1.Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse
perform as a priority before administering the medication?
A) Checking the client's blood pressure
B) Checking the client's peripheral pulses
C) Checking the most recent potassium level
D) Checking the client's intake-and-output record for the last 24 hours
ANS: A
Rationale: Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used to treat
hypertension. One common side effect is postural hypotension. Therefore the nurse would check the
client’s blood pressure immediately before administering each dose. Checking the client’s peripheral
pulses, the results of the most recent potassium level, and the intake and output for the previous 24
hours are not specifically associated with this mediation.
2.A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides
instructions to the client about the test. Which statement by the client indicates a need for further
instruction?
A) "The test will take about 30 minutes."
B) "I need to fast for 8 hours before the test."
C) "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the
morning of the test."
D) "I need to take a laxative after the test is completed, because the liquid that I’ll have to drink for
the test can be constipating."
ANS: C
Rationale: An upper GI series involves visualization of the esophagus, duodenum, and upper jejunum by
means of the use of a contrast medium. It involves swallowing a contrast medium (usually barium),
which
is administered in a flavored milkshake. Films are taken at intervals during the test, which takes about 30
minutes. No special preparation is necessary before a GI series, except that NPO status must be
maintained for 8 hours before the test. After an upper GI series, the client is prescribed a laxative to
,hasten elimination of the barium. Barium that remains in the colon may become hard and difficult to
expel, leading to fecal impaction.
3.A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a prescribed
medication is higher than the normal dose. The nurse calls the physician's answering service and is told
that the physician is off for the night and will be available in the morning. The nurse should:
A) Call the nursing supervisor
B) Ask the answering service to contact the on-call physician
C) Withhold the medication until the physician can be reached in the morning
D) Administer the medication but consult the physician when he becomes available
ANS: B
Rationale: The nurse has a duty to protect the client from harm. A nurse who believes that a physician’s
prescription may be in error is responsible for clarifying the prescription before carrying it out. Therefore
the nurse would not administer the medication; instead, the nurse would withhold the medication until
the
dose can be clarified. The nurse would not wait until the next morning to obtain clarification. It is
premature to call the nursing supervisor.
4.An emergency department (ED) nurse is monitoring a client with suspected acute myocardial infarction
(MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the sudden onset of
premature ventricular contractions (PVCs) on the monitor, checks the client's carotid pulse, and
determines that the PVCs are not resulting in perfusion. The appropriate action by the nurse is:
A) Documenting the findings
B) Asking the ED physician to check the client
C) Continuing to monitor the client's cardiac status
D) Informing the client that PVCs are expected after an MI
ANS: B
Feedback: INCORRECT
Rationale: PVCs are a result of increased irritability of ventricular cells. Peripheral pulses may be absent
or
diminished with the PVCs themselves because the decreased stroke volume of the premature beats may
in
,turn decrease peripheral perfusion. Because other rhythms also cause widened QRS complexes, it is
essential that the nurse determine whether the premature beats are resulting in perfusion of the
extremities. This is done by palpating the carotid, brachial, or femoral artery while observing the monitor
for widened complexes or by auscultating for apical heart sounds. In the situation of acute MI, PVCs may
be considered warning dysrhythmias, possibly heralding the onset of ventricular tachycardia or
ventricular
fibrillation. Therefore the nurse would not tell the client that the PVCs are expected. Although the nurse
will continue to monitor the client and document the findings, these are not the most appropriate
actions
of those provided. The most appropriate action would be to ask the ED physician to check the client.
Test-Taking Strategy: Use the process of elimination. Recalling the significance of PVCs after acute MI and
noting the strategic words "not perfusing" will direct you to the correct option. Review the significance
of
PVCs after acute MI if you had difficulty with this question.
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered
collaborative care (6th ed., pp. 747, 748). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Critical Care
Points Earned: 0.0/1.0
Correct Answer(s): B
5.
NPO status is imposed 8 hours before the procedure on a client scheduled to undergo electroconvulsive
therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the client's record and notes
that the client routinely takes an oral antihypertensive medication each morning. The nurse should:
A) Administer the antihypertensive with a small sip of water
B) Withhold the antihypertensive and administer it at bedtime
C) Administer the medication by way of the intravenous (IV) route
D) Hold the antihypertensive and resume its administration on the day after the ECT
, ANS: A
Feedback: INCORRECT
Rationale: General anesthesia is required for ECT, so NPO status is imposed for 6 to 8 hours before
treatment to help prevent aspiration. Exceptions include clients who routinely receive cardiac
medications,
antihypertensive agents, or histamine (H2) blockers, which should be administered several hours before
treatment with a small sip of water. Withholding the antihypertensive and administering it at bedtime
and
withholding the antihypertensive and resuming administration on the day after the ECT are incorrect
actions, because antihypertensives must be administered on time; otherwise, the risk for rebound
hypertension exists. The nurse would not administer a medication by way of a route that has not been
prescribed.
Test-Taking Strategy: Use the process of elimination. Use your knowledge of the principles of medication
administration to help eliminate the option that involves administering the medication by way of a route
other than the prescribed one. Recalling that antihypertensives must be administered on a regular
schedule will assist you in eliminating the options that involve withholding the medication. Review
preprocedure care for the client scheduled for ECT if you had difficulty with this question.
Reference: Stuart, G., & Laraia, M. (2009). Principles and practice of psychiatric nursing (9th ed., p. 539).
St Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Mental Health
Points Earned: 0.0/1.0
Correct Answer(s): A
6.
A client who recently underwent coronary artery bypass graft surgery comes to the physician's office for
a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed. Which response
by the nurse is therapeutic?
A) "Tell me more about what you’re feeling."
perform as a priority before administering the medication?
A) Checking the client's blood pressure
B) Checking the client's peripheral pulses
C) Checking the most recent potassium level
D) Checking the client's intake-and-output record for the last 24 hours
ANS: A
Rationale: Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used to treat
hypertension. One common side effect is postural hypotension. Therefore the nurse would check the
client’s blood pressure immediately before administering each dose. Checking the client’s peripheral
pulses, the results of the most recent potassium level, and the intake and output for the previous 24
hours are not specifically associated with this mediation.
2.A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides
instructions to the client about the test. Which statement by the client indicates a need for further
instruction?
A) "The test will take about 30 minutes."
B) "I need to fast for 8 hours before the test."
C) "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the
morning of the test."
D) "I need to take a laxative after the test is completed, because the liquid that I’ll have to drink for
the test can be constipating."
ANS: C
Rationale: An upper GI series involves visualization of the esophagus, duodenum, and upper jejunum by
means of the use of a contrast medium. It involves swallowing a contrast medium (usually barium),
which
is administered in a flavored milkshake. Films are taken at intervals during the test, which takes about 30
minutes. No special preparation is necessary before a GI series, except that NPO status must be
maintained for 8 hours before the test. After an upper GI series, the client is prescribed a laxative to
,hasten elimination of the barium. Barium that remains in the colon may become hard and difficult to
expel, leading to fecal impaction.
3.A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a prescribed
medication is higher than the normal dose. The nurse calls the physician's answering service and is told
that the physician is off for the night and will be available in the morning. The nurse should:
A) Call the nursing supervisor
B) Ask the answering service to contact the on-call physician
C) Withhold the medication until the physician can be reached in the morning
D) Administer the medication but consult the physician when he becomes available
ANS: B
Rationale: The nurse has a duty to protect the client from harm. A nurse who believes that a physician’s
prescription may be in error is responsible for clarifying the prescription before carrying it out. Therefore
the nurse would not administer the medication; instead, the nurse would withhold the medication until
the
dose can be clarified. The nurse would not wait until the next morning to obtain clarification. It is
premature to call the nursing supervisor.
4.An emergency department (ED) nurse is monitoring a client with suspected acute myocardial infarction
(MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the sudden onset of
premature ventricular contractions (PVCs) on the monitor, checks the client's carotid pulse, and
determines that the PVCs are not resulting in perfusion. The appropriate action by the nurse is:
A) Documenting the findings
B) Asking the ED physician to check the client
C) Continuing to monitor the client's cardiac status
D) Informing the client that PVCs are expected after an MI
ANS: B
Feedback: INCORRECT
Rationale: PVCs are a result of increased irritability of ventricular cells. Peripheral pulses may be absent
or
diminished with the PVCs themselves because the decreased stroke volume of the premature beats may
in
,turn decrease peripheral perfusion. Because other rhythms also cause widened QRS complexes, it is
essential that the nurse determine whether the premature beats are resulting in perfusion of the
extremities. This is done by palpating the carotid, brachial, or femoral artery while observing the monitor
for widened complexes or by auscultating for apical heart sounds. In the situation of acute MI, PVCs may
be considered warning dysrhythmias, possibly heralding the onset of ventricular tachycardia or
ventricular
fibrillation. Therefore the nurse would not tell the client that the PVCs are expected. Although the nurse
will continue to monitor the client and document the findings, these are not the most appropriate
actions
of those provided. The most appropriate action would be to ask the ED physician to check the client.
Test-Taking Strategy: Use the process of elimination. Recalling the significance of PVCs after acute MI and
noting the strategic words "not perfusing" will direct you to the correct option. Review the significance
of
PVCs after acute MI if you had difficulty with this question.
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered
collaborative care (6th ed., pp. 747, 748). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Critical Care
Points Earned: 0.0/1.0
Correct Answer(s): B
5.
NPO status is imposed 8 hours before the procedure on a client scheduled to undergo electroconvulsive
therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the client's record and notes
that the client routinely takes an oral antihypertensive medication each morning. The nurse should:
A) Administer the antihypertensive with a small sip of water
B) Withhold the antihypertensive and administer it at bedtime
C) Administer the medication by way of the intravenous (IV) route
D) Hold the antihypertensive and resume its administration on the day after the ECT
, ANS: A
Feedback: INCORRECT
Rationale: General anesthesia is required for ECT, so NPO status is imposed for 6 to 8 hours before
treatment to help prevent aspiration. Exceptions include clients who routinely receive cardiac
medications,
antihypertensive agents, or histamine (H2) blockers, which should be administered several hours before
treatment with a small sip of water. Withholding the antihypertensive and administering it at bedtime
and
withholding the antihypertensive and resuming administration on the day after the ECT are incorrect
actions, because antihypertensives must be administered on time; otherwise, the risk for rebound
hypertension exists. The nurse would not administer a medication by way of a route that has not been
prescribed.
Test-Taking Strategy: Use the process of elimination. Use your knowledge of the principles of medication
administration to help eliminate the option that involves administering the medication by way of a route
other than the prescribed one. Recalling that antihypertensives must be administered on a regular
schedule will assist you in eliminating the options that involve withholding the medication. Review
preprocedure care for the client scheduled for ECT if you had difficulty with this question.
Reference: Stuart, G., & Laraia, M. (2009). Principles and practice of psychiatric nursing (9th ed., p. 539).
St Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Mental Health
Points Earned: 0.0/1.0
Correct Answer(s): A
6.
A client who recently underwent coronary artery bypass graft surgery comes to the physician's office for
a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed. Which response
by the nurse is therapeutic?
A) "Tell me more about what you’re feeling."
