Fundamentals of Nursing Quiz (36-40)

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Fundamentals of Nursing Quiz no. 36 - 40

36. A client is scheduled for blood to be drawn from the radial artery for an arterial blood gas determination. Before the blood is drawn, an Allen's test is performed to determined the adequacy of the:

a) ulnar circulation
b) carotid circulation
c) femoral circulation
d) popliteal circulation

37. A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client, knowing that he client is at risk for which acid-base disorder?

a) metabolic acidosis
b) metabolic alkalosis
c) respiratory acidosis
d) respiratory alkalosis

38. A nurse caring for a client with an ileostomy understands that he client is most at risk for developing which acid-base disorder?

a) metabolic acidosis
b) metabolic alkalosis
c) respiratory acidosis
d) respiratory alkalosis

39. A nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Based on this documentation, which of the following did the nurse observe?

a) respirations that cease for several seconds
b) respirations that are regular but abnormally slow
c) respirations that are labored and increased in depth and rate
d) respirations that are abnormally deep, regular, and increased in rate

40. A client is brought to the emergency room stating that he has accidentally been taking two times his prescribed dose of warfarin (Coumadin) for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to do which of the following next?

a) prepare to administer an antidote
b) draws a sample for type and crossmatch and transfuse the client
c) draws a sample for an activated partial thromboplastin time (aPTT)
d) draws a sample for prothrombin (PT) and international normalized ratio (INR) level






Fundamentals of Nursing Quiz:
ANSWERS AND RATIONALE

36) A
- Before radial puncture for obtaining an arterial specimen for arterial blood gases, you should perform an Allen’s test to determine adequate ulnar circulation. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. Options B, C, and D are incorrect options.

37) B
- Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid. Options A, C, and D are incorrect.

38) A
- Intestinal secretions are high in bicarbonate and may be lost through enteric drainage tubes or an ileostomy, or with diarrhea. These conditions result in metabolic acidosis. Options B, C, and D are incorrect because they do not occur in the client with an ileostomy.

39) D
- Kussmaul’s respirations are abnormally deep, regular, and increased in rate. Apnea is described as respirations that cease for several seconds. In bradypnea, respirations are regular but abnormally slow. In hyperpnea, respirations are labored and increased in depth and rate.

40) D
- The next action is to draw a sample for PT and INR level to determine the client’s anticoagulation status and risk for bleeding. These results will provide information as to how to best treat this client if an antidote (vitamin K) or blood transfusion is needed. The aPTT monitors the effects of heparin therapy.


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Fundamentals Nursing Test Bank (31-35)

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31. A nurse is caring for a client with a nasogastric tube. Nasogastric tube irrigation are prescribed to be performed once every shift. The client's serum electrolyte results indicate a potassium level of 4.5 mEq/L and a sodium level of 132 mEq/L. Based on these laboratory findings, the nurse selects which solution to use for the nasogastric tube irrigation?a) tap water
b) sterile water
c) sodium chloride
d) distilled water

32. A nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L. The nurse reports the serum sodium level to the physician and the physician prescribes dietary instructions based on the sodium level. Which food item does the nurse instruct the client to avoid?

a) peas
b) cauliflower
c) low-fat yogurt
d) processed oat cereals

33. A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical manifestations would the nurse expect to note in the client?

a) twitching
b) negative Trousseau's sign
c) hypoactive bowel sounds
d) hypoactive deep tendon reflexes

34. A nurse plans care for a client with chronic obstructive pulmonary disease, knowing that he client most likely to experience what type of acid-base imbalance?

a) metabolic acidosis
b) metabolic alkalosis
c) respiratory acidosis
d) respiratory alkalosis

35. A nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition?

a) sodium level of 145 mEq/L
b) potassium level of 3.0 mEq/L
c) magnesium level of 2.0 mg/dL
d) phosporus level of 4.0 mg/dL





Fundamentals Nursing Test Bank:
ANSWERS AND RATIONALE

31) C
- A potassium level of 4.5 mEq/L is within normal range. A sodium level of 132 mEq/L is low, indicating hyponatremia. In clients with hyponatremia, sodium (isotonic) chloride should be used rather than water for gastrointestinal irrigations.

32) D
- The normal serum sodium level is 135 to 145 mEq/L. A serum sodium level of 150 mEq/L indicates hypernatremia. Based on this finding, the nurse would instruct the client to avoid foods high in sodium. Low-fat yogurt, cauliflower, and peas are good food sources of phosphorus. Processed foods are high in sodium content.

33) A
- Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau’s or Chvostek’s sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.

34) C
Respiratory acidosis is most often caused by hypoventilation. Chronic respiratory acidosis is most commonly caused by chronic obstructive pulmonary disease. In end-stage disease, pathological changes lead to airway collapse, air trapping, and disturbance of ventilation-perfusion relationships. Options A, B, and C are incorrect options.

35) B
- Clinical manifestations of respiratory alkalosis include headache, tachypnea, paresthesias, tetany, vertigo, convulsions, hypokalemia, and hypocalcemia. Options A, C, and D identify normal laboratory values. Option B identifies the presence of hypokalemia.


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NCLEX Review - Fundamentals of Nursing 7th edition (26-30)

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NCLEX Review - Fundamentals of Nursing 7th edition

26. The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds a client lying on the floor. The nurse performs a thorough assessment, assists the client back to bed, notifies the physician of the incident, and completes an incident report. Which of the following should the nurse document on the incident report?

a) the client fell out of bed
b) the client climbed over the side rails
c) the client was found lying on the floor
d) the client became restless and tried to get out of bed

27. A client is brought to the emergency room by emergency medical services (EMS) after being hit by a car. The name of the client is not known and the client has sustained a severe head injury and multiple fractures, and unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which of the following is the best action?

a) obtain a court order for the surgical procedure
b) transport the victim to the operating room for surgery
c) call the police to identify the client and locate the family
d) ask the EMS team to sign the informed consent

28. A nurse is reading a physician's progress notes in the client's record and reads that the physician has documented "insensible fluid loss of approximately 800 ml daily." The nurse understands that this type of fluid loss can occur through:

a) the skin
b) urinary output
c) wound drainage
d) the gastrointestinal tract

29. A nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse determines that the client understands the food sources of potassium if the client states that the food item lowest in potassium is:

a) apples
b) carrots
c) spinach
d) avocado

30. A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a potassium level of 5.5 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a potassium value at this level?

a) the client with colitis
b) the client with cushing's syndrome
c) the client who has been overusing laxatives
d) the client who has sustained a traumatic burn




Fundamentals of Nursing 7th edition:
ANSWERS AND RATIONALE

26) C
- The incident report should contain the client’s name, age, and diagnosis. The report should contain a factual description of the incident, any injuries experienced by those involved, and the outcome of the situation. Option 3 is the only option that describes the facts as observed by the nurse. Options A, B, and D are interpretations of the situation and are not factual information as observed by the nurse.

27) B
- Generally, there are two situations in which informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent. Option A will delay emergency treatment and option D is inappropriate. Although option C may be pursued, it is not the best action.

28) A
- Sensible losses are those of which the person is aware, such as through wound drainage, gastrointestinal tract losses, and urination. Insensible losses may occur without the person’s awareness. Insensible losses occur daily through the skin and the lungs.

29) A
- A medium apple provides about 159 mg of potassium. A large carrot provides 341 mg, spinach (3½ oz) provides 470 mg, and a medium avocado provides 1097 mg of potassium.

30) D
A serum potassium level higher than 5.1 mEq/L indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing’s syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.



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NCLEX Review about Immune System Disorders 41-45

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Welcome to NCLEX Review about Immune System Disorders. Before you begin answering the questions, you may first want to take a peek about the material that will surely help you the pass the NCLEX examination :

Complete NCLEX Study Materials


Enjoy answering and I hope that NCLEX Review and Secrets can somehow help you in your future examination. Good Luck.


41. A nurse is monitoring a client with herpes simplex virus who is receiving intravenous (IV) acyclovir (Zovorax). Which of the following laboratory results would be of concern as a possible adverse effect of this medication?

a) blood urea nitrogen (BUN) of 36 mg/dL
b) platelet count of 300,000 cells/mm3
c) white blood cell count of 6000 cells/mm3
d) red blood cell count of 5.2 million cells/mm3

42. A client with acquired immunodeficiency syndrome (AIDS) is receiving ganciclovor (Cytovene). The nurse takes which priority nursing action in caring for this client?

a) ensuring that the client uses an electric razor for shaving
b) administering the medication with an antacid
c) monitoring for signs of hyperglycemia
d) administering the medication without food

43. A client with acquired immunodeficiency syndrome (AIDS) has been started on therapy with zidovudine also called azidothymidine (AZT)(Retrovir). The nurse monitors the results of which laboratory blood study for adverse effects of therapy?

a) complete blood count (CBC)
b) blood urea nitrogen (BUN) level
c) creatinine level
d) potassium concentration

44. A client with acquired immunodeficiency syndrome (AIDS) is receiving didanosine (Videx). The nurse reviewing the client's laboratory results should most closely monitor serum levels of:

a) cholesterol
b) amylase
c) glucose
d) protein

45. A client is receiving zalcitabine (Hivid). The nurse plans to monitor the results of which study to determine the effectiveness of this medication?

a) enzyme-linked immunosorbent assay (ELISA)
b) western blot
c) CD4+ cell count
d) complete blood cell (CBC) count with differential





NCLEX Review about Immune System Disorders:
ANSWERS AND RATIONALE

41) A
- Although the most common adverse reactions with this medication are phlebitis and inflammation at the IV site, reversible nephrotoxicity evidenced by an elevated serum creatinine and BUN levels can occur in some clients. The cause of nephrotoxicity is deposition of acyclovir in the renal tubules. The risk of renal injury is increased by dehydration and by the use of other nephrotoxic medications. The values identified in options B, C, and D are within normal limits.

42) A
- Because ganciclovir causes neutropenia and thrombocytopenia as the most frequent side effects, the nurse monitors for signs and symptoms of bleeding and implements the same precautions as for a client receiving anticoagulant therapy. The medication does not have to be taken on an empty stomach or without food and should not be taken with an antacid. The medication may cause hypoglycemia, but not hyperglycemia.

43) A
- Common adverse effects of this medication are agranulocytopenia and anemia. The nurse monitors the CBC results for these changes. BUN, creatinine, and potassium are unrelated to this medication.

44) B
- This medication is toxic to both the pancreas and the liver. A serum amylase level that is increased 1.5 to 2 times normal may signify pancreatitis and may be potentially fatal in the client with AIDS. Therefore, the nurse monitors the results of amylase and liver function studies closely. Options A, C, and D are unrelated to this medication.

45) C
- Zalcitabine slows the progression of acquired immunodeficiency syndrome (AIDS) by improving the CD4+ cell count. A CBC with differential may be done as part of an ongoing monitoring of the status of the client with AIDS, and to detect adverse effects of other medications. The ELISA and the Western blot are performed to diagnose AIDS initially.


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NCLEX Review about Immune System Disorders (1-5)


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NCLEX Review about Immune System Disorders (46-50)

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NCLEX Review - Fundamentals of Nursing 7th edition (21-25)

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Fundamentals of Nursing 7th edition

21. A hospitalized client tells the nurse that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. The appropriate response to the client is which of the following?

a) I will sign as a witness to your signature
b) you will need to find a witness on your own
c) whoever is available at the time will sign as a witness for you
d) I will call the nursing supervisor to seek assistance regarding your request


22. The nurse has made an error in documenting an assessment finding on a client and obtains the client's record to correct the error. The nurse corrects the error by:

a) documenting a late entry into the client's record
b) trying to erase the error for space to write in the correct data
c) using Wite-Out to delete the error to write in the correct data
d) drawing one line through the error, initiating and dating the line, and then documenting the correct information


23. The nurse employed in a hospital is waiting to receive a report from the laboratory via the fascimile (fax) machine. The fax machine activates and the nurse expects the report but instead receives a sexually oriented photograph. The appropriate initial nursing action is to:

a) call the police
b) cut up the photograph and throw it away
c) call the nursing supervisor and report the incident
d) call the laboratory and ask for the individual's name that sent the photograph

24. The nursing instructor provides a lecture to nursing students regarding the issue of client's rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which of the following, if identified by the student, indicates an understanding of a violation of this client right?

a) performing a procedure without consent
b) threatening to give a client a medication
c) telling the client that he or she cannot leave the hospital
d) observing care provided to the client without the client's permission

25. The nursing staff is sitting in the lounge taking their morning break. A nursing assistant tells the group that she thinks that he unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. Which legal tort has the nursing assistant violated?

a) libel
b) slander
c) assault
d) negligence





Fundamentals of Nursing 7th edition:
ANSWERS AND RATIONALE

21) D
- Living wills are required to be in writing and signed by the client. The client’s signature must be witnessed by specified individuals or notarized. Many states prohibit any employee, including a nurse of a facility where the client is receiving care, from being a witness. Option B is nontherapeutic and not a helpful response. The nurse should seek the assistance of the nursing supervisor.

22) D
- If the nurse makes an error in documenting in the client’s record, the nurse should follow agency policies to correct the error. This includes drawing one line through the error, initialing and dating the line, and then documenting the correct information. A late entry is used to document additional information not remembered at the initial time of documentation. Erasing data from the client’s record and the use of Wite-Out are prohibited.

23) C
- Sexual harassment in the workplace is prohibited by state and federal laws. Sexually suggestive jokes, touching, pressuring a co-worker for a date, and open displays of or transmitting sexually oriented photographs or posters are examples of conduct that could be considered sexual harassment by another worker. If the nurse believes that he or she is being subjected to unwelcome sexual conduct, these concerns should be reported to the nursing supervisor immediately. Option A is unnecessary at this time. Options B and D are not appropriate initial actions.

24) D
- Invasion of privacy takes place with unreasonable intrusion into an individual’s private affairs. Performing a procedure without consent is an example of battery. Threatening to give a client a medication constitutes assault. Telling the client that the client cannot leave the hospital constitutes false imprisonment.

25) B
- Defamation is a false communication or a careless disregard for the truth that causes damage to someone’s reputation, either in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of a harmful or an offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a specific professional group.




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Fundamentals Nursing Test Bank (16-20)

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Fundamentals Nursing Test Bank


16. The nurse calls the physician regarding a new medication order because the dosage prescribed is higher than the recommended dosage. Then nurse is unable to locate the physician and the medication is due to administered. Which action should the nurse take?

a) contact the nursing supervisor
b) administer the dose prescribed
c) hold the medication until the physician can be contacted
d) administer the recommended dose until the physician can be located

17. A nursing graduate is employed as a staff nurse in a local hospital. During orientation, the new graduate asks the nurse educator about the need to obtain professional liability insurance. The appropriate response by the nurse educator is:

a) it is very expensive and not necessary
b) the hospital's liability insurance will cover your actions
c) the majority of suits are filled against physicians and the hospital
d) nurses are encouraged to have their own professional insurance

18. The registered nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which action first?

a) call the hospital lawyer
b) refuse to float to the ICU
c) call the nursing supervisor
d) report to the ICU and identify tasks that can be performed safely

19. The nurse gives an inaccurate dose of medication to a client. Following assessment of the client, the nurse completes an incident report. The nurse notifies the nursing supervisor of the medication error and calls the physician to report the occurrence. The nurse who administered the inaccurate medication dose understands that:

a) the error will result in suspension
b) the incident will be reported to the board of nursing
c) the incident will be documented in the personnel file
d) an incident report needs to be completed and is a method of promoting quality care and risk management

20. A nurse works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. The appropriate initial action by the nurse is which of the following?

a)  call security
b) call the police
c) call the nursing supervisor
d) lock the co-worker in the medication room until help is obtained




Fundamentals Nursing Test Bank:
ANSWERS AND RATIONALE

16) A
- If the physician writes an order that requires clarification, the nurse’s responsibility is to contact the physician for clarification. If there is no resolution regarding the order because the physician cannot be located or because the order remains as it was written after talking with the physician, the nurse then should contact the nurse manager or nursing supervisor for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the order until obtaining clarification.

17) D
- Nurses need their own professional liability insurance for protection against malpractice law suits. Nurses erroneously assume that they are protected by an agency’s professional liability policies. Usually, when a nurse is sued, the employer also is sued for the nurse’s actions or inactions. Even though this is the norm, nurses are encouraged to have their own professional liability insurance.

18) D
- Floating is an acceptable legal practice used by hospitals to solve their understaffing problems. Legally, a nurse cannot refuse to float unless a union contract guarantees that nurses can work only in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountering this situation, the nurse should set priorities and identify potential areas of harm to the client. The nursing supervisor is called if the nurse is expected to perform tasks that he or she cannot safely perform. Calling the hospital lawyer is a premature action.

19) D
- Documentation of unusual occurrences, incidents, and accidents and of the nursing actions taken as a result of the occurrence is internal to the institution or agency and allows the nurse and administration to review the quality of care and determine any potential risks present. Based on the information provided in the question, the nurse’s error will not result in suspension,  nor will it be documented in the personnel file. The error and the situation presented in the question are not a reason for notifying the board of nursing.

20) C
- Nurse practice acts require reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision of the impaired nurse. This incident needs to be reported to the nursing supervisor, who will then report to the board of nursing and other authorities, such as the police, as required. The nurse may call security if a disturbance occurs, but no information in the question supports this need, and therefore this is not the initial action. Option D is an inappropriate and unsafe action.


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Fundamentals of Nursing Quiz (11-15)

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Fundamentals of Nursing Quiz

11. An antihypertensive medication has been prescribed for a client with hypertension. The client tells the clinic nurse that she would like to take a herbal substance to help lower her blood pressure. The nurse should take which appropriate action?

a) tell the client that herbal substances are not safe and should never be used
b) advise the client to discuss the use of a herbal substance with the physician
c) teach the client how to take her blood pressure so that it can be monitored easily
d) tell the client that if she takes the herbal substance she will need to have her blood pressure checked frequently

12. A nurse educator is providing in-service education to the nursing staff regarding transcultural nursing care when a staff member asks the nurse educator to describe the concept of acculturation. The appropriate response is which of the following?

a) it is a subjective perspective of the person's heritage and a sense of belonging to a group
b) it is a group of individuals in a society who are culturally distinct and have a unique identity
c) it is a process of learning a different culture to adapt to a new or changing environment
d) it is a group that shares some of the characteristics of the larger population group of which it is a part

13. The nurse understands that which of the following statements regarding herbal therapies is true?

a) zinc is used for insomnia
b) ginger is used to improve memory
c) echinacea is used for erectile dysfunction
d) black cohosh produces estrogen-like effects

14. Which of the following are low-risk therapies? Select all that apply

a) herbs
b) prayer
c) touch
d) massage
e) relaxation
f) acupuncture

15. The nurse has just assisted a client back to bed after a fall. The nurse and physician have assessed the client, and have determined that he client is not injured. After completing the incident report, the nurse should take which action next?

a) reassess the client
b) conduct a staff meeting to describe the fall
c) document in the nurse's notes that an incident report was completed
d) contact the nursing supervisor to update information regarding the fall





Fundamentals of Nursing Quiz:
ANSWERS AND RATIONALE

11) B
- Although herbal substances may have some beneficial effects, not all herbs are safe to use. Clients who are being treated with conventional medication therapy should be advised to avoid herbal substances with similar pharmacological effects because the combination may lead to an excessive reaction or to unknown interaction effects. Therefore, the nurse would advise the client to discuss the use of the herbal substance with the physician. Options A, C, and D are inappropriate nursing actions.

12) C
- Acculturation is a process of learning a different culture to adapt to a new or changing environment. Option A describes ethnic identity. Option B describes an ethnic group. Option D describes a subculture.

13) D
- Black cohosh produces estrogen-like effects. Zinc stimulates the immune system and is used for its antiviral properties. Echinacea stimulates the immune system and ginger is used for nausea and vomiting.

14) B, C, D, E
- Low-risk therapies include meditation, relaxation techniques, imagery, music therapy, massage, touch, laughter and humor, and spiritual measures, such as prayer.  The other options are not considered low-risk therapies.

15) A
- The client’s fall should be treated as private information and shared on a “need to know” basis. Communication regarding the event should involve only those participating in the client’s care. An incident report is a problem-solving document; however, its completion is not documented in the nurse’s notes. If the nursing supervisor has been made aware of the incident, the supervisor will contact the nurse if status update is desired. After a client’s fall, the nurse must frequently reassess the client, because potential complications do not always appear immediately after the fall.


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NCLEX Review about Immune System Disorders 36-40

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NCLEX Review about Immune System Disorders

36. A home care nurse provides instructions to a client with systemic lupus erythematosus (SLE) about measures to manage fatigue. Which statement by the client indicates the need for further instruction?

a) I need to avoid long periods of rest
b) I need to sit whenever possible
c) I should take a hot bath every evening
d) I should engage in moderate low-impact exercise when I am not tired

37. A nurse is reviewing the results of serum laboratory studies for a client with acquired immunodeficiency syndrome (AIDS) who is receiving didanosine (Videx). The nurse interprets that the client may have the medication discontinued by the physician if which of the following laboratory test results is significantly elevated?

a) serum cholesterol level
b) serum amylase level
c) blood glucose concentration
d) serum protein concentration


38. A client with acquired immunodeficiency syndrome (AIDS) who is taking zidovudine (Retrovir) 200 mg orally three times daily has severe neutropenia noted on the follow-up laboratory studies. The nurse interprets that which of the following is likely to occur at this point?

a) prednisone (Deltasone) probably will be added to the medication regimen
b) epoetin (Epogen) probably will be added to the medication regimen
c) the medication dose probably will be reduced
d) the medication probably will be discontinued until laboratory results indicated bone marrow recovery

39. A client with human immunodeficiency virus (HIV) infection is taking indinavir (Crixivan). The nurse plans to tell the client which of the following when providing instructions about the use of this medication?

a) take the medication with water on an empty stomach
b) take the medication with a high-fat snack
c) take the medication with the large meal of the day
d) store the medication in the refrigerator

40. A client is receiving acyclovir (Zovirax) by the intravenous (IV) route for treatment of cytomegalovirus (CMV) infection. After reconstituting the powder dispensed by the pharmacy, the nurse administers this medication by:

a) continuous IV infusion over 12 hours
b) continuous IV infusion over 24 hours
c) rapid IV bolus over 5 minutes
d) slow IV infusion over 1 hour






NCLEX Review about Immune System Disorders:
ANSWERS AND RATIONALE

36) C
- To help reduce fatigue in the client with SLE, the nurse should instruct the client to sit whenever possible, to avoid hot baths, to schedule moderate low-impact exercises when not fatigued, and to maintain a balanced diet. The client is instructed not to rest for long periods because it promotes joint stiffness.

37) B
- A serum amylase level that is increased 1.5 to 2 times normal may signify pancreatitis from the medication, which can be potentially fatal. The medication may have to be discontinued. The medication also is hepatotoxic, which can result in liver failure. Options A, C, and D are not associated with this medication.

38) B
- Hematological monitoring should be done every 2 weeks in the client taking zidovudine. If severe anemia or severe neutropenia develops, treatment should be discontinued until evidence of bone marrow recovery is noted. If anemia or neutropenia is mild, a reduction in dosage may be sufficient. The administration of prednisone may further alter the immune function. Epoetin alfa is administered to clients experiencing anemia.

39) A
- To maximize absorption, the medication should be administered with water on an empty stomach. The medication can be taken 1 hour before a meal or 2 hours after a meal, or it can be administered with skim milk, coffee, tea, or a low-fat meal. It is not administered with a large meal. The medication should be stored at room temperature and protected from moisture, because moisture can degrade the medication.

40) D
- Acyclovir is dispensed as a powder to be reconstituted for IV administration and is administered by slow IV infusion over 1 hour. It is not given as an IV bolus or continuous infusion or by intramuscular or subcutaneous injection. To minimize the risk of renal damage, the client should be hydrated during the infusion and for 2 hours after the infusion.


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      NCLEX Review - Fundamentals of Nursing Study Guide (6-10)

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      Fundamentals of Nursing Study Guide

      6.The role of the nurse regarding complementary and alternative medicine (CAM) should include:

      a) recommending herbal remedies that the client should use
      b) educating the client about "good" versus "bad" therapies
      c) discouraging the client from using any alternative therapies
      d) educating the client about therapies that he or she is using or is interested in using

      7. A nursing student is discussing cultural diversity issues in a clinical conference when a nursing instructor asks the student to describe ethnocentrism. Which statement by the student indicates a lack of understanding of the issue of ethnocentrism?

      a) it is a tendency to view one's own ways as best
      b) it is acting in a manner that is superior to other cultures
      c) it is imposing one's beliefs on individuals from another culture
      d) it is believing that one's own way is the only acceptable way

      8. When communicating with a cultural diverse client who speaks a different language, the best practice for the nurse is to:

      a) speak loudly and slowly
      b) stand close to the client and speak loudly
      c) arrange for an interpreter when communicating with the client
      d) speak to the client and family together to increase the chances that the topic will be understood

      9. Which of the following clients has the lowest risk of obesity and diabetes mellitus?

      a) a 45 year-old Native-American male
      b) a 23 year-old Asian-American female
      c) a 35 year-old Hispanic-American male
      d) a 40 year-old African-American female

      10. A nurse is bathing a hospitalized Native American client of the Navajo culture and notes that the client avoids eye contact during the procedure. The nurse makes which interpretation about the client's behavior?

      a) the client is depressed
      b) the client is displaying disrespectful mannerisms
      c) the client is displaying behavior that is a common cultural action
      d) the client is humiliated because of hte need to be cared for by someone else





      Fundamentals of Nursing Study Guide:
      ANSWERS AND RATIONALE:

      6) C
      - Complementary (alternative) therapies include a wide variety of treatment modalities that are used in addition to conventional therapy to treat a disease or illness. Educating the client about therapies that he or she uses or is interested in using is the nurse’s role. Options A, B, and C are all inappropriate actions for the nurse to take.

      7) C
      - Ethnocentrism is a tendency to view one’s own way of life as the most desirable, acceptable, or best and to act in a superior manner toward another culture. Cultural imposition is the tendency to impose one’s own beliefs, values, and patterns of behavior on individuals from another culture.

      8) C
      - Arranging for an interpreter would be the best practice when communicating with a client who speaks a different language. Options A and B are inappropriate and are ineffective ways in which to communicate. Option D is inappropriate because it violates privacy and does not ensure correct translation.

      9) B
      - Asian Americans have the lowest risk of obesity and diabetes mellitus from the options provided.  Native Americans, African Americans, and Hispanic Americans have a high risk of obesity and diabetes mellitus.

      10) C
      - Native American clients often avoid eye contact when being cared for by health care personnel. In this culture, eye contact is considered a sign of disrespect. Therefore, this client's action is culturally appropriate behavior. Options A, B, and D are inappropriate interpretations of the client's behavior.



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      NCLEX Review - Fundamentals of Nursing Study Guide (1-5)

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      NCLEX Review - Fundamentals of Nursing Study Guide 


      1. A nurse is providing discharge instructions to a Chinese client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. Which nursing action is appropriate?

      a) continue with the instructions, verifying client understanding
      b) walk around the client so that the nurse constantly faces the client
      c) give the client a dietary booklet and return later to continue with the instructions
      d) tell the client about the importance of the instructions for the maintenance of health care

      2. A nurse is preparing a plan of care for a client who is a Jehovah's Witness. The client has been told that the surgery is necessary. The nurse considers the client's religious preferences in developing the plan of care and documents that:

      a) faith healing is practiced primarily
      b) medication administration is not allowed
      c) surgery is prohibited in this religious group
      d) the administration of blood and blood products is forbidden

      3. Which of the following meal trays would be appropriate for the nurse to deliver to a client of Jewish faith who follows a koshier diet?

      a) pork roast, rice, vegetables, mixed fruit, milk
      b) crab salad on a croissant, vegetables with dip, potato salad, milk
      c) sweet and sour chicken with rice and vegetables, mixed fruit, juice
      d) fettucini Alfredo with shrimp and vegetables, salad, mixed fruit, iced tea

       4. An ambulatory care nurse is discussing preoperative procedures wit ha Chinese-American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. The nurse interprets this nonverbal behavior as:

      a) reflecting a cultural value
      b) an acceptance of the treatment
      c) the client is agreeable to the required procedures
      d) the client understands the preoperative procedures

      5. A Chinese-American client experiencing anemia, which is believed to be a yin disorder, is likely to treat it with:

      a) magnetic therapy
      b) intercessory prayer
      c) foods considered to be yin
      d) foods considered to be yang





       Fundamentals of Nursing Study Guide: 
      ANSWERS AND RATIONALE

      1) A
      - Most Chinese maintain a formal distance with others, which is a form of respect. Many Chinese are uncomfortable with face-to-face communications, especially when eye contact is direct. If the client turns away from the nurse during a conversation, the most appropriate action is to continue with the conversation. Walking around to the client so that the nurse faces the client is in direct conflict with the cultural practice. The client may consider returning later to continue with the explanation as a rude gesture. Telling the client about the importance of the instructions for the maintenance of health care may be viewed as degrading.

      2) D
      - Among Jehovah’s Witnesses, surgery is not prohibited, but the administration of blood and blood products is forbidden. Faith healing is forbidden in this religious group. Administration of medication is an acceptable practice, except if the medication is derived from blood products.

      3)  C
      - In the Jewish religion, those who are kosher believe that the dairy-meat combination is not acceptable. Pork and pork products are not allowed in the traditional Jewish religion. Only fish that have scales and fins are allowed; meats that are allowed include animals that are vegetable eaters, cloven-hoofed, and ritually slaughtered.

      4) A
      Nodding or smiling by a Chinese-American client may reflect only the cultural value of interpersonal harmony. This nonverbal behavior may not be an indication of agreement with the speaker, an acceptance of the treatment, or an understanding of the procedure.

      5) D
      - In the yin and yang theory, health is believed to exist when all aspects of the person are in perfect balance. Yin foods are cold and yang foods are hot. Cold foods are eaten when one has a hot illness and hot foods are eaten when one has a cold illness. Options A and B are not associated with the yin and yang theory.


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      NCLEX Review about Immune System Disorders (31-35)

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      NCLEX Review about Immune System Disorders

      31. The client with acquired immunodeficiency syndrome has begun therapy with zidovudine (Retrovir, azidothymidine, AZT, ZDV). The nurse carefully monitors which of the following laboratory results during treatment with this medication?

      a) blood culture
      b) blood glucose level
      c) blood urea nitrogen level
      d) complete blood count

      32. The nurse is reviewing the results of serum laboratory studies drawn on a client with acquired immunodeficiency syndrome who is receiving didanosine (Videx). The nurse interprets that he client may have the medication discontinued by the physician if which of the following significantly elevated results is noted?

      a) serum protein level
      b) blood glucose level
      c) serum amylase level
      d) serum creatinine level

      33. The nurse is caring for a post-renal transplantation client taking cyclosporin (Sandimmune, Gengraf, Neoral). Th nurse notes an increase in one of he client's vital signs and the client is complaining of a headache. What is the vital sign that is most likely increased?

      a) pulse
      b) respiration
      c) blood pressure
      d) pulse oximetry

      34. Ketoconazole (Nizoral) is prescribed for a client with a diagnosis of candidiasis. Select the interventions that the nurse includes when administering this medication. Select all that apply

      a) restrict fluid intake
      b) instruct the client to avoid alcohol
      c) monitor liver function studies
      d) administer the medication with a antacid
      e) instruct the client to avoid exposure to the sun
      f) administer the medication on an empty stomach

      35. The nurse has an order to begin administering foscarnet (Foscavir) to the client with cytomegalovirus retinitis and acquired immunodeficiency syndrome (AIDS). The nurse assesses the latest results of which laboratory study prior to administering the dose?

      a) serum albumin level
      b) serum creatinine level
      c) CD4 count
      d) lymphocyte count





      NCLEX Review about Immune System Disorders:
      ANSWERS AND RATIONALE

      31) D
      - Common side effects of this medication therapy are leukopenia and anemia. The nurse monitors the complete blood count results for these changes. Options A, B, and C are unrelated to the use of this medication.

      32) C
      - Didanosine (Videx) can cause pancreatitis. A serum amylase level that is increased to 1.5 to 2 times normal may signify pancreatitis in the client with acquired immunodeficiency syndrome and is potentially fatal. The medication may have to be discontinued. The medication is also hepatotoxic and can result in liver failure.

      33) C
      - Hypertension can occur in a client taking cyclosporine (Sandimmune, Gengraf, Neoral) and, because this client is also complaining of a headache, the blood pressure is the vital sign to be monitoring most closely. Other adverse effects include infection, nephrotoxicity, and hirsutism. Options A, B, and D are unrelated to the use of this medication.

      34) B, C, E
      - Ketoconazole (Nizoral) is an antifungal medication. It is administered with food (not on an empty stomach) and antacids are avoided for 2 hours after taking the medication to ensure absorption. The medication is hepatotoxic and the nurse monitors liver function studies. The client is instructed to avoid exposure to the sun because the medication increases photosensitivity. The client is also instructed to avoid alcohol. There is no reason for the client to restrict fluid intake. In fact, this could be harmful to the client.

      35) B
      - Foscarnet (Foscavir) is very toxic to the kidneys. The serum creatinine level is monitored prior to therapy, two or three times weekly during induction therapy, and at least weekly during maintenance therapy. It also may cause decreased levels of calcium, magnesium, phosphorus, and potassium. Thus, these levels are also measured with the same frequency.


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        NCLEX Review about Immune System Disorders (26-30)

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        NCLEX Review about Immune System Disorders

        26. The client who is human immunodeficiency virus seropositive has been taking zalcitabine (ddC, Hivid) as a component of treatment. The nurse plans to monitor which of the following most closely while the client is taking this medication?

        a) platelet count
        b) glucose level
        c) red blood cell count
        d) liver function studies

        27. The nurse is assigned to care for a client with cytomegalovirus retinitis and acquired immunodeficiency syndrome who is receiving foscarnet (Foscavir), an antiviral. The nurse checks the latest results of which of the following laboratory studies while the client is taking this medication?

        a) CD4 cell count
        b) serum albumin level
        c) serum creatinine level
        d) lymphocyte count

        28. The client with acquired immunodeficiency syndrome and Pneumocystis jiroveci infection has been receiving pentamidine (Pentam 300). The client develops a temperature of 101F. The nurse does further monitoring of the client, knowing that his sign would most likely indicate that the:

        a) dose of the medication is too low
        b) client is experiencing toxic effects of the medication
        c) client has developed inadequacy of thermoregulation
        d) result of another infection caused by leukopenic effects of the medication

        29. Saquinavir (Invirase) is prescribed for the client who is seropositive for human immunodeficiency virus. The nurse reinforces medication instructions and tells the client to:

        a) avoid sun exposure
        b) eat low-calorie foods
        c) eat foods that are low in fat
        d) take the medication on an empty stomach

        30. The client who is human immunodeficiency virus seropositive has been taking Stavudine (d4t, Zerit). The nurse monitors which of the following most closely while the client is taking this medication?

        a) gait
        b) appetite
        c) level of consciousness
        d) gastrointestinal function





        NCLEX Review about Immune System Disorders:
        ANSWERS AND RATIONALE

        26) D
        - Zalcitabine (ddC, Hivid) is an antiretroviral (nucleoside reverse transcriptase inhibitor) used to manage human immunodeficiency virus infection in combination with other antiretrovirals. Zalcitabine also has been used as a single agent in clients who are intolerant of other regimens. Zalcitabine can cause serious liver damage, and liver function studies should be monitored closely. Options A, B, and C are not associated specifically with the use of this medication.

        27) C
        - Foscarnet (Foscavir) is toxic to the kidneys. The serum creatinine level is monitored before therapy, two or three times per week during induction therapy, and at least weekly during maintenance therapy. Foscarnet also may cause decreased levels of calcium, magnesium, phosphorus, and potassium. Thus, these levels also are measured with the same frequency.

        28) D
        - Frequent side effects of this medication include leukopenia, thrombocytopenia, and anemia. The client should be monitored routinely for signs and symptoms of infection. Options 1, 2, and 3 are inaccurate interpretations.

        29) A
        - Saquinavir is an antiretroviral (protease inhibitor) used with other antiretroviral medications to manage human immunodeficiency virus infection. Saquinavir is administered with meals and is best absorbed if the client consumes high-calorie, high-fat meals. Saquinavir can cause photosensitivity, and the nurse should instruct the client to avoid sun exposure.

        30) A
        - Stavudine (d4t, Zerit) is an antiretroviral used to manage human immunodeficiency virus infection in clients who do not respond to or who cannot tolerate conventional therapy. The medication can cause peripheral neuropathy, and the nurse should monitor the client’s gait closely and ask the client about paresthesia.



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