A client is taking prescribed ibuprofen, 300 mg orally four times daily, to relieve
joint pain resulting from rheumatoid arthritis. The client tells the
... [Show More] nurse that the
medication is causing nausea and indigestion. The nurse should tell the client to:
A. Contact the health care provider Incorrect
B. Stop taking the medication
C. Take the medication with food Correct
D. Take the medication twice a day instead of four times
Rationale: Ibuprofen is a nonsteroidal antiinflammatory medication. Side effects
include nausea (with or without vomiting) and dyspepsia (heartburn, indigestion,
or epigastric pain). If gastrointestinal distress occurs, the client should be
instructed to take the medication with milk or food. The nurse would not instruct
the client to stop the medication or instruct the client to adjust the dosage of a
prescribed medication; these actions are not within the legal scope of the role of
the nurse. Contacting the health care provider is premature, because the client’s
complaints are side effects that occasionally occur and can be relieved by taking
the medication with milk or food.
Test-Taking Strategy: Use guidelines related to medication administration to
assist you to eliminate the options that indicate to stop the medication or adjust
the prescribed dose. To select from the remaining options, think about the side
effects of the medication. Review the side effects of ibuprofen and the measures
to relieve them if you had difficulty with this question.
Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook
2015. (pp. 594-595) St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Giddens Concepts: Client Education, Safety
HESI Concepts: Safety, Teaching and Learning/Patient Education
Awarded 0.0 points out of 1.0 possible points.
11.ID: 9476768998
A client's oral intake of liquids includes 120 mL on the night shift, 800 mL on the
day shift, and 650 mL on the evening shift. The client is receiving an intravenous
(IV) antibiotic every 12 hours, diluted in 50 mL of normal saline solution. The
nurse empties 700 mL of urine from the client's Foley catheter at the end of the
day shift. Thereafter, 500 mL of urine is emptied at the end of the evening shift
and 325 mL at the end of the night shift. Nasogastric tube drainage totals 155 mL
for the 24-hour period, and the total drainage from the Jackson-Pratt device is
175 mL. What is the client's total intake during the 24-hour period? Type your
answer in the space provided. ____1670____mL
Correct
Correct Responses
1. 1670
Rationale: The client’s 24-hour total oral intake is 1570 mL, and the IV intake
totals 100 mL (50 mL of normal saline solution every 12 hours). Therefore the 24-
hour intake total is 1670 mL.
Test-Taking Strategy: Focus on the subject, the client’s total intake in a 24-hour
period. Add the oral intake and then note that every 12 hours the client is
receiving an IV antibiotic that is diluted in 50 mL of normal saline solution.
Therefore the total IV intake is 100 mL in 24 hours. Review calculation of intake
and output if you had difficulty with this question.
Reference: Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M.
(2013). Fundamentals of nursing. (8th ed., pp. 898-900, 1052). St. Louis: Mosby.
Cognitive Ability: Understanding
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Fluids & Electrolytes
Giddens Concepts: Clinical Judgment, Fluid and Electrolytes
HESI Concepts: Clinical Decision Making/Clinical Judgment, Fluid and Electrolytes
Awarded 1.0 points out of 1.0 possible points.
12.ID: 9476763531
Lorazepam 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a
client for the management of anxiety. The nurse prepares the medication as
prescribed and administers the medication over a period of:
A. 3 minutes Correct
B. 10 seconds
C. 15 seconds
D. 30 minutes
Rationale: Lorazepam is a benzodiazepine. When administered by IV injection,
each 2 mg or fraction thereof is administered over a period of 1 to 5 minutes. Ten
seconds and 30 seconds are brief periods. Thirty minutes is a lengthy period.
Test-Taking Strategy: Focus on the subject, administration of a medication by way
of IV injection. Eliminate the options that indicate delivery times of 10 and 15
seconds, because these periods are very brief. Next eliminate the option of 30
minutes because of its lengthiness. Review the procedure for administering
lorazepam by way of IV injection if you had difficulty with this question.
Reference: Gahart, B., & Nazareno, A. (2015). 2015 Intravenous
medications (31st ed., p.766). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision Making/Clinical Judgment, Safety
Awarded 1.0 points out of 1.0 possible points.
13.ID: 9476786122
A nurse, conducting an assessment of a client being seen in the clinic for
symptoms of a sinus infection, asks the client about medications that he is
taking. The client tells the nurse that he is taking nefazodone hydrochloride . On
the basis of this information, the nurse determines that the client most
likely has a history of:
A. Depression Correct
B. Diabetes mellitus
C. Hyperthyroidism
D. Coronary artery disease
Rationale: Nefazodone hydrochloride is an antidepressant used as maintenance
therapy to prevent relapse of an acute depression. Diabetes mellitus,
hypethyroidism, and coronary artery disease are not treated with this
medication.
Test-Taking Strategy: Knowledge regarding the use of this medication is required
to answer this question correctly. Recalling that nefazodone hydrochloride is an
antidepressant will direct you to the correct option. Review this medication if you
had difficulty with this question.
Reference: Lehne, R. (2013). Pharmacology for nursing care (8th ed., p.372). St.
Louis: Saunders.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Pharmacology
Giddens Concepts: Clinical Judgment, Evidence
HESI Concepts: Clinical Decision Making/Clinical Judgment, Evidence Based
Practice/Evidence
Awarded 1.0 points out of 1.0 possible points.
14.ID: 9476790943
Phenelzine sulfate is prescribed for a client with depression. The nurse provides
information to the client about the adverse effects of the medication and tells the
client to contact the health care provider immediately if she experiences:
A. Dry mouth
B. Restlessness
C. Feelings of depression
D. Neck stiffness or soreness Correct
Rationale: Phenelzine sulfate, a monoamine oxidase inhibitor (MAOI), is an
antidepressant and is used to treat depression. Hypertensive crisis, an adverse
effect of this medication, is characterized by hypertension, frontally radiating
occipital headache, neck stiffness and soreness, nausea, vomiting, sweating,
fever and chills, clammy skin, dilated pupils, and palpitations. Tachycardia,
bradycardia, and constricting chest pain may also be present. The client is taught
to be alert to any occipital headache radiating frontally and neck stiffness or
soreness, which could be the first signs of a hypertensive crisis. Dry mouth and
restlessness are common side effects of the medication.
Test-Taking Strategy: Use the process of elimination and focus on the subject, the
symptoms that should prompt the client to contact the health care provider
immediately. Recalling that the medication is an MAOI and the common and
adverse effects of the medication will help direct you to the correct option.
Review the side effects and adverse effects of this medication if you had difficulty
with this question.
Reference: Lehne, R. (2013). Pharmacology for nursing care (8th ed., pp. 378-
379). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Mental Health
Giddens Concepts: Client Education, Safety HESI Concepts: Safety, Teaching and
Learning/Patient Education
Awarded 1.0 points out of 1.0 possible points.
15.ID: 9476768957
Risperidone is prescribed for a client hospitalized in the mental health unit for the
treatment of a psychotic disorder. Which finding in the client’s medical record
would prompt the nurse to contact the prescribing health care provider before
administering the medication?
A. The client has a history of cataracts.
B. The client has a history of hypothyroidism.
C. The client takes a prescribed antihypertensive. Correct
D. The client is allergic to acetylsalicylic acid (aspirin).
Rationale: Risperidone is an antipsychotic medication. Contraindications to the
use of risperidone include cardiac disorders, cerebrovascular disease,
dehydration, hypovolemia, and therapy with antihypertensive agents.
Risperidone is used with caution in clients with a history of seizures. History of
cataracts, hypothyroidism, or allergy to aspirin does not affect the administration
of this medication.
Test-Taking Strategy: Knowledge of the contraindications to the use of risperidone
is required to answer this question correctly. It is important to remember that one
such contraindication is therapy with an antihypertensive medication. If you are
unfamiliar with the contraindications to the use of risperidone, review this
content.
Reference: Lilley, L., Rainforth Collins, S., Harrington, S., & Snyder J.
(2014). Pharmacology and the nursing process (7th ed., p.271). St. Louis: Mosby.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Giddens Concepts: Collaboration, Safety HESI Concepts: Collaboration/Managing
Care, Safety
Awarded 1.0 points out of 1.0 possible points.
16.ID: 9476793824
A client who has been undergoing long-term therapy with an antipsychotic
medication is admitted to the inpatient mental health unit. Which finding does
the nurse, knowing that long-term use of an antipsychotic medication can cause
tardive dyskinesia, monitor in the client?
A. Fever
B. Diarrhea
C. Hypertension
D. Tongue protrusion Correct
Rationale: Tardive dyskinesia is a severe reaction associated with long-term use
of antipsychotic medications. The clinical manifestations include abnormal
movements (dyskinesia) and involuntary movements of the mouth, tongue
(“flycatcher tongue”), and face. In its most severe form, tardive dyskinesia
involves the fingers, arms, trunk, and respiratory muscles. When this occurs, the
medication is discontinued. Fever, diarrhea, and hypertension are not
characteristics of tardive dyskinesia.
Test-Taking Strategy: Knowledge of the clinical manifestations associated with
tardive dyskinesia is needed to answer this question correctly. Recalling that the
clinical manifestations of tardive dyskinesia include abnormal movements and
involuntary movements will direct you to the correct option. If you had difficulty
with this question, review the characteristics of tardive dyskinesia.
Reference: Lilley, L., Rainforth Collins, S., Harrington, S., & Snyder J.
(2014). Pharmacology and the nursing process (7th ed., p. 268). St. Louis: Mosby.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Pharmacology
Giddens Concepts: Clinical Judgment, Psychosis
HESI Concepts: Clinical Decision Making/Clinical Judgment, Cogintion-Psychosis
Awarded 1.0 points out of 1.0 possible points.
17.ID: 9476758005
A nurse is reviewing the record of a client scheduled for electroconvulsive
therapy (ECT). Which diagnosis, if noted on the client's record, would indicate a
need to contact the health care provider who is scheduled to perform the ECT?
A. Recent stroke Correct
B. Hypothyroidism
C. History of glaucoma
D. Peripheral vascular disease
Rationale: Several conditions pose risks in the client scheduled for ECT. Among
them are recent myocardial infarction or stroke and cerebrovascular
malformations or intracranial lesions. Hypothyroidism, glaucoma, and peripheral
vascular disease are not contraindications to this treatment.
Test-Taking Strategy: Knowledge regarding the risks associated with ECT is
required to answer this question correctly. Note the word "recent" in the correct
option, which should help recognize the correct option. Review contraindications
to ECT if you had difficulty with this question.
Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed.,
pp. 594-595). St. Louis: Mosby.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Mental Health
Giddens Concepts: Collaboration, Safety HESI Concepts: Collaboration/Managing
Care, Safety
Awarded 1.0 points out of 1.0 possible points.
18.ID: 9476767491
A client scheduled for suprapubic prostatectomy has listened to the surgeon's
explanation of the surgery. The client later asks the nurse to explain again how
the prostate is going to be removed. The nurse tells the client that the prostate
will be removed through:
A. A lower abdominal incision Correct
B. An upper abdominal incision
C. An incision made in the perineal area
D. The urethra, with the use of a cutting wire
Rationale: A lower abdominal incision is used in suprapubic or retropubic
prostatectomy. An upper abdominal incision is not used to remove the prostate.
An incision between the scrotum and anus is made when a perineal
prostatectomy is performed. Transurethral resection is performed through the
urethra; an instrument called a resectoscope is used to cut the tissue by means
of a high-frequency current.
Test-Taking Strategy: To answer this question accurately, you must be familiar
with this surgery and how it is performed. Focusing on the data in the question
and noting the word "suprapubic" will direct you to the correct option. Review the
procedure for performing a suprapubic prostatectomy if you had difficulty with
this question.
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing:
Patient-centered collaborative care. (7th ed., p.1639). St. Louis: Saunders.
Cognitive Ability: Understanding
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Renal
Giddens Concepts: Client Education, Elimination
HESI Concepts: Elimination, Teaching and Learning/Patient Education
Awarded 1.0 points out of 1.0 possible points.
19.ID: 9476763501
A nurse is preparing a poster for a health fair booth promoting primary
prevention of skin cancer. Which recommendations does the nurse include on the
poster? Select all that apply.
A. Seek medical advice if you find a skin lesion. Correct
B. Use sunscreen with a low sun protection factor (SPF).
C. Avoid sun exposure before 10 a.m. and after 4 p.m. Incorrect
D. Wear a hat, opaque clothing, and sunglasses when out in the
sun. Correct
E. Examine the body every 6 months for possibly cancerous or
precancerous lesions. Incorrect
Rationale: Measures to prevent skin cancer include avoiding sun exposure
between 10 a.m. and 4 p.m.; using sunscreen with a high SPF; wearing a hat,
opaque clothing, and sunglasses when out in the sun; and examining the body
every month for possibly cancerous or precancerous lesions. The client should
also seek medical advice if any changes in a skin lesion are noted.
Test-Taking Strategy: Focus on the subject, the prevention of skin cancer. Read
each option carefully. Eliminate the option that includes the words “low sun
protection factor.” Next eliminate the option that includes “every 6 months.” To
select from the remaining options, recall that the skin should be protected from
the sun even more carefully between the hours of 10 a.m. and 4 p.m. Review the
risk factors associated with skin cancer if you had difficulty with this question.
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing:
Patient-centered collaborative care. (7th ed., p.503). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching and Learning
Content Area: Adult Health/Oncology
Giddens Concepts: Cellular Regulation, Health Promotion
HESI Concepts: Cellular Regulation, Health, Wellness, and Illness-Health
Promotion [Show Less]