1.ID: 383711499

Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse

perform as a priority before administering the medication?

Checking the client's blood pressure Correct

Checking the client's peripheral pulses

Checking the most recent potassium level

Checking the client's intake-and-output record for the last 24 hours

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.ID: 383744011

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?

"The test will take about 30 minutes."

"I need to fast for 8 hours before the test."

"I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the

morning of the test." Correct

"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."

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.ID: 383705015

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:

Call the nursing supervisor

Ask the answering service to contact the on-call physician Correct

Withhold the medication until the physician can be reached in the morning

Administer the medication but consult the physician when he becomes available

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.ID: 383708500

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:

Documenting the findings

Asking the ED physician to check the client Correct

Continuing to monitor the client's cardiac status

Informing the client that PVCs are expected after an MI

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.

5.ID: 383704545

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:

Administer the antihypertensive with a small sip of water Correct

Withhold the antihypertensive and administer it at bedtime

Administer the medication by way of the intravenous (IV) route

Hold the antihypertensive and resume its administration on the day after the ECT

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.

6.ID: 383706660

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?

"Tell me more about what you’re feeling." Correct

"That’s a normal response after this type of surgery."

"It will take time, but, I promise you, you will get over this depression."

"Every client who has this surgery feels the same way for about a month."

Rationale: When a client expresses feelings of depression, it is extremely important for the nurse to

further explore these feelings with the client. In stating, "This is a normal response after this type of

surgery" the nurse provides false reassurance and avoids addressing the client’s feelings. "It will take

time, but, I promise you, you will get over the depression" is also a false reassurance, and it does not

encourage the expression of feelings. "Every client who has this surgery feels the same way for about a

month" is a generalization that avoids the client’s feelings.

7.ID: 383705009

A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts the

fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that the fluid

is yellow and has a strong odor. Which of the following actions should be the nurse’s priority?

Contacting the physician Correct

Documenting the findings

Checking the fluid for protein

Continuing to monitor the client and the FHR

Rationale: The FHR is assessed for at least 1 minute when the membranes rupture. The nurse also checks

the quantity, color, and odor of the amniotic fluid. The fluid should be clear (often with bits of vernix)

and have a mild odor. Fluid with a foul or strong odor, cloudy appearance, or yellow coloration suggests

chorioamnionitis and warrants notifying the physician. A large amount of vernix in the fluid suggests that

the fetus is preterm. Greenish, meconium-stained fluid may be seen in cases of postterm gestation or

placental insufficiency. Checking the fluid for protein is not associated with the data in the question.

Although the nurse would continue to monitor the client and the FHR and would document the findings,

contacting the physician is the priority.

8.ID: 383705011

A nurse has assisted a physician in inserting a central venous access device into a client with a diagnosis

of severe malnutrition who will be receiving parenteral nutrition (PN). After insertion of the catheter, the

nurse immediately plans to:

Call the radiography department to obtain a chest x-ray Correct

Check the client's blood glucose level to serve as a baseline measurement

Hang the prescribed bag of PN and start the infusion at the prescribed rate

Infuse normal saline solution through the catheter at a rate of 100 mL/hr to maintain patency

Rationale: One major complication associated with central venous catheter placement is pneumothorax,

which may result from accidental puncture of the lung. After the catheter has been placed but before it

is used for infusions, its placement must be checked with an x-ray. Hanging the prescribed bag of PN and

starting the infusion at the prescribed rate and infusing normal saline solution through the catheter at a

rate of 100 mL/hr to maintain patency are all incorrect because they could result in the infusion of

solution into a lung if a pneumothorax is present. Although the nurse may obtain a blood glucose

measurement to serve as a baseline, this action is not the priority.

9.ID: 383705041

A rape victim being treated in the emergency department says to the nurse, "I’m really worried that I’ve

got HIV now." What is the appropriate response by the nurse?

"HIV is rarely an issue in rape victims."

"Every rape victim is concerned about HIV."

"You’re more likely to get pregnant than to contract HIV."

"Let's talk about the information that you need to determine your risk of contracting HIV." Correct

Rationale: HIV is a concern of rape victims. Such concern should always be addressed, and the victim

should be given the information needed to evaluate his or her risk. Pregnancy may occur as a result of

rape, and pregnancy prophylaxis can be offered in the emergency department or during follow-up, once

the results of a pregnancy test have been obtained. However, stating, “You’re more likely to get pregnant

than to contract HIV” avoids the client’s concern. Similarly, "HIV is rarely an issue in rape victims” and

"Every rape victim is concerned about HIV" are generalized responses that avoid the client’s concern.

10.ID: 383703603

A client is taking prescribed ibuprofen (Motrin), 300 mg orally four times daily, to relieve joint pain

resulting from rheumatoid arthritis. The client tells the nurse that the medication is causing nausea and

indigestion. The nurse should tell the client to:

Contact the physician

Stop taking the medication

Take the medication with food Correct

Take the medication twice a day instead of four times