01. A client receives a short-acting insulin and an intermediateacting insulin before breakfast at 0800. Using the chart below, when should the nurse expect the intermediate insulin to start to take effect?
a. 1500
b. 1300
c. 1000
d. 0900
02. A client has an I.V. line in place for 3 days and begins to complain of discomfort at the insertion site.Based on the client’s progress notes below, what condition has most likely occurred?
a. Infiltration
b. Phlebitis
c. Infection
d. Infection and infiltration
03. When administering medication, the nurse ensures client safety by following the rights of medication administration. Identity the “rights of medication administration.” Select all that apply.
a. Right room
b. Right client
c. Right dose
d. Right medication
e. Right time
f. Right route
04. A client is to be started on a new diuretic medication.Which of the following should be included in the teaching plan? Select all that apply.
a. Advise the client to reduce his dietary sodium intake.
b. Encourage the use of salt substitutes.
c. Tell the client to alert the physician about any visible edema.
d. Instruct the client to take the medication as directed.
e. Suggest taking the medication just before bedtime to establish a routine
05. After suffering an acute myocardial infarction (MI), a client with a history of type 1 diabetes is prescribed metoprolol (Lopressor) I.V. Which nursing interventions are associated with I.V. administration of
metoprolol? Select all that apply.
a. Monitor glucose levels closely.
b. Monitor for heart block and bradycardia.
c. Monitor blood pressure closely.
d. Mix the drug in 50 ml of dextrose 5% in water and infuse over 30 minutes.
e. Be aware that the drug isn’t compatible with morphine.
06. A client with an I.V. line in place complains of pain at the insertion site. Assessment of the site reveals a vein that’s red, warm, and hard. Which of the following actions should the nurse take? Select all that apply.
a. Slow the infusion rate while notifying the prescriber.
b. Discontinue the infusion at the affected site.
c. Restart the infusion distal to the discontinued I.V. site.
d. Assess the client for skin sloughing.
e. Apply warm soaks to the I.V. site.
f. Document the assessment, nursing actions taken, and the client’s response.
07. A physician prescribes I.V. heparin 25,000 units in 250 ml of normal saline solution to infuse at 600 units/hour for a client who suffered an acute myocardial infarction. After 6 hours of heparin therapy, the client’s partial thromboplastin time is subtherapeutic. The physician orders the infusion to be increased to 800 units/hour. The nurse should set the infusion pump to deliver how many milliliters per hour? Record your answer using a whole number.
_________________________________ milliliters/hour
08. After undergoing small-bowel resection, a client is prescribed metronidazole (Flagyl) 500 mg I.V. The mixed I.V. solution contains 100 ml. The nurse is to administer the drug over 30 minutes. The drop factor of the available I.V. tubing is 15 gtt/ml. What is the drip rate in drops per minute? Record your answer using a whole number.
_________________________________ drops/minute
09. After sustaining a closed head injury, a client is prescribed phenytoin (Dilantin) 100 mg I.V. every 8 hours for seizure prophylaxis. Which nursing interventions are necessary when administering phenytoin?Select all that apply.
a. Administer phenytoin through any peripheral I.V. site.
b. Mix I.V. doses in solutions containing dextrose 5% in water.
c. Administer an I.V. bolus no faster than 50 mg/ minute.
d. Monitor electrocardiogram (ECG), blood pressure,and respiratory status continuously when
administering phenytoin I.V.
e. Don’t use an inline filter when administering the drug.
f. Keep in mind that early toxicity may cause drowsiness, nausea, vomiting, nystagmus, ataxia,
dysarthria, tremor, and slurred speech.
10. A nurse is preparing a teaching plan for a client who was prescribed enalapril maleate (Vasotec) for treatment of hypertension. Which of the following instructions should the nurse include in the teaching plan? Select all that apply.
a. Instruct the client to avoid salt substitutes.
b. Tell the client that light-headedness is a common adverse effect that doesn’t need to be reported.
c. Inform the client that he may have a sore throat for the first few days of therapy.
d. Advise the client to report facial swelling or difficulty breathing immediately.
e. Tell the client that blood tests will be necessary every 3 weeks for 2 months and periodically
after that.
f. Advise the client not to change position suddenly to minimize orthostatic hypotension.
11.A 56-year-old client is receiving chemotherapy that has the potential to cause pulmonary toxicity. Which of the following symptoms indicates a toxic response to the chemotherapy?
a.Decrease in appetite.
b.Drowsiness.
c.Spasms of the diaphragm.
12.The client is receiving an I.V. infusion of 5% dextrose in normal saline running at 125 ml/hour. When hanging a new bag of fluid, the nurse notes swelling and hardness at the infusion site. The nurse
should first:
a.Discontinue the infusion.
b.Apply a warm soak to the site.
c.Stop the flow of solution temporarily.
d.Irrigate the needle with normal saline.
13.Total parenteral nutrition (TPN) is prescribed for a client who has recently had a significant small and large bowel resection and is currently not taking anything by mouth. The nurse should:
a.Administer TPN through a nasogastric or gastrostomy tube.
b.Handle TPN using strict aseptic technique.
c.Auscultate for bowel sounds prior to administering TPN.
d.Designate a peripheral intravenous (IV) site for TPN administration.
14.To prevent development of peripheral neuropathies associated with isoniazid administration, the nurse should teach the client to:
a.Avoid excessive sun exposure.
b.Follow a low-cholesterol diet.
c.Obtain extra rest.
d.Supplement the diet with pyridoxine (vitamin B6).
15.When giving an I.M. injection, the nurse should insert the needle into the muscle at an angle of:
a.15 degrees.
b.30 degrees.
c.45 degrees.
d.90 degrees
Answer & Rational
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