, Chapter 01: The Nursing Process and Drug Therapy
MULTIPLE CHOICE
1. During an intravenous (IV) infusion of amphotericin B, a patient develops tingling
K K K
and numbnessin his toes and fingers. What will the nurse do first? K
a. Discontinue the infusion immediately.
b. Reduce the infusion rate gradually until the adverse effects
K K
subside.
c. Administer the medication by rapid IV infusion to reduce
K K
these effects.
d. Nothing; these are expected side effects of this medication.
ANS: A
Once the intravenous infusion of amphotericin B has begun, vital signs must be m
K K K
onitored frequently to assess for adverse reactions such as cardiac dysrhythmias,v
K
isual disturbances, paresthesias (numbness or tingling of the hands or feet), respir
K
atory difficulty, pain, fever, chills,and nausea. If these adverse effects or a severe
K
reaction occur, the infusion must be discontinued(while the patient is closely mon
K
itored) and the prescriber contacted. The other options are incorrect.
K
DIF: COGNITIVE LEVEL: Applying
(Application)TOP: NURSINGPROCESS
: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
The nurse is writing a nursing diagnosis for a plan of care for a patient who
has been newlydiagnosed with type 2 diabetes. Which statement reflects th
ecorrect format for a nursing diagnosis?
a. Anxiety
b. Anxiety related to new drug therapy
c. Anxiety related to anxious feelings about drug therapy, as evidenced by
?
, statements
such as “I’m upset about having to test my blood sugars.”
d. Anxiety related to new drug therapy, as evidenced by statements such as
“I’m
upset about having to test my blood sugars.”
ANS: D
Formulation of nursing diagnoses is usually a three-
step process. “Anxiety” ismissing the
“related to” and “as evidenced by” portions of defining characteristics. “Anxiety r
elated to new drug therapy” is missing the “as evidenced by” portion of definingch
aracteristics. The statementbeginning “Anxiety related to anxious feelings” is inco
rrect because the “related to” section is simply a restatement of the problem “anxie
ty,” not a separate factor related to the response.
DIF: COGNITIVE LEVEL: Understanding
?
, (Comprehension)TOP: NURSING PROCESS:
Nursing Diagnosis
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
2. The patient is to receive oral guaifenesin (Mucinex) twice a day. Today, the nurs
ewas busy andgave the medication 2 hours after the scheduled dose was due. Wh
K
attype of problem does this represent?
a. “Right time”
b. “Right dose”
c. “Right route”
d. “Right
medication”
ANS: A
“Right time” is correct because the medication was given more than 30 m
K
inutes after the scheduled dose was due. “Dose” is incorrect because thed
K
ose is not related to the time the
K K K
medication administration is scheduled. “Route” is incorrect because the route
K
is not affected.“Medication” is incorrect because the medication ordered will
K
not change.
K
DIF: COGNITIVE LEVEL: Applying
(Application)TOP: NURSINGPROCESS
: Implementation
MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control
3. The nurse has been monitoring the patient’s progress on a new drug regimen
since the first doseand documenting the patient’s therapeutic response to the
?
MULTIPLE CHOICE
1. During an intravenous (IV) infusion of amphotericin B, a patient develops tingling
K K K
and numbnessin his toes and fingers. What will the nurse do first? K
a. Discontinue the infusion immediately.
b. Reduce the infusion rate gradually until the adverse effects
K K
subside.
c. Administer the medication by rapid IV infusion to reduce
K K
these effects.
d. Nothing; these are expected side effects of this medication.
ANS: A
Once the intravenous infusion of amphotericin B has begun, vital signs must be m
K K K
onitored frequently to assess for adverse reactions such as cardiac dysrhythmias,v
K
isual disturbances, paresthesias (numbness or tingling of the hands or feet), respir
K
atory difficulty, pain, fever, chills,and nausea. If these adverse effects or a severe
K
reaction occur, the infusion must be discontinued(while the patient is closely mon
K
itored) and the prescriber contacted. The other options are incorrect.
K
DIF: COGNITIVE LEVEL: Applying
(Application)TOP: NURSINGPROCESS
: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
The nurse is writing a nursing diagnosis for a plan of care for a patient who
has been newlydiagnosed with type 2 diabetes. Which statement reflects th
ecorrect format for a nursing diagnosis?
a. Anxiety
b. Anxiety related to new drug therapy
c. Anxiety related to anxious feelings about drug therapy, as evidenced by
?
, statements
such as “I’m upset about having to test my blood sugars.”
d. Anxiety related to new drug therapy, as evidenced by statements such as
“I’m
upset about having to test my blood sugars.”
ANS: D
Formulation of nursing diagnoses is usually a three-
step process. “Anxiety” ismissing the
“related to” and “as evidenced by” portions of defining characteristics. “Anxiety r
elated to new drug therapy” is missing the “as evidenced by” portion of definingch
aracteristics. The statementbeginning “Anxiety related to anxious feelings” is inco
rrect because the “related to” section is simply a restatement of the problem “anxie
ty,” not a separate factor related to the response.
DIF: COGNITIVE LEVEL: Understanding
?
, (Comprehension)TOP: NURSING PROCESS:
Nursing Diagnosis
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
2. The patient is to receive oral guaifenesin (Mucinex) twice a day. Today, the nurs
ewas busy andgave the medication 2 hours after the scheduled dose was due. Wh
K
attype of problem does this represent?
a. “Right time”
b. “Right dose”
c. “Right route”
d. “Right
medication”
ANS: A
“Right time” is correct because the medication was given more than 30 m
K
inutes after the scheduled dose was due. “Dose” is incorrect because thed
K
ose is not related to the time the
K K K
medication administration is scheduled. “Route” is incorrect because the route
K
is not affected.“Medication” is incorrect because the medication ordered will
K
not change.
K
DIF: COGNITIVE LEVEL: Applying
(Application)TOP: NURSINGPROCESS
: Implementation
MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control
3. The nurse has been monitoring the patient’s progress on a new drug regimen
since the first doseand documenting the patient’s therapeutic response to the
?
