NURSIN
Final Study Guide
1. Anticonvulsant medication administration.
A client is receiving Keppra to control seizures. What statement by the client to the nurse
indicates an understanding regarding administration of this medication?
a. “I need to take more of my Keppra when I am having a stressful day.”
b. “I will be able to stop taking this medicine in about a year.”
c. “I will probably need to take this medicine all my life.”
d. “I will never have another seizure if I take this medicine.”
A patient has been taking phenytoin (Dilantin) for 2 years. Which action will the nurse take when evaluating for adverse effects
of the medication?
a. Inspect the oral mucosa.
b. Listen to the lung sounds.
c. Auscultate the bowel tones.
d. Check pupil reaction to light.
Phenytoin can cause gingival hyperplasia, but does not affect bowel tones, lung sounds, or pupil reaction to light.
A client with a history of seizures is scheduled for an arteriogram at 10:00AM and is to have
nothing my mouth before the test. The client is scheduled to receive a daily prescribed dose of
Dilantin at 9AM. What action should the nurse take regarding this situation?
a. Omit the 0900 dose.
b. Give the same dosage of the drug rectally.
c. Ask the physician if the drug can be given IV.
d. Administer the drug with 30ml of water at 0900.
2. Documenting seizures
While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic
seizure. Which action should the nurse take?
a. Insert an oral airway during the seizure to maintain a patent airway.
b
. Restrain the patient’s arms and legs to prevent injury during the seizure.
c. Time and observe and record the details of the seizure and postictal state.
d
. Avoid touching the patient to prevent further nervous system stimulation.
Because the diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the
length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure
are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure.
3. Stopping vs controlling seizures.
Which prescribed intervention will the nurse implement first for a patient in the emergency department who is experiencing
continuous tonic-clonic seizures?
a. Give Keppra 750 mg IVPB.
b
. Monitor level of consciousness (LOC).
c. Obtain computed tomography (CT) scan.
d
. Administer lorazepam (Ativan) 4 mg IV.
, To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the
benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary.
Phenytoin will also be administered, but it is not rapidly acting. Patients who are experiencing tonic-clonic seizures are
nonresponsive, although the nurse should assess LOC after the seizure.
4. Managing tonic-clonic seizures
A high school teacher who has just been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse,
“I cannot teach anymore, it will be too upsetting if I have a seizure at work.” Which response by the nurse is best?
a. “You might benefit from some psychologic counseling.”
b
. “Epilepsy usually can be well controlled with medications.”
c. “You will want to contact the Epilepsy Foundation for assistance.”
d
. “The Department of Vocational Rehabilitation can help with work retraining.”
The nurse should inform the patient that most patients with seizure disorders are controlled with medication. The other
information may be necessary if the seizures persist after treatment with antiseizure medications is implemented.
5. Seizure patient education
The home health registered nurse (RN) is planning care for a patient with a seizure disorder related to a recent head injury.
Which nursing action can be delegated to a licensed practical/vocational nurse (LPN/LVN)?
a. Make referrals to appropriate community agencies.
b
. Place medications in the home medication organizer.
c. Teach the patient and family how to manage seizures.
d
. Assess for use of medications that may precipitate seizures.
27-year-old patient who has been treated for status epilepticus in the emergency department will be transferred to the medical
nursing unit. Which equipment should the nurse have available in the patient’s assigned room (select all that apply)?
a. Side-rail pads
b. Tongue blade
c. Oxygen mask
d. Suction tubing
The nurse observes a patient ambulating in the hospital hall when the patient’s arms and legs suddenly jerk and the patient falls
to the floor. The nurse will first
a. assess the patient for a possible head injury.
b
. give the scheduled dose of divalproex (Depakote).
c. document the timing and description of the seizure.
d
. notify the patient’s health care provider about the seizure.
The patient who has had a myoclonic seizure and fall is at risk for head injury and should first be evaluated and treated
for this possible complication. Documentation of the seizure, notification of the seizure, and administration of
antiseizure medications are also appropriate actions, but the initial action should be assessment for injury.
, 1. Burn fluid replacement
A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to
be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what
rate should the nurse infuse the IV fluids?
a. 350 mL/hour
b
. 523 mL/hour
c. 938 mL/hour
d
. 1250 mL/hour
Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and the other half over the next 16
hours. In this case, the patient should receive half of the initial rate, or 938 mL/hr.
2. Burn pain control
The nurse is reviewing the medication administration record (MAR) on a patient with partial-thickness burns. Which
medication is best for the nurse to administer before scheduled wound debridement?
a. Ketorolac (Toradol)
b
. Lorazepam (Ativan)
c. Gabapentin (Neurontin)
d
. Hydromorphone (Dilaudid)
Opioid pain medications are the best choice for pain control. The other medications are used as adjuvants to enhance the effects
of opioids.
3. Hydration assessment for acute burn patients
The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically
increased. Which action by the nurse would best ensure adequate kidney function?
a. Continue to monitor the urine output.
b
. Monitor for increased white blood cells (WBCs).
c. Assess that blisters and edema have subsided.
d
. Prepare the patient for discharge from the burn unit.
The patient’s urine output indicates that the patient is entering the acute phase of the burn injury and moving on from
the emergent stage. At the end of the emergent phase, capillary permeability normalizes and the patient begins to
diuresis large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer
in some patients. Blisters and edema begin to resolve, but this process requires more time. White blood cells may
increase or decrease, based on the patient’s immune status and any infectious processes. The WBC count does not
indicate kidney function. The patient will likely remain in the burn unit during the acute stage of burn injury.
During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving
adequate fluid infusion?
a. Check skin turgor.
b
. Monitor daily weight.
Final Study Guide
1. Anticonvulsant medication administration.
A client is receiving Keppra to control seizures. What statement by the client to the nurse
indicates an understanding regarding administration of this medication?
a. “I need to take more of my Keppra when I am having a stressful day.”
b. “I will be able to stop taking this medicine in about a year.”
c. “I will probably need to take this medicine all my life.”
d. “I will never have another seizure if I take this medicine.”
A patient has been taking phenytoin (Dilantin) for 2 years. Which action will the nurse take when evaluating for adverse effects
of the medication?
a. Inspect the oral mucosa.
b. Listen to the lung sounds.
c. Auscultate the bowel tones.
d. Check pupil reaction to light.
Phenytoin can cause gingival hyperplasia, but does not affect bowel tones, lung sounds, or pupil reaction to light.
A client with a history of seizures is scheduled for an arteriogram at 10:00AM and is to have
nothing my mouth before the test. The client is scheduled to receive a daily prescribed dose of
Dilantin at 9AM. What action should the nurse take regarding this situation?
a. Omit the 0900 dose.
b. Give the same dosage of the drug rectally.
c. Ask the physician if the drug can be given IV.
d. Administer the drug with 30ml of water at 0900.
2. Documenting seizures
While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic
seizure. Which action should the nurse take?
a. Insert an oral airway during the seizure to maintain a patent airway.
b
. Restrain the patient’s arms and legs to prevent injury during the seizure.
c. Time and observe and record the details of the seizure and postictal state.
d
. Avoid touching the patient to prevent further nervous system stimulation.
Because the diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the
length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure
are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure.
3. Stopping vs controlling seizures.
Which prescribed intervention will the nurse implement first for a patient in the emergency department who is experiencing
continuous tonic-clonic seizures?
a. Give Keppra 750 mg IVPB.
b
. Monitor level of consciousness (LOC).
c. Obtain computed tomography (CT) scan.
d
. Administer lorazepam (Ativan) 4 mg IV.
, To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the
benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary.
Phenytoin will also be administered, but it is not rapidly acting. Patients who are experiencing tonic-clonic seizures are
nonresponsive, although the nurse should assess LOC after the seizure.
4. Managing tonic-clonic seizures
A high school teacher who has just been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse,
“I cannot teach anymore, it will be too upsetting if I have a seizure at work.” Which response by the nurse is best?
a. “You might benefit from some psychologic counseling.”
b
. “Epilepsy usually can be well controlled with medications.”
c. “You will want to contact the Epilepsy Foundation for assistance.”
d
. “The Department of Vocational Rehabilitation can help with work retraining.”
The nurse should inform the patient that most patients with seizure disorders are controlled with medication. The other
information may be necessary if the seizures persist after treatment with antiseizure medications is implemented.
5. Seizure patient education
The home health registered nurse (RN) is planning care for a patient with a seizure disorder related to a recent head injury.
Which nursing action can be delegated to a licensed practical/vocational nurse (LPN/LVN)?
a. Make referrals to appropriate community agencies.
b
. Place medications in the home medication organizer.
c. Teach the patient and family how to manage seizures.
d
. Assess for use of medications that may precipitate seizures.
27-year-old patient who has been treated for status epilepticus in the emergency department will be transferred to the medical
nursing unit. Which equipment should the nurse have available in the patient’s assigned room (select all that apply)?
a. Side-rail pads
b. Tongue blade
c. Oxygen mask
d. Suction tubing
The nurse observes a patient ambulating in the hospital hall when the patient’s arms and legs suddenly jerk and the patient falls
to the floor. The nurse will first
a. assess the patient for a possible head injury.
b
. give the scheduled dose of divalproex (Depakote).
c. document the timing and description of the seizure.
d
. notify the patient’s health care provider about the seizure.
The patient who has had a myoclonic seizure and fall is at risk for head injury and should first be evaluated and treated
for this possible complication. Documentation of the seizure, notification of the seizure, and administration of
antiseizure medications are also appropriate actions, but the initial action should be assessment for injury.
, 1. Burn fluid replacement
A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to
be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what
rate should the nurse infuse the IV fluids?
a. 350 mL/hour
b
. 523 mL/hour
c. 938 mL/hour
d
. 1250 mL/hour
Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and the other half over the next 16
hours. In this case, the patient should receive half of the initial rate, or 938 mL/hr.
2. Burn pain control
The nurse is reviewing the medication administration record (MAR) on a patient with partial-thickness burns. Which
medication is best for the nurse to administer before scheduled wound debridement?
a. Ketorolac (Toradol)
b
. Lorazepam (Ativan)
c. Gabapentin (Neurontin)
d
. Hydromorphone (Dilaudid)
Opioid pain medications are the best choice for pain control. The other medications are used as adjuvants to enhance the effects
of opioids.
3. Hydration assessment for acute burn patients
The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically
increased. Which action by the nurse would best ensure adequate kidney function?
a. Continue to monitor the urine output.
b
. Monitor for increased white blood cells (WBCs).
c. Assess that blisters and edema have subsided.
d
. Prepare the patient for discharge from the burn unit.
The patient’s urine output indicates that the patient is entering the acute phase of the burn injury and moving on from
the emergent stage. At the end of the emergent phase, capillary permeability normalizes and the patient begins to
diuresis large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer
in some patients. Blisters and edema begin to resolve, but this process requires more time. White blood cells may
increase or decrease, based on the patient’s immune status and any infectious processes. The WBC count does not
indicate kidney function. The patient will likely remain in the burn unit during the acute stage of burn injury.
During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving
adequate fluid infusion?
a. Check skin turgor.
b
. Monitor daily weight.
