08 Oct The nurse is explaining to a new student nurse the nursing process. Which of the following is the correct order of this process?

The nurse is explaining to a new student nurse the nursing process. Which of the following is the correct order of this process?

 

 Assessment, nursing diagnosis, planning, implementation, evaluation

 

 Implementation, planning, evaluation, assessment, nursing diagnosis

 

 Assessment, planning, nursing diagnosis, implementation, evaluation

 

 Planning, assessment, nursing diagnosis, implementation, evaluation

 

Question 2The nurse receives a client with a risk for injury due to taking sedatives. This is included in what phase of the nursing process?

 

 Nursing diagnosis

 

 Implementation

 

 Evaluation

 

 Planning

 

Question 3The nurse has just given a dose of antibiotic. Which measurement checks for the highest plasma/serum concentration of the drug?

 

 Albumin level

 

 Trough level

 

 Half-life level

 

 Peak level

 

Question 4When entering the client’s room for assessment purposes, which of these things would be inappropriate by the nurse? (Select all that apply)

 

 Agreeing to be friends on social media

 

 The nurse shares his/her own date of birth

 

 Taking a picture of the client’s wound and sharing it outside of work

 

 Asking the client to share their name and date of birth

 

 Knocking on the door

 

 Handwashing

 

Question 5The nurse is explaining the disintegration of enteric coated tablets to a client. Where would the nurse teach that this occurs at in the body?

 

 Stomach

 

 Liver

 

 Small intestines

 

 Colon

 

Question 6A client is going home on a medication that can not be stopped suddenly, which is included in the discharge teaching. What part of the nursing process is this included in?

 

 Planning

 

 Evaluation

 

 Nursing diagnosis

 

 Implementation

 

Question 7The nurse recognizes that which of the following are examples of objective data?  (Select all that apply.)

 

 Nausea

 

 Observed productive cough

 

 Observed condition of the patients wound

 

 Complaint of ear pain

 

 Heart rate from radial pulse

 

 Lab values

 

 Reported allergies

 

Question 8The nurse acknowledges that the correct sequence of the 4 processes of pharmacokinetics are:

 

 Distribution, absorption, metabolism, excretion

 

 Absorption, metabolism, distribution, excretion

 

 Distribution, metabolism, absorption, excretion

 

 Absorption, distribution, metabolism, excretion

 

Question 9The nurse knows that for a drug to pass rapidly through the GI membrane it needs to be what?

 

 Lipid soluble and ionized

 

 Water soluble and ionized

 

 Water soluble and nonionized

 

 Lipid soluble and nonionized

 

Question 10A nurse is explaining evidence-based practice (EBP) to a new student nurse. Which statements are a part of EBP? (Select all that apply)

 

 Integrate client’s preferences into the client’s care

 

 Practice nursing as it has always been done

 

 Always apply the 3 step process of nursing – assessment, planning, and implementation

 

 Guided by research, use the most currently approved approach to providing client care

 

Question 11Which of these assessments is not considered essential prior to giving medications to an acutely ill client?

 

 Vital signs and O2 saturations

 

 Mood

 

 Pain rating

 

 Level of consciousness

 

Question 12Which of these factors might impair the absorption of an oral medication?

 

 Hepatic insufficiency

 

 The presence of food in the stomach

 

 Renal insufficiency

 

 High serum albumin

 

Question 13You receive a patient with a new diagnosis of epilepsy. The doctor has order a larger than normal dose to reach the minimal effective serum concentration level. You realize this is known as what?

 

 Peak dose

 

 Loading dose

 

 Toxic dose

 

 Therapeutic dose

 

Question 14A client reports that he has been swallowing his nitroglycerin instead of leaving it under his tongue. Teaching is needed. What can happen if sublingual medications are swallowed?

 

 The medication effects will simply be delayed

 

 First pass may inactivate the medication

 

 The medication effects will be increased due to first pass effect

 

 An esophageal burn will occur

 

Question 15Revision of a client’s care plan goals is included in which phase of the nursing process?

 

 Planning

 

 Evaluation

 

 Assessment

 

 Implementation

 

Question 16A malnourished elderly client has a low albumin level. What is the implication of this finding? (Select all that apply)

 

 Protein insufficiency can lead to loss of metabolizing enzymes and consequential drug accumulation.

 

 Low albumin levels will lead to receptor disintegration, so more medication will be needed.

 

 Blood brain barrier crossover will be impaired. Albumin is a lipid. More medicine will be needed.

 

 Albumin insufficiency signifies impaired absorption. Doses will need to be increased.

 

 Less protein binding will occur. Medication will be more free to bind with target receptors. This may cause excessive effects.

 

Question 17A laboring mother wants to know why pain medication is not advisable. What rationales could the nurse offer for this? (Select all that apply)

 

 The blood brain barrier of an infant isn’t fully developed, so infants are at risk for sedation.

 

 The baby will not be able to eliminate the medication until it has its first stool.

 

 The liver of an infant is not well developed, so the effects of sedation can linger in the infant.

 

 Epidural analgesia offers an alternative that will not harm the infant.

 

 The baby can be given naloxone, so analgesia really isn’t a problem. It just isn’t “natural”.

 

Question 18A client who takes theophylline for asthma is experiencing theophylline toxicity. Which of these may be a contributing factor? (Select all that apply)

 

 Chewing the capsule

 

 Taking the medication with food

 

 Cirrhosis with gallstones

 

 First pass effect

 

 Forgetfulness leading to double dosing

 

Question 19The nurse is wanting to measure the margin of safety of a medication. Which description below is correct for this measurement?

 

 Therapeutic range

 

 Biologic half life

 

 Duration of action

 

 Therapeutic index

 

Question 20If phenobarbital has a four day half-life, and a client accidentally took 200 mg of the drug on Tuesday morning, and no intervention occurred, how much medication will remain in the bloodstream of that client on Thursday morning?

 

 150 mg

 

 75 mg

 

 100 mg

 

 50 mg

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