Answers and Explanations

Chapter Quiz

The Answer is 3
The nurse is conducting a home visit with a client who has a history of angina. Which of the following BEST demonstrates that further teaching about nitroglycerin therapy is required?

Category: Adverse effects/contraindications/side effects/interactions
1. Taking a nitroglycerin tablet prior to exertion is an appropriate way to help prevent angina-related symptoms induced by activity.
2. Taking no more than 3 doses in a 15-minute period of time is appropriate nitroglycerin dosing instructions.
3. CORRECT: Nitroglycerin tablets may lose effectiveness if not protected from light. Therefore, they should be stored in dark containers.
4. Blurred vision is a significant side effect of nitroglycerin therapy that should be immediately reported to the physician.
The Answer is 4
The nurse assesses the peripheral IV site of a client receiving a doxorubicin infusion and suspects extravasation. After stopping the infusion and disconnecting the IV tubing, which of the following should the nurse do next?

Category: Adverse effects/contraindications/side effects/interactions
1. Hot compresses should not be applied in an doxorubicin-associated extravasation.
2. Although a cold compress is recommended in an doxorubicin-associated extravasation, it should not be applied until residual drug removal has been attempted.
3. Although elevating the arm for 48 hours is recommended, this should not be done until after the residual drug has been removed.
4. CORRECT: The first step the nurse should take is to attempt to remove any residual drug using a 1–3 mL syringe.
The Answer is 3
The nurse is preparing to discharge a 72-year-old man on warfarin therapy for a pulmonary embolism. The nurse’s discharge teaching should include which of the following instructions?

Category: Adverse effects/contraindications/side effects/interactions
1. The intake of foods containing vitamin K should not be altered from baseline.
2. Herbal medications may interfere with the effectiveness of warfarin.
3. CORRECT: Alcohol can increase the anticoagulant effect of warfarin and should be avoided.
4. Warfarin can be taken without regard to food intake, although gastrointestinal upset may be diminished if taken with food.
The Answer is 4
A 75-year-old woman has been prescribed amitriptyline hydrochloride to manage neuropathic pain associated with diabetic neuropathy. She reports to the nurse that her pain level has decreased from a 7 to a 3 on a scale of 1–10. However, she is experiencing severe xerostomia. Which of the following strategies should the nurse choose to help relieve this symptom?

Category: Adverse effects/contraindications/side effects/interactions
1. Increasing caffeine intake will not relieve xerostomia.
2. Decreasing fluid intake will not relieve xerostomia.
3. Increasing dietary sodium will not relieve xerostomia.
4. CORRECT: Strategies to reduce xerostomia (dry mouth) include increasing fluid intake and chewing sugar-free gum.
The Answer is 2
Prior to administering digoxin 0.125 mg PO to a client with chronic heart failure, the nurse determines that the apical pulse is 56. Which of the following should the nurse do FIRST?

Category: Adverse effects/contraindications/side effects/interactions
1. Unless the physician’s order specifies otherwise, when the client’s apical pulse drops below 60, the nurse should hold the dose and notify the physician.
2. CORRECT: Unless the physician’s order specifies otherwise, when the client’s apical pulse drops below 60, the nurse should hold the dose and notify the physician.
3. Although an EKG may be indicated, it is not generally the first course of action.
4. Although obtaining a digoxin level may be indicated, it is not generally the first course of action.
The Answer is 3
A 65-year-old man with metastatic colon cancer has been prescribed hydromorphone PO/PRN to help manage his pain. The nurse knows that the rectal route of administration is contraindicated when which of the following is present?

Category: Adverse effects/contraindications/side effects/interactions
1. The rectal route of administration may be preferred when a client has nausea and vomiting.
2. The rectal route of administration may be preferred when a client has difficulty swallowing.
3. CORRECT: The rectal route of administration should NOT be used in clients who have anal or rectal lesions, mucositis, thrombocytopenia, or neutropenia.
4. The rectal route of administration may also be appropriate for a client who has a fever.
The Answer is 1, 2, 4
A client is admitted for gastrointestinal bleeding. He has a platelet count of 15,000/mm and platelets have been ordered from the blood bank. Which of the following does the nurse know are required for platelet transfusions? Select all that apply.

Category: Blood and blood products
1. CORRECT: The donor and recipient should be ABO-compatible.
2. CORRECT: The donor and recipient should be Rh-compatible.
3. Crossmatching is not required for platelet transfusions.
4. CORRECT: Platelets are administered using specialized platelet filters.
The Answer is 2
A client’s red blood cell transfusion was discontinued due to an acute hemolytic transfusion reaction. Which of the following strategies should the nurse use to BEST minimize the risk of such a reaction?

Category: Blood and blood products
1. Monitoring the client’s temperature may help to promptly alert the nurse to a reaction but does not prevent it from occurring.
2. CORRECT: The most common cause of an acute hemolytic transfusion reaction is the administration of ABO-incompatible blood. By verifying client-identifying information according to hospital policy, the nurse can minimize the risk of a client being transfused with ABO-incompatible blood.
3. Administering meperidine may alleviate symptoms associated with a reaction but does not prevent it from developing.
4. Administering acetaminophen may be indicated to prevent hypersensitivity reactions, but this action will not minimize the risk of an acute hemolytic transfusion reaction from taking place.
The Answer is 2
A client is receiving a blood transfusion. The nurse observes that the client is experiencing diarrhea, abdominal pain, and chills. Which of the following actions should the nurse take FIRST?

Category: Blood and blood products
1. Assisting the client to the bathroom may be an appropriate comfort measure but should not be performed first.
2. CORRECT: Signs and symptoms of a transfusion reaction may include chills, diarrhea, fever, hives, pruritus, flushing, and abdominal or back pain. The nurse’s first action should be to stop the transfusion.
3. Meperidine may alleviate rigors, which the client was not experiencing.
4. Getting a warming blanket may be an appropriate comfort measure but should not be performed first.
The Answer is 1, 2, 4
The nurse aspirates a central venous catheter prior to drug administration but is not able to verify blood return. The nurse does not feel resistance when flushing or see any fluid leakage, swelling, or redness around the catheter site. Which of the following does the nurse know are appropriate steps? Select all that apply.

Category: Central venous access devices
1. CORRECT: Flushing the catheter with saline using a 10-mL syringe and a push-pull technique are appropriate steps to try to verify blood return in a central venous catheter.
2. CORRECT: Instructing the client to cough before reattempting aspiration is an appropriate step to try to verify blood return in a central venous catheter.
3. Administering IV medication (particularly cytotoxic medications) and fluids should not be performed until other steps are taken to verify proper placement of the catheter by assessing for patency and blood return.
4. CORRECT: Initiating a declotting protocol per policy is an appropriate step to try to verify blood return in a central venous catheter.
The Answer is 2
A client is admitted for pulmonary embolism and is receiving heparin 1,500 units/hour IV. In case of a serious bleeding reaction, the nurse has which of the following drugs readily available?

Category: Central venous access devices
1. Vitamin K is not an antidote for heparin and does not reverse the effects of the drug.
2. CORRECT: The antidote for heparin is protamine sulfate.
3. Promethazine hydrochloride is not an antidote for heparin and does not reverse the effects of the drug.
4. Protamine is not an antidote for heparin and does not reverse the effects of the drug.
The Answer is 3
A client with known heparin-induced thrombocytopenia (HIT) is undergoing chemotherapy and is having a central venous access device placed. Which of the following types of central venous access device does the nurse know BEST minimizes the risk of HIT-related complication?

Category: Central venous access devices
1. A Hickman does not contain valves and is routinely flushed with heparin.
2. A Broviac does not contain valves and is routinely flushed with heparin.
3. CORRECT: A Groshong is a valved catheter that does not require heparin flushing.
4. A port does not contain valves and is routinely flushed with heparin.
The Answer is 3
A client has been instructed by his physician to increase his warfarin sodium dose from 5 mg to 7.5 mg. He only has 5-mg tablets available. How many tablets should the nurse instruct him to take?

Category: Dose calculation
1. Taking half a tablet would only provide 2.5 mg of warfarin sodium.
2. Taking one tablet would only provide 5 mg of warfarin sodium.
3. CORRECT: Taking one and a half tablets containing 5 mg of warfarin sodium each will achieve a total dose of 7.5 mg.
4. Taking two tablets would provide 10 mg of warfarin sodium.
The Answer is 2
The nurse is preparing to set up an intravenous infusion of normal saline 1,000 mL over a 6-hour period. The tubing drop factor is 10 gtt/mL. Which of the following rates of infusion should the nurse choose?

Category: Dose calculation
1. 12 gtt/min is not the correct rate of infusion.
2. CORRECT: 28 gtt/min is the correct rate of infusion, arrived at as follows: 1,000 mL/6 hours × 10 gtt/mL/60 min/hour = 27.8 or 28 gtt/min.
3. 33 gtt/min is not the correct rate of infusion.
4. 36 gtt/min is not the correct of infusion.
The Answer is 1
A man weighs 165 lb. and is being treated for shock. The nurse is preparing a dopamine hydrochloride infusion to start at 5 mcg/kg/min. The nurse has prepared the following to infuse: dopamine 400 mg in 250 mL D₅W. Which of the following rates of infusion should the nurse choose?

Category: Dose calculation
1. CORRECT: The correct rate of infusion is 14 mL/hour, arrived at as follows: First convert 165 lb. to kg by dividing by 2.2 (75 kg). Then, convert 400 mg/250 mL to mcg/mL by dividing 400 mg/250 mL and multiplying the result (1.6 mg/mL) by 1,000 (1,600 mcg/m). Next, multiply the weight (75 kg) by the ordered dose (5 mcg/kg/min), and multiply the result (375 mcg/min) by 60. This equals 22,500 mcg/hr. Calculate mL/hr by dividing 22,500 mcg/hr by 1,600 mcg/mL. The appropriate rate is 14 mL/hr.
2. A rate of infusion of 16 mL/hour is not correct.
3. A rate of infusion of 22.5 mL/hour is not correct.
4. A rate of infusion of 37.5 mL/hour is not correct.
A 45-year-old woman with breast cancer is receiving doxorubicin 60 mg/m² as part of her cancer therapy. She is 5 ft. 6 in. tall and weighs 145 lb. Her body surface area is 1.75 m². What is the correct dose that the nurse should administer? Record your answer using one decimal place.

The Answer is 105 mg

Category: Dose calculation

Answer: 60 mg/m² × 1.75 m² = 105 mg
The Answer is 3
A client is admitted with sickle-cell anemia and voices concerns about becoming addicted to pain medicine. The nurse explains the difference between physical dependence, tolerance, and addiction. Which of the following symptoms or behaviors does the nurse know is BEST associated with addiction?

Category: Pharmacological pain management
1. Withdrawal symptoms when the drug is abruptly stopped are associated with physical dependence on a particular drug, not addiction.
2. Withdrawal symptoms when the drug dose is reduced are associated with physical dependence on a particular drug, not addiction.
3. CORRECT: Addiction is characterized by compulsive use of a drug for reasons other than therapeutic benefit.
4. A state of adaptation is associated with tolerance to a particular drug, not addiction.
The Answer is 3
A client is admitted with severe back pain and is requesting pain medication. During her assessment, the nurse notes the client has been taking acetaminophen 650 mg every 4 hours at home with minimal relief. Based on this information, which of the following PRN-ordered drug(s) should the nurse consider administering?

Category: Pharmacological pain management
1. Hydrocodone with acetaminophen would increase the client’s intake of acetaminophen. The maximum recommended dose of acetaminophen in a 24 hour period is 4 g.
2. Giving the client more acetaminophen would increase intake above the maximum recommended dose of 4 g in a 24-hour period.
3. CORRECT: Ibuprofen is the only pain relief medication listed that does not contain acetaminophen.
4. Acetaminophen with oxycodone would increase the client’s intake of acetaminophen. The maximum recommended dose of acetaminophen in a 24-hour period is 4 g.
The Answer is 2
A 14-year-old boy has been prescribed amphetamine and dextroamphetamine for attention-deficit/hyperactivity disorder (ADHD). The nurse explains that the client should be alert for which of the following adverse drug effects?

Category: Medication administration
1. Adderall may be associated with weight loss, not weight gain.
2. CORRECT: Adderall may be associated with depression.
3. Adderall may be associated with agitation or restlessness, not somnolence.
4. Adderall may be associated with tachycardia, not bradycardia.
The Answer is 4, 2, 1, 3
The nurse is administering a drug by Z-track and must follow the proper technique. Place the following steps in the appropriate order. All options must be used.

Category: Medication administration
1. The third step in proper Z-track technique is to withdraw the needle.
2. The second step in proper Z-track technique is to administer the drug IM.
3. The last step in proper Z-track technique is the release the skin.
4. The first step in proper Z-track technique is to displace the skin lateral to the injection site.
The Answer is 2
A client admitted with chronic heart failure is taking furosemide. Which of the following statements, if made by the client, BEST demonstrates to the nurse that the client understands the side effects associated with this drug?

Category: Medication administration
1. Lasix may be associated with hypotension.
2. CORRECT: Furosemide may decrease potassium. Eating foods rich in potassium is advised.
3. Lasix may be associated with nocturia.
4. Lasix does not have to be taken with food.
The Answer is 1
The nurse is administering vancomycin 1 g every 12 hours for a soft tissue infection. The nurse reminds the client to report symptoms associated with one of the serious side effects of the drug, ototoxicity. Which of the following statements by the client indicates to the nurse that the client may be experiencing this adverse reaction?

Category: Medication administration
1. CORRECT: Tinnitus may indicate that ototoxicity is developing.
2. A feeling that the IV is burning is not related to the development of ototoxicity.
3. Itchiness of the skin is not related to the development of ototoxicity.
4. The sensation of a bad taste in the mouth is not related to the development of ototoxicity.
The Answer is 2
A client is leaving the clinic with a new prescription for lisinopril. Which of the following suggestions can the nurse make to minimize one of the major effects of lisinopril?

Category: Expected actions/outcomes
1. Eating fruits and vegetables high in iron will not minimize the side effects of lisinopril.
2. CORRECT: The hypotensive effect of lisinopril may be reduced by rising slowly from a lying to a sitting position.
3. Increasing fluid intake will not minimize the side effects of lisinopril.
4. Avoiding aspirin-containing drugs will not minimize the side effects of lisinopril.
The Answer is 2
The nurse is administering a doxorubicin IV push to a client with breast cancer. Which of the following should the nurse explain is to be expected during therapy with this drug?

Category: Expected actions/outcomes
1. Burning at the IV site during administration is not a side effect of doxorubicin.
2. CORRECT: A common side effect of doxorubicin is red-colored urine.
3. Permanent alopecia is not a side effect of doxorubicin.
4. Teeth discoloration is not a side effect of doxorubicin.
The Answer is 1, 2, 4
A 60-year-old woman with anorexia nervosa is having an indwelling central venous access device placed in preparation for total parenteral nutrition (TPN) administration. Which of the following factors does the nurse know accounts for the client’s increased risk of thrombophlebitis with a peripheral intravenous line? Select all that apply.

Category: Total parenteral nutrition
1. CORRECT: The risk of thrombophlebitis is increased in individuals over the age of 60.
2. CORRECT: The risk of thrombophlebitis is increased in individuals undergoing treatment with hypertonic fluids.
3. The risk of thrombophlebitis is increased with hypertonic, not hypotonic, IV therapy.
4. CORRECT: The risk of thrombophlebitis is increased in individuals with poor peripheral venous access.