NURSING DOCX
Questions
1. 1.ID: 383709206
A nurse in a physician's office is reviewing the medical record of a child with a
diagnosis of lactose intolerance. Which of the following findings does the nurse
expect to see documented in the child's record?
A. Fatty stools
B. Episodes of foul-smelling ribbonlike stools
C. Episodes of profuse watery diarrhea and vomiting
D. Episodes of cramping abdominal pain and excessive
flatus Correct
Rationale: Manifestations of lactose intolerance include diarrhea that is frothy
(but not fatty), abdominal distention, cramping abdominal pain, and excessive
flatus. The presence of fatty stools may indicate a problem with bile flow. Foul-
smelling ribbonlike stool is a clinical manifestation of Hirschsprung disease.
Profuse watery diarrhea and vomiting is one clinical manifestation of celiac
disease.
Awarded 1.0 points out of 1.0 possible points.
2. 2.ID: 383706682
Warfarin sodium (Coumadin) is prescribed for a hospitalized client. While
transcribing the physician's prescription, the nurse notes that the client is taking
levothyroxine (Synthroid) to treat hypothyroidism. The nurse calls the physician
to confirm the prescription for warfarin sodium because:
A. Warfarin sodium amplifies the effect of levothyroxine
B. Levothyroxine amplifies the effect of warfarin sodium Correct
C. Warfarin sodium is contraindicated with the use of
levothyroxine
D. A severe allergic reaction may occur if warfarin sodium is
administered concurrently with levothyroxine
Rationale: Levothyroxine accelerates the degradation of vitamin K–dependent
clotting factors. As a result, the effects of warfarin sodium are enhanced. If
warfarin sodium administration is instituted in a client who takes levothyroxine,
the dose of warfarin sodium should be reduced. Warfarin sodium is not
contraindicated in the client who is using levothyroxine. Concurrent
administration does not cause an allergic reaction.
Test-Taking Strategy: Knowledge regarding the medication interactions that may
occur with levothyroxine is required to answer the question. Remember that
levothyroxine accelerates the degradation of vitamin K–dependent clotting
, factors. This will direct you to the correct option. Review considerations in the
administration of levothyroxine and warfarin sodium if you had difficulty with this
question.
Reference: Lehne, R. (2010). Pharmacology for nursing care (7th ed., p. 694). St.
Louis: Saunders.
Cognitive Ability: Understanding
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Awarded 1.0 points out of 1.0 possible points.
3. 3.ID: 383707951
A nurse is caring for a client who is immobilized in skeletal traction after
sustaining a leg fracture in a motor vehicle crash. The nurse notes that the client
is restless, and the client complains of being bored. Which problem does the
nurse identify on the basis of this information?
A. Lack of control
B. Lack of physical mobility
C. Lack of adequate diversional activity Correct
D. Lack of energy to bathe and feed self
Rationale: A characteristic of lack of adequate diversional activity is the
expression of boredom by the client. The question does not identify client
difficulties with coordination, range of motion, or muscle strength, which would
lack of physical mobility. Nor does the question address client’s lack of energy to
perform activities of daily living (bathing/hygiene self-care deficit) or lack of
control.
Awarded 1.0 points out of 1.0 possible points.
4. 4.ID: 383712001
A nurse in a physician's office is conducting a 2-week postpartum assessment of
a client. During abdominal assessment, the nurse is unable to palpate the uterine
fundus. This finding would prompt the nurse to:
A. Document the findings Correct
B. Ask the physician to see the client immediately
C. Ask another nurse to check for the uterine fundus
D. Place the client in the supine position for 5 minutes, then
recheck the abdomen
, Rationale: Involution is the progressive descent of the uterus into the pelvic
cavity after delivery. Twenty-four hours after birth, descent of the fundus begins
at a rate of approximately 1 fingerbreadth, or approximately 1 cm, per day. By
the 10th to 14th day, the fundus is in the pelvic cavity and cannot be palpated
abdominally. Asking the physician to see the client immediately, having another
nurse check for the uterine fundus, and placing the client in the supine position
for 5 minutes and rechecking the abdomen are all incorrect and unnecessary
actions in light of the assessment finding.
Awarded 1.0 points out of 1.0 possible points.
5. 5.ID: 383710084
A nurse is providing instruction about insulin therapy and its administration to an
adolescent client who has just been found to have diabetes mellitus. Which
statement by the client indicates a need for further instruction?
A. "It’s important to rotate injection sites."
B. "I need to store the insulin in a cool, dry place."
C. "I need to keep any unopened bottles of insulin in the
freezer." Correct
D. "I need to check the expiration date on the insulin before I use
it."
Rationale: Insulin is stored in a cool, dry place. It should not be placed in the
freezer or exposed to excess heat or agitation. Injection sites should be rotated to
ensure adequate insulin absorption and to prevent complications of insulin
administration. Once a bottle of insulin has been opened, it is dated and
discarded as recommended. The client should check the expiration date on the
insulin vial before using it.
Awarded 1.0 points out of 1.0 possible points.
6. 6.ID: 383703617
A client with myasthenia gravis is taking neostigmine bromide (Prostigmin). The
nurse determines that the client is gaining a therapeutic effect from the
medication after noting:
A. Bradycardia
B. Increased heart rate
C. Decreased blood pressure
D. Improved swallowing function Correct
, Rationale: Neostigmine bromide, a cholinergic medication that prevents the
destruction of acetylcholine, is used to treat myanthenia gravis. The nurse would
monitor the client for a therapeutic response, which includes increased muscle
strength, an easing of fatigue, and improved chewing and swallowing function.
Bradycardia, increased heart rate, and decreased blood pressure are signs of an
adverse reaction to the medication.
Awarded 1.0 points out of 1.0 possible points.
7. 7.ID: 383703635
A nurse is assessing a client with hepatitis for signs of jaundice. Which area does
the nurse check, knowing that it will provide the best data regarding the
presence of jaundice?
A. Lips
B. Soles
C. Palms
D. Mucous membranes Correct
Rationale: Assessment of the skin, sclera, and mucous membranes provides the
best data regarding the presence of jaundice. The color of the lips provides data
regarding the presence of cyanosis. Although assessment of the skin provides
adequate data regarding jaundice, the soles and palms are not the best areas of
skin for assessment.
Awarded 1.0 points out of 1.0 possible points.
8. 8.ID: 383712466
A client with advanced chronic renal failure (CRF) and oliguria has been taught
about sodium and potassium restriction between dialysis treatments. The nurse
determines that the client understands this restriction if the client states that it is
acceptable to use:
A. Salt substitutes
B. Herbs and spices Correct
C. Salt with cooking only
D. Processed foods as desired
Rationale: Most clients with renal failure retain sodium. The client with renal
failure is instructed not to add salt at the table or during food preparation. Herbs
and spices may be used as an alternative to salt to enhance the flavor of food.
The client with advanced CRF is instructed to limit potassium intake. The client is
also instructed to avoid salt substitutes, many of which are composed of
potassium chloride, if oliguria is present. Processed foods are discouraged
because they are high in sodium.
Questions
1. 1.ID: 383709206
A nurse in a physician's office is reviewing the medical record of a child with a
diagnosis of lactose intolerance. Which of the following findings does the nurse
expect to see documented in the child's record?
A. Fatty stools
B. Episodes of foul-smelling ribbonlike stools
C. Episodes of profuse watery diarrhea and vomiting
D. Episodes of cramping abdominal pain and excessive
flatus Correct
Rationale: Manifestations of lactose intolerance include diarrhea that is frothy
(but not fatty), abdominal distention, cramping abdominal pain, and excessive
flatus. The presence of fatty stools may indicate a problem with bile flow. Foul-
smelling ribbonlike stool is a clinical manifestation of Hirschsprung disease.
Profuse watery diarrhea and vomiting is one clinical manifestation of celiac
disease.
Awarded 1.0 points out of 1.0 possible points.
2. 2.ID: 383706682
Warfarin sodium (Coumadin) is prescribed for a hospitalized client. While
transcribing the physician's prescription, the nurse notes that the client is taking
levothyroxine (Synthroid) to treat hypothyroidism. The nurse calls the physician
to confirm the prescription for warfarin sodium because:
A. Warfarin sodium amplifies the effect of levothyroxine
B. Levothyroxine amplifies the effect of warfarin sodium Correct
C. Warfarin sodium is contraindicated with the use of
levothyroxine
D. A severe allergic reaction may occur if warfarin sodium is
administered concurrently with levothyroxine
Rationale: Levothyroxine accelerates the degradation of vitamin K–dependent
clotting factors. As a result, the effects of warfarin sodium are enhanced. If
warfarin sodium administration is instituted in a client who takes levothyroxine,
the dose of warfarin sodium should be reduced. Warfarin sodium is not
contraindicated in the client who is using levothyroxine. Concurrent
administration does not cause an allergic reaction.
Test-Taking Strategy: Knowledge regarding the medication interactions that may
occur with levothyroxine is required to answer the question. Remember that
levothyroxine accelerates the degradation of vitamin K–dependent clotting
, factors. This will direct you to the correct option. Review considerations in the
administration of levothyroxine and warfarin sodium if you had difficulty with this
question.
Reference: Lehne, R. (2010). Pharmacology for nursing care (7th ed., p. 694). St.
Louis: Saunders.
Cognitive Ability: Understanding
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Awarded 1.0 points out of 1.0 possible points.
3. 3.ID: 383707951
A nurse is caring for a client who is immobilized in skeletal traction after
sustaining a leg fracture in a motor vehicle crash. The nurse notes that the client
is restless, and the client complains of being bored. Which problem does the
nurse identify on the basis of this information?
A. Lack of control
B. Lack of physical mobility
C. Lack of adequate diversional activity Correct
D. Lack of energy to bathe and feed self
Rationale: A characteristic of lack of adequate diversional activity is the
expression of boredom by the client. The question does not identify client
difficulties with coordination, range of motion, or muscle strength, which would
lack of physical mobility. Nor does the question address client’s lack of energy to
perform activities of daily living (bathing/hygiene self-care deficit) or lack of
control.
Awarded 1.0 points out of 1.0 possible points.
4. 4.ID: 383712001
A nurse in a physician's office is conducting a 2-week postpartum assessment of
a client. During abdominal assessment, the nurse is unable to palpate the uterine
fundus. This finding would prompt the nurse to:
A. Document the findings Correct
B. Ask the physician to see the client immediately
C. Ask another nurse to check for the uterine fundus
D. Place the client in the supine position for 5 minutes, then
recheck the abdomen
, Rationale: Involution is the progressive descent of the uterus into the pelvic
cavity after delivery. Twenty-four hours after birth, descent of the fundus begins
at a rate of approximately 1 fingerbreadth, or approximately 1 cm, per day. By
the 10th to 14th day, the fundus is in the pelvic cavity and cannot be palpated
abdominally. Asking the physician to see the client immediately, having another
nurse check for the uterine fundus, and placing the client in the supine position
for 5 minutes and rechecking the abdomen are all incorrect and unnecessary
actions in light of the assessment finding.
Awarded 1.0 points out of 1.0 possible points.
5. 5.ID: 383710084
A nurse is providing instruction about insulin therapy and its administration to an
adolescent client who has just been found to have diabetes mellitus. Which
statement by the client indicates a need for further instruction?
A. "It’s important to rotate injection sites."
B. "I need to store the insulin in a cool, dry place."
C. "I need to keep any unopened bottles of insulin in the
freezer." Correct
D. "I need to check the expiration date on the insulin before I use
it."
Rationale: Insulin is stored in a cool, dry place. It should not be placed in the
freezer or exposed to excess heat or agitation. Injection sites should be rotated to
ensure adequate insulin absorption and to prevent complications of insulin
administration. Once a bottle of insulin has been opened, it is dated and
discarded as recommended. The client should check the expiration date on the
insulin vial before using it.
Awarded 1.0 points out of 1.0 possible points.
6. 6.ID: 383703617
A client with myasthenia gravis is taking neostigmine bromide (Prostigmin). The
nurse determines that the client is gaining a therapeutic effect from the
medication after noting:
A. Bradycardia
B. Increased heart rate
C. Decreased blood pressure
D. Improved swallowing function Correct
, Rationale: Neostigmine bromide, a cholinergic medication that prevents the
destruction of acetylcholine, is used to treat myanthenia gravis. The nurse would
monitor the client for a therapeutic response, which includes increased muscle
strength, an easing of fatigue, and improved chewing and swallowing function.
Bradycardia, increased heart rate, and decreased blood pressure are signs of an
adverse reaction to the medication.
Awarded 1.0 points out of 1.0 possible points.
7. 7.ID: 383703635
A nurse is assessing a client with hepatitis for signs of jaundice. Which area does
the nurse check, knowing that it will provide the best data regarding the
presence of jaundice?
A. Lips
B. Soles
C. Palms
D. Mucous membranes Correct
Rationale: Assessment of the skin, sclera, and mucous membranes provides the
best data regarding the presence of jaundice. The color of the lips provides data
regarding the presence of cyanosis. Although assessment of the skin provides
adequate data regarding jaundice, the soles and palms are not the best areas of
skin for assessment.
Awarded 1.0 points out of 1.0 possible points.
8. 8.ID: 383712466
A client with advanced chronic renal failure (CRF) and oliguria has been taught
about sodium and potassium restriction between dialysis treatments. The nurse
determines that the client understands this restriction if the client states that it is
acceptable to use:
A. Salt substitutes
B. Herbs and spices Correct
C. Salt with cooking only
D. Processed foods as desired
Rationale: Most clients with renal failure retain sodium. The client with renal
failure is instructed not to add salt at the table or during food preparation. Herbs
and spices may be used as an alternative to salt to enhance the flavor of food.
The client with advanced CRF is instructed to limit potassium intake. The client is
also instructed to avoid salt substitutes, many of which are composed of
potassium chloride, if oliguria is present. Processed foods are discouraged
because they are high in sodium.
