Module 8
Questions
1. 1.ID: 383694396
A physician’s prescription reads, “Phenytoin (Dilantin) 0.1 g by mouth twice daily.”
The medication label
... [Show More] indicates that the bottle contains 100-mg capsules. How
many capsules does the nurse prepare for administration of one dose?
Correct
Correct Responses: "1"
Rationale: Convert 0.1 g to milligrams: 1000 mg = 1 g; therefore 0.1 g =
100 mg. Next use the medication
formula:
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IMG src="/objects/NCLEX/silvestri1e_v1/mod_08/images/exam/M08Q044E02.gif"
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Test-Taking
Strategy: First, convert 0.1 g to mg. Next. follow the formula for the calculation
of the correct dose. Recheck your work and ensure that the answer makes sense. If
you had difficulty with this question, review medication calculation
problems.
Level
of Cognitive Ability:
Applying
<
i>
Client
Needs: Physiological
Integrity
<
i>
Integrat
ed Process: Nursing
Process/Implementation
Content Area: Medication
Calculations
Refe
rence: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed.,
pp. 695-699). St. Louis: Mosby.
Awarded 1.0 out of 1.0 possible points.
2. 2.ID: 383694320A client has a prescription for short-term therapy with enoxaparin (Lovenox). The
nurse explains to the client that this medication is being prescribed to:
A. Prevent pain
B. Relieve back spasms
C. Increase the client’s energy level
D. Reduce the risk of deep vein thrombosis Correct
Rationale: Enoxaparin is an anticoagulant that is administered to prevent deep
vein thrombosis and thromboembolism in selected at-risk clients. It is not used to
prevent pain, relieve back spasms, or increase the energy level.
Test-Taking Strategy: To answer this question accurately, it is necessary to be
familiar with this medication and its intended effects. Recalling that this medication
is an anticoagulant will direct you to the correct option. Review the action of this
medication if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Reference: Lehne, R. (2010). Pharmacology for nursing care (7th ed., p. 602). St.
Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
3. 3.ID: 383695637
A client receiving parenteral nutrition (PN) requires fat emulsion (lipids), which will
be piggybacked to the PN solution. On obtaining a bottle of fat emulsion, the nurse
notes that fat globules are floating at the top of the solution. Which of these
actions should the nurse take?
A. Shaking the bottle vigorously
B. Requesting a new bottle from the pharmacy Correct
C. Rotating the bottle gently back and forth to mix the globules
D. Running the bottle under warm water until the globules disappear
Rationale: The nurse should not hang a fat emulsion that contains visible fat
globules. Another bottle of solution should be obtained and used in its place. When
PN is combined with fat emulsion, the solution should not be used if there is a
visible “ring” noted in the container of solution. The actions in the other options are
incorrect.
Test-Taking Strategy: Remember that options that are comparable or alike are not
likely to be correct. With this in mind, eliminate rotating the bag and shaking thebottle first. To select from the remaining options, think about the significance of
seeing fat globules in the solution and imagine the potential adverse effect of fat
globules in the client’s bloodstream. This will direct you to the correct option.
Review the procedures for administration of fat emulsion if you had difficulty with
this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Parenteral Nutrition
Reference: Gahart, B., & Nazareno, A. (2010). 2010 intravenous medications (26th
ed., p. 576). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
4. 4.ID: 383695130
Risperidone (Risperdal) is prescribed for a client with a diagnosis of schizophrenia.
Which laboratory study does the nurse expect to see among the physician’s
prescriptions?
A. Platelet count Correct
B. Creatinine level
C. Sedimentation rate
D. Red blood cell count
Rationale: Baseline assessment includes renal and liver function parameters.
Risperidone is used with caution — often at a reduced dosage — in clients with
renal or hepatic impairment, clients with underlying cardiovascular disorders, and
in older or debilitated clients. The laboratory tests identified in the other options
are not necessary.
Test-Taking Strategy: Use the process of elimination. Recalling that this medication
is used with caution in clients with renal or hepatic failure will direct you to the
correct option. Review this medication if you had difficulty with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: PharmacologyReference: Kee, J., Hayes, E., & McCuistion, L. (2009). Pharmacology: A nursing
process approach (6th ed., p. 402). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
5. 5.ID: 383695122
The serum theophylline level of a client who is taking the medication (Theo-24) is
16 mcg/mL. On the basis of this result, the nurse will initially:
A. Document the normal value on the chart Correct
B. Call the healthcare provider immediately
C. Call the rapid response team to help with the emergency
D. Call the pharmacy to alert the pharmacist regarding the client’s
theophylline level
Rationale: The normal therapeutic range for theophylline is 10 to 20 mcg/mL. A
level above 20 mcg/mL is considered toxic. A value of 16 mcg/mL is within the
therapeutic range.
Test-Taking Strategy: Specific knowledge regarding the therapeutic range for this
medication is necessary to answer this question. Recalling that the normal
therapeutic range for theophylline levels is 10 to 20 mcg/mL will direct you to the
correct option. Review the nursing considerations related to this medication if you
had difficulty with this question.
Level of Cognitive Ability: Understanding
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Reference: Kee, J., Hayes, E., & McCuistion, L. (2009). Pharmacology: A nursing
process approach (6th ed., p. 608). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
6. 6.ID: 383695614
A nurse has obtained a unit of blood from the blood bank and properly checked the
blood bag with another nurse. Which of the following parameters does the nurse
assess just before hanging the transfusion?
A. Skin color
B. Vital signs Correct
C. Latest platelet count
D. Urine output over the last 24 hours
Rationale: A change in vital signs may indicate that a transfusion reaction is
occurring. This is why the nurse assesses vital signs before the procedure, every
15 minutes for the first half-hour, and every half-hour thereafter. The other optionsdo not need to be assessed just before the start of a transfusion. The nurse should
be aware of fluid volume status, as well as weight. to help identify fluid volume
overload, but this is not the priority before start of a blood infusion.
Test-Taking Strategy: The strategic words in the question are “just before,” which
tell you that the correct option must be assessed for possible comparison during
the transfusion. Use the ABCs (airway, breathing, and circulation) to find the
correct option. Review the procedure for administering blood if you had difficulty
with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Blood administration
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing:
Patient-centered collaborative care (6th ed., p. 918). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
7. 7.ID: 383694391
At 1300, the nurse is documenting the receipt of a unit of packed blood cells at the
hospital blood bank. The nurse calculates that the transfusion must be started by:
A. 1315
B. 1330 Correct
C. 1345
D. 1400
Rationale: Blood must be hung within 30 minutes after obtaining it from the blood
bank. After that time, the temperature of the blood becomes warm and could be
unsafe for use. Therefore 1345 and 1400 are incorrect. It is not necessary to hang
the blood within 15 minutes of receiving it from the blood bank.
Test-Taking Strategy: Knowledge of the standard procedures related to blood
administration is needed to answer this question correctly. Remember that blood
must be hung within 30 minutes after obtaining it from the blood bank. Review this
procedure if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/PlanningContent Area: Blood Administration
References: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing:
Patient-centered collaborative care (6th ed., p. 918). St. Louis: Saunders.
Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th ed., p. 792).
St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
8. 8.ID: 383697107
A nurse hangs a 500-mL bag of intravenous (IV) fluid for an assigned client. One
hour later the client complains of chest tightness, is dyspneic and apprehensive,
and has an irregular pulse. The IV bag has 100 mL remaining. Which of the
following actions should the nurse take first?
A. Removing the IV
B. Sitting the client up in bed
C. Shutting off the IV infusion Correct
D. Slowing the rate of infusion
Rationale: The client’s symptoms are indicative of speed shock, which results from
the rapid infusion of drugs or a bolus infusion. In this case, the nurse would note
that 400 mL has infused over 60 minutes. The first action on the part of the nurse
is shutting off the IV infusion. Other actions may follow in rapid sequence: The
nurse may elevate the head of the bed to aid the client’s breathing and then
immediately notify the healthcare provider. Slowing the infusion rate is
inappropriate because the client will continue to receive fluid. The IV does not need
to be removed. It may be needed to manage the complication.
Test-Taking Strategy: Use the process of elimination, focusing on the data in the
question. Note the question contains the strategic word “first.” Recognizing the
signs of speed shock and recalling the appropriate interventions should also direct
you to the option of shutting off the IV infusion. Review the initial nursing actions
for speed shock if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Intravenous Therapy
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing:
Patient-centered collaborative care (6th ed., p. 230). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.9. 9.ID: 383694370
A client taking hydrochlorothiazide reports to the clinic for follow-up blood tests.
For which side effect of the medication does the nurse monitor the client’s
laboratory results?
A. Hypokalemia Correct
B. Hypocalcemia
C. Hypernatremia
D. Hypermagnesemia
Rationale: The client taking a potassium-wasting diuretic such as
hydrochlorothiazide must be monitored for reductions in the potassium level. Other
fluid and electrolyte imbalances that may occur with use of this medication are
hyponatremia, hypercalcemia, hypomagnesemia, and hypophosphatemia. The
nurse should also educate the client about foods that are rich in potassium.
Test-Taking Strategy: Use the process of elimination, recalling that most thiazide
diuretics names end with -zide. Remembering that hypokalemia is a concern when
a client is taking a potassium-wasting diuretic will direct you to the correct option.
If this question was difficult for you, review the side effects of this medication.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Pharmacology
Reference: Edmunds, M. (2010). Introduction to clinical pharmacology (6th ed., p.
236). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
10. 10.ID: 383697122
A nurse is caring for a client with a diagnosis of chronic renal failure who is
receiving dialysis. Epoetin alfa (Epogen), to be administered subcutaneously, has
been prescribed, and the nurse is drawing the medication from a single-use vial.
The nurse should prepare the medication by:
A. Shaking the vial before drawing up the medication
B. Drawing up the medication and discarding the unused portion Correct
C. Obtaining the medication from the medication freezer and allowing it to
thaw
D. Mixing the medication with 0.1 mL of heparin before administration to
prevent clotting [Show Less]