Basic Pharmacology for Nurses 17th Ed by Clayton – Willihnganz-Test Bank

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Basic Pharmacology for Nurses 17th Ed by Clayton – Willihnganz-Test Bank

Chapter 02: Basic Principles of Drug Action and Drug Interactions

Clayton/Willihnganz: Basic Pharmacology for Nurses, 17th Edition

 

MULTIPLE CHOICE

 

  1. The nurse assesses hives in a patient started on a new medication. What is the nurse’s priority action?
a. Notify physician of allergic reaction.
b. Notify physician of idiosyncratic reaction.
c. Notify physician of potential teratogenicity.
d. Notify physician of potential tolerance.

 

 

ANS:  A

An allergic reaction is indicative of hypersensitivity and manifests with hives and/or urticaria, which are easily identified. An idiosyncratic reaction occurs when something unusual or abnormal happens when a drug is first administered. A teratogenic reaction refers to the occurrence of birth defects related to administration of the drug. Tolerance refers to the body’s requirement for increasing dosages to achieve the same effects that a lower dose once did.

 

DIF:    Cognitive Level: Application          REF:   Page 17          OBJ:   4

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety

 

  1. The nurse administers an initial dose of a steroid to a patient with asthma. Thirty minutes after administration, the nurse finds the patient agitated and stating that “everyone is out to get me.” What is the term for this unusual reaction?
a. Desired action
b. Adverse effect
c. Idiosyncratic reaction
d. Allergic reaction

 

 

ANS:  C

Idiosyncratic reactions are unusual, abnormal reactions that occur when a drug is first administered. Patients typically exhibit an overresponsiveness to a medication related to diminished metabolism. These reactions are believed to be related to genetic enzyme deficiencies. Desired actions are expected responses to a medication. Adverse effects are reactions that occur in another system of the body; they are usually predictable. Allergic reactions appear after repeated medication dosages.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 18          OBJ:   4

TOP:   Nursing Process Step: Evaluation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Patient Education; Clinical Judgment; Caregiving; Safety; Sensory Perception

 

  1. Which is the best description of when drug interactions occur?
a. On administration of toxic dosages of a drug
b. On an increase in the pharmacodynamics of bound drugs
c. On the alteration of the effect of one drug by another drug
d. On increase of drug excretion

 

 

ANS:  C

Drug interactions may be characterized by an increase or decrease in the effectiveness of one or both of the drugs. Toxicity of one drug may or may not affect the metabolism of another one. Drug interactions may result from either increased or decreased pharmacodynamics. Drug interactions may result from either increased or decreased excretion.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 18          OBJ:   5

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Safety; Patient Education; Clinical Judgment

 

  1. What occurs when two drugs compete for the same receptor site, resulting in increased activity of the first drug?
a. Desired action
b. Synergistic effect
c. Carcinogenicity
d. Displacement

 

 

ANS:  D

The displacement of the first drug from receptor sites by a second drug increases the amount of the first drug because more unbound drug is available. An expected response of a drug is the desired action. A synergistic effect is the effect of two drugs being greater than the effect of each chemical individually or the sum of the individual effects. Carcinogenicity is the ability of a drug to cause cells to mutate and become cancerous.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 19          OBJ:   6

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Safety; Patient Education

 

  1. What do drug blood levels indicate?
a. They confirm if the patient is taking a generic form of a drug.
b. They determine if the patient has sufficient body fat to metabolize the drug.
c. They verify if the patient is taking someone else’s medications.
d. They determine if the amount of drug in the body is in a therapeutic range.

 

 

ANS:  D

The amount of drug present may vary over time and the blood level must remain in a therapeutic range in order to obtain the desired result. Generic drugs do not necessarily produce a different drug blood level than proprietary medications. Body fat is not measured by drug blood levels. Drug blood levels only measure the amount of drug in the body; they do not determine the source of the medication.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 17          OBJ:   4

TOP:   Nursing Process Step: Evaluation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety

 

  1. What is the process by which a drug is transported by circulating body fluids to receptor sites?
a. Osmosis
b. Distribution
c. Absorption
d. Biotransformation

 

 

ANS:  B

Distribution refers to the ways in which drugs are transported by the circulating body fluids to the sites of action (receptors), metabolism, and excretion. Osmosis is the process of moving solution across a semipermeable membrane to equalize the dilution on each side. Absorption is the process by which a drug is transferred from its site of entry into the body to the circulating fluids for distribution. Biotransformation, also called metabolism, is the process by which the body inactivates drugs.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 15          OBJ:   3

TOP:   Nursing Process Step: Planning

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Patient Education; Clinical Judgment; Safety

 

  1. The nurse assesses which blood level to determine the amount of circulating medication in a patient?
a. Peak
b. Trough
c. Drug
d. Therapeutic

 

 

ANS:  C

When a drug is circulating in the blood, a blood sample may be drawn and assayed to determine the amount of drug present; this is known as the drug blood level. Peak levels are only those drug blood levels that are at their maximum before metabolism starts to decrease the amount of circulating drug. Trough levels are only those drug blood levels that are at their minimum when metabolism has decreased the amount of circulating drug and before an increase caused by a subsequent dose of the medication. Therapeutic levels are only those within a prescribed range of blood levels determined to bring about effective action of the medication.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 17          OBJ:   3

TOP:   Nursing Process Step: Evaluation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Patient Education; Clinical Judgment; Safety

 

  1. The nurse administers 50 mg of a drug at 6:00 AM that has a half-life of 8 hours. What time will it be when 25 mg of the drug has been eliminated from the body?
a. 8:00 AM
b. 11:00 AM
c. 2:00 PM
d. 6:00 PM

 

 

ANS:  C

Fifty percent of the medication, or 25 mg, will be eliminated in 8 hours, or at 2:00 PM. 8:00 AM is 2 hours after administration; the half-life is 8 hours. 11:00 AM is 4 hours after administration; the half-life is 8 hours. 6:00 PM is 12 hours after administration; the half-life is 8 hours.

 

DIF:    Cognitive Level: Analysis               REF:   Page 15          OBJ:   2

TOP:   Nursing Process Step: Evaluation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety; Elimination; Health Promotion

 

  1. What will the nurse need to determine first in order to mix two drugs in the same syringe?
a. Absorption rate of the drugs
b. Compatibility of the drugs
c. Drug blood level of each drug
d. Medication adverse effects

 

 

ANS:  B

Knowledge of absorption is important but not in order to mix drugs. In order to mix two drugs, compatibility is determined so there is no deterioration when the drugs are mixed in the same syringe. Drug level does not indicate if it is acceptable to mix medications in the same syringe. Adverse effects are important for the nurse to know, but not in order to mix drugs.

 

DIF:    Cognitive Level: Application          REF:   Page 19          OBJ:   6

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety

 

  1. A patient developed hives and itching after receiving a drug for the first time. Which instruction by the nurse is accurate?
a. Stop the medication and encourage the patient to wear a medical alert bracelet that explains the allergy.
b. Explain to the patient that these are signs and symptoms of an anaphylactic reaction.
c. Emphasize to the patient the importance to inform medical personnel that in the future a lower dosage of this drug is necessary.
d. Instruct the patient that it would be safe to take the drug again because this instance was a mild reaction.

 

 

ANS:  A

This initial allergic reaction is mild, and the patient is more likely to have an anaphylactic reaction at the next exposure; a medical alert bracelet is necessary to explain the reaction. Signs and symptoms of an anaphylactic reaction are respiratory distress and cardiovascular collapse. A more severe reaction will occur at the next exposure, and the patient should not receive the drug again.

 

DIF:    Cognitive Level: Application          REF:   Page 18          OBJ:   4

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Patient Education; Clinical Judgment; Safety

 

  1. When obtaining a patient’s health history, which assessment data would the nurse identify as having the most effect on drug metabolism?
a. History of liver disease
b. Intake of a vegetarian diet
c. Sedentary lifestyle
d. Teacher as an occupation

 

 

ANS:  A

Liver enzyme systems are the primary site for metabolism of drugs. Intake of a vegetarian diet may affect absorption but not metabolism. Sedentary lifestyle and occupations could affect metabolism (exposure to environmental pollutants), but these do not have the most significant effect on metabolism.

 

DIF:    Cognitive Level: Application          REF:   Page 16          OBJ:   3

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Patient Education; Clinical Judgment; Safety

 

  1. A physician’s order indicates to administer a medication to the patient via the percutaneous route. The nurse can anticipate that the patient will receive this medication
a. intramuscularly.
b. subcutaneously.
c. topically.
d. rectally.

 

 

ANS:  C

The percutaneous route refers to drugs that are absorbed through the skin and mucous membranes. Methods of the percutaneous route include inhalation, sublingual (under the tongue), or topical (on the skin) administration. The parenteral route bypasses the gastrointestinal (GI) tract by using subcutaneous (subcut), intramuscular (IM), or intravenous (IV) injection. The parenteral route bypasses the GI tract by using subcut, IM, or IV injection. In the enteral route, the drug is administered directly into the GI tract by the oral, rectal, or nasogastric route.

 

DIF:    Cognitive Level: Application          REF:   Page 14          OBJ:   1

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Patient Education; Clinical Judgment; Safety

 

  1. A nurse is preparing to administer tetracycline to a patient diagnosed with an infection. Which medication should not be administered with tetracycline?
a. Ativan
b. Tylenol
c. Colace
d. Mylanta

 

 

ANS:  D

Administering tetracycline with Mylanta can provide an antagonistic effect that will result in decreased absorption of the tetracycline. Ativan, Tylenol, and Colace are not contraindicated to administer with tetracycline.

 

DIF:    Cognitive Level: Application          REF:   Page 18          OBJ:   5 | 6

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Patient Education; Clinical Judgment; Safety

 

MULTIPLE RESPONSE

 

  1. Which statement(s) about liberation of drugs is/are true? (Select all that apply.)
a. A drug must be dissolved in body fluids before it can be absorbed into body tissues.
b. A solid drug taken orally must disintegrate and dissolve in GI fluids to allow for absorption into the bloodstream for transport to the site of action.
c. The process of converting the drug into a soluble form can be controlled to a certain degree by the dosage form.
d. Converting the drug to a soluble form can be influenced by administering the drug with or without food in the patient’s stomach.
e. Elixirs take longer to be liberated from the dosage form.

 

 

ANS:  A, B, C, D

Regardless of the route of administration, a drug must be dissolved in body fluids before it can be absorbed into body tissues. Before a solid drug taken orally can be absorbed into the bloodstream for transport to the site of action, it must disintegrate and dissolve in the GI fluids and be transported across the stomach or intestinal lining into the blood. The process of converting a drug into a soluble form can be partially controlled by the pharmaceutical dosage form used (e.g., solution, suspension, capsules, and tablets with various coatings). The conversion process can also be influenced by administering the drug with or without food in the patient’s stomach. Elixirs are already drugs dissolved in a liquid and do not need to be liberated from the dosage form.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 14          OBJ:   3

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Patient Education; Clinical Judgment; Safety

 

  1. Which are routes of drug excretion? (Select all that apply.)
a. GI tract; feces
b. Genitourinary (GU) tract; urine
c. Lymphatic system
d. Circulatory system; blood/plasma
e. Respiratory system; exhalation

 

 

ANS:  A, B, E

The GI system is a primary route for drug excretion. The GU and the respiratory systems do function in the excretion of drugs. The lymphatic and circulatory systems are involved with drug distribution, not drug excretion.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 15          OBJ:   3

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Patient Education; Clinical Judgment; Safety; Elimination

 

  1. Which route(s) enable(s) drug absorption more rapidly than the subcut route? (Select all that apply.)
a. IV route
b. IM route
c. Inhalation/sublingual
d. Intradermal route
e. Enteral route

 

 

ANS:  A, B, C

IV route of administration enables drug absorption more rapidly than the subcut route. IM route of administration enables drug absorption more rapidly because of greater blood flow per unit weight of muscle. Inhalation/sublingual route of administration enables drug absorption more rapidly than the subcut route. Intradermally administered drugs are absorbed more slowly because of the limited available blood supply in the dermis. Enterally administered drugs are absorbed more slowly because of the biotransformation process.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 14          OBJ:   1 | 3

TOP:   Nursing Process Step: Evaluation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Patient Education; Clinical Judgment; Safety

 

  1. The nurse recognizes that which factor(s) would contribute to digoxin toxicity in a 92-year-old patient? (Select all that apply.)
a. Taking the medication with meals
b. Prolonged half-life of the drug digoxin
c. Impaired renal function
d. Diminished mental capacity

 

 

ANS:  B, C

Impaired renal and hepatic function in older adults impairs metabolism and excretion of drugs, thus prolonging the half-life of a medication. Food would decrease the absorption of the drug. Diminished mental capacity does not contribute to drug toxicity unless it is due to administration errors.

 

DIF:    Cognitive Level: Application          REF:   Page 15          OBJ:   2 | 3 | 7

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Health Promotion and Maintenance

NOT:  CONCEPT(S): Patient Education; Clinical Judgment; Safety

 

  1. Which statement(s) about variables that influence drug action is/are true? (Select all that apply.)
a. An older adult will require increased dosage of a drug to achieve the same therapeutic effect as that seen in a younger person.
b. Body weight can affect the therapeutic response of a medication.
c. Chronic smokers may metabolize drugs more rapidly than nonsmokers.
d. A patient’s attitude and expectations affect the response to medication.
e. Reduced circulation causes drugs to absorb more rapidly.

 

 

ANS:  B, C, D

Body weight can affect response to medications; typically, obese patients require an increase in dosage and underweight patients a decrease in dosage. Chronic smoking enhances metabolism of drugs. Attitudes and expectations play a major role in an individual’s response to drugs. Older adults require decreased dosages of drugs to achieve a therapeutic effect. Decreased circulation causes drugs to absorb more slowly.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 16 | Page 17

OBJ:   5 | 6 | 7           TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Patient Education; Clinical Judgment; Safety

 

  1. Which factor(s) affect(s) drug actions? (Select all that apply.)
a. Teratogenicity
b. Age
c. Body weight
d. Metabolic rate
e. Illness

 

 

ANS:  B, C, D, E

Age, body weight, metabolic rate, and illness may contribute to a variable response to a medication. Teratogenicity does not contribute to a variable response to a medication.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 16 | Page 17

OBJ:   7                    TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Patient Education; Clinical Judgment; Safety

 

COMPLETION

 

  1. A patient receives 200 mg of a medication that has a half-life of 12 hours. How many mg of the drug would remain in the patient’s body after 24 hours?

 

ANS:

50

 

The half-life is defined as the amount of time required for 50% of the drug to be eliminated from the body. If a patient is given 200 mg of a drug that has a half-life of 12 hours, then 50 mg of the drug would remain in the body after 24 hours.

 

DIF:    Cognitive Level: Analysis               REF:   Page 15          OBJ:   2 | 3

TOP:   Nursing Process Step: Evaluation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety

Chapter 10: Parenteral Administration: Intradermal, Subcutaneous, and Intramuscular Routes

Clayton/Willihnganz: Basic Pharmacology for Nurses, 17th Edition

 

MULTIPLE CHOICE

 

  1. The nurse is educating a patient about diabetes. Based on recommendations from the American Diabetes Association, which statement by the nurse is best regarding site rotation?
a. “Insulin injection sites should always be in the abdomen to ensure absorption into the stomach.”
b. “It is important to rotate injection sites systematically within one area before progressing to a new site for injection.”
c. “Following exercise, site rotation is not indicated because the circulation in the muscles will absorb the medication efficiently.”
d. “If you aspirate, site rotation can be done every other day to avoid developing problems with absorption.”

 

 

ANS:  B

The American Diabetes Association Clinical Practice recommendations include rotating injections systematically at one site before progressing to another. Insulin is not absorbed into the stomach. Failure to rotate sites can result in lipohypertrophy or lipoatrophy. When subcutaneous (subcut) insulin is administered, aspiration should never be performed.

 

DIF:    Cognitive Level: Application          REF:   Page 132        OBJ:   2

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Safe, Effective Care Environment

NOT:  CONCEPT(S): Clinical Judgment; Safety; Patient Education

 

  1. Which technique by the nurse is accurate when administering heparin to a thin, older adult patient?
a. Aspirate before injecting the medication.
b. Inject at a 45-degree angle.
c. Inject at a 90-degree angle.
d. Massage site following injection.

 

 

ANS:  B

For thin individuals, the skin may need to be pinched and a 45-degree angle used to avoid administration into the muscle. Heparin should never be aspirated. Subcut injections are properly administered at a 45-degree angle. The injection site of heparin should never be massaged.

 

DIF:    Cognitive Level: Application          REF:   Page 136        OBJ:   2

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety; Development

 

  1. The nurse is preparing to administer kindergarten immunizations at the local health clinic. Which anatomic site would be best for the injection of the immunizations containing 0.5 mL?
a. Rectus femoris
b. Dorsogluteal
c. Deltoid
d. Ventrogluteal

 

 

ANS:  C

The deltoid muscle is often used because of its easy access and the fact that it can tolerate 0.5 mL of medication volume. Having the child disrobe is not efficient in this setting.

 

DIF:    Cognitive Level: Application          REF:   Page 138 | Page 139

OBJ:   5                    TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety; Development

 

  1. A 65-year-old man who weighs 180 lb (81.8 kg) is to receive 1.5 mL of a viscous antibiotic by intramuscular (IM) injection. Which needle and syringe will be used?
a. 5/8 inch, 25-gauge needle with 5 mL syringe
b. 1 inch, 28-gauge needle with 4 mL syringe
c. 1 inch, 21-gauge needle with 3 mL syringe
d. 3 inch, 16-gauge needle with 1.5 mL syringe

 

 

ANS:  C

It is important to correlate the syringe size to the size of the patient and the tissue mass. The usual amount injected intramuscularly is 0.5 to 2 mL. Needle lengths commonly used for adults are 1 to 1 inches long. A longer needle may be used for a significantly obese adult. Commonly used needle gauges for IM injections are 20 to 22 gauge. A 5/8 inch, 25-gauge needle is too short and too small to administer a viscous medication. A 1 inch, 28-gauge needle is too small to administer a viscous medication. A 3 inch, 16-gauge needle is too large and too long to administer medication to a patient this size.

 

DIF:    Cognitive Level: Application          REF:   Page 136        OBJ:   3

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety

 

  1. Which is the preferred IM site for injecting a 6-month-old child?
a. Dorsogluteal
b. Abdominal
c. Vastus lateralis
d. Deltoid muscle

 

 

ANS:  C

The vastus lateralis is generally the preferred IM site in infants because it has the largest muscle mass for that age group. The muscles are not well developed in other areas for this age group. The dorsogluteal muscle is not developed well enough in a child this age to provide a safe site for injection. The abdominal muscles are not appropriate for IM injection. The deltoid muscle is not developed well enough in a child this age to provide a safe site for injection.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 137        OBJ:   5

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety; Development

 

  1. Which angle is appropriate when administering an IM medication in the dorsogluteal site to a 46-year-old obese man?
a. 45 degrees
b. 60 degrees
c. 75 degrees
d. 90 degrees

 

 

ANS:  D

A 90-degree angle is used to reach the IM area of the dorsogluteal site. A 45-, 60-, or 75-degree angle does not ensure that the needle will penetrate to the muscle in an obese patient.

 

DIF:    Cognitive Level: Application          REF:   Page 138        OBJ:   3

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety

 

  1. Which parenteral route has the longest absorption time?
a. Intradermal
b. Subcut
c. IM
d. Intravenous (IV)

 

 

ANS:  A

Absorption rate is determined by the proximity of the medication to the vascular system. Medication injected into an intradermal site is farther away from the vascular system than the other sites. Therefore, absorption in this site is the slowest. Subcut tissue is more vascular than intradermal tissue. IM tissue is more vascular than intradermal tissue. IV administration places medication directly into the vascular system.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 132        OBJ:   1

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Safe, Effective Care Environment

NOT:  CONCEPT(S): Clinical Judgment; Safety; Care Coordination

 

  1. Which site is identified by the posterior superior iliac spine and greater trochanter?
a. Ventrogluteal
b. Dorsogluteal
c. Vastus lateralis
d. Rectus femoris

 

 

ANS:  B

The dorsogluteal site is identified by drawing an imaginary line from the posterior superior iliac spine to the greater trochanter of the femur. The injection is then administered at any point between the imaginary straight line and below the curve of the iliac crest (hipbone).

 

DIF:    Cognitive Level: Comprehension   REF:   Page 138        OBJ:   4

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment

 

  1. Which nursing action is accurate when administering an IM injection using the Z track method?
a. Use a 1-inch needle.
b. Add 0.5 mL of air to the syringe.
c. Vigorously massage the injection site.
d. Pinch up the skin.

 

 

ANS:  B

Adding 0.5 mL of air ensures that the drug will clear the needle. A 1-inch needle may not ensure deep muscle penetration. Massaging the injection site could cause the medication to leak into the muscle tissue. The skin should be stretched, not pinched up.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 140        OBJ:   3

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment

 

  1. Which gauge needles are used for subcut injections?
a. 14 to 16 gauge
b. 18 to 21 gauge
c. 22 to 24 gauge
d. 25 to 29 gauge

 

 

ANS:  D

Commonly used gauges for subcut injection are 25 to 29 gauge. Needles that are 14 to 16 gauge are used for administration of blood or large volumes of fluid in a short period of time. Needles that are 18 to 21 gauge are used for routine parenteral fluid administration. Needles that are 22 to 24 gauge are used for administering fluids or medication via small veins.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 135        OBJ:   2

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety

 

  1. When is it acceptable to use the deltoid muscle as an injection site for infants?
a. Medication is irritating.
b. Dose is a long-acting medication.
c. Child is combative.
d. Volume is quite small.

 

 

ANS:  D

The deltoid site should be used in infants only when the volume is quite small, the medication is nonirritating, and the dose will be quickly absorbed. Irritating and long-acting medications should be injected in deep muscle tissue such as the vastus lateralis. A combative child should be adequately restrained and injected in a fairly large muscle mass.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 138        OBJ:   5

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety

 

  1. Which action by the nurse is most accurate when administering an intradermal injection?
a. Insert the needle at a 45-degree angle.
b. Inject 0.1 mL.
c. Use a 22-gauge needle.
d. Wipe the site with alcohol after injection.

 

 

ANS:  B

Small volumes, usually 0.1 mL, are injected. The needle is inserted at a 15-degree angle. A 26-gauge needle is used. After injection, the site should not be wiped with alcohol.

 

DIF:    Cognitive Level: Application          REF:   Page 133        OBJ:   1

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety

 

  1. Which assessment by the nurse is most important to obtain prior to performing allergy sensitivity testing?
a. Identify areas of loose connective tissue.
b. Question the patient about frequency of exercise.
c. Determine if the patient is using aspirin.
d. Palpate and measure the size of induration.

 

 

ANS:  C

It is important to determine if the patient has taken any antihistamines or anti-inflammatory agents for 24 to 48 hours prior to allergy testing. Loose connective tissue is assessed prior to administering injections subcutaneously. Exercise routine is not significant prior to allergy testing. Palpation and measurement of the size of induration are done after the procedure.

 

DIF:    Cognitive Level: Application          REF:   Page 132        OBJ:   1

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety

 

  1. The nurse administers a skin prick test (SPT) to a patient at 9:00 AM. The earliest time the nurse can expect to read the test is
a. the next day at 9:00 AM.
b. by 9:00 PM the same day.
c. by 9:10 AM the same day.
d. one week from the date and time of administration.

 

 

ANS:  C

The SPT can be read in 10 to 20 minutes after administration, depending on protocol.

 

DIF:    Cognitive Level: Application          REF:   Page 134        OBJ:   1

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Care Coordination

 

  1. The nurse cleansing the skin surface of a patient prior to injection will start at the
a. periphery and work inward in a back and forth motion.
b. periphery and work inward in a cyclical motion.
c. injection site and work outward in a straight line.
d. injection site and work outward in a circular motion.

 

 

ANS:  D

The skin surface is cleansed prior to injection starting at the injection site and working outward in a circular motion toward the periphery.

 

DIF:    Cognitive Level: Application          REF:   Page 139        OBJ:   3

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety; Infection

 

MULTIPLE RESPONSE

 

  1. The nurse is preparing to administer allergy sensitivity testing to a patient. Which statement(s) pertain(s) to this type of administration? (Select all that apply.)
a. Allergy sensitivity testing requires the intradermal route.
b. Injections are made into the loose connective tissue.
c. Equipment needed includes gloves, antiseptic pledget, metric ruler, and physician’s order sheet.
d. Record of previous injection sites is needed.
e. The needle should be inserted at a 15-degree angle with the needle bevel up.

 

 

ANS:  A, C, E

Allergy sensitivity testing requires the intradermal route. Before administering allergy testing, gathering of equipment and physician’s orders are necessary. This route is injected into the dermal layer of skin, using a 15-degree angle. Connective tissue, having poor blood supply, is not appropriate for injection of medication. Previous injection sites would not factor into the decision about where to conduct allergy testing.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 132        OBJ:   1

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety

 

  1. Which statement(s) about administering medications parenterally is/are true? (Select all that apply.)
a. Subcut absorption is slower than intradermal absorption.
b. Two mL or less should be administered in a subcut site.
c. The gluteal area is recommended for children.
d. Needles 1 to 1 inches in length are common for IM injections.
e. The scapular areas of the back may be used for intradermal injections.

 

 

ANS:  B, D, E

No more than 2 mL of medication should be injected into a subcut site. Needle length of 1 to 1 inches is common for IM injections. The upper chest, scapular areas of the back, and the inner aspect of the forearms are commonly used as sites for intradermal injections. Subcutaneous absorption is faster than intradermal absorption. Because of the undeveloped muscle mass in children, the gluteal area is not recommended for IM injection.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 132        OBJ:   1 | 2 | 3

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety

 

  1. The vastus lateralis muscle is appropriate for injections for which patient(s)? (Select all that apply.)
a. Children younger than 3 years of age
b. Elderly
c. Debilitated
d. Nonambulatory
e. Ambulatory
f. Healthy

 

 

ANS:  A, E, F

Children younger than 3 years of age, ambulatory patients, and otherwise healthy patients may receive injections in the vastus lateralis. Elderly, debilitated, and nonambulatory patients may have reduced muscle mass in the vastus lateralis and therefore poor absorption of injected medications.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 132 | Page 134

OBJ:   4 | 5                TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety; Development

 

  1. The nurse administers B12 IM to a patient in a long-term care facility. After administering this medication, the nurse will (Select all that apply.)
a. carefully recap the needle.
b. identify the patient.
c. massage site of injection.
d. dispose of the used needle according to policy.
e. apply a small bandage to the site.

 

 

ANS:  D, E

After administering an IM injection, the nurse should dispose of used needles according to policy and apply a small bandage to the site. Needles should never be recapped following use. The patient requires identification before the injection is given. After the needle is removed, gentle pressure should be applied to the site. Massage can increase the pain if the muscle mass is stressed by the amount of medication given.

 

DIF:    Cognitive Level: Application          REF:   Page 136 | Page 137

OBJ:   3                    TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Safe, Effective Care Environment| NCLEX Client Needs Category: Physiological Integrity                    NOT:  CONCEPT(S): Clinical Judgment; Safety

Chapter 20: Introduction to Cardiovascular Disease and Metabolic Syndrome

Clayton/Willihnganz: Basic Pharmacology for Nurses, 17th Edition

 

MULTIPLE CHOICE

 

  1. A patient with a body mass index (BMI) of 25 would be considered to be in which weight category?
a. Underweight
b. Normal weight
c. Overweight
d. Obese

 

 

ANS:  C

A BMI of less than 18.5 is considered underweight. A BMI of 18.5 to 24.9 is considered normal weight. A BMI of 25 to 29.9 is considered overweight. A BMI of 30 to 34.9 is considered obesity, class I; 35 to 39.9 is considered obesity, class II; and more than 40 is considered extreme obesity.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 319        OBJ:   1

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Nutrition; Health Promotion

 

  1. What is the most critical approach to the treatment of metabolic syndrome?
a. Psychotherapy
b. Pharmacotherapy
c. Lifestyle management
d. Patient education

 

 

ANS:  C

Lifestyle management is critical for managing metabolic syndrome; other approaches will not be effective without it. Psychotherapy, pharmacotherapy, and patient education are not the most critical approaches to treating metabolic syndrome.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 317 | Page 320

OBJ:   2                    TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Nutrition; Health Promotion

 

  1. Healthy diets should include no more than which percentage of saturated fat based on total calories?
a. 30%
b. 10%
c. 7%
d. 2%

 

 

ANS:  C

A healthy diet should have no more than 7% of calories from saturated fat. A diet with 30% or 10% saturated fat would not be considered a healthy diet. A diet can have up to 7% saturated fat before it is considered unhealthy.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 320        OBJ:   3

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Nutrition; Health Promotion

 

  1. Which ethnic group or gender is at greatest risk for developing metabolic syndrome?
a. Hispanic women
b. Asian men
c. African American men
d. White women

 

 

ANS:  A

Hispanic women have the highest incidence rate of metabolic syndrome at 27%. Asian men, African American men, and white women are not at the highest risk for metabolic syndrome.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 318        OBJ:   1

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Nutrition; Health Promotion

 

  1. What is the incidence of metabolic syndrome in the United States?
a. 1 in 3000
b. 1 in 300
c. 1 in 30
d. 1 in 3

 

 

ANS:  D

The incidence of metabolic syndrome in the United States is 1 in 3, or about 50 million adults. One in 3000, 1 in 300, and 1 in 30 are each less than the incidence of metabolic syndrome in the United States.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 318        OBJ:   1

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Nutrition; Health Promotion

 

  1. Which is the mechanism of action demonstrated by exercise in managing blood glucose levels?
a. Exercise causes release of glucose and promotes a reduced blood glucose level.
b. Exercise on a regular basis causes a reduction in lean body mass, which helps regulate blood glucose levels.
c. Increased muscle mass and less fat tends to normalize blood glucose levels because glucose is used by muscle cells when exercising.
d. Exercise stimulates the liver, the primary storage and utilization site of glucose, to release glucose.

 

 

ANS:  C

Exercise leads to more muscle and less fat, so blood glucose levels tend to return to normal. Exercise increases the rate of glucose uptake in the contracting skeletal muscles. Exercise on a regular basis prevents reduction in lean body mass and protein wasting. The liver is not the primary storage and utilization site of glucose.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 321        OBJ:   3

TOP:   Nursing Process Step: Planning

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Nutrition; Health Promotion

 

  1. Which instruction by the nurse is accurate to include in a patient’s care to manage metabolic syndrome?
a. Encourage the client to exercise 20 minutes every day.
b. Eliminate alcohol intake.
c. Increase simple carbohydrates in the diet.
d. Reduce stress.

 

 

ANS:  D

Stress reduction is important in the management of metabolic syndrome. Twenty minutes of exercise is not adequate. Alcohol intake needs to be restricted but does not have to be eliminated. Complex carbohydrates are appropriate in the management of metabolic syndrome.

 

DIF:    Cognitive Level: Application          REF:   Page 320        OBJ:   2

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Nutrition; Health Promotion; Patient Education

 

MULTIPLE RESPONSE

 

  1. What lifestyle choice(s) may aggravate metabolic syndrome? (Select all that apply.)
a. Excessive tobacco smoking
b. Inadequate hydration
c. Excessive exercise
d. Inadequate caloric intake
e. Excessive consumption of alcohol

 

 

ANS:  A, E

Smoking and excessive consumption of alcohol may aggravate metabolic syndrome. Metabolic syndrome is not directly affected by inadequate hydration. Metabolic syndrome is directly affected by a sedentary lifestyle, not excessive exercise. Metabolic syndrome is directly affected by increased, not inadequate, caloric intake.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 320        OBJ:   2

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Nutrition; Health Promotion

 

  1. In addition to type 2 diabetes and heart disease, which condition(s) is/are associated with metabolic syndrome? (Select all that apply.)
a. Dementia
b. Insomnia
c. Renal disease
d. Obstructive sleep apnea
e. Orthostatic hypotension
f. Polycystic ovary syndrome

 

 

ANS:  A, C, D, F

Dementia, renal disease, obstructive sleep apnea, and polycystic ovary syndrome are associated with metabolic syndrome. Insomnia and orthostatic hypotension are not associated with metabolic syndrome.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 318        OBJ:   1

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Nutrition; Health Promotion

 

  1. Drug therapy for initial treatment of metabolic syndrome is targeted at controlling which condition(s)? (Select all that apply.)
a. Obstructive sleep apnea
b. Diabetes mellitus
c. Hypertension
d. Obesity
e. Dyslipidemia
f. Insulin resistance

 

 

ANS:  B, C, E

Pharmacologic approaches to managing metabolic syndrome are targeted toward controlling diabetes, hypertension, and dyslipidemia. There is no pharmacologic intervention for obstructive sleep apnea. Obesity should be addressed before pharmacologic therapy begins. Insulin resistance is not dealt with pharmacologically in the early management of metabolic syndrome.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 321        OBJ:   4

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Nutrition; Health Promotion

 

  1. Which cardiovascular condition(s) is/are related to coronary artery diseases (CADs)? (Select all that apply.)
a. Angina pectoris
b. Pulmonary stenosis
c. Acute myocardial infarction
d. Pericarditis
e. Venous stasis ulcers

 

 

ANS:  A, C

Angina pectoris and acute myocardial infarction are considered CADs. Pulmonary stenosis is a congenital heart disease. Pericarditis is inflammation of the tissue surrounding the heart. Venous stasis ulcers are not related to CAD.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 317        OBJ:   1

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Perfusion

 

  1. Metabolic syndrome includes which key characteristic(s)? (Select all that apply.)
a. Hyperglycemia
b. Abdominal obesity
c. Low high-density lipoproteins
d. Hypertension
e. Osteoporosis

 

 

ANS:  A, B, C, D

Metabolic syndrome is characterized by hyperglycemia, abdominal obesity, low high-density lipoproteins, and hypertension. Osteoporosis is not a characteristic of metabolic syndrome.

 

DIF:    Cognitive Level: Analysis               REF:   Page 318        OBJ:   1

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Nutrition; Health Promotion

 

  1. The mother of a school-aged child asks the nurse how to help prevent her child from acquiring metabolic syndrome. The nurse informs the child’s mother that education for children in primary grades should focus on which action(s)? (Select all that apply.)
a. Treatment of dyslipidemia
b. Prevention of smoking
c. Importance of moderate activity
d. Discouraging use of alcohol
e. Increase in saturated fat

 

 

ANS:  B, C, D

Primary prevention of metabolic syndrome is becoming a common thread in curriculum for children in the primary grades. This education focuses on the importance of moderate activity, dietary choices, and the prevention of alcohol and smoking. Treatment of dyslipidemia is not considered primary prevention. Diet should include reduced intake of saturated fat.

 

DIF:    Cognitive Level: Application          REF:   Page 318 | Page 320

OBJ:   2                    TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Nutrition; Health Promotion; Development

 

COMPLETION

 

  1. Weight: 140 pounds. Height: 5 feet 4 inches. What is the BMI?

 

ANS:

24.03

 

140 ÷ (64)2 ´ 703 = 24.03

 

DIF:    Cognitive Level: Analysis               REF:   Page 319        OBJ:   1

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment

 

  1. Weight: 70 kilograms. Height: 164 cm (1.65 m). What is the BMI?

 

ANS:

25.71

 

70 ÷ (1.65)2 = 25.71

 

DIF:    Cognitive Level: Analysis               REF:   Page 319        OBJ:   1

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment

Chapter 30: Drugs Used to Treat Lower Respiratory Disease

Clayton/Willihnganz: Basic Pharmacology for Nurses, 17th Edition

 

MULTIPLE CHOICE

 

  1. A patient has questions regarding a recently prescribed antitussive agent. Which response by the nurse is the best?
a. “It will eliminate your cough at night.”
b. “It will reduce the frequency of your cough.”
c. “It should be used in the morning.”
d. “It should be taken before sleep.”

 

 

ANS:  B

Antitussive agents act by suppressing the cough center in the brain. The expected therapeutic outcome is reduced frequency of nonproductive cough to promote rest. Antitussive agents should be taken as prescribed by the health care provider. Antitussives are not likely to eliminate a cough. Antitussives should be taken throughout the day.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 464        OBJ:   3

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Patient Education

 

  1. Which is a common expectorant in over-the-counter medications?
a. Dextromethorphan
b. Diphenhydramine
c. Guaifenesin
d. Codeine

 

 

ANS:  C

Guaifenesin is used for symptomatic relief of conditions characterized by a dry, nonproductive cough such as the common cold, bronchitis, laryngitis, pharyngitis, and sinusitis. Guaifenesin is also used to remove mucous plugs from the respiratory tract. Dextromethorphan is an antitussive. Diphenhydramine is an anticholinergic agent with antihistaminic and antitussive properties. Codeine is an antitussive.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 469        OBJ:   3

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment

 

  1. What is the reason for administering sodium chloride to a patient with emphysema?
a. To increase blood sodium levels
b. To decrease mucus viscosity
c. To reduce metabolic needs of the body
d. To decrease bronchial irritation

 

 

ANS:  B

Sodium chloride acts by hydrating mucus. This will decrease the viscosity of mucous plugs, which makes it easier for patients to cough up the dry hardened plugs blocking the bronchial tubes. Sodium chloride is not given to increase serum sodium iodide levels. Sodium does not reduce metabolic needs of the body or bronchial irritation.

 

DIF:    Cognitive Level: Application          REF:   Page 469        OBJ:   3

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Gas Exchange

 

  1. Within minutes of the initiation of a nebulizer treatment with a sympathomimetic bronchodilator, the patient turns on his call light and states that he feels “panicky” and his heart is racing. Which action will the nurse take?
a. Reassure the patient this is expected.
b. Add more diluents to the nebulizer.
c. Administer a sedative.
d. Stop treatment and notify the health care provider.

 

 

ANS:  D

Sympathomimetic drugs increase sympathetic nervous stimulation. Symptoms such as nervousness, palpitations, tremors, tachycardia, and anxiety typically are dose related. These symptoms should be reported to the health care provider immediately because the patient may require a decreased dosage. These symptoms could lead to further complications if allowed to persist and are not common adverse effects. Although this may be a common result, it is not an expected outcome. Diluting the medication would not decrease the dose. Although a sedative might be appropriate for the patient, this is not the intervention of choice.

 

DIF:    Cognitive Level: Analysis               REF:   Page 473 | Page 474

OBJ:   5                    TOP:   Nursing Process Step: Planning

MSC:  NCLEX Client Needs Category: Safe, Effective Care Environment

NOT:  CONCEPT(S): Clinical Judgment; Gas Exchange; Safety

 

  1. Premedication assessments before the use of anticholinergic bronchodilating agents should verify that the patient has no history of which condition?
a. Diabetes
b. Hypertension
c. Liver disease
d. Glaucoma

 

 

ANS:  D

Anticholinergic bronchodilating agents cause mydriasis (dilation of the pupils) and cycloplegia (loss of power in the ciliary muscle); therefore, they should not be used in patients with a history of closed-angle glaucoma. Diabetes, hypertension, and liver disease are not affected by the use of anticholinergic bronchodilating agents.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 474        OBJ:   5

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Safe, Effective Care Environment

NOT:  CONCEPT(S): Clinical Judgment; Safety

 

  1. A patient is seen in the emergency department. The patient had been maintained on theophylline (Theo Dur), and a blood sample reveals the serum theophylline level is subtherapeutic. Which may cause a subtherapeutic serum level?
a. Cimetidine use
b. Drug tolerance
c. Smoking
d. Overuse of the inhaler

 

 

ANS:  C

The patient is not tolerant to the drug if the serum theophylline levels are too low. Cimetidine would enhance the effects of theophylline, not decrease the effects. Smoking reduces the therapeutic effects of xanthine derivatives, including theophylline. Overuse of the inhaler would cause a high level of serum theophylline.

 

DIF:    Cognitive Level: Application          REF:   Page 468        OBJ:   5

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Health Promotion and Maintenance

NOT:  CONCEPT(S): Clinical Judgment; Safety

 

  1. What is the action of zafirlukast (Accolate), a leukotriene receptor antagonist?
a. Dilates the alveolar sacs
b. Decreases leukotriene release
c. Inhibits histamine release
d. Increases viscosity of secretions

 

 

ANS:  B

Leukotrienes are a class of anti-inflammatory agents that block leukotriene formation, and they are part of the inflammatory pathway that causes bronchoconstriction. Leukotrienes work to reduce bronchoconstriction, and they do not inhibit histamine release or affect viscosity of secretions.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 478        OBJ:   N/A

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment

 

  1. What is albuterol (Proventil) used to treat?
a. Acute bronchospasm
b. Acute allergies
c. Nasal congestion
d. Dyspnea on exertion

 

 

ANS:  A

The short-acting beta agonists have a rapid onset (few minutes) and are used to treat acute bronchospasm. Beta agonists are not used to treat allergies. Decongestants are used for nasal congestion. Long-acting beta agonists are used for exertional dyspnea.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 472        OBJ:   6

TOP:   Nursing Process Step: Planning

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment

 

  1. From where do the fluids of the respiratory tract originate?
a. Specialized mucous glands called goblet cells
b. Lymph fluid drawn across nasal membranes by osmosis
c. Specialized beta cells in the islets of Langerhans
d. Cells that produce aqueous humor

 

 

ANS:  A

The fluids of the respiratory tract originate from specialized mucous glands (goblet cells) and serous glands that line the respiratory tract. The goblet cells produce gelatinous mucus that forms a thin layer over the interior surfaces of the trachea, bronchi, and bronchioles. Lymph does not make up fluid in the respiratory tract. The beta cells in the islets of Langerhans are located in the pancreas. Cells that produce aqueous humor are located in the interior of the eye.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 459        OBJ:   1

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment

 

  1. What structures in the respiratory tract assist in removing foreign bodies such as smoke and bacteria?
a. Villi
b. Golgi bodies
c. Ciliary hairs
d. Erector pili

 

 

ANS:  C

Normally, respiratory tract fluid forms a protective layer over the trachea, bronchi, and bronchioles. Foreign bodies, such as smoke particles and bacteria, are caught in the respiratory tract fluid and are swept upward by ciliary hairs that line the bronchi and trachea to the larynx, where they are removed by the cough reflex. The villi are hair-like protrusions into the intestine emanating from the wall of the intestine. The purpose of the villi is to slow the passage of food and allow food particles to be captured among these finger-like villi so that the blood inside the villi can absorb the nutrients in the food. The primary function of the Golgi apparatus, an organelle found in most eukaryotic cells, is to process proteins targeted to the plasma membrane, lysosomes, or endosomes and those that will be formed from the cell and to sort them within vesicles. Thus, it functions as a central delivery system for the cell. Erector pili are small muscles that cause hairs on the skin to rise when contracted.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 459        OBJ:   1

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment

 

  1. The nurse is providing instruction about ipratropium (Atrovent) to a patient with chronic obstructive pulmonary disease (COPD). Which is a common adverse effect that tends to resolve with therapy?
a. Anxiety
b. Dry mouth
c. Tachycardia
d. Urine retention

 

 

ANS:  B

Dry mouth is usually mild and tends to resolve with continued therapy. Anxiety, tachycardia, and urine retention are not common adverse effects.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 475        OBJ:   5 | 6

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Patient Education; Safety

 

  1. An adult patient is admitted for an asthma attack. Which assessment obtained by the nurse would support that albuterol (Proventil) was effective?
a. Decrease in wheezing present on auscultation
b. Less dyspnea while positioned in a high Fowler’s position
c. Sputum production is clear and watery
d. Respiratory rate decreased to 38 breaths/min

 

 

ANS:  A

A bronchodilator would open the airways and result in a reduction of wheezing. Less dyspnea while positioned in a high Fowler’s position, clear and watery sputum, and a respiratory rate decreased to 38 breaths/min would not indicate that the medication was effective.

 

DIF:    Cognitive Level: Application          REF:   Page 474 | Page 475

OBJ:   5                    TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Gas Exchange

 

  1. A child has been diagnosed with asthma and the nurse is providing education to the family. Which statement by the mother indicates a need for further teaching?
a. “I will place the stuffed animals in the freezer overnight.”
b. “We will confine our dog to the kitchen area.”
c. “I should wash bedding in hot water.”
d. “A damp cloth should be used when I dust.”

 

 

ANS:  B

Pets should be removed from the home or kept outside if at all possible.

 

DIF:    Cognitive Level: Application          REF:   Page 468        OBJ:   1

TOP:   Nursing Process Step: Evaluation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Patient Education; Communication; Safety; Health Promotion

 

  1. The nurse is providing nutrition information to a patient diagnosed with a lower respiratory tract disease. What is the rationale for limiting caffeine?
a. Caffeine increases the respiratory rate.
b. Caffeine can result in thicker lung secretions.
c. Caffeine will increase the anxiety response associated with dyspnea.
d. Caffeine can cause bronchospasm.

 

 

ANS:  B

Avoid caffeine-containing beverages because caffeine is a weak diuretic. Diuresis promotes thickening of lung secretions, making it more difficult to expectorate them.

 

DIF:    Cognitive Level: Application          REF:   Page 468        OBJ:   N/A

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety; Gas Exchange; Nutrition; Patient Education

 

  1. The nurse is teaching a patient with a history of COPD to self-administer tiotropium (Spiriva) by dry powder inhalation. Which information provided by the nurse is accurate?
a. The medication capsules can be used multiple times.
b. Press on the canister while inhaling.
c. Avoid breathing into the mouthpiece.
d. Wash the device with cold water.

 

 

ANS:  C

The patient should not breathe into the mouthpiece at any time. Capsules are meant to be used as a single dose and should be disposed of after taking the daily dose. The HandiHaler uses capsules of medication that should be pierced before the patient inhales. The inhaler should be washed with hot water.

 

DIF:    Cognitive Level: Application          REF:   Page 475        OBJ:   5

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety; Patient Education

 

  1. The health care provider in an outpatient clinic has prescribed omalizumab (Xolair) to a patient. Which primary outcome will the nurse teach the patient to expect?
a. Easier expectoration of phlegm
b. Less frequent asthma exacerbations
c. Increased moisture of the mucous membranes
d. Liquefaction of thick secretions

 

 

ANS:  B

The primary therapeutic outcome associated with omalizumab therapy is reduced frequency of acute asthmatic exacerbations. Easier expectoration of phlegm, increased moisture of the mucous membranes, and liquefaction of thick secretions are not outcomes of omalizumab.

 

DIF:    Cognitive Level: Application          REF:   Page 480        OBJ:   5

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Patient Education

 

  1. The nurse is obtaining a history of respiratory symptoms on a patient with the diagnosis of COPD. The patient reports smoking one pack of cigarettes per day for the past 20 years. The nurse calculates the pack years as
a. 5.
b. 10.
c. 20.
d. 40.

 

 

ANS:  C

Pack years is defined as number of packs of cigarettes smoked per day times the number of years of smoking; 1 ´ 20 = 20.

 

DIF:    Cognitive Level: Analysis               REF:   Page 465        OBJ:   2

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment

 

  1. A resident in a long-term care facility diagnosed with COPD has a new medication order for indacaterol. When the nurse is providing education to the resident regarding this medication, information will include that
a. it is a short-acting beta antagonist.
b. the patient should wait approximately 5 minutes between inhalations.
c. onset of action is within 5 minutes.
d. duration of action is about 12 hours.

 

 

ANS:  C

Onset of action is within 5 minutes. Indacaterol is an ultra-long-acting beta 2 agonist.

Patients using inhaled bronchodilators should wait approximately 10 minutes. Duration of action is about 24 hours.

 

DIF:    Cognitive Level: Application          REF:   Page 473        OBJ:   4

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Patient Education; Safety

 

MULTIPLE RESPONSE

 

  1. Which statement(s) is/are true regarding the nursing assessment of a patient with a respiratory disorder? (Select all that apply.)
a. Central cyanosis typically is observed on the fingers and earlobes.
b. Clubbing of the fingernails is a sign of hypoxia.
c. As oxygen levels diminish, mental alertness will progressively deteriorate.
d. The normal respiratory rate in an adult is 10 breaths/min.
e. Episodes of apnea are present in Cheyne-Stokes.

 

 

ANS:  B, C, E

Fingernail clubbing is a sign of hypoxia. Mental status will deteriorate as the oxygen level in the body diminishes. Apnea is present in Cheyne-Stokes respirations. Central cyanosis is not observed on the fingers and earlobes. The normal respiratory rate in an adult is more than 10 breaths/min.

 

DIF:    Cognitive Level: Application          REF:   Page 466        OBJ:   1 | 2

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Gas Exchange

 

  1. What is true about arterial blood gases (ABGs)? (Select all that apply.)
a. They are measured from an arterial sample.
b. They measure partial pressures of carbon dioxide.
c. They measure blood pH.
d. They measure partial pressures of sodium.
e. They measure partial pressures of oxygen.

 

 

ANS:  A, B, C, E

ABGs are taken from samples from arterial blood, which must be drawn and analyzed immediately. ABGs measure partial pressures of carbon dioxide and bicarbonate, pH, and partial pressures of oxygen. ABGs do not measure partial pressures of sodium.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 460        OBJ:   2 | 4 | 5

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Gas Exchange

 

  1. The nurse is completing the admission of an older adult patient with a history of COPD whose diagnosis is pneumonia. Which assessments would be most important to include in obtaining the history? (Select all that apply.)
a. Smoking history and exposure to secondhand smoke
b. Current medications
c. Chief complaint and onset of symptoms
d. Support system
e. Home oxygen use
f. Liver function

 

 

ANS:  A, B, C, D, E

It is important to assess present and past respiratory history (including smoking history and exposure to secondhand smoke), obtain thorough medication history, ascertain the chief complaint and current pulmonary symptoms (including cough and sputum color), determine the patient’s support system, and ask about any home treatments when obtaining information from a patient with acute and chronic lung disease. Liver function testing is not necessary for the assessment of this patient.

 

DIF:    Cognitive Level: Application          REF:   Page 465        OBJ:   1 | 2

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety

 

  1. Which physical assessment(s) would be pertinent to the patient with asthma? (Select all that apply.)
a. Lung sounds
b. Patient color
c. Respiratory rate and effort
d. Peak expiratory flow
e. Pulse oximetry reading
f. Bowel sounds

 

 

ANS:  A, B, C, D, E

Lung sounds, pallor and color, respiratory rate and effort, peak expiratory flow, and pulse oximetry should be assessed in the patient with asthma. Assessment of bowel sounds is not pertinent.

 

DIF:    Cognitive Level: Application          REF:   Page 465        OBJ:   1 | 2

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Gas Exchange; Safety

 

  1. Which principle(s) would be when teaching a patient to use a steroid inhaler? (Select all that apply.)
a. Frequent oral hygiene is necessary.
b. The inhaler should be used on a PRN basis only.
c. Rinse and spit after inhalation of the medication.
d. When taking a steroid drug as well as a bronchodilator, the bronchodilator should be administered first.
e. Hold the breath for 10 seconds during inhalation of the medication.

 

 

ANS:  A, C, D, E

Steroid medications may predispose patients to secondary fungal infections in the mouth. To prevent this, patients should be instructed on good oral hygiene technique and told to gargle and rinse the mouth with a hydrogen peroxide mouthwash after each aerosol treatment. In addition to good oral hygiene, patients should rinse and spit after inhalation of the medication. When a bronchodilator and steroid are prescribed, the bronchodilator should be administered as the first puff of medication and, after waiting a few minutes, the steroid medication should be administered. This procedure facilitates bronchodilation so that the second medication will have a better chance of reaching lower parts of the lungs. Patients should hold their breath for 10 seconds during inhalation of the medication so that the medication is fully inhaled. Steroid inhalers should be used on a regular basis to prevent symptoms.

 

DIF:    Cognitive Level: Application          REF:   Page 468        OBJ:   6

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Health Promotion and Maintenance

NOT:  CONCEPT(S): Clinical Judgment; Patient Education; Safety; Health Promotion

 

  1. Which statement(s) about acetylcysteine is/are true? (Select all that apply.)
a. It reduces viscosity of secretions.
b. It treats acetaminophen toxicity.
c. It is stored at room temperature.
d. It is given to improve airway flow.
e. It is odorless.
f. It is administered by inhalation.

 

 

ANS:  A, B, D, F

Acetylcysteine is given to reduce the viscosity of secretions, used to treat acetaminophen toxicity, used to improve airway flow, and is a mucolytic given by inhalation. Acetylcysteine should be refrigerated after opening and has an odor similar to that of rotten eggs.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages 470-471

OBJ:   N/A                TOP:   Nursing Process Step: Planning

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Gas Exchange

 

  1. Which statement(s) about ipratropium bromide (Atrovent) is/are true? (Select all that apply.)
a. It is administered by aerosol inhalation.
b. It relieves nasal congestion.
c. It decreases mucus secretion.
d. It has minimal effect on ciliary activity.
e. It is used for short-term treatment of bronchospasm.
f. It may cause tachycardia or urinary retention.

 

 

ANS:  A, D, F

Ipratropium bromide is administered by aerosol inhalation, has minimal effect on ciliary activity, and may cause tachycardia, urinary retention, or exacerbation of pulmonary symptoms. Ipratropium bromide does not relieve nasal congestion; has minimal effect on mucous secretion, sputum volume, and viscosity; and is used as a bronchodilator for long-term treatment of reversible bronchospasm associated with COPD.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 474 | Page 475

OBJ:   5                    TOP:   Nursing Process Step: Planning

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Gas Exchange

 

  1. The nurse is preparing to administer two inhalations of ipratropium bromide (Atrovent). When providing this medication, the nurse will instruct the patient to (Select all that apply.)
a. hold the canister horizontally.
b. keep the eyes closed.
c. exhale through the mouthpiece.
d. wait 15 seconds before the second inhalation.
e. shake the canister thoroughly prior to use.

 

 

ANS:  B, D, E

The eyes should be kept closed because temporary blurred vision may result if the aerosol is sprayed into the eyes. The patient should wait approximately 15 seconds and repeat the second inhalation. The canister should be shaken thoroughly prior to use. The base of the canister should be held vertically. The patient should inhale through the mouthpiece.

 

DIF:    Cognitive Level: Application          REF:   Page 475        OBJ:   5 | 6

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Patient Education

Chapter 40: Drugs Used in Men’s and Women’s Health

Clayton/Willihnganz: Basic Pharmacology for Nurses, 17th Edition

 

MULTIPLE CHOICE

 

  1. A female patient has developed leukorrhea since being on oral broad spectrum antibiotics for the past week for a lower respiratory infection. Which organism causes leukorrhea?
a. Herpes simplex
b. Mycoplasma hominis
c. Human papillomavirus (HPV)
d. Candida albicans

 

 

ANS:  D

Candida albicans infections of the mouth, gastrointestinal tract, or vagina may develop as secondary infections during the use of broad spectrum antibiotics, such as penicillins, tetracyclines, and cephalosporins. Herpes simplex, Mycoplasma hominis, and HPV do not cause leukorrhea.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 618        OBJ:   1

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Infection

 

  1. A patient states that she has a difficult time remembering when to resume her triphasic contraceptive pills following her menses. Which alternative plan will the nurse suggest that she discuss with her health care provider?
a. Changing to the 28-day packet
b. Using the inert pills every other month
c. Changing her prescription to the mini pill
d. Calling the health care provider whenever she forgets to get appropriate instruction

 

 

ANS:  A

Using the 28-day packet would allow her to continue with the same type of combination oral contraception. The 28-day packet would allow her to continue daily pills and eliminate the need to recall. Using the inert pills on alternate months will alter her menstrual schedule. Changing to the mini pill might not meet her contraceptive needs. It is unnecessary and inappropriate to contact the provider for missed doses.

 

DIF:    Cognitive Level: Application          REF:   Pages 623-626

OBJ:   2                    TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Health Promotion and Maintenance

NOT:  CONCEPT(S): Clinical Judgment; Health Promotion; Communication; Collaboration; Adherence

 

  1. Which is more likely to be experienced by women taking the mini pill as an oral contraceptive?
a. Ovulation, dysmenorrhea, and breakthrough bleeding
b. Excessive weight gain and breast tenderness
c. Increased estrogen-related adverse effects
d. Difficulty breastfeeding after pregnancy

 

 

ANS:  A

The mini pill is made up of progestin, which inhibits ovulation. This form of contraception is an alternative for women particularly susceptible to adverse effects caused by estrogen therapy. Between 30% and 40% of women continue to ovulate with this form of contraception, however, and there is a slightly higher incidence of uterine and tubal pregnancies. Dysmenorrhea, manifested by irregular or infrequent menses and spotting between cycles, is common in women taking the mini pill. The mini pill has a reduced chance for weight gain and breast tenderness, does not contain estrogen, and does not cause difficulty with breastfeeding.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 625        OBJ:   2

TOP:   Nursing Process Step: Evaluation

MSC:  NCLEX Client Needs Category: Health Promotion and Maintenance

NOT:  CONCEPT(S): Clinical Judgment

 

  1. The nurse is obtaining a history on a patient who is seeking oral contraceptives. Which condition would contraindicate the use of oral contraceptives?
a. Sexually transmitted diseases (STDs)
b. Hypothyroidism
c. Varicose veins
d. Thromboembolic disease

 

 

ANS:  D

Women who have a history of thromboembolic disease must consult with a health care provider before obtaining a prescription for an oral contraceptive. Serious adverse effects include embolisms and thrombus formation, cardiac abnormalities, seizures, and severe depression. STDs, hypothyroidism, and varicose veins do not pose a problem with contraceptive therapy.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 625        OBJ:   2

TOP:   Nursing Process Step: Evaluation

MSC:  NCLEX Client Needs Category: Health Promotion and Maintenance

NOT:  CONCEPT(S): Clinical Judgment; Safety

 

  1. A patient diagnosed with benign prostatic hypertrophy asks why tamsulosin (Flomax), an alpha-1 adrenergic blocking agent, has been prescribed. Which explanation by the nurse is most accurate?
a. It inhibits the action of testosterone.
b. It improves sexual function.
c. It reduces the size of the prostate.
d. It increases urinary flow.

 

 

ANS:  D

Alpha-1 adrenergic blocking agents are used to relax the smooth muscle of the bladder and prostate. Tamsulosin specifically blocks alpha 1 receptors on the prostate gland and certain areas of the bladder neck, causing muscle relaxation and increased urine flow in men with enlarged prostate glands. Adrenergic blocking agents do not affect hormone production, directly affect sexual function, or affect prostate size.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 631        OBJ:   4

TOP:   Nursing Process Step: Evaluation

MSC:  NCLEX Client Needs Category: Health Promotion and Maintenance

NOT:  CONCEPT(S): Clinical Judgment; Communication; Patient Education

 

  1. Which type of drug is most effective in the treatment of erectile dysfunction (ED)?
a. Phosphodiesterase inhibitors
b. Antiandrogen agents
c. Sympathomimetic agents
d. Alpha-1 adrenergic blocking agents

 

 

ANS:  A

Sildenafil (Viagra), a phosphodiesterase inhibitor, increases cyclic guanosine monophosphate concentrations in the corpus cavernosum, which results in smooth muscle relaxation and greater blood flow into the corpus cavernosum, producing an erection. Antiandrogen agents, sympathomimetic agents, and adrenergic blocking agents are not effective in treating ED.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 634        OBJ:   5

TOP:   Nursing Process Step: Evaluation

MSC:  NCLEX Client Needs Category: Health Promotion and Maintenance

NOT:  CONCEPT(S): Clinical Judgment

 

  1. The nurse is teaching a patient beginning therapy with dutasteride (Avodart). How long will it take before the patient can expect results?
a. 24 hours
b. 2 weeks
c. 1 month
d. 6 months

 

 

ANS:  D

Longer than 6 to 12 months of treatment may be necessary to assess whether a therapeutic response has been achieved.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 633        OBJ:   4

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment

 

  1. Why must caution be used when taking a phosphodiesterase inhibitor to enhance male sexual function?
a. It can become habit forming.
b. Life-threatening consequences can occur with cardiovascular disorders.
c. It is an ineffective treatment.
d. It is expensive and available only by special prescription.

 

 

ANS:  B

The patient must consult with a health care provider before using a phosphodiesterase inhibitor. People with cardiovascular disorders are particularly susceptible to life-threatening consequences with its use. It is unlikely that a patient will develop physiologic dependence on the medication, although psychological dependence may occur. Phosphodiesterase inhibitors can be a very effective treatment for ED. Phosphodiesterase inhibitors are readily available online and are not expensive.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 635        OBJ:   5

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Perfusion; Safety; Patient Education

 

  1. What is the mechanism whereby estrogen functions as a contraceptive?
a. Inhibiting luteinizing hormone (LH), blocking release of ovum from a follicle
b. Thinning cervical mucus, which inhibits sperm migration
c. Trapping the ovum in the endometrial wall, preventing its growth
d. Blocking follicle-stimulating hormone (FSH), thereby preventing release of ovum

 

 

ANS:  D

Estrogens block pituitary release of FSH, preventing the ovaries from developing a follicle from which the ovum is released. Progestins inhibit pituitary release of LH, the hormone responsible for releasing an ovum from a follicle. Estrogens and progestins alter cervical mucus by making it thick and viscous, inhibiting sperm migration. Hormones also change the endometrial wall, impairing implantation of the fertilized ovum.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 623        OBJ:   N/A

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Reproduction

 

  1. The nurse is instructing a patient on use of a transdermal contraceptive. When evaluating the patient’s understanding of the information provided, the nurse identifies a need for further education when the patient states
a. “Apply the first patch during the first 24 hours of the menstrual period.”
b. “Use a backup contraceptive concurrently for the first 7 days of the first cycle.”
c. “Fold the used patch over on itself before discarding.”
d. “Trim the patch carefully prior to application.”

 

 

ANS:  D

Patches should not be cut. The first patch should be applied during the first 24 hours of the menstrual period. A backup contraceptive should be used concurrently for the first 7 days of the first cycle. When removing the patch, it should be folded over on itself and placed in a sturdy container.

 

DIF:    Cognitive Level: Analysis               REF:   Page 628        OBJ:   3

TOP:   Nursing Process Step: Evaluation

MSC:  NCLEX Client Needs Category: Health Promotion and Maintenance| NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety; Communication; Patient Education

 

  1. A woman using the NuvaRing vaginal ring informs the nurse that the ring was accidentally expelled a day ago. The nurse will instruct this patient to
a. rinse the ring in cool water and reinsert as soon as possible.
b. rinse the ring in hot water and reinsert as soon as possible.
c. rinse the ring in lukewarm water, reinsert, and use a nonhormonal backup contraceptive.
d. insert a new ring.

 

 

ANS:  C

If the ring is expelled for longer than 3 hours, the patient should be instructed to rinse it in cool or lukewarm water, reinsert, and use a nonhormonal backup contraceptive for the next 7 consecutive days of continuous ring use. It is not necessary to insert a new ring after a day.

 

DIF:    Cognitive Level: Application          REF:   Page 630        OBJ:   3

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Health Promotion and Maintenance| NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety; Communication; Patient Education

 

MULTIPLE RESPONSE

 

  1. The health care provider has instructed a patient to use over-the-counter miconazole (Monistat) cream to treat her vaginal yeast infection. What information is important to include in patient education? (Select all that apply.)
a. Wash the genital area thoroughly before inserting the vaginal cream.
b. Wash the applicator before usage.
c. Wear a minipad to catch remaining discharge following vaginal administration.
d. Wash hands before and after administration.
e. The sexual partner may require treatment as well.

 

 

ANS:  A, C, D, E

It is imperative that proper cleansing of the genital area be done regularly using soap and water; rinse and dry well. A minipad should be worn to catch remaining discharge. Hands should be washed before and after medication insertion and before and after toileting. Both partners in a sexual relationship require treatment. The male partner may require oral anti-infectives. The vaginal applicator should be thoroughly washed with soap and water after each use and then dried.

 

DIF:    Cognitive Level: Application          REF:   Page 622        OBJ:   1

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Health Promotion and Maintenance

NOT:  CONCEPT(S): Clinical Judgment; Safety; Communication; Patient Education

 

  1. A nurse working at the community health clinic receives a call from a teen patient who reports that she has missed one of her birth control pills. Which response by the nurse is accurate? (Select all that apply.)
a. Take the missed pill now.
b. Take the next pill at the regularly scheduled time.
c. Come into the clinic for a pregnancy test.
d. Start with the next month’s pill packet at day 1.
e. Take the missed pill and the next pill together at the next regularly scheduled time.

 

 

ANS:  A, B

If a patient misses one pill, she should take the missed pill immediately. Even if a patient misses one pill, she should take the next pill for that day on time after taking the missed pill immediately. A pregnancy test is not necessary. Starting the next month’s pill packet at day 1 is not the appropriate action to take. Taking both the missed pill and the next pill at the next scheduled time is not the appropriate action to take.

 

DIF:    Cognitive Level: Application          REF:   Page 626        OBJ:   2

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Health Promotion and Maintenance

NOT:  CONCEPT(S): Clinical Judgment; Safety; Communication; Patient Education

 

  1. The nurse is completing a female reproductive history on a 16 year old. What important assessment(s) should be included? (Select all that apply.)
a. Breast self-examination (BSE) routine
b. Age of menarche and pattern of menses
c. Smoking and blood pressure history when seeking a prescription for oral contraceptive pills (OCPs)
d. Sexual orientation and number of partners
e. Number of pregnancies, live births, miscarriages, and abortions
f. Nutritional intake of carbohydrates

 

 

ANS:  A, B, C, D, E

All women of reproductive age should perform regular BSEs. Onset and pattern of menses provide baseline assessments for future comparison. OCPs are contraindicated in women who smoke or have hypertension. Sexual orientation and number of partners provide a baseline assessment for future STD assessments. Gestational history provides baseline information for future pregnancies. Nutritional intake of carbohydrates is not included when obtaining a female reproductive history.

 

DIF:    Cognitive Level: Application          REF:   Page 618 | Page 619

OBJ:   N/A                TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Health Promotion and Maintenance

NOT:  CONCEPT(S): Clinical Judgment; Safety; Communication; Patient Education

 

  1. The nurse is giving instructions to a young female at an outpatient clinic regarding combination OCP therapy. What information will the nurse include? (Select all that apply.)
a. Medication should be taken at approximately the same time daily.
b. A backup birth control method should be used for the first 6 months.
c. Medication should be discontinued 1 year before attempting pregnancy.
d. Headaches, dizziness, and chest or abdominal pain should be reported immediately.
e. If a pill is missed, take it immediately and remain on schedule for the next dosage.

 

 

ANS:  A, D, E

Medications should be taken at approximately the same time daily. Headaches, dizziness, and chest or abdominal pain should be reported immediately to the health care provider because these may be symptoms of a serious adverse effect. If one pill is missed, patients are directed to take it as soon as possible and continue with their normal schedule. If more than one pill is missed and a period is skipped, patients should return to their health care provider for a pregnancy test before restarting contraception. A backup contraceptive method is recommended at any point with OCP therapy. Because of a possibility of birth defects, the pill should be discontinued 3 months before attempting pregnancy.

 

DIF:    Cognitive Level: Application          REF:   Pages 625-627

OBJ:   2                    TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Health Promotion and Maintenance

NOT:  CONCEPT(S): Clinical Judgment; Safety; Communication; Patient Education

 

  1. The nurse will teach the patient beginning therapy with alfuzosin, an alpha-1 adrenergic blocking agent, to expect which common (and usually self-limiting) adverse effect(s)? (Select all that apply.)
a. Nausea
b. Insomnia
c. Dizziness
d. Headache
e. Lethargy
f. Anorexia

 

 

ANS:  C, D, E

Dizziness, headache, and lethargy are adverse effects of treatment with alfuzosin. Nausea, insomnia, and anorexia are not adverse effects of treatment with alfuzosin.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages 631-632

OBJ:   4                    TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety; Communication; Patient Education

 

  1. The nurse at an outpatient clinic is educating a group of young adults regarding prevention of the spread of sexually transmitted infections. Information will include (Select all that apply.)
a. the use of hormonal contraceptives.
b. the use of latex condoms when infection is present.
c. abstinence.
d. frequent use of nonoxynol 9.
e. the importance of “partner services.”

 

 

ANS:  C, E

Abstinence will prevent sexually transmitted infections, and use of sexual abstinence during the communicable phase of any disease will prevent reinfection. All sexual partners need to understand the importance of “partner services,” the documentation of all sexual partners for the purpose of providing evaluation and treatment. Hormonal contraceptives do not prevent sexually transmitted infections. When infections are present, abstain from sexual intercourse. A recent study indicates that frequent use of nonoxynol 9 may actually increase the risk of HIV infection during vaginal intercourse because of irritation of vaginal tissues.

 

DIF:    Cognitive Level: Application          REF:   Page 622        OBJ:   1

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Health Promotion and Maintenance| NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Safety; Communication; Patient Education; Infection

Chapter 48: Substance Abuse

Clayton/Willihnganz: Basic Pharmacology for Nurses, 17th Edition

 

MULTIPLE CHOICE

 

  1. A 16-year-old male has been referred to the community mental health center following legal charges of driving under the influence. Which screening tests would be appropriate to use on this patient?
a. Drug Abuse Screening Test (DAST)
b. Adolescent Alcohol Involvement Scale (AAIS)
c. Adolescent Drug Abuse Diagnosis (ADAD)
d. Minnesota Multiphasic Personality Inventory (MMPI 2)

 

 

ANS:  B

The adolescent patient has legal problems associated with alcohol use. The AAIS screening instrument would be appropriate to use. DAST is a comprehensive screening and assessment instrument. ADAD is an adolescent drug abuse diagnosis instrument. MMPI is a personality inventory.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 777        OBJ:   2

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

NOT:  CONCEPT(S): Clinical Judgment; Addiction

 

  1. A patient admitted 48 hours ago has a diagnosis of gastrointestinal (GI) bleeding and is receiving IV hydration and transfusions. When making rounds, the nurse observes the patient to be having a tonic-clonic seizure. What may be the cause of the seizure?
a. Low blood counts as a result of bleeding
b. Alcohol withdrawal
c. Alkalosis
d. Inadequate nutrition

 

 

ANS:  B

Alcohol withdrawal symptoms can begin within a few hours of discontinuation of drinking and may continue for 3 to 10 days. Withdrawal symptoms may be severe and include visual and auditory hallucinations and tonic-clonic seizures. The patient’s admitting diagnosis, GI bleeding, may be associated with alcohol abuse. Denial is a common symptom associated with alcoholism, and the patient may not have been honest about alcohol intake when the health care provider took the history on admission. History may be obtained from the patient’s family or significant other. It is unlikely that the blood loss is significant enough to induce seizures. Alkalosis is not likely the cause of seizures in this case; the patient is more likely to be acidotic from the combined dehydration and withdrawal. Common causes in the setting of alcohol withdrawal include alcoholic ketoacidosis and ingestion of alcohols or medications that result in metabolic acidosis (e.g., methanol, ethylene glycol, salicylate). Inadequate nutrition is not likely to cause seizures in this patient.

 

DIF:    Cognitive Level: Application          REF:   Page 780        OBJ:   5

TOP:   Nursing Process Step: Evaluation

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

NOT:  CONCEPT(S): Clinical Judgment; Addiction

 

  1. A nurse working the night shift suspects that a colleague is abusing alcohol. Which action by the nurse is most important?
a. “Good faith” reporting is unfaithful to a colleague.
b. Reporting will result in loss of the colleague’s license.
c. It is not of concern, and the nurse won’t be penalized for refusing to get involved.
d. State guidelines may mandate to report substance abuse.

 

 

ANS:  D

In some states, when substance abuse of a colleague is suspected, reporting is mandatory. Professionals must be loyal to their patients and protect them from harm. “Good faith” reporting should not be viewed as disloyalty to a colleague. Licenses are often not revoked when a colleague self-reports or is reported for substance abuse. Health professionals may be named in a civil lawsuit if they fail to report suspected impairment of another professional.

 

DIF:    Cognitive Level: Analysis               REF:   Page 778        OBJ:   3

TOP:   Nursing Process Step: Planning

MSC:  NCLEX Client Needs Category: Safe, Effective Care Environment

NOT:  CONCEPT(S): Clinical Judgment; Addiction; Health Care Law

 

  1. What does a urinalysis that is positive for the drug tested indicate?
a. It indicates illegal drug use.
b. It verifies drug dependency.
c. It is a violation of the individual’s constitutional rights.
d. It verifies whether the drug is present in the specimen.

 

 

ANS:  D

Positive urinalysis simply indicates the presence of the drug being tested for in the urine specimen. The person may have a prescription for a substance found in the urine or may have been accidentally dosed with it. Presence of the substance in the urine does not indicate dependence because the person may only be an episodic user of the substance. Asking for the person’s permission to collect a specimen and examine it does not violate the person’s constitutional rights. The Supreme Court has ruled that drug screening does not violate one’s constitutional right to privacy or represent an unreasonable search.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 779        OBJ:   N/A

TOP:   Nursing Process Step: Evaluation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Addiction

 

  1. What will the nurse instruct patients who are on daily disulfiram (Antabuse) to avoid?
a. All forms of cough syrup
b. Alcohol
c. Benzodiazepines
d. Aspirin products

 

 

ANS:  B

Disulfiram is used to reduce the desire for alcohol by inducing severe nausea and vomiting when a patient ingests alcohol while on this drug. Reactions can be quite severe, and patients must understand the need to avoid all forms of alcohol while taking this medication. Not all cough syrups contain alcohol. Benzodiazepines and aspirin do not react with disulfiram.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 791        OBJ:   5

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Addiction; Safety; Patient Education

 

  1. Which protects individuals who have been successfully rehabilitated from substance abuse from discrimination related to past addiction?
a. Americans with Disabilities Act (ADA)
b. National Council on Alcoholism and Drug Dependence
c. Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF)
d. American Medical Association (AMA)

 

 

ANS:  A

Persons dependent on drugs, but who are no longer using drugs illegally and are receiving treatment for chemical dependence, or who have been rehabilitated successfully are protected by the ADA from discrimination on the basis of past drug addiction. The National Council on Alcoholism and Drug Dependence is a voluntary health agency dedicated to educating the public about alcoholism. The ATF is a principal law enforcement agency in the U.S. Department of Justice dedicated to preventing terrorism, reducing violent crime, and protecting the United States. The AMA is a professional organization for physicians.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 778        OBJ:   1

TOP:   Nursing Process Step: Planning

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Addiction; Health Care Law

 

  1. What must be administered before glucose infusions for a patient in alcohol withdrawal to prevent Wernicke’s encephalopathy?
a. Chlordiazepoxide (Librium)
b. Thiamine
c. Diazepam (Valium)
d. Bromocriptine (Parlodel)

 

 

ANS:  B

Thiamine and multiple vitamins should be administered routinely to patients in alcohol withdrawal. Intravenous fluid therapy for rehydration may be necessary, but thiamine must be administered before glucose infusion to prevent Wernicke’s encephalopathy. Benzodiazepines are given for treatment of anxiety and seizures associated with alcohol withdrawal. Bromocriptine is not used to prevent Wernicke’s encephalopathy.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 780        OBJ:   5

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Addiction; Safety

 

  1. What effect will occur if a patient being treated with naltrexone (ReVia) for substance abuse ingests opioids or alcohol?
a. Increased euphoria
b. Nausea, vomiting, and diarrhea
c. Deep sedation
d. An absence of the “high” associated with drugs

 

 

ANS:  D

Naltrexone is an opioid antagonist prescribed to block the pharmacologic effects of the “high” associated with opioids and alcohol. Studies report less alcohol craving and fewer drinking days, especially when naltrexone is combined with psychosocial treatment. Naltrexone prevents the euphoria associated with taking drugs like opioids and alcohol. These are symptoms of taking alcohol in combination with disulfiram (Antabuse). Naltrexone is not sedating.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 781 | Page 782

OBJ:   5                    TOP:   Nursing Process Step: Evaluation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Addiction

 

  1. A patient is admitted into a substance abuse treatment center and is withdrawing from alcohol. Which statement made by the patient’s family member shows a need for further education?
a. “Withdrawal symptoms can begin within a few hours of discontinuation of drinking.”
b. “Withdrawal symptoms will improve within 24 hours.”
c. “Less than 1% of patients develop delirium tremens.”
d. “Benzodiazepines are commonly used for detoxification.”

 

 

ANS:  B

Withdrawal symptoms may continue for 3 to 10 days. Withdrawal symptoms can begin within a few hours of discontinuation of drinking. Less than 1% of patients develop delirium tremens. Benzodiazepines are commonly used for detoxification.

 

DIF:    Cognitive Level: Analysis               REF:   Page 780        OBJ:   5

TOP:   Nursing Process Step: Evaluation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Addiction; Safety; Communication

 

  1. The nurse is assisting with the development of care plan for a patient withdrawing from cocaine. What would be the first nursing diagnosis priority for this patient?
a. Altered nutrition; less than body requirements
b. Risk for altered peripheral tissue perfusion
c. Risk for fluid volume deficit
d. High risk for self-directed violence

 

 

ANS:  D

Depression with suicidal ideation is generally the most serious problem associated with cocaine withdrawal. Altered nutrition, risk for altered peripheral tissue perfusion, and risk for fluid volume deficit are not the priorities for a patient withdrawing from cocaine.

 

DIF:    Cognitive Level: Analysis               REF:   Page 785        OBJ:   5

TOP:   Nursing Process Step: Diagnosis

MSC:  NCLEX Client Needs Category: Safe, Effective Care Environment

NOT:  CONCEPT(S): Clinical Judgment; Addiction; Safety; Interpersonal Violence

 

  1. The nurse is transcribing an order for disulfiram on a patient in alcohol rehabilitation. When planning the time of day to administer this medication the nurse will document that disulfiram be given
a. before breakfast.
b. with lunch.
c. before dinner.
d. at bedtime.

 

 

ANS:  D

Disulfiram should be administered at bedtime to avoid the complications of sedative effects.

 

DIF:    Cognitive Level: Application          REF:   Page 791        OBJ:   5

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Safe, Effective Care Environment

NOT:  CONCEPT(S): Clinical Judgment; Addiction; Safety

 

  1. Which patient assessment will the nurse expect to observe when a patient has ingested alcohol while on disulfiram (Antabuse)?
a. Unconsciousness
b. Hypertension
c. GI bleeding
d. Severe vomiting

 

 

ANS:  D

Severe vomiting occurs when alcohol is ingested while a patient is on disulfiram therapy. Disulfiram blocks the metabolism of acetaldehyde, a metabolite of alcohol. Elevated levels of acetaldehyde produce a reaction causing nausea, severe vomiting, sweating, throbbing headache, dizziness, blurred vision, and confusion. Disulfiram will not generally cause unconsciousness when alcohol is ingested with it, does not cause hypertension when taken in combination with alcohol, and does not cause GI bleeding.

 

DIF:    Cognitive Level: Application          REF:   Page 791        OBJ:   5

TOP:   Nursing Process Step: Evaluation

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

NOT:  CONCEPT(S): Clinical Judgment; Addiction

 

  1. What is the rationale for administering acamprosate (Campral)?
a. Withdrawal from alcohol addiction
b. Maintenance of sobriety
c. Improvement of renal function
d. Correction of electrolyte imbalances

 

 

ANS:  B

Acamprosate is used in alcohol rehabilitation programs for chronic alcoholics who want to maintain sobriety. Drugs likely to be given during withdrawal from alcohol addiction include anticonvulsants, thiamine, benzodiazepines, and beta blockers. Acamprosate does not improve renal function. Acamprosate does not correct electrolyte imbalances.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 790        OBJ:   4

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Addiction

 

MULTIPLE RESPONSE

 

  1. What important point(s) of patient education should be included about disulfiram (Antabuse) therapy? (Select all that apply.)
a. The patient should return for liver function tests in 10 to 14 days following initiation of therapy.
b. Headache, fatigue, and a metallic taste are common adverse effects that usually resolve.
c. Avoid alcohol ingestion to prevent a reaction.
d. Carefully read all labels for possible alcohol content, including perfumes and over-the-counter (OTC) medications such as cough syrups.
e. Report to the health care provider any allergic symptoms, such as hives or pruritus.

 

 

ANS:  A, B, C, D

Baseline laboratory data include liver function tests and alcohol screening. Headache, fatigue, and a metallic taste are common adverse effects of disulfiram. Disulfiram is a drug used to treat chronic alcoholism that produces a very unpleasant reaction to alcohol. Patients should be instructed to read all labels of topical substances and OTC drugs for alcohol content, as well as avoiding any foods that may be prepared with alcohol. Disulfiram is unlikely to cause allergic reactions.

 

DIF:    Cognitive Level: Application          REF:   Page 791        OBJ:   5

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Addiction; Safety Patient Education

 

  1. A health professional colleague is suspected of having a substance abuse problem because of the person’s frequent absenteeism, mood swings when at work, diminished alertness, and poor patient care. Which action(s) will the nurse take? (Select all that apply.)
a. Confront the individual.
b. Document specific examples of inappropriate actions.
c. Avoid assigning this individual to patients with narcotic medication orders or high acuities.
d. Notify law enforcement of the suspicions.
e. Submit a confidential report to an appropriate supervisor.

 

 

ANS:  B, E

Observation and documentation are crucial to building a record of repeat instances over time to support the suspicion of impairment. Examples of inappropriate actions need to be well documented over time. An accurate record can also be useful in helping the impaired individual to recognize the problems and submit voluntarily to treatment. If a health professional suspects that a colleague is impaired, a confidential report should be made to an appropriate supervisor familiar with institutional policy. Confronting the individual, avoiding assigning this individual to patients with narcotic medication orders or high acuities, and notifying law enforcement of the suspicions are not appropriate actions to take.

 

DIF:    Cognitive Level: Application          REF:   Page 778 | Page 779

OBJ:   3                    TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

NOT:  CONCEPT(S): Clinical Judgment; Addiction; Safety

 

  1. A patient has completed substance abuse treatment for alcoholism. What will assist in long-term goal attainment and promote abstinence? (Select all that apply.)
a. Naltrexone therapy
b. Regular attendance at NA
c. Regular contact with his program sponsor
d. Following the 12-step program of AA
e. Diazepam therapy to reduce the likelihood of DTs

 

 

ANS:  A, C, D

Treatment may require pharmacologic treatment, such as disulfiram or naltrexone therapy. Regular contact with a sponsor provides support and continuity in the process of maintaining sobriety. Treatment requires lifelong effort with a combination of psychosocial support; use of the 12-step program will assist the patient in maintaining recovery. NA stands for Narcotics Anonymous; this patient should attend meetings of AA, or Alcoholics Anonymous. Diazepam has a high potential for abuse and should not be used with recovering addicts.

 

DIF:    Cognitive Level: Application          REF:   Pages 781-782

OBJ:   4                    TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

NOT:  CONCEPT(S): Clinical Judgment; Addiction; Health Promotion

 

  1. Clonidine (Catapres) is used in treating which opioid withdrawal symptom(s)? (Select all that apply.)
a. Hypertension
b. Tremors
c. Agitation
d. Depression
e. Sweating
f. Nausea

 

 

ANS:  B, C, E

Clonidine is useful in decreasing tremors, agitation, and sweating associated with opioid withdrawal. Clonidine does not have a hypotensive effect, treat depression, or alleviate nausea.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 782        OBJ:   5

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

NOT:  CONCEPT(S): Clinical Judgment; Addiction

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