Chapter 6 My Nursing Test Banks

 

Adams, Pharmacology for Nurse: A Pathophysiologic Approach, 4/E
Chapter 6

Question 1

Type: MCSA

The nurse follows the nursing process when conducting medication education about insulin. The step of evaluation is best demonstrated by which question?

1. Is your abdomen the best place to inject insulin?

2. What questions do you have about insulin?

3. Can you recognize when you are experiencing hypoglycemia?

4. Can you tell me four points you remember about how to take your insulin?

Correct Answer: 4

Rationale 1: The nurse is evaluating the effectiveness of medication education by asking the patient for feedback from the education provided. Asking the patient what questions she has about insulin is an assessment question. Asking the patient if her abdomen is the best place to inject insulin is an assessment question. Asking the patient if she can recognize when she is experiencing hypoglycemia is an assessment question.

Rationale 2: The nurse is evaluating the effectiveness of medication education by asking the patient for feedback from the education provided. Asking the patient what questions she has about insulin is an assessment question. Asking the patient if her abdomen is the best place to inject insulin is an assessment question. Asking the patient if she can recognize when she is experiencing hypoglycemia is an assessment question.

Rationale 3: The nurse is evaluating the effectiveness of medication education by asking the patient for feedback from the education provided. Asking the patient what questions she has about insulin is an assessment question. Asking the patient if her abdomen is the best place to inject insulin is an assessment question. Asking the patient if she can recognize when she is experiencing hypoglycemia is an assessment question.

Rationale 4: The nurse is evaluating the effectiveness of medication education by asking the patient for feedback from the education provided. Asking the patient what questions she has about insulin is an assessment question. Asking the patient if her abdomen is the best place to inject insulin is an assessment question. Asking the patient if she can recognize when she is experiencing hypoglycemia is an assessment question.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 6-1

Question 2

Type: MCMA

The nurse assesses the patient with diabetes mellitus prior to administering medications. Which questions are important to ask the patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

 

Standard Text: Select all that apply.

1. Are you allergic to any medications?

2. Are you taking any herbal or over-the-counter medications?

3. How difficult is it for you to maintain your ideal body weight?

4. Will you please tell me about the kind of diet you follow?

5. What other medications are you currently taking?

Correct Answer: 1,2,5

Rationale 1: These questions refer specifically to medications. Diet and ideal body weight are important questions, but do not refer specifically to medication administration.

Rationale 2: These questions refer specifically to medications. Diet and ideal body weight are important questions, but do not refer specifically to medication administration.

Rationale 3: These questions refer specifically to medications. Diet and ideal body weight are important questions, but do not refer specifically to medication administration.

Rationale 4: These questions refer specifically to medications. Diet and ideal body weight are important questions, but do not refer specifically to medication administration.

Rationale 5: These questions refer specifically to medications. Diet and ideal body weight are important questions, but do not refer specifically to medication administration.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-2

Question 3

Type: MCSA

The physician has prescribed a nitroglycerine (Nitrodur) patch for the patient. What is the best outcome for this patient as it relates to use of the medication?

1. Patient will be able to identify the expiration date of the medication prior to discharge.

2. Patient will verbalize three side effects of the medication prior to discharge.

3. Patient will state the reason for receiving the medication prior to discharge.

4. Patient will demonstrate correct application of the patch prior to discharge.

Correct Answer: 4

Rationale 1: It is important for the patient using a transdermal medication to be able to correctly apply the patch. The patient does not need to identify side effects of the medication in order to correctly apply the patch. The patient does not need to state the reason for the medication in order to correctly apply the patch. The patient does not need to identify the expiration date of the medication in order to correctly apply the patch.

Rationale 2: It is important for the patient using a transdermal medication to be able to correctly apply the patch. The patient does not need to identify side effects of the medication in order to correctly apply the patch. The patient does not need to state the reason for the medication in order to correctly apply the patch. The patient does not need to identify the expiration date of the medication in order to correctly apply the patch.

Rationale 3: It is important for the patient using a transdermal medication to be able to correctly apply the patch. The patient does not need to identify side effects of the medication in order to correctly apply the patch. The patient does not need to state the reason for the medication in order to correctly apply the patch. The patient does not need to identify the expiration date of the medication in order to correctly apply the patch.

Rationale 4: It is important for the patient using a transdermal medication to be able to correctly apply the patch. The patient does not need to identify side effects of the medication in order to correctly apply the patch. The patient does not need to state the reason for the medication in order to correctly apply the patch. The patient does not need to identify the expiration date of the medication in order to correctly apply the patch.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 6-4

Question 4

Type: MCSA

The patient is receiving albuterol (Proventil) for treatment of bronchospasm related to asthma. What is the initial nursing intervention as it relates to this medication?

1. Monitor the patient for relief of bronchospasms.

2. Monitor the patient for nausea and headache.

3. Monitor the patients serum drug levels.

4. Provide the patient with age-appropriate education about albuterol (Proventil).

Correct Answer: 1

Rationale 1: Monitoring drug effects, in this case, the relief of bronchospasms, is a primary intervention that nurses perform. Nausea and headache are expected side effects, but monitoring for these side effects is not part of the initial intervention. Education about medication is important, but is not part of the initial intervention. Monitoring of serum drug levels for albuterol (Proventil) is not indicated.

Rationale 2: Monitoring drug effects, in this case, the relief of bronchospasms, is a primary intervention that nurses perform. Nausea and headache are expected side effects, but monitoring for these side effects is not part of the initial intervention. Education about medication is important, but is not part of the initial intervention. Monitoring of serum drug levels for albuterol (Proventil) is not indicated.

Rationale 3: Monitoring drug effects, in this case, the relief of bronchospasms, is a primary intervention that nurses perform. Nausea and headache are expected side effects, but monitoring for these side effects is not part of the initial intervention. Education about medication is important, but is not part of the initial intervention. Monitoring of serum drug levels for albuterol (Proventil) is not indicated.

Rationale 4: Monitoring drug effects, in this case, the relief of bronchospasms, is a primary intervention that nurses perform. Nausea and headache are expected side effects, but monitoring for these side effects is not part of the initial intervention. Education about medication is important, but is not part of the initial intervention. Monitoring of serum drug levels for albuterol (Proventil) is not indicated.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6-5

Question 5

Type: MCSA

The patient is receiving an oral antibiotic as treatment for cellulitis of the lower extremity. The patients outcome is Patient will state a key point about antibiotic treatment for cellulitis. Which statement by the patient provides the best evaluation by the nurse at this time?

1. If the pain gets too bad, I can take my prescribed pain medication.

2. If the swelling continues, I can apply an ice pack.

3. I need to take all the pills even if my leg looks better.

4. I must keep my leg elevated until the swelling goes down.

Correct Answer: 3

Rationale 1: Taking all the medication even if the leg looks better is a key point about antibiotic therapy and meets the patients outcome. Keeping the leg elevated does not address the outcome for antibiotic treatment. Applying an ice pack does not address the outcome for antibiotic treatment. Taking pain medication does not address the outcome for antibiotic treatment.

Rationale 2: Taking all the medication even if the leg looks better is a key point about antibiotic therapy and meets the patients outcome. Keeping the leg elevated does not address the outcome for antibiotic treatment. Applying an ice pack does not address the outcome for antibiotic treatment. Taking pain medication does not address the outcome for antibiotic treatment.

Rationale 3: Taking all the medication even if the leg looks better is a key point about antibiotic therapy and meets the patients outcome. Keeping the leg elevated does not address the outcome for antibiotic treatment. Applying an ice pack does not address the outcome for antibiotic treatment. Taking pain medication does not address the outcome for antibiotic treatment.

Rationale 4: Taking all the medication, even if the leg looks better is a key point about antibiotic therapy and meets the patients outcome. Keeping the leg elevated does not address the outcome for antibiotic treatment. Applying an ice pack does not address the outcome for antibiotic treatment. Taking pain medication does not address the outcome for antibiotic treatment.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 6-6

Question 6

Type: MCMA

The physician has prescribed quetiapine (Seroquel) for the patient with chronic auditory hallucinations. The patient has stopped taking the medication. The nurse incorrectly uses the diagnosis of noncompliance. What is essential for the nurse to assess prior to using this nursing diagnosis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

 

Standard Text: Select all that apply.

1. Do cultural or religious issues have an impact on taking the medication?

2. Has the patient made an informed decision not to take the medication?

3. Is the noncompliance related to a lack of finances?

4. Did the patient understand why the medication had been prescribed?

5. Are side effects causing the patient to refuse the medication?

Correct Answer: 1,3,4,5

Rationale 1: A lack of understanding of the reason the medication was prescribed, the occurrence of side effects, cultural or religious issues, and a lack of finances, can all contribute to noncompliance with medications. Noncompliance assumes that the patient has been properly educated about the medication and has made an informed decision not to take it. The nursing diagnosis of noncompliance would not be appropriate in this case.

Rationale 2: A lack of understanding of the reason the medication was prescribed, the occurrence of side effects, cultural or religious issues, and a lack of finances can all contribute to noncompliance with medications. Noncompliance assumes that the patient has been properly educated about the medication and has made an informed decision not to take it. The nursing diagnosis of noncompliance would not be appropriate in this case.

Rationale 3: A lack of understanding of the reason the medication was prescribed, the occurrence of side effects, cultural or religious issues, and a lack of finances can all contribute to noncompliance with medications. Noncompliance assumes that the patient has been properly educated about the medication and has made an informed decision not to take it. The nursing diagnosis of noncompliance would not be appropriate in this case.

Rationale 4: A lack of understanding of the reason the medication was prescribed, the occurrence of side effects, cultural or religious issues, and a lack of finances can all contribute to noncompliance with medications. Noncompliance assumes that the patient has been properly educated about the medication and has made an informed decision not to take it. The nursing diagnosis of noncompliance would not be appropriate in this case.

Rationale 5: A lack of understanding of the reason the medication was prescribed, the occurrence of side effects, cultural or religious issues, and a lack of finances can all contribute to noncompliance with medications. Noncompliance assumes that the patient has been properly educated about the medication and has made an informed decision not to take it. The nursing diagnosis of noncompliance would not be appropriate in this case.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-2

Question 7

Type: MCSA

The nurse is preparing for medication administration to a group of patients. What is the best overall outcome for the patients?

1. Patients will take the medications after receiving medication instruction.

2. Patients will receive the best therapeutic outcome from the medications.

3. Patients will state the reason they are receiving the medications.

4. Patients will experience minimal side effects after taking the medications.

Correct Answer: 2

Rationale 1: Outcomes should focus first on the therapeutic outcome of the medications. The fact that the patient takes the medication is not the best overall outcome for the patients. The treatment of side effects is not the best overall outcome for the patients. Having the patients state the reason they are receiving the medications is the best overall outcome for the patients.

Rationale 2: Outcomes should focus first on the therapeutic outcome of the medications. The fact that the patient takes the medication is not the best overall outcome for the patients. The treatment of side effects is not the best overall outcome for the patients. Having the patients state the reason they are receiving the medications is the best overall outcome for the patients.

Rationale 3: Outcomes should focus first on the therapeutic outcome of the medications. The fact that the patient takes the medication is not the best overall outcome for the patients. The treatment of side effects is not the best overall outcome for the patients. Having the patients state the reason they are receiving the medications is the best overall outcome for the patients.

Rationale 4: Outcomes should focus first on the therapeutic outcome of the medications. The fact that the patient takes the medication is not the best overall outcome for the patients. The treatment of side effects is not the best overall outcome for the patients. Having the patients state the reason they are receiving the medications is the best overall outcome for the patients.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 6-4

Question 8

Type: MCSA

The nurse is managing care for several patients at a diabetic treatment center. What is the primary intervention for the nurse?

1. To administer the correct medicine to the correct patient at the correct dose and the correct time via the correct route

2. To return the patient to an optimum level of wellness while limiting adverse effects related to the patients medical diagnosis

3. To include any cultural or ethnic preferences in the administration of the medication

4. To answer any questions the patient may have about the medicine, or any possible side effect of the medication

Correct Answer: 2

Rationale 1: Interventions are aimed at returning the patient to an optimum level of wellness and limiting adverse effects related to the patients medical diagnosis or condition. The correct patient, dose, and time refer to the five rights of medication administration and, while important, is not the best, overall nursing intervention. Answering questions the patient may have is an appropriate intervention, but is not the best overall intervention. While important to include cultural and ethnic preferences, this is not the best overall intervention.

Rationale 2: Interventions are aimed at returning the patient to an optimum level of wellness and limiting adverse effects related to the patients medical diagnosis or condition. The correct patient, dose, and time refer to the five rights of medication administration and, while important, is not the best, overall nursing intervention. Answering questions the patient may have is an appropriate intervention, but is not the best overall intervention. While important to include cultural and ethnic preferences, this is not the best overall intervention.

Rationale 3: Interventions are aimed at returning the patient to an optimum level of wellness and limiting adverse effects related to the patients medical diagnosis or condition. The correct patient, dose, and time refer to the five rights of medication administration and, while important, is not the best, overall nursing intervention. Answering questions the patient may have is an appropriate intervention, but is not the best overall intervention. While important to include cultural and ethnic preferences, this is not the best overall intervention.

Rationale 4: Interventions are aimed at returning the patient to an optimum level of wellness and limiting adverse effects related to the patients medical diagnosis or condition. The correct patient, dose, and time refer to the five rights of medication administration and, while important, is not the best, overall nursing intervention. Answering questions the patient may have is an appropriate intervention, but is not the best overall intervention. While important to include cultural and ethnic preferences, this is not the best overall intervention.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6-5

Question 9

Type: MCSA

What is the most significant role for nurses as defined by state nurse practice acts and by regulating bodies such as The Joint Commission (TJC)?

1. Planning care

2. Teaching

3. Assessment

4. Evaluating care

Correct Answer: 2

Rationale 1: State nurse practice acts and regulating bodies such as the Joint Commission consider teaching to be a primary role for nurses, giving it the weight of law and key important accreditation standards. Assessment, planning, and evaluation are important, but not the most significant roles of the nurse according to state nurse practice acts and Joint Commission.

Rationale 2: State nurse practice acts and regulating bodies such as the Joint Commission consider teaching to be a primary role for nurses, giving it the weight of law and key important accreditation standards. Assessment, planning, and evaluation are important, but not the most significant roles of the nurse according to state nurse practice acts and Joint Commission.

Rationale 3: State nurse practice acts and regulating bodies such as the Joint Commission consider teaching to be a primary role for nurses, giving it the weight of law and key important accreditation standards. Assessment, planning, and evaluation are important, but not the most significant roles of the nurse according to state nurse practice acts and Joint Commission.

Rationale 4: State nurse practice acts and regulating bodies such as the Joint Commission consider teaching to be a primary role for nurses, giving it the weight of law and key important accreditation standards. Assessment, planning, and evaluation are important, but not the most significant roles of the nurse according to state nurse practice acts and Joint Commission.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 6-5

Question 10

Type: MCSA

The Joint Commission (TJC) documented that patient education was deficient on several medical-surgical units of a local hospital. A nursing committee was formed to address this problem and focused on what likely nursing intervention?

1. Providing educational pamphlets about medications to the patients.

2. Asking the physicians to provide medication education to the patients.

3. Discussing medications each time they are administered to patients.

4. Requesting more frequent pharmacy consults for the patients.

Correct Answer: 3

Rationale 1: Discussing medications each time they are administered is an effective way to increase the amount of education provided. Medication education is considered to be a responsibility of the nurse, not the physician or pharmacist. Educational pamphlets can be effective, but are not as effective as the nurse providing education to the patient.

Rationale 2: Discussing medications each time they are administered is an effective way to increase the amount of education provided. Medication education is considered to be a responsibility of the nurse, not the physician or pharmacist. Educational pamphlets can be effective, but are not as effective as the nurse providing education to the patient.

Rationale 3: Discussing medications each time they are administered is an effective way to increase the amount of education provided. Medication education is considered to be a responsibility of the nurse, not the physician or pharmacist. Educational pamphlets can be effective, but are not as effective as the nurse providing education to the patient.

Rationale 4: Discussing medications each time they are administered is an effective way to increase the amount of education provided. Medication education is considered to be a responsibility of the nurse, not the physician or pharmacist. Educational pamphlets can be effective, but are not as effective as the nurse providing education to the patient.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6-5

Question 11

Type: MCSA

The nurse has several educational pamphlets for the patient about medications the patient is receiving. Prior to giving the patient these pamphlets, what is a primary assessment for the nurse?

1. Assess the patients readiness to learn new information.

2. Assess the patients religious attitudes toward medicine.

3. Assess the patients reading level.

4. Assess the patients cultural bias toward taking medicine.

Correct Answer: 3

Rationale 1: Educational pamphlets are ineffective if the reading level is above what the patient can understand. Assessing the patients readiness to learn, cultural bias, and religious attitudes are important, but not as important as the patients reading level.

Rationale 2: Educational pamphlets are ineffective if the reading level is above what the patient can understand. Assessing the patients readiness to learn, cultural bias, and religious attitudes are important, but not as important as the patients reading level.

Rationale 3: Educational pamphlets are ineffective if the reading level is above what the patient can understand. Assessing the patients readiness to learn, cultural bias, and religious attitudes are important, but not as important as the patients reading level.

Rationale 4: Educational pamphlets are ineffective if the reading level is above what the patient can understand. Assessing the patients readiness to learn, cultural bias, and religious attitudes are important, but not as important as the patients reading level.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-2

Question 12

Type: MCSA

The nurse is caring for an adolescent with depression and suicidal thoughts. The nursing diagnosis is Risk for Suicide related to depression. What is the best outcome for this adolescent?

1. The patient will discuss his feelings in group therapy today.

2. The patient will list five reasons why he should not harm himself today.

3. The patient will not commit any acts of self-harm today.

4. The patient will take the antidepressant medication as prescribed today.

Correct Answer: 3

Rationale 1: The patient not committing any acts of self-harm relates to the problem statement in the nursing diagnosis and is measurable. Listing five reasons why the patient should not harm himself will not prevent him from committing an act of self-harm. Taking antidepressant medication will not prevent the patient from committing an act of self-harm. Discussion of feelings will not prevent the patient from committing an act of self-harm.

Rationale 2: The patient not committing any acts of self-harm relates to the problem statement in the nursing diagnosis and is measurable. Listing five reasons why the patient should not harm himself will not prevent him from committing an act of self-harm. Taking antidepressant medication will not prevent the patient from committing an act of self-harm. Discussion of feelings will not prevent the patient from committing an act of self-harm.

Rationale 3: The patient not committing any acts of self-harm relates to the problem statement in the nursing diagnosis and is measurable. Listing five reasons why the patient should not harm himself will not prevent him from committing an act of self-harm. Taking antidepressant medication will not prevent the patient from committing an act of self-harm. Discussion of feelings will not prevent the patient from committing an act of self-harm.

Rationale 4: The patient not committing any acts of self-harm relates to the problem statement in the nursing diagnosis and is measurable. Listing five reasons why the patient should not harm himself will not prevent him from committing an act of self-harm. Taking antidepressant medication will not prevent the patient from committing an act of self-harm. Discussion of feelings will not prevent the patient from committing an act of self-harm.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 6-1

Question 13

Type: MCSA

The nurse is assessing a newly admitted patients current medications. What does the best objective data include?

1. The patients wife tells the nurse what medications the patient has been receiving.

2. The nurse checks the prescription bottles the patient has brought to the hospital.

3. The nurse asks the physician what medications the patient was currently taking.

4. The patient lists the medications that have been prescribed.

Correct Answer: 2

Rationale 1: Objective data includes information gathered through assessment, and not necessarily what the patient says or perceives. The most reliable and objective assessment by the nurse is to check the patients prescription medication bottles. A list of medications provided by the patient and the patients wife is subjective, not objective data. Asking the physician what medication the patient was receiving is subjective data, and the physician may not remember all the medication the patient was receiving.

Rationale 2: Objective data includes information gathered through assessment, and not necessarily what the patient says or perceives. The most reliable and objective assessment by the nurse is to check the patients prescription medication bottles. A list of medications provided by the patient and the patients wife is subjective, not objective data. Asking the physician what medication the patient was receiving is subjective data, and the physician may not remember all the medication the patient was receiving.

Rationale 3: Objective data includes information gathered through assessment, and not necessarily what the patient says or perceives. The most reliable and objective assessment by the nurse is to check the patients prescription medication bottles. A list of medications provided by the patient and the patients wife is subjective, not objective data. Asking the physician what medication the patient was receiving is subjective data, and the physician may not remember all the medication the patient was receiving.

Rationale 4: Objective data includes information gathered through assessment, and not necessarily what the patient says or perceives. The most reliable and objective assessment by the nurse is to check the patients prescription medication bottles. A list of medications provided by the patient and the patients wife is subjective, not objective data. Asking the physician what medication the patient was receiving is subjective data, and the physician may not remember all the medication the patient was receiving.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-1

Question 14

Type: MCSA

The nurse is administering medications to an elderly patient. Which laboratory tests are important for the nurse to assess prior to the administration of medication?

1. Complete blood count (CBC) and electrolytes

2. Kidney and liver function tests

3. Arterial blood gases (ABGs) and basic metabolic panel

4. Lipid panel and thyroid function tests

Correct Answer: 2

Rationale 1: Renal and hepatic function tests are essential for many patients, particularly older patients and those who are critically ill, as these will be used to determine the proper drug dosage. Complete blood count (CBC) and electrolytes will not help to determine the proper drug dosage. Lipid panel and thyroid function tests will not help to determine the proper drug dosage. Arterial blood gases (ABGs) and a basic metabolic panel will not help to determine the proper drug dosage.

Rationale 2: Renal and hepatic function tests are essential for many patients, particularly older patients and those who are critically ill, as these will be used to determine the proper drug dosage. Complete blood count (CBC) and electrolytes will not help to determine the proper drug dosage. Lipid panel and thyroid function tests will not help to determine the proper drug dosage. Arterial blood gases (ABGs) and a basic metabolic panel will not help to determine the proper drug dosage.

Rationale 3: Renal and hepatic function tests are essential for many patients, particularly older patients and those who are critically ill, as these will be used to determine the proper drug dosage. Complete blood count (CBC) and electrolytes will not help to determine the proper drug dosage. Lipid panel and thyroid function tests will not help to determine the proper drug dosage. Arterial blood gases (ABGs) and a basic metabolic panel will not help to determine the proper drug dosage.

Rationale 4: Renal and hepatic function tests are essential for many patients, particularly older patients and those who are critically ill, as these will be used to determine the proper drug dosage. Complete blood count (CBC) and electrolytes will not help to determine the proper drug dosage. Lipid panel and thyroid function tests will not help to determine the proper drug dosage. Arterial blood gases (ABGs) and a basic metabolic panel will not help to determine the proper drug dosage.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-2

Question 15

Type: MCSA

Which of the following correctly identifies and orders the primary steps of the nursing process?

1. Establish nursing diagnosis, assessment, intervene, collaborate, evaluation

2. Establish goals, assessment, intervention, planning, communication

3. Assessment, establish nursing diagnosis, planning, interventions, evaluation

4. Assessment, planning, establish objectives, communication, evaluation

Correct Answer: 3

Rationale 1: The primary steps (in order) include assessment, establish nursing diagnosis, planning, interventions, evaluation. Although some steps might not be in this precise order, assessment is done first. The establishment of goals and objectives is generally considered part of planning. Communication is important, but is not a primary step of the nursing process.

Rationale 2: The primary steps (in order) include assessment, establish nursing diagnosis, planning, interventions, evaluation. Although some steps might not be in this precise order, assessment is done first. The establishment of goals and objectives is generally considered part of planning. Communication is important, but is not a primary step of the nursing process.

Rationale 3: The primary steps (in order) include assessment, establish nursing diagnosis, planning, interventions, evaluation. Although some steps might not be in this precise order, assessment is done first. The establishment of goals and objectives is generally considered part of planning. Communication is important, but is not a primary step of the nursing process.

Rationale 4: The primary steps (in order) include assessment, establish nursing diagnosis, planning, interventions, evaluation. Although some steps might not be in this precise order, assessment is done first. The establishment of goals and objectives is generally considered part of planning. Communication is important, but is not a primary step of the nursing process.

Global Rationale:

Cognitive Level: Remembering

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-1

Question 16

Type: MCSA

About which of the following patient assessment data sets would the nurse be most concerned prior to medication administration?

1. White blood cell count, ability to speak, and temperature

2. Age, allergies, and level of consciousness

3. Hair color, gender, and body mass index

4. Weight, height, and blood type

Correct Answer: 2

Rationale 1: Of the data sets listed, age, allergies, and level of consciousness includes the most concerning data, with allergies and level of consciousness being the most concerning. In every situation, the nurse should know whether the patient is allergic to a medication prior to administering. If a patient has an impaired level of consciousness, the route of drug administration needs to be addressed. Hair color is not concerning, while the other listed data are of concern only in certain situations with certain drugs.

Rationale 2: Of the data sets listed, age, allergies, and level of consciousness includes the most concerning data, with allergies and level of consciousness being the most concerning. In every situation, the nurse should know whether the patient is allergic to a medication prior to administering. If a patient has an impaired level of consciousness, the route of drug administration needs to be addressed. Hair color is not concerning, while the other listed data are of concern only in certain situations with certain drugs.

Rationale 3: Of the data sets listed, age, allergies, and level of consciousness includes the most concerning data, with allergies and level of consciousness being the most concerning. In every situation, the nurse should know whether the patient is allergic to a medication prior to administering. If a patient has an impaired level of consciousness, the route of drug administration needs to be addressed. Hair color is not concerning, while the other listed data are of concern only in certain situations with certain drugs.

Rationale 4: Of the data sets listed, age, allergies, and level of consciousness includes the most concerning data, with allergies and level of consciousness being the most concerning. In every situation, the nurse should know whether the patient is allergic to a medication prior to administering. If a patient has an impaired level of consciousness, the route of drug administration needs to be addressed. Hair color is not concerning, while the other listed data are of concern only in certain situations with certain drugs.

Global Rationale:

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-2

Question 17

Type: MCSA

A trauma patient in the emergency department has a low hemoglobin and hematocrit, and has an order to receive normal saline IV solution. Which nursing diagnosis would be most appropriate regarding the need for administering the IV solution?

1. Activity intolerance

2. Fluid volume deficit

3. Decreased cardiac output

4. Risk for Infection

Correct Answer: 2

Rationale 1: The drop in hemoglobin and hematocrit signify blood loss following trauma. Fluid volume deficit would be the best nursing diagnosis. The patients activity might be altered, and he might be at risk for infection following the trauma, but these do not relate to administering the IV normal saline. It is more likely that the patient has a drop in hemoglobin and hematocrit as a result of the trauma than a cardiac problem.

Rationale 2: The drop in hemoglobin and hematocrit signify blood loss following trauma. Fluid volume deficit would be the best nursing diagnosis. The patients activity might be altered, and he might be at risk for infection following the trauma, but these do not relate to administering the IV normal saline. It is more likely that the patient has a drop in hemoglobin and hematocrit as a result of the trauma than a cardiac problem.

Rationale 3: The drop in hemoglobin and hematocrit signify blood loss following trauma. Fluid volume deficit would be the best nursing diagnosis. The patients activity might be altered, and he might be at risk for infection following the trauma, but these do not relate to administering the IV normal saline. It is more likely that the patient has a drop in hemoglobin and hematocrit as a result of the trauma than a cardiac problem.

Rationale 4: The drop in hemoglobin and hematocrit signify blood loss following trauma. Fluid volume deficit would be the best nursing diagnosis. The patients activity might be altered, and he might be at risk for infection following the trauma, but these do not relate to administering the IV normal saline. It is more likely that the patient has a drop in hemoglobin and hematocrit as a result of the trauma than a cardiac problem.

Global Rationale:

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 6-3

Question 18

Type: MCSA

Which statement about the nursing process is accurate?

1. Generally, goals are more measurable than outcomes.

2. Goals involve very specific criteria that evaluate interventions.

3. Obtaining the outcomes is essential for goal attainment.

4. After selecting the nursing diagnosis, interventions are completed.

Correct Answer: 3

Rationale 1: Outcomes are specific, measurable criteria that are used to measure goal attainment. The planning phase (including outcomes and goals) follows nursing diagnosis. Goals are more general than specific.

Rationale 2: Outcomes are specific, measurable criteria that are used to measure goal attainment. The planning phase (including outcomes and goals) follows nursing diagnosis. Goals are more general than specific.

Rationale 3: Outcomes are specific, measurable criteria that are used to measure goal attainment. The planning phase (including outcomes and goals) follows nursing diagnosis. Goals are more general than specific.

Rationale 4: Outcomes are specific, measurable criteria that are used to measure goal attainment. The planning phase (including outcomes and goals) follows nursing diagnosis. Goals are more general than specific.

Global Rationale:

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-4

Question 19

Type: MCSA

Which nursing intervention would take priority following administration of a new medication?

1. Monitoring lab values

2. Monitoring the patients respiratory status

3. Prescribing additional medications if side effects occur

4. Measuring patient weight

Correct Answer: 2

Rationale 1: Any time a new medication is provided to the patient, it is important to monitor for an allergic reaction. Anaphylaxis, a life-threatening allergic reaction, can impair breathing. Monitoring lab values and measuring weight might be appropriate nursing interventions with some medications, but would not be the priority. Nurses do not prescribe medications.

Rationale 2: Any time a new medication is provided to the patient, it is important to monitor for an allergic reaction. Anaphylaxis, a life-threatening allergic reaction, can impair breathing. Monitoring lab values and measuring weight might be appropriate nursing interventions with some medications, but would not be the priority. Nurses do not prescribe medications.

Rationale 3: Any time a new medication is provided to the patient, it is important to monitor for an allergic reaction. Anaphylaxis, a life-threatening allergic reaction, can impair breathing. Monitoring lab values and measuring weight might be appropriate nursing interventions with some medications, but would not be the priority. Nurses do not prescribe medications.

Rationale 4: Any time a new medication is provided to the patient, it is important to monitor for an allergic reaction. Anaphylaxis, a life-threatening allergic reaction, can impair breathing. Monitoring lab values and measuring weight might be appropriate nursing interventions with some medications, but would not be the priority. Nurses do not prescribe medications.

Global Rationale:

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6-5

Question 20

Type: MCSA

A patient with hypertension is receiving medication to lower his blood pressure. Which of the following demonstrates the evaluation process related to medication administration?

1. Asking the patient whether he is compliant in taking his medications

2. Determining that goals were not met 3 days following medication administration

3. Administration of IV antihypertensive agents

4. Determination of the patients baseline blood pressure

Correct Answer: 2

Rationale 1: Evaluation is the final step in the nursing process where goal attainment is determined. Administering medications is the intervention step. Determining the patients baseline blood pressure and asking him about compliance would be the assessment step.

Rationale 2: Evaluation is the final step in the nursing process where goal attainment is determined. Administering medications is the intervention step. Determining the patients baseline blood pressure and asking him about compliance would be the assessment step.

Rationale 3: Evaluation is the final step in the nursing process where goal attainment is determined. Administering medications is the intervention step. Determining the patients baseline blood pressure and asking him about compliance would be the assessment step.

Rationale 4: Evaluation is the final step in the nursing process where goal attainment is determined. Administering medications is the intervention step. Determining the patients baseline blood pressure and asking him about compliance would be the assessment step.

Global Rationale:

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 6-1 and 6-6

Question 21

Type: MCSA

Which of the following identifies the collection of objective data?

1. The patient rates her pain a 5 on a 010 pain scale.

2. The patient states she is anxious.

3. The patient has a wound measured at 5 centimeters in length.

4. The patient informs the nurse that she weighs 150 pounds.

Correct Answer: 3

Rationale 1: Objective data are gathered through physical assessment, laboratory tests, and other diagnostic sources. Subjective data consist of what the patient says or perceives.

Rationale 2: Objective data are gathered through physical assessment, laboratory tests, and other diagnostic sources. Subjective data consist of what the patient says or perceives.

Rationale 3: Objective data are gathered through physical assessment, laboratory tests, and other diagnostic sources. Subjective data consist of what the patient says or perceives.

Rationale 4: Objective data are gathered through physical assessment, laboratory tests, and other diagnostic sources. Subjective data consist of what the patient says or perceives.

Global Rationale:

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 6-2

Question 22

Type: MCMA

When teaching the patient about a new medication, the nurse should include which information?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Adverse effects that can be expected

2. Which adverse effect to report to the health care provider

3. The drugs therapeutic action

4. Chemical composition of the drug

5. Name of the drug manufacturer

Correct Answer: 1,2,3

Rationale 1: In order to help the patient identify and prevent adverse effects, the patient should be taught the therapeutic action, adverse effects, and when to notify the health care provider of adverse effects.

Rationale 2: In order to help the patient identify and prevent adverse effects, the patient should be taught the therapeutic action, adverse effects, and when to notify the health care provider of adverse effects.

Rationale 3: In order to help the patient identify and prevent adverse effects, the patient should be taught the therapeutic action, adverse effects, and when to notify the health care provider of adverse effects.

Rationale 4: It is not necessary to teach the patient the chemical makeup of the drug.

Rationale 5: It is not necessary to teach the patient the name of the drug manufacturer.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6-2

Question 23

Type: MCMA

A nurse is preparing care for a newly admitted diabetic patient. Which information would be critical for the nurse to assess?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Medical history

2. Current lab results

3. Medication allergies

4. Use of dietary supplements

5. Number of previous hospitalizations

Correct Answer: 1,2,3,4

Rationale 1: Medical history may reveal conditions that contraindicate the use of certain drugs.

Rationale 2: Current lab results may reveal important information about the health of organs, such as the kidneys and liver, which would be important to metabolism and excretion of drugs.

Rationale 3: Allergies to one drug may cross over to another drug and would need to be avoided.

Rationale 4: Some dietary supplements can interact with drugs.

Rationale 5: While this is good information, it is not critical to this admission.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-2

Question 24

Type: MCMA

A nurse is caring for a patient diagnosed with acute asthma who is taking several medications. The nurse would suspect a common adverse drug effect with which symptoms?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Headache

2. Nausea

3. Vomiting

4. Changes in blood pressure

5. Loss of hearing

Correct Answer: 1,2,3,4

Rationale 1: Headache is a common adverse effect of some medications.

Rationale 2: Nausea is a common adverse effect of some medications.

Rationale 3: Vomiting is a common adverse effect of some medications.

Rationale 4: Changes in blood pressure is a common adverse effect of some medications.

Rationale 5: Loss of hearing would be considered a serious adverse effect, not a common one.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-2

Question 25

Type: MCMA

A nurse is reinforcing discharge instructions concerning food?drug interactions. The nurse determines that the patient understands when the patient makes which statement?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. I should take my medications with water to avoid any problems with my medications being absorbed.

2. I cannot take one of my medications with grapefruit juice because it will decrease the absorption of the medication.

3. I need to be sure to read the prescription label because the pharmacist will indicate if I need to take my medication with food or without food.

4. I should take my daily vitamin 2 hours after my medication so they do not affect each other.

5. If I take my medication with hot tea, it will not affect absorption.

Correct Answer: 1,2,3,4

Rationale 1: The safest fluid to take with medications is water.

Rationale 2: Grapefruit juice can increase absorption of certain drugs and should be avoided.

Rationale 3: The pharmacist will indicate on the medication label if the medication should be taken with or without food.

Rationale 4: Herbal supplements and vitamins can cause adverse effects when taken with medication.

Rationale 5: Taking medication with caffeine or a hot drink can affect absorption and the effectiveness of medication.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-11

Question 26

Type: MCMA

A patient returns to the clinic for follow up after taking a newly prescribed medication for a month. The nurse recognizes medication teaching was successful when the patient makes which statement?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Ive been taking my medication on an empty stomach like the prescription label said to.

2. I always take my medication with a full glass of water.

3. Im not drinking any alcohol close to the time that I take my medication.

4. I switched all my medications to one pharmacy like you suggested.

5. I was glad I could take my medications and supplements together. I dont really like to take a lot of pills during the day.

Correct Answer: 1,2,3,4

Rationale 1: Some medications must be taken on an empty stomach. It is important to know if the medication should be taken with food or on an empty stomach.

Rationale 2: Taking medications with water will decrease the chance of an interaction that can occur with other juices or fluids.

Rationale 3: Alcohol can cause adverse interactions with medications.

Rationale 4: Filling all prescriptions at the same pharmacy will assist the pharmacist in comparing current and new medications for interactions.

Rationale 5: It is best not to take herbal supplements and vitamins with prescribed medications to avoid interactions.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 6-11

Question 27

Type: MCMA

A nurse is caring for a patient who is exhibiting signs of an adverse reaction to warfarin (Coumadin). Which statements made by the patient would lead the nurse to suspect that this is the case?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Im from the South, and we have buttermilk almost every meal.

2. I was suffering so much from hot flashes until my friend told me to try an herb called St. Johns wort. I dont seem to have as many symptoms as before.

3. My husband makes me put garlic in everything! He heard it helps keep our blood pressure normal.

4. I heard ginkgo was really good for improving memory so I started taking it a couple of months ago.

5. I was having difficulty sleeping a couple months ago, and my neighbor recommended I try kava. It seems to calm my nerves.

Correct Answer: 1,2,3,4

Rationale 1: Calcium products do not affect the action of warfarin.

Rationale 2: St. Johns wort may increase the risk for bleeding when taken with warfarin.

Rationale 3: Garlic may increase the risk for bleeding when taken with warfarin.

Rationale 4: Ginkgo may increase the risk for bleeding when taken with warfarin.

Rationale 5: Kava can increase drowsiness and sedation when taken with CNS depressants. It does not interact with warfarin.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-11

Adams, Pharmacology for Nurse: A Pathophysiologic Approach, 4/E

Copyright 2014 by Pearson Education, Inc.

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