Hurst Readiness Practice Exam 2
A client has been prescribed vancomycin 1 gram IV every 12 hours for the treatment of methicillin-resistant staphylococcus aureus (MRSA). Which action by a new nurse when administering this medication would require intervention by the charge nurse?(Ans- This dose of medication should be delivered over at least 60 minutes to prevent hypotension and ototoxicity.
The nurse is caring for a client taking benazepril. Which symptoms would be important for the nurse to report to the primary healthcare provider?(Ans- Weight gain of 5 pounds in one week is a s/s of an adverse effect of ACE inhibitor use. Weight gain is a sign of fluid retention.
Angioedema is an adverse effect of ACE inhibitors and can be life threatening. This should be reported immediately to the healthcare provider.
The potassium level is too high. Hyperkalemia is an adverse effect of an ACE inhibitor and needs to be reported.
The nurse is caring for a client taking spironolactone. Which dietary change should the nurse teach the client to make when starting treatment with this medication?(Ans- Spironolactone is a potassium sparing diuretic. Salt substitutes have potassium instead of sodium and should be avoided.
When assessing a client, the nurse finds that in response to painful stimuli the upper extremities exhibit flexion of the arm, wrist, and fingers with adduction of the limb, while the lower extremity exhibits extension, internal rotation, and plantar flexion. How would the nurse accurately document this finding?(Ans- This describes decorticate posturing because they are moving towards the core of the body. 1 / 3
Decerebrate posturing (Ans- when the client is stimulated, and teeth clench and the arms are stiffly extended, adducted, and hyperpronated.
The legs are stiffly extended with plantar flexion of the feet. Abnormal extension occurs with lesions in the area of the brain stem.
A client being treated for osteoporosis with alendronate reports experiencing slight heartburn after taking the medicine. What should the nurse suggest to reduce this side effect?(Ans- Increased heartburn can be reduced or prevented by drinking plenty of water, sitting upright following the administration of the medication, and avoiding sucking on the tablet.
What precautions should be taken with computer monitors that display client health information to ensure client's confidentiality?(Ans- 2. Have the screen placed facing away from any visitor or client care area where information could be viewed by unauthorized persons.
The nurse receives new healthcare provider prescriptions on a client diagnosed with Addison's disease. Which prescriptions should the nurse recognize as being inappropriately written and requiring clarification from the prescriber?(Ans- Use "daily" or "every day". QD is an unapproved abbreviation.
T.I.W. stands for three times a week; however, it is an unapproved abbreviation. Use "three times a week".
The client has just returned from electroconvulsive therapy (ECT) and is very drowsy. What is the position of choice for the nurse to place the client in until full consciousness is regained?(Ans- When someone is very sedated and not fully conscious, we want them on their side so the airway remains open and the secretions can drain. 2 / 3
A client is hospitalized because of severe malnutrition related to anorexia nervosa. What is the most important goal for this client?(Ans- Until appropriate weight is gained, the client continues to be at risk for major health complications including hypotension, cardiac arrhythmias, poor muscle tone, increased risk for infection, abnormal liver function, and damaged kidneys.
A client comes to the clinic reporting palpitations, as well as nausea and vomiting while taking metronidazole. The nurse notes that the client is flushed and has a heart rate of 118 bpm. Based on this information, what is the most important question for the nurse to ask the client?(Ans- Flushing, nausea and vomiting, palpitations, tachycardia, psychosis are signs of disulfiram-type reaction seen when using products containing alcohol (cologne, after shave lotion, or path splashes) or ingesting alcohol products while taking metronidazole.
Antibiotic: take metronidazole on an empty stomach
What should a community health nurse include when planning a presentation on prevention and early detection of colon cancer?(Ans- A diet high in vegetables, fruits, and whole grains has been linked with a decreased risk of colorectal cancer;
exercise regularly
The guaiac-based fecal occult blood test detects blood in the stool through a chemical reaction. This test is done yearly.
The nurse is searching for information about the nursing care of a client receiving an experimental drug for the treatment of obesity. Which database is most likely to address this issue?(Ans- The Cumulative Index for Nursing and Allied Health Literature (CINAHL) is a source for reviewing nursing and allied health information.
- / 3