measured by timing from the beginning of one contraction to the
beginning of the next contraction.
Duration is measured by timing from the end of one contraction to the beginning of
the next contraction.
Duration is measured by timing from the beginning of one contraction to the end of
the same contraction.
Duration is measured by timing from the peak of one contraction to the end of the
same contraction.
Correct Answer
Duration is measured by timing from the beginning of one contraction to the
end of the same contraction.
Answer A refers to frequency
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,Question 5
A 6-year-old client is admitted to the unit with a hemoglobin of 6g/dL. The physician
has written an order to transfuse 2 units of whole blood. When discussing the
treatment, the child's mother tells the nurse that she does not believe in having blood
transfusions and that she will not allow her child to have the treatment. What nursing
action is most appropriate?
Ask the mother to leave while the blood transfusion is in progress
Encourage the mother to reconsider
Explain the consequences without treatment
Notify the physician of the mother's refusal
Correct Answer
Notify the physician of the mother's refusal.
If the client’s mother refuses the blood transfusion, the doctor should be notified.
Because the client is a minor, the court might order treatment.
Question 6
The client is having fetal heart rates of 90-110bpm during the contractions. The first
action the nurse should take is:
Reposition the monitor
Turn the client to her left side
Ask the client to ambulate
Prepare the client for delivery
Correct Answer
Turn the client to her left side.
The normal fetal heart rate is 120–160 bpm; 100–110bpm is bradycardia. The first
action would be to turn the client to the left side and apply oxygen.
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, Question 7
The nurse is assigned to care for the client with a Steinmen pin. During pin care, she
notes that the LPN uses sterile gloves and Q-tips to clean the pin. Which action
should the nurse take at this time?
Assisting the LPN with opening sterile packages and peroxide
Telling the LPN that clean gloves are allowed
Telling the LPN that the registered nurse should perform pin care
Asking the LPN to clean the weights and pulleys with peroxide
Correct Answer
Assisting the LPN with opening sterile packages and peroxide.
The nurse is performing the pin care correctly when she uses sterile gloves and Q-
tips. A licensed practical nurse can perform pin care. there is no need to clean the
weights. and the nurse can help with opening the packages but it isn’t required
Question 8
An elderly client with an abdominal surgery is admitted to the unit following surgery.
In anticipation of complications of anesthesia and narcotic administration, the nurse
should:
Administer oxygen via nasal cannula
Have narcan (naloxane) available
Prepare to administer blood products
Prepare to do cardioresuscitation
Correct Answer
Have narcan (naloxane) available.
Narcan is the antidote for narcotic overdose. If hypoxia occurs. the client should
have oxygen administered by mask. not cannula.
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