EXAM 2 NURS 3100
(M6) The nurse follows the nursing process when conducting medication education about
insulin. What will the nurse ask the client to evaluate theclient's knowledge ofinsulin?
A.
"Is your abdomen the best place to injectinsulin?"
B.
"Can you tell me four points you remember about how to take yourinsulin?"
C.
"Can you recognize when you are experiencinghypoglycemia?"
D.
"What questions do you have aboutinsulin?" - ANS-"Can you tell me four points you remember
about how to take yourinsulin?"
Rationale: The nurse is evaluating the effectiveness of medication education by asking the client
for feedback from the education provided. Asking the patient what questions he or she has
about insulin is an assessment question. Asking the client if his or her abdomen is the best
place to inject insulin is an assessment question. Asking the client if he or she can recognize
when he or she is experiencing hypoglycemia is an assessment question.
The nurse assesses the client with diabetes mellitus prior to administering medications. Which
questions are important to ask theclient?
Select all that apply.
A.
"Are you allergic to anymedications?"
B.
"Are you taking any herbal orover-the-counter (OTC)medications?"
C.
"How difficult is it for you to maintain your ideal bodyweight?"
D.
"Will you please tell me about the kind of diet youfollow?"
E.
"What other medications are you currentlytaking?" - ANS-A.
"Are you allergic to anymedications?"
B.
"Are you taking any herbal orover-the-counter (OTC)medications?"
D.
"Will you please tell me about the kind of diet youfollow?"
E.
"What other medications are you currentlytaking?"
,Rationale: Questions about allergies and which medications are being taken are assessment
questions. Questions about normal diet help to assess health management and are pertinent to
drug administration. Ideal body weight is an important question but does not refer specifically to
medication administration.
The healthcare provider has prescribed a nitroglycerine(Nitrodur) patch for the client. The nurse
understands that which of the following is the best outcome for this client as it relates to use of
themedication?
A.
Client will demonstrate correct application of the patch prior to discharge.
B.
Client will be able to identify the expiration date of the medication prior to discharge.
C.
Client will verbalize three side effects of the medication prior to discharge.
D.
Client will state the reason for receiving the medication prior to discharge. - ANS-A.
Client will demonstrate correct application of the patch prior to discharge.
ationale: The overall goal of nursing care related to pharmacotherapy is the safe and effective
R
administration of medication. In thisinstance, the most important aspect of client teaching is that
the client be able to correctly apply the patch. If the patch is not correctlyapplied, the other
issues are irrelevant. The client does not need to identify side effects of the medication in order
to correctly apply the patch. The client does not need to state the reason for the medication in
order to correctly apply the patch. The client does not need to identify the expiration date of the
medication in order to correctly apply the patch.
The client is receiving albuterol(Proventil) for treatment of bronchospasm related to asthma.
What is the primary nursing intervention as it relates to thismedication?
A.
Monitor theclient's serum drug levels.
B.
Monitor the client for relief of bronchospasms.
C.
Monitor the client for nausea and headache.
D.
Provide the client withage-appropriate education about albuterol(Proventil). - ANS-B.
Monitor the client for relief of bronchospasms
Rationale: Monitoring drugeffects, in thiscase, the relief ofbronchospasms, is a primary
intervention that nurses perform. Nausea and headache are expected sideeffects, but
monitoring for these side effects is not part of the primary intervention. Education about
medication is important but is not part of the primary intervention. Monitoring of serum drug
levels for albuterol(Proventil) is not indicated.
,The client is receiving an oral antibiotic as treatment for cellulitis of the lower extremity. The
client's outcome is"Client will state a key point about antibiotic treatment forcellulitis." Which
statement would the nurse evaluate as best indicating this outcome has beenmet?
A.
"I must keep my leg elevated until the swelling goesdown."
B.
"I need to take all the pills even if my leg looksbetter."
C.
"If the swellingcontinues, I can apply an icepack."
D.
"If the pain gets toobad, I can take my prescribed painmedication." - ANS-B.
"I need to take all the pills even if my leg looksbetter."
ationale: Taking all the medication even if the leg looks better is a key point about antibiotic
R
therapy and meets theclient's outcome. Keeping the leg elevated does not address the
outcome for antibiotic treatment. Applying an ice pack does not address the outcome for
antibiotic treatment. Taking pain medication does not address the outcome for antibiotic
treatment.
The healthcare provider has prescribed quetiapine(Seroquel) for the client with chronic auditory
hallucinations. The client has stopped taking the medication. The nurse incorrectly uses the
diagnosis of"noncompliance." In which situation would this diagnosis beappropriate?
A.
The client reported a physical change as the reason for stopping the medication.
B.
The client made an informed decision not to take the medication.
C.
The client was unsure about how to order a refill for the prescription.
D.
The client did not understand why the medication was prescribed. - ANS-B.
The client made an informed decision not to take the medication.
Rationale: Noncompliance assumes that the client has been properly educated about the
medication and has made an informed decision not to take it. A lack of understanding for the
reason the medication was prescribed or being unsure of how to obtain a refill of the
prescription is related to a knowledgedeficit, not noncompliance. Reports of a physical change
since taking the medication would be diagnosed as pertaining to the change.
The nurse is preparing for medication administration to a group of clients. What is the best
overall outcome for theclients?
A.
Clients will receive the best therapeutic outcome from the medications.
B.
Clients will take the medications after receiving medication instruction.
, C.
Clients will state the reason they are receiving the medications.
D.
Clients will experience minimal side effects after taking the medications. - ANS-A.
Clients will receive the best therapeutic outcome from the medications.
Rationale: Outcomes should focus first on the therapeutic outcome of the medications. The fact
that the client takes the medication is not the best overall outcome for the clients. The treatment
of side effects is not the best overall outcome for the clients. Having the clients state the reason
they are receiving the medications is the best overall outcome for the clients.
The nurse is managing care for several clients at a diabetic treatment center. The nurse
understands that which of the following is the priority nursingintervention?
A.
To answer any questions the client may have about themedicine, or any possible side effect of
the medication
B.
To return the client to an optimum level of wellness while limiting adverse effects related to the
client's medical diagnosis
C.
To administer the correct medicine to the correct client at the correct dose and the correct time
via the correct route
D.
To include any cultural or ethnic preferences in the administration of the medication - ANS-B.
To return the client to an optimum level of wellness while limiting adverse effects related to the
client's medical diagnosis
ationale: Interventions are aimed at returning the client to an optimum level of wellness and
R
limiting adverse effects related to theclient's medical diagnosis or condition. The correctclient,
dose, and time refer to the five"rights" of medication administrationand, whileimportant, is not
thebest, overall nursing intervention. Answeringquestions, the client may have is an
appropriate intervention but is not the best overall intervention. While important to include
cultural and ethnicpreferences, this is not the best overall intervention.
What is the most significant role for nurses as defined by state nurse practice acts and by
regulating bodies such as The JointCommission?
A.
Ordering lab tests
B.
Discharging clients
C.
Client teaching
D.
Prescribing medication - ANS-C.
(M6) The nurse follows the nursing process when conducting medication education about
insulin. What will the nurse ask the client to evaluate theclient's knowledge ofinsulin?
A.
"Is your abdomen the best place to injectinsulin?"
B.
"Can you tell me four points you remember about how to take yourinsulin?"
C.
"Can you recognize when you are experiencinghypoglycemia?"
D.
"What questions do you have aboutinsulin?" - ANS-"Can you tell me four points you remember
about how to take yourinsulin?"
Rationale: The nurse is evaluating the effectiveness of medication education by asking the client
for feedback from the education provided. Asking the patient what questions he or she has
about insulin is an assessment question. Asking the client if his or her abdomen is the best
place to inject insulin is an assessment question. Asking the client if he or she can recognize
when he or she is experiencing hypoglycemia is an assessment question.
The nurse assesses the client with diabetes mellitus prior to administering medications. Which
questions are important to ask theclient?
Select all that apply.
A.
"Are you allergic to anymedications?"
B.
"Are you taking any herbal orover-the-counter (OTC)medications?"
C.
"How difficult is it for you to maintain your ideal bodyweight?"
D.
"Will you please tell me about the kind of diet youfollow?"
E.
"What other medications are you currentlytaking?" - ANS-A.
"Are you allergic to anymedications?"
B.
"Are you taking any herbal orover-the-counter (OTC)medications?"
D.
"Will you please tell me about the kind of diet youfollow?"
E.
"What other medications are you currentlytaking?"
,Rationale: Questions about allergies and which medications are being taken are assessment
questions. Questions about normal diet help to assess health management and are pertinent to
drug administration. Ideal body weight is an important question but does not refer specifically to
medication administration.
The healthcare provider has prescribed a nitroglycerine(Nitrodur) patch for the client. The nurse
understands that which of the following is the best outcome for this client as it relates to use of
themedication?
A.
Client will demonstrate correct application of the patch prior to discharge.
B.
Client will be able to identify the expiration date of the medication prior to discharge.
C.
Client will verbalize three side effects of the medication prior to discharge.
D.
Client will state the reason for receiving the medication prior to discharge. - ANS-A.
Client will demonstrate correct application of the patch prior to discharge.
ationale: The overall goal of nursing care related to pharmacotherapy is the safe and effective
R
administration of medication. In thisinstance, the most important aspect of client teaching is that
the client be able to correctly apply the patch. If the patch is not correctlyapplied, the other
issues are irrelevant. The client does not need to identify side effects of the medication in order
to correctly apply the patch. The client does not need to state the reason for the medication in
order to correctly apply the patch. The client does not need to identify the expiration date of the
medication in order to correctly apply the patch.
The client is receiving albuterol(Proventil) for treatment of bronchospasm related to asthma.
What is the primary nursing intervention as it relates to thismedication?
A.
Monitor theclient's serum drug levels.
B.
Monitor the client for relief of bronchospasms.
C.
Monitor the client for nausea and headache.
D.
Provide the client withage-appropriate education about albuterol(Proventil). - ANS-B.
Monitor the client for relief of bronchospasms
Rationale: Monitoring drugeffects, in thiscase, the relief ofbronchospasms, is a primary
intervention that nurses perform. Nausea and headache are expected sideeffects, but
monitoring for these side effects is not part of the primary intervention. Education about
medication is important but is not part of the primary intervention. Monitoring of serum drug
levels for albuterol(Proventil) is not indicated.
,The client is receiving an oral antibiotic as treatment for cellulitis of the lower extremity. The
client's outcome is"Client will state a key point about antibiotic treatment forcellulitis." Which
statement would the nurse evaluate as best indicating this outcome has beenmet?
A.
"I must keep my leg elevated until the swelling goesdown."
B.
"I need to take all the pills even if my leg looksbetter."
C.
"If the swellingcontinues, I can apply an icepack."
D.
"If the pain gets toobad, I can take my prescribed painmedication." - ANS-B.
"I need to take all the pills even if my leg looksbetter."
ationale: Taking all the medication even if the leg looks better is a key point about antibiotic
R
therapy and meets theclient's outcome. Keeping the leg elevated does not address the
outcome for antibiotic treatment. Applying an ice pack does not address the outcome for
antibiotic treatment. Taking pain medication does not address the outcome for antibiotic
treatment.
The healthcare provider has prescribed quetiapine(Seroquel) for the client with chronic auditory
hallucinations. The client has stopped taking the medication. The nurse incorrectly uses the
diagnosis of"noncompliance." In which situation would this diagnosis beappropriate?
A.
The client reported a physical change as the reason for stopping the medication.
B.
The client made an informed decision not to take the medication.
C.
The client was unsure about how to order a refill for the prescription.
D.
The client did not understand why the medication was prescribed. - ANS-B.
The client made an informed decision not to take the medication.
Rationale: Noncompliance assumes that the client has been properly educated about the
medication and has made an informed decision not to take it. A lack of understanding for the
reason the medication was prescribed or being unsure of how to obtain a refill of the
prescription is related to a knowledgedeficit, not noncompliance. Reports of a physical change
since taking the medication would be diagnosed as pertaining to the change.
The nurse is preparing for medication administration to a group of clients. What is the best
overall outcome for theclients?
A.
Clients will receive the best therapeutic outcome from the medications.
B.
Clients will take the medications after receiving medication instruction.
, C.
Clients will state the reason they are receiving the medications.
D.
Clients will experience minimal side effects after taking the medications. - ANS-A.
Clients will receive the best therapeutic outcome from the medications.
Rationale: Outcomes should focus first on the therapeutic outcome of the medications. The fact
that the client takes the medication is not the best overall outcome for the clients. The treatment
of side effects is not the best overall outcome for the clients. Having the clients state the reason
they are receiving the medications is the best overall outcome for the clients.
The nurse is managing care for several clients at a diabetic treatment center. The nurse
understands that which of the following is the priority nursingintervention?
A.
To answer any questions the client may have about themedicine, or any possible side effect of
the medication
B.
To return the client to an optimum level of wellness while limiting adverse effects related to the
client's medical diagnosis
C.
To administer the correct medicine to the correct client at the correct dose and the correct time
via the correct route
D.
To include any cultural or ethnic preferences in the administration of the medication - ANS-B.
To return the client to an optimum level of wellness while limiting adverse effects related to the
client's medical diagnosis
ationale: Interventions are aimed at returning the client to an optimum level of wellness and
R
limiting adverse effects related to theclient's medical diagnosis or condition. The correctclient,
dose, and time refer to the five"rights" of medication administrationand, whileimportant, is not
thebest, overall nursing intervention. Answeringquestions, the client may have is an
appropriate intervention but is not the best overall intervention. While important to include
cultural and ethnicpreferences, this is not the best overall intervention.
What is the most significant role for nurses as defined by state nurse practice acts and by
regulating bodies such as The JointCommission?
A.
Ordering lab tests
B.
Discharging clients
C.
Client teaching
D.
Prescribing medication - ANS-C.
