Pharmacology A Patient Centered Nursing Process Approach 8th Edition By Kee – Hayes – Test Bank

$20.00

Description

INSTANT DOWNLOAD COMPLETE TEST BANK WITH ANSWERS

 

Pharmacology A Patient Centered Nursing Process Approach 8th Edition By Kee – Hayes – Test Bank

 

Sample  Questions

 

Chapter 06: Herbal Therapies

Test Bank

 

MULTIPLE CHOICE

 

  1. A family member expresses concern that a patient is taking several herbal remedies and worries that they may be unsafe. The nurse will respond by saying that herbs
a. are classified as medications by the Dietary Supplement Health and Education Act of 1994.
b. are regulated by the government and are determined to be safe.
c. aren’t usually effective but are generally harmless.
d. should be discussed with the patient’s provider in conjunction with other medications.

 

 

ANS:  D

Herbs are sometimes useful but can also be useless or dangerous. There are two types of monographs under development to compile information about these substances, but there are no agencies that regulate safety and efficacy. Patients should always tell providers if they are taking any herbal remedies since there are known drug-herbal interactions and side effects.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 62

TOP:   NURSING PROCESS: Nursing Intervention: Patient Teaching

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. A pregnant woman tells the nurse that she is taking ginger to reduce morning sickness. What will the nurse tell this patient?
a. “Ginger can cause fetal birth defects.”
b. “Ginger is not safe during pregnancy.”
c. “Ginger can cause abortion in low doses.”
d. “Ginger may be taken in low doses for up to 4 days.”

 

 

ANS:  D

Ginger may be taken during pregnancy for morning sickness, but only on a short-term, low-dose basis. There is no indication that it causes fetal birth defects. Ginger is an abortifacient in large amounts.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 69

TOP:   NURSING PROCESS: Nursing Intervention: Patient Teaching

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. A patient asks the nurse about an herbal supplement and reports that it has a USP seal of approval. The nurse explains that this indicates
a. identity, potency, purity, and labeling accuracy.
b. premarket testing for safety and efficacy.
c. structure and function claims may be made.
d. the supplement’s ability to prevent and treat disease.

 

 

ANS:  A

The USP “seal of approval” is a fee-based test and reports on identity, potency, purity, and labeling accuracy. It does not indicate premarket research on safety and accuracy, does not allow manufacturers to make claims about the function of the products, and does not indicate the substance’s ability to prevent and treat disease.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 63

TOP:   NURSING PROCESS: Nursing Intervention: Patient Teaching

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. A woman reports using aloe vera to treat constipation. Which response by the nurse is correct?
a. “Aloe vera is for external use only.”
b. “Please tell me if you are taking cardiac medications or diuretics.”
c. “Side effects of aloe vera are common.”
d. “You may experience a decrease in menstrual flow while taking aloe vera.”

 

 

ANS:  B

Patients taking aloe vera should consult with their provider if taking cardiac medications or diuretics. It is for internal and external use. Side effects are rare except with long-term use or in large doses. Aloe vera can increase menstrual flow.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 67

TOP:   NURSING PROCESS: Assessment/Nursing Intervention

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. A woman who is experiencing hot flashes associated with menopause asks the nurse about using black cohosh. Which response by the nurse is correct?
a. “Black cohosh may be used long term in place of hormone replacement therapy.”
b. “Black cohosh may contribute to iron toxicity.”
c. “Black cohosh may interact with antihypertensive drugs.”
d. “Black cohosh treats menopausal symptoms without altering hormone levels.”

 

 

ANS:  C

Black cohosh may increase the action of antihypertensive medications. It should not be used longer than 6 months. It may decrease iron absorption, contributing to iron deficiency. Black cohosh suppresses luteinizing hormone and optimizes estrogen levels.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 67

TOP:   NURSING PROCESS: Nursing Intervention: Patient Teaching

MSC:  NCLEX: Physiological Integrity: Reduction of Risk Potential

 

  1. A patient who has HIV asks the nurse about taking echinacea to improve immune function. What will the nurse tell this patient?
a. “The root extract is useful for treating upper respiratory and urinary tract infections.”
b. “This use is currently being studied in patients who have HIV.”
c. “Use it as needed when antibiotics fail to treat your infections.”
d. “You may use it safely up to 8 weeks at a time as a preventive medication.”

 

 

ANS:  B

The use of echinacea to stimulate the immune system of patients with HIV is being investigated, but its use is currently not recommended.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 68

TOP:   NURSING PROCESS: Nursing Intervention: Patient Teaching

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. The nurse is counseling a female patient who reports taking feverfew to treat premenstrual syndrome and migraines. Which statement by the patient indicates understanding of the teaching?
a. “I should experience immediate effects with this herb.”
b. “I should not take feverfew if I get pregnant.”
c. “I should take feverfew with nonsteroidal anti-inflammatory drugs (NSAIDs) to enhance its effects.”
d. “If I develop gastrointestinal (GI) upset, I should stop taking feverfew immediately.”

 

 

ANS:  B

Feverfew should be avoided during pregnancy. Patients may not experience effects for 4 to 6 weeks. Patients should not take feverfew with NSAIDs without consulting the provider. Discontinuing feverfew abruptly can cause rebound headache.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 68

TOP:   NURSING PROCESS: Nursing Intervention: Patient Teaching

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. The nurse is providing preoperative education to a patient who will have surgery in several weeks. The patient denies taking anticoagulant medications but reports using herbal supplements. Which herb would cause the nurse to be concerned?
a. Echinacea
b. Ginkgo biloba
c. Kava
d. Sage

 

 

ANS:  B

Ginkgo can prolong bleeding time and therefore should be discontinued 2 weeks prior to surgery.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 69

TOP:   NURSING PROCESS: Nursing Intervention: Patient Teaching

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. The nurse provides counseling to a patient who reports taking kava to treat anxiety-related symptoms. Which statement by the patient indicates understanding of the teaching?
a. “I may take kava with lorazepam (Ativan).”
b. “I may develop a serious skin disorder while taking kava.”
c. “I should avoid alcohol while taking kava.”
d. “I should avoid St. John’s wort and valerian while taking kava.”

 

 

ANS:  C

Kava can cause drowsiness and may cause liver damage. Patients should be cautioned against drinking alcohol while taking kava. Kava increases the effect of other benzodiazepines, so it should not be taken with lorazepam. It does not cause skin disorders. It may be taken with St. John’s wort and valerian.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 70

TOP:   NURSING PROCESS: Nursing Intervention: Patient Teaching

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. The spouse of a patient who is an alcoholic asks the nurse about dietary supplements that may help prevent liver disease. Which herb will the nurse suggest the patient discuss with a provider who has prescriptive authority?
a. Ginkgo biloba
b. Kava
c. Milk thistle
d. Sage

 

 

ANS:  C

Milk thistle can prevent damage to liver cells and stimulates regeneration of liver cells.

 

DIF:    COGNITIVE LEVEL: Understanding (Comprehension) REF:   Page 71

TOP:   NURSING PROCESS: Nursing Intervention

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. A patient reports taking St. John’s wort to treat symptoms of depression and asks the nurse how to use this product safely and effectively. Which response by the nurse is correct?
a. “Apply sunscreen while taking St. John’s wort.”
b. “It is safe to take St. John’s wort with prescription antidepressants.”
c. “St. John’s wort does not affect nutrition.”
d. “You should take St. John’s wort as needed when symptoms occur.”

 

 

ANS:  A

St. John’s wort can cause photosensitivity, so patients should be counseled to use sunscreen. It should not be taken with prescription antidepressants because it increases the risk of suicidal ideation. It interferes with the absorption of iron and other minerals. Effects do not occur for 4 to 8 weeks, so it cannot be taken as needed.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 71

TOP:   NURSING PROCESS: Nursing Intervention: Patient Teaching

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. A man is diagnosed with benign prostatic hypertrophy and wants to avoid surgery. He asks the nurse about using saw palmetto. What information will the nurse include when teaching this patient about this herb?
a. “Gastric disturbances are common while using this herb.”
b. “Saw palmetto may help treat erectile dysfunction (ED) as well.”
c. “Use saw palmetto for up to 30 days and stop taking it when effects occur.”
d. “You should stop taking the herb 1 to 2 weeks prior to prostate-specific antigen (PSA) testing.”

 

 

ANS:  D

Saw palmetto can cause a false-negative test result for PSA, so patients should stop taking it 1 to 2 weeks prior to this test. GI effects are rare. It is not effective in treating ED. Effects usually don’t occur until 30 days, and it may be taken long term.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 72

TOP:   NURSING PROCESS: Nursing Intervention: Patient Teaching

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. A patient is taking valerian, or “herbal valium,” to induce sleep. What will the nurse teach this patient about this herb?
a. Habituation and addiction are likely.
b. Hangover effects are common with usual doses.
c. Liver function tests must be monitored with long-term use.
d. Valerian has a high risk for overdose.

 

 

ANS:  C

Liver function tests must be monitored with long-term use, and valerian should be discontinued if these are elevated. Habituation and addiction are rare. Hangover effects occur with high doses. There is no increased risk for overdose.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 72

TOP:   NURSING PROCESS: Nursing Intervention: Patient Teaching

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. A patient asks the nurse about the safety of herbal products in general. Which response by the nurse is correct?
a. “Consumers should research products and their manufacturers before taking.”
b. “Manufacturers are required to list interactions of herbs with drugs and food.”
c. “Products manufactured for drug and grocery store chains are safe.”
d. “Toxicological analysis is required of all commercial herbal products.”

 

 

ANS:  A

There are no comprehensive regulations of herbal supplements regarding safety and efficacy, so consumers should research herbs and product manufacturers. Companies manufacturing for drug and grocery stores are suspect and do not always list all ingredients on their labels.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 66

TOP:   NURSING PROCESS: Nursing Intervention: Patient Teaching

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. Which information can consumers expect to be included in labeling of herbal products?
a. Actions and uses
b. Interactions and precautions
c. Scientific name of the product
d. Safety and efficacy study results

 

 

ANS:  C

Manufacturers should list the scientific name of the product and the parts of the plant used in preparation. They are not required to list actions, uses, interactions, precautions, and any results of safety or efficacy studies.

 

DIF:    COGNITIVE LEVEL: Understanding (Comprehension) REF:   Page 76

TOP:   NURSING PROCESS: N/A

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

MULTIPLE RESPONSE

 

  1. Which herbal remedies are often used for gastrointestinal disorders? (Select all that apply.)
a. Chamomile
b. Cranberry
c. Dong quai
d. Echinacea
e. Ginger
f. Peppermint

 

 

ANS:  A, E, F

Chamomile, ginger, and peppermint are often used to treat gastrointestinal disorders.

 

DIF:    COGNITIVE LEVEL: Remembering (Knowledge)         REF:   Pages 67, 69, 71

TOP:   NURSING PROCESS: N/A

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

Chapter 07: Pediatric Pharmacology

Test Bank

 

MULTIPLE CHOICE

 

  1. The nurse is preparing to administer a medication to a 6-month-old infant. The nurse will monitor closely for signs of drug toxicity based on the knowledge that, compared to adults, infants have
a. an increased percentage of total body fat.
b. immature hepatic and renal function.
c. more protein receptor sites.
d. more rapid gastrointestinal transit time.

 

 

ANS:  B

The liver and kidneys are the primary organs for metabolism and excretion and are immature in infants. This allows drugs to accumulate and increases the risk for drug toxicity. Infants have a lower proportion of body fat than adults and fewer protein receptors. They do have more rapid gastrointestinal transit time, but this decreases the amount of drug absorbed.

 

DIF:    COGNITIVE LEVEL: Understanding (Comprehension) REF:   Pages 81-82

TOP:   NURSING PROCESS: Evaluation

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. The nurse reviews information about a drug and learns that it is best absorbed in an acidic environment. When giving this drug to a 1-year-old patient, the nurse will expect to administer a dose that will be
a. equal to an adult dose.
b. less than an adult dose.
c. more than an adult dose.
d. twice the usual adult dose.

 

 

ANS:  C

Because the child’s gastric pH is more alkaline than the adult’s, less drug will be absorbed. Therefore, the dose should be increased.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 80

TOP:   NURSING PROCESS: Nursing Intervention

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. The nurse assumes care for an infant who is showing signs of drug toxicity to a drug given several hours prior. The nurse checks the dose and confirms that the dose is consistent with standard dosing guidelines. Which characteristic of the drug will likely explain this response in this patient?
a. It is acidic.
b. It is highly protein-bound.
c. It is not fat-soluble.
d. It is water-soluble.

 

 

ANS:  B

With fewer protein-binding sites, there is more active drug available. This requires a reduction in the dose for infants. Drugs that are acidic are not as readily absorbed in infants, since their gastric pH tends to be more alkaline. Infants have a lower proportion of body fat; fat-soluble drugs would need to be decreased to prevent toxicity. Until about age 2 years of age, pediatric patients require larger than usual doses of water-soluble drugs to achieve therapeutic effects.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 81

TOP:   NURSING PROCESS: N/A

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. The parent is concerned about giving a child medication because of the lack of knowledge about the effects of drugs on children. The nurse discusses legislation passed in 2002 and 2003 about pediatric pharmacology. Which is true about these laws?
a. They forbid providers from prescribing medications unless they have been FDA- approved for use in children.
b. They mandate consistent, evidence-based dosing guidelines for use in children.
c. They provide federal grants to fund pediatric pharmaceutical research.
d. They require drug manufacturers to study pediatric medication use.

 

 

ANS:  D

In 2003, a law known as the Pediatric Research Equity Act joined the Best Pharmaceuticals Act of 2002 to require drug manufacturers to study pediatric medication use and offer incentives for pediatric pharmacology research. Providers are not forbidden to prescribe drugs in children that are not FDA-approved. The laws do not mandate the use of evidence-based guidelines and do not provide grants to fund research.

 

DIF:    COGNITIVE LEVEL: Understanding (Comprehension) REF:   Page 80

TOP:   NURSING PROCESS: N/A

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. The nurse will administer an intravenous medication to an adolescent patient. When preparing the adolescent for the IV insertion, which is an appropriate action by the nurse?
a. Allowing the patient to verbalize concerns about the procedure
b. Covering the insertion site with a bandage after the procedure is completed
c. Explaining any possible adverse drug reactions
d. Reassuring the patient that only one body part will be used

 

 

ANS:  A

Allowing the adolescent to verbalize concerns about the medication and its regimen may offer opportunities to clarify misconceptions and teach new information. Preschool-age children may have concerns about harm to their body and need to have sites covered. Adolescents still have a present focus, so discussing future adverse reactions is not especially helpful. Preschool and school-age children fear bodily harm and require reassurance that only one body part will be affected.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Pages 84-85

TOP:   NURSING PROCESS: Planning

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. An infant will receive a topical medication. What instruction will the nurse include when teaching the parents how to administer the medication?
a. “Apply a thin layer to the affected area.”
b. “Apply liberally to the skin on and around the area.”
c. “Use the medication less frequently than what is recommended for adults.”
d. “Use the medication more frequently than what is recommended for adults.”

 

 

ANS:  A

Topical medications may be altered by skin tissue condition. Children have thinner, more porous skin and have a proportionately higher skin surface area than adults and thus absorb topical medications more readily. Caregivers should be advised to use only a thin layer on the affected body part. This difference in skin does not affect the frequency of administering topical medications.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 81

TOP:   NURSING PROCESS: Nursing Intervention: Patient Teaching

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The provider has ordered that vitamin D drops be given to a newborn. Based on the knowledge of drug distribution in infants, the nurse understands that the infant may need
a. a higher dose.
b. a lower dose.
c. less frequent dosing.
d. more frequent dosing.

 

 

ANS:  B

Neonates and young infants tend to have less body fat than older children, meaning that they need less of fat-soluble medications since these medications won’t be bound in fat tissue. Higher doses would lead to drug toxicity. Body fat does not affect the frequency of dosing.

 

DIF:    COGNITIVE LEVEL: Understanding (Comprehension) REF:   Page 81

TOP:   NURSING PROCESS: N/A

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. The nurse is caring for a 5-year-old child. The child is taking a drug that has a known therapeutic range in adults, and the nurse checks that the ordered dose is correct and notes that the child’s serum drug level is within normal limits. The child complains of a headache, which is a common sign of toxicity for this drug. Which action will the nurse take?
a. Administer the drug since the drug levels are normal.
b. Attribute the headache to non-drug causes.
c. Hold the next dose and contact the provider.
d. Request an order for an analgesic medication.

 

 

ANS:  C

The therapeutic ranges established for many drug levels are based on adult studies, so it is important for the nurse to assess pediatric patients in conjunction with monitoring drug levels. The nurse should notify the provider of the reaction. Because headaches are a symptom of toxicity for this drug, the nurse should not ignore the symptom.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 82

TOP:   NURSING PROCESS: Nursing Intervention

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The nurse is preparing to give a 7-year-old child a bitter-tasting oral medication. The child asks the nurse if the medicine tastes bad. To help the child take this medication, which action will the nurse take?
a. Allow the child to delay taking the medication until the parent arrives.
b. Enlist the assistance of other staff to help restrain the child.
c. Tell the child that it doesn’t taste bad if it is swallowed quickly.
d. Tell the child that it tastes bad and offer a choice of beverages to drink afterwards.

 

 

ANS:  D

School-age children should be permitted more control, involvement in the process, and honest information. The nurse should tell the child the truth and offer the child a choice about what to drink to wash down the medicine. Medications must be given on schedule, so allowing the child a choice about when to take a medication is not acceptable. Restraining a child should not be used unless other methods have failed. Telling the child the medication doesn’t taste bad is not honest and will reduce the child’s trust in the nurse.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Pages 83-84

TOP:   NURSING PROCESS: Nursing Intervention

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. The nurse is preparing to administer an oral liquid medication to an 11-month-old child who is fussy and uncooperative. Which action will the nurse take to facilitate giving this medication?
a. Adding honey to the medication to improve the taste
b. Putting the medication in the infant’s formula
c. Requesting an injectable form of the medication
d. Using a syringe and allowing the parent to give the medication

 

 

ANS:  D

When possible, family members or caregivers should be solicited to assist in medication administration. Infants should not receive honey because of the risk of botulism. A syringe allows more control over the amount of medication in the infant’s mouth and should be used. Mixing the medication in a bottle requires ensuring that the infant takes the entire bottle in order to get the medication dose. Using an injectable form of medication is more traumatic and should be used only when an oral route is not possible or is contraindicated.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Pages 82-83

TOP:   NURSING PROCESS: Planning

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. A 2-year-old child will receive several doses of an intramuscular medication. The nurse caring for this child will use which intervention to help the child cope with this regimen?
a. Allowing the child to give “pretend” shots to a doll with an empty syringe
b. Allowing the child to select a Band-Aid to wear after each medication is given
c. Ensuring privacy while giving the medication
d. Explaining that the medicine will help the child to feel better

 

 

ANS:  A

Simple explanations, a firm approach, and enlisting the imagination of a toddler through play may enhance cooperation. Allowing the child to practice on a doll may help the toddler tolerate the injections. Preschool and school-age children fear bodily injury, and Band-Aids are important with those age groups. Adolescents need privacy, and school-age children and adolescents can understand the use of a medication in relation to future outcomes.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 83

TOP:   NURSING PROCESS: Assessment

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. A preschool-age child has moderate dehydration and needs a rapid bolus of fluids. To provide atraumatic care and administer fluids most effectively, what action will the nurse take?
a. Apply a eutectic mixture of local anesthetic (EMLA) just before inserting an intravenous line.
b. Ask the child’s parents to restrain the child during venipuncture so fluids may be administered.
c. Request an order for nasogastric (NG) fluids to avoid the trauma of venipuncture.
d. Use a powdered lidocaine preparation prior to insertion of the intravenous needle.

 

 

ANS:  D

One method to ensure atraumatic care is through the use of topical analgesics before IV injections. Powdered lidocaine preparations are effective in reducing the pain and fear associated with invasive procedures, such as venipuncture. EMLA is useful only if applied 1 to 2.5 hours prior to IV insertion. Asking parents to restrain the child for a painful procedure can cause stress and anxiety for both the child and the parents. NG fluids are traumatic and are uncomfortable long past the insertion of the NG tube.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 83

TOP:   NURSING PROCESS: Planning

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. The nurse is preparing to administer an intramuscular medication to a 4-year-old child who starts to cry and screams, “I don’t want a shot!” What is the nurse’s next action?
a. Acknowledge that shots hurt and tell the child to be brave.
b. Engage the child in a conversation about preschool and favorite activities.
c. Enlist the assistance of another nurse to help restrain the child.
d. Explain to the child that it will only hurt for a few seconds.

 

 

ANS:  B

Distraction may be used for pain and anxiety control in this age group. Engaging the child in a conversation may distract the child from the anxiety of the imminent injection. It is not correct to tell the child to be brave since this belittles the feelings expressed by the child. Preschool children have a limited sense of time, so telling the child that the pain will only last a few seconds may not be effective. Restraining the child with other staff should be used last after other methods have failed.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 83

TOP:   NURSING PROCESS: Planning

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. A 14-year-old female who has type 1 diabetes mellitus that has been well-controlled for several years is admitted to the hospital for treatment of severe hyperglycemia. The patient’s lab values indicate poor glycemic control for the past 3 months. The nurse caring for this patient will suspect which cause for the change in diabetic control?
a. Adolescent rebellion and noncompliance
b. Changes in cognitive function
c. Hormonal fluctuations
d. Possible experimentation with drugs or alcohol

 

 

ANS:  C

In adolescence, hormonal changes and growth spurts may necessitate changes in medication dosages; many children with chronic illness require dosage adjustments in the early teen years.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 84

TOP:   NURSING PROCESS: Assessment

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. The nurse is teaching a 15-year-old female patient and her parents about an antibiotic the adolescent will begin taking. The drug is known to decrease the effectiveness of oral contraceptive pills (OCPs). The nurse will
a. ask the adolescent and her parents whether she is taking OCPs.
b. tell her parents privately that pregnancy may occur if she is taking OCPs.
c. tell her privately that the medication may decrease the effectiveness of OCPs.
d. warn her and her parents that she may get pregnant if she is relying on OCPs.

 

 

ANS:  C

When soliciting adolescent health histories, the nurse should consider issues related to sexual practices and should provide privacy when asking sensitive questions or giving sensitive information. The other actions do not allow for patient privacy.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 86

TOP:   NURSING PROCESS: Nursing Intervention: Patient Teaching

MSC:  NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

Chapter 11: The Nursing Process in Patient-Centered Pharmacotherapy

Test Bank

 

MULTIPLE CHOICE

 

  1. The nurse provides teaching about the sedative side effects of a medication ordered to be given at 8:00 PM daily. The patient works a 7:00 PM to 7:00 AM shift. The nurse explores options including taking the medication at 8:00 AM instead of in the evening. Which QSEN competency do the nurse’s actions best demonstrate?
a. Collaboration and teamwork
b. Evidence-based practice
c. Patient-centered care
d. Patient safety

 

 

ANS:  C

Patient-centered care recognizes the patient as the source of control and provides care based on respect for the patient’s preferences, values, and needs.

 

DIF:    COGNITIVE LEVEL: Understanding (Comprehension) REF:   Page 113

TOP:   NURSING PROCESS: Planning      MSC:  NCLEX: Management of Care

 

  1. The nurse learns that a patient cannot afford a prescribed medication and enlists the assistance of the social worker and an outside agency to provide medications at a lower cost. Which QSEN competency do the nurse’s actions best demonstrate?
a. Collaboration and teamwork
b. Evidence-based practice
c. Patient-centered care
d. Quality improvement

 

 

ANS:  A

Collaboration and teamwork involve interprofessional communication and shared decision-making to provide patient care.

 

DIF:    COGNITIVE LEVEL: Understanding (Comprehension) REF:   Page 114

TOP:   NURSING PROCESS: Nursing Intervention

MSC:  NCLEX: Management of Care

 

  1. A 5-year-old child with type 1 diabetes mellitus has repeated hospitalizations for episodes of hyperglycemia related to poor control. The parents tell the nurse that they can’t keep track of everything that has to be done to care for their child. The nurse reviews medications, diet, and symptom management with the parents and draws up a daily checklist for the family to use. This is an example of the principles outlined in
a. Guiding Principles of Patient Engagement.
b. National Alliance for Quality Care.
c. Nursing Process.
d. Quality and Safety Education for Nurses.

 

 

ANS:  A

Guiding Principles of Patient Engagement address the dynamic partnership among patients, families, and health care providers.

 

DIF:    COGNITIVE LEVEL: Understanding (Comprehension) REF:   Page 114

TOP:   NURSING PROCESS: Nursing Intervention

MSC:  NCLEX: Management of Care

 

  1. The nurse is preparing to administer a medication and reviews the patient’s chart for drug allergies, serum creatinine, and blood urea nitrogen (BUN) levels. The nurse’s actions are reflective of which phase of the nursing process?
a. Assessment
b. Evaluation
c. Implementation
d. Planning

 

 

ANS:  A

Assessment involves gathering information about the patient and the drug, including any previous use of the drug.

 

DIF:    COGNITIVE LEVEL: Understanding (Comprehension) REF:   Pages 114-115

TOP:   NURSING PROCESS: Assessment

MSC:  NCLEX: Management of Care

 

  1. Which assessment is categorized as objective data?
a. A list of herbal supplements regularly used
b. Lab values associated with drugs the patient is taking
c. The ages and relationship to the patient of all household members
d. Usual dietary patterns and intake

 

 

ANS:  B

Objective data are measured and detected by another person and would include lab values. The other examples are subjective data.

 

DIF:    COGNITIVE LEVEL: Understanding (Comprehension) REF:   Page 115

TOP:   NURSING PROCESS: Assessment

MSC:  NCLEX: Management of Care

 

  1. The nurse reviews a patient’s database and learns that the patient lives alone, is forgetful, and does not have an established routine. The patient will be sent home with three new medications to be taken at different times of day. The nurse develops a daily medication chart and enlists a family member to put the patient’s pills in a pill organizer. This is an example of which phase of the nursing process?
a. Assessment
b. Evaluation
c. Implementation
d. Planning

 

 

ANS:  C

The implementation phase involves education and patient care in order to assist the patient to accomplish the goals of treatment.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Pages 117-118

TOP:   NURSING PROCESS: Nursing Intervention

MSC:  NCLEX: Management of Care

 

  1. A patient who is hospitalized for chronic obstructive pulmonary disease wants to go home. The nurse and the patient discuss the patient’s situation and decide that the patient may go home when able to perform self-care without dyspnea and hypoxia. This is an example of which phase of the nursing process?
a. Assessment
b. Evaluation
c. Implementation
d. Planning

 

 

ANS:  D

Planning involves goal-setting which, for this patient, means being able to perform self-care activities without dyspnea and hypoxia.

 

DIF:    COGNITIVE LEVEL: Understanding (Comprehension) REF:   Page 115

TOP:   NURSING PROCESS: Planning      MSC:  NCLEX: Management of Care

 

  1. A patient will be sent home with a metered-dose inhaler, and the nurse is providing teaching. Which is a correctly written goal for this process?
a. The nurse will demonstrate correct use of a metered-dose inhaler to the patient.
b. The nurse will teach the patient how to administer medication with a metered-dose inhaler.
c. The patient will know how to self-administer the medication using the metered-dose inhaler.
d. The patient will independently administer the medication using the metered-dose inhaler at the end of the session.

 

 

ANS:  D

Goals must be patient-centered and clearly state the outcome with a reasonable deadline and should identify components for evaluation.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Pages 115-116

TOP:   NURSING PROCESS: Planning      MSC:  NCLEX: Management of Care

 

  1. The nurse is developing a plan of care for a patient who has chronic lung disease and hypoxia. The patient has been admitted for increased oxygen needs above a baseline of 2 L/min. The nurse develops a goal stating, “The patient will have oxygen saturations of > 95% on room air at the time of discharge from the hospital.” What is wrong with this goal?
a. It cannot be evaluated.
b. It is not measurable.
c. It is not patient-centered.
d. It is not realistic.

 

 

ANS:  D

This goal is not realistic because the patient is not usually on room air and should not be expected to attain that goal by discharge from this hospitalization.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 116

TOP:   NURSING PROCESS: Planning      MSC:  NCLEX: Management of Care

 

  1. The nurse is developing a teaching plan for an elderly patient who will begin taking an antihypertensive drug that causes dizziness and orthostatic hypotension. Which nursing diagnosis is appropriate for this patient?
a. Deficient knowledge related to drug side effects
b. Ineffective health maintenance related to age
c. Readiness for enhanced knowledge related to medication side effects
d. Risk for injury related to side effects of the medication

 

 

ANS:  D

This patient has an increased risk for injury because of drug side effects, so this is an appropriate nursing diagnosis.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 115

TOP:   NURSING PROCESS: Nursing Diagnosis

MSC:  NCLEX: Management of Care

 

  1. An older patient must learn to administer a medication using a device that requires manual dexterity. The patient becomes frustrated and expresses lack of self-confidence in performing this task. Which action will the nurse perform next?
a. Ask the patient to keep trying until the skill is learned.
b. Provide written instructions with illustrations showing each step of the skill.
c. Schedule multiple sessions and practice each step separately.
d. Teach the procedure to family members who can administer the medication for the patient.

 

 

ANS:  C

Nurses should be sensitive to patient’s level of frustration when teaching skills. In this case, breaking the steps down into individual parts will help with this patient’s frustration level.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 116

TOP:   NURSING PROCESS: Planning      MSC:  NCLEX: Management of Care

 

  1. A school-age child will begin taking a medication to be administered 5 mL three times daily. The child’s parent tells the nurse that, with a previous use of the drug, the child repeatedly forgot to bring the medication home from school, resulting in missed evening doses. What will the nurse recommend?
a. Asking the provider if the medication may be taken before school, after school, and at bedtime
b. Putting a note on the child’s locker to encourage the child to take responsibility for medication administration
c. Asking the provider if 7.5 mL may be taken in the morning and 7.5 mL may be taken in the evening so that the correct amount is given daily
d. Taking the noon dose to school every day and giving it to the school nurse to administer

 

 

ANS:  C

For busy families with school-age children, it may be necessary to adjust the medication schedule to one that fits their schedule. The nurse should ask the provider if a revised schedule is possible. In this case, the revised schedule would involve not taking the medication while at school. Putting a note on the locker is not likely to be effective. It is not correct to adjust the dose.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 117

TOP:   NURSING PROCESS: Nursing Intervention/Planning

MSC:  NCLEX: Management of Care

 

  1. A high-school student regularly forgets to use a twice-daily inhaled corticosteroid to prevent asthma flares and is repeatedly admitted to the hospital. The child’s parent tells the nurse that the child has been told that forgetting to take the medication causes frequent hospitalizations. The nurse will
a. encourage the child to take responsibility for taking the medication.
b. reinforce the need to take prescribed medications to avoid hospitalizations.
c. suggest putting the inhaler with the child’s toothbrush to use before brushing teeth.
d. suggest that the child’s parents administer the medication to increase compliance.

 

 

ANS:  C

It is important to empower patients to take responsibility for managing medications. Putting the medication with the toothbrush can help this child remember to use it. Telling the child to take medications and reminding the child that failure to do so results in hospitalization is not working. Asking the child’s parents to administer the medication does not empower the adolescent to take responsibility.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 118

TOP:   NURSING PROCESS: Planning/Nursing Intervention

MSC:  NCLEX: Management of Care

 

  1. An adolescent patient who has acne is given a regimen of topical medications and an oral antibiotic that generally clears up lesions to fewer than 10 within 6 to 8 weeks. At a 2-month follow-up, the patient continues to have more than 25 lesions. The child’s parent affirms that the child is using the medications as prescribed. Which evaluation statement is correct for this patient?
a. “Goal of fewer than 10 lesions in 6 to 8 weeks is not met.”
b. “Goal that the medication will be effective is not met.”
c. “Goal that the patient will take medications as prescribed is not met.”
d. “Goal that the patient understands the medication regimen is not met.”

 

 

ANS:  A

All indications are that this patient is taking the medications and they are not effective. The first statement is correct because it identifies a measurable goal and a specific time frame.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 116

TOP:   NURSING PROCESS: Evaluation  MSC:  NCLEX: Management of Care

Chapter 17: Nutritional Support

Test Bank

 

MULTIPLE CHOICE

 

  1. The nurse is preparing to administer enteral nutrition to a patient. Which assessment finding would prompt the nurse to hold the nutrition and notify the patient’s provider?
a. Blood pressure of 90/60 mm Hg
b. Decreased bowel sounds
c. A productive cough
d. A temperature of 37.8° C

 

 

ANS:  B

Enteral nutrition requires adequate small bowel function with digestion, absorption, and gastrointestinal motility. The nurse should assess for abdominal distension and a decrease or absence of bowel sounds. Patients may still receive enteral feedings if hypotension, cough, or elevated temperature are present.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 244

TOP:   NURSING PROCESS: Assessment

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort: Nutrition

 

  1. The nurse is preparing to administer an enteral feeding to a patient who receives 300 mL of Isocal over 30 minutes every 4 hours. The nurse checks the residual prior to initiating the feeding and notes a residual amount of 50 mL of formula. Which action will the nurse take next?
a. Administer the feeding as ordered.
b. Administer the feeding over 60 minutes.
c. Hold the feeding and notify the patient’s provider.
d. Wait 1 hour and recheck the residual again.

 

 

ANS:  A

The nurse should determine gastric residual before each feeding when patients are receiving intermittent feedings. A residual greater than 50% of a previous feeding indicates delayed gastric emptying and warrants notifying the provider. This patient has a residual less than 50%, so the nurse may proceed with the next feeding. A residual of 50 mL is significant in patients receiving continuous enteral feedings. The nurse cannot change the rate of an enteral infusion without an order from the provider.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 247

TOP:   NURSING PROCESS: Nursing Intervention/Evaluation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort: Nutrition

 

  1. The provider calculates the enteral nutrition needs for a nonambulatory patient and determines that the patient will need 300 mL of Ultracal every 4 hours. Which method of delivery will the nurse use to administer these feedings?
a. 300 mL every 4 hours given via syringe as a 10-minute bolus
b. 300 mL every 4 hours given via enteral pump as a 45-minute infusion
c. 75 mL per hour via enteral pump as a continuous infusion
d. 150 mL every 2 hours via gravity infusion

 

 

ANS:  B

Intermittent enteral feedings are an inexpensive and safe method of administering enteral nutrition and may be used when patients are nonambulatory. Three hundred to 400 mL of solution may be given and should infuse over 30 to 60 minutes. While bolus methods may be used for patients receiving 250 to 400 mL of solution, this method is not tolerated well by non-ambulatory patients and may cause nausea, vomiting, aspiration, abdominal cramping, and diarrhea. Continuous feedings are used for critically ill patients. Gravity feedings cannot be well-controlled and may infuse too fast or too slow.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Pages 245-246

TOP:   NURSING PROCESS: Nursing Intervention

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort: Nutrition

 

  1. The nurse is preparing a patient who will receive intermittent enteral nutrition at home with a hyperosmolar solution. What information will the nurse include when teaching this patient?
a. How to perform the Valsalva maneuver
b. The need to consume extra fluids between feedings
c. The need to decrease dietary fiber
d. The need to remain supine during infusion of the enteral solution

 

 

ANS:  B

Dehydration can occur if patients do not receive enough water during or between feedings, so patients should be taught to consume extra water. The Valsalva maneuver is taught to patients who receive TPN to prevent embolus. Enteral feedings can cause diarrhea, so decreased fiber may aggravate that.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 246

TOP:   NURSING PROCESS: Nursing Intervention: Patient Education

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort: Nutrition

 

  1. The nurse assumes care of a patient who has been receiving intermittent enteral feedings of 240 mL of Osmolite every 4 hours for the past 48 hours. The patient is in bed with the head of the bed elevated 60 degrees. The enteral tubing is intact, and the enteral pump is infusing at 360 mL per hour. The nurse notes 60 mL of solution left in the bag. The tubing is not labeled. What will the nurse do?
a. Change and label the enteral tubing when this infusion is complete.
b. Increase the infusion rate to 480 mL per hour to complete the infusion.
c. Lower the head of the bed to 30 degrees.
d. Stop the infusion and check for residual before resuming the infusion.

 

 

ANS:  A

All enteral equipment should be labeled and changed every 24 hours. Since the tubing is not labeled, the nurse should change and label it as soon as the current infusion is complete. The infusion is set so that 240 mL will infuse over 45 minutes, which is appropriate, so the rate does not need to be increased. The head of the bed should be at least 30 degrees, so there is no need to lower the head of the bed. The nurse should check for residual just prior to administering the next infusion, but it is not indicated at this point.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 246

TOP:   NURSING PROCESS: Nursing Intervention/Evaluation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort: Nutrition

 

  1. The nurse dilutes an antibiotic before administering it through a patient’s nasogastric tube. The patient asks why this is necessary. The nurse explains that diluting the antibiotic helps to
a. improve absorption.
b. improve hydration.
c. prevent diarrhea.
d. prevent emboli.

 

 

ANS:  C

Liquid medication must be properly diluted when given through a feeding tube because most liquid medications are hyperosmolar and can cause abdominal distention, cramping, vomiting, and diarrhea. Diluting the liquid medication does not change absorption, improve overall hydration, or prevent embolus formation.

 

DIF:    COGNITIVE LEVEL: Understanding (Comprehension) REF:   Page 246

TOP:   NURSING PROCESS: Nursing Intervention

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort: Nutrition

 

  1. The nurse is caring for a patient who is receiving total parenteral nutrition (TPN). The nurse will carefully monitor this patient for which symptom(s)?
a. Coughing and shortness of breath
b. Decreased breath sounds
c. Diarrhea
d. Nausea and abdominal distension

 

 

ANS:  A

TPN with IV therapy is prone to air embolism. Symptoms of air embolism are coughing and dyspnea. Decreased breath sounds occur with aspiration, which is a complication of nasogastric feedings. Diarrhea, nausea, and abdominal distension occur with nasogastric feedings.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 249

TOP:   NURSING PROCESS: Evaluation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort: Nutrition

 

  1. The nurse is preparing to hang a new bag for a patient who is receiving total parenteral nutrition (TPN). During this procedure, the nurse will instruct the patient to take a deep breath and then perform which action?
a. Exhale slowly and bear down.
b. Exhale slowly to the count of 10.
c. Hold the breath and bear down.
d. Take several rapid, shallow breaths.

 

 

ANS:  C

Valsalva’s maneuver is performed by taking a breath, holding it, and bearing down. Patients are instructed to perform this maneuver in order to prevent the formation of air emboli.

 

DIF:    COGNITIVE LEVEL: Understanding (Comprehension) REF:   Page 250

TOP:   NURSING PROCESS: Nursing Intervention

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort: Nutrition

 

  1. Which patient is most likely to be a candidate for total parenteral nutrition (TPN) rather than enteral nutrition?
a. A patient who is comatose after having had a stroke
b. A patient who has a fractured mandible following a motor vehicle accident
c. A patient who has cerebral palsy and severe dysphagia
d. A patient who is pregnant and has intractable hyperemesis gravidarum

 

 

ANS:  D

The patient who is vomiting will be unable to tolerate enteral nutrition. Enteral feedings require a functioning gastrointestinal tract. TPN is more costly and does not carry significant benefits when compared with risks, so it should only be used when enteral nutrition cannot be used.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 244

TOP:   NURSING PROCESS: Assessment

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort: Nutrition

 

  1. The nurse is preparing to administer enteral nutrition to a patient who has had a stroke and who cannot swallow. A family member asks why the patient isn’t receiving intravenous nutrition. What information will the nurse provide to the family member?
a. Parenteral nutrition carries a higher risk of infection.
b. Parenteral nutrition does not provide sufficient calories.
c. Parenteral nutrition increases the risk of aspiration.
d. Parenteral nutrition is hyperosmolar and increases the risk of dehydration.

 

 

ANS:  A

Total parenteral nutrition (TPN) carries a greater risk of sepsis than enteral nutrition. TPN can provide sufficient calories, and there is no increased risk of aspiration with TPN. TPN does not increase the risk of dehydration.

 

DIF:    COGNITIVE LEVEL: Understanding (Comprehension) REF:   Page 244

TOP:   NURSING PROCESS: Nursing Intervention

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort: Nutrition

 

  1. A patient who has been receiving continuous enteral nutrition has had several large, watery stools. The nurse will contact the provider to discuss which intervention?
a. Administering antidiarrheal medications
b. Slowing the rate of infusion
c. Starting total parenteral nutrition
d. Thickening the nutrition solution

 

 

ANS:  B

The most common cause of diarrhea during a feeding is dumping syndrome as a result of rapid feed infusion. Slowing the feeding is the appropriate initial action. Antidiarrheal medications are not indicated unless slowing the infusion fails. Total parenteral nutrition is not indicated for patients with a functioning gastrointestinal tract. Thickening the solution will increase the solute load and increase the risk for diarrhea.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 246

TOP:   NURSING PROCESS: Nursing Intervention

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort: Nutrition

 

  1. A patient who has been receiving total parenteral nutrition (TPN) for several days accidently removes the intravenous (IV) line. While waiting for the IV therapy nurse, the nurse caring for this patient will monitor for which complication?
a. Air embolism
b. Dehydration
c. Hypoglycemia
d. Infection

 

 

ANS:  C

Sudden interruption of TPN therapy can lead to hypoglycemia because of the sudden drop in glucose and the patient’s continued increased insulin levels. Air embolism is a complication associated with changing TPN bags. Dehydration is not a complication of a sudden interruption of TPN. Infection is an ongoing concern, but the risk does not increase with a sudden interruption of TPN.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 248

TOP:   NURSING PROCESS: Assessment/Nursing Intervention

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort: Nutrition

 

  1. The nurse is preparing to discontinue total parenteral nutrition (TPN) therapy for a patient who has been receiving TPN for several days. The nurse will contact the provider to discuss an order for
a. antibiotics.
b. intravenous insulin.
c. isotonic dextrose.
d. nasogastric feedings.

 

 

ANS:  C

Abruptly discontinuing TPN can lead to hypoglycemia. Patients should receive an isotonic dextrose solution for 12 to 24 hours after TPN is discontinued to prevent this reaction. Antibiotics are used when signs of infection are observed. Intravenous insulin would compound hypoglycemia. Nasogastric feedings are indicated if the patient needs continued feeding therapy and has an intact GI tract.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 248

TOP:   NURSING PROCESS: Planning/Nursing Intervention

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort: Nutrition

 

  1. The nurse is caring for a patient with severe burns who will begin receiving total parenteral nutrition (TPN). The patient asks why TPN is necessary. The nurse explains that TPN is used for which reason?
a. To minimize pulmonary complications
b. To prevent hyperglycemia and fluid overload
c. To promote wound healing and maintain cell integrity
d. To restore fluid and electrolyte imbalance

 

 

ANS:  C

TPN is indicated for patients with severe burns who are in negative nitrogen balance. TPN enhances wound healing and provides the nutrients necessary to prevent cellular catabolism. While some pulmonary complications, such as aspiration pneumonia, do not occur with TPN, there is a risk of air embolism. Hyperglycemia and fluid overload may occur.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 248

TOP:   NURSING PROCESS: Nursing Intervention: Patient Teaching

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort: Nutrition

 

  1. The nurse is caring for an adult with severe burns who weighs 60 kg. Prior to initiating total parenteral nutrition (TPN) therapy, the nurse reviews the orders. Which TPN order is correct for this patient?
a. 3000 kcal, 120 g amino acids per day
b. 2400 kcal, 50 g amino acids per day
c. 1500 kcal, 100 g amino acids per day
d. 3600 kcal, 150 g amino acids per day

 

 

ANS:  A

Patients should receive 30 to 60 kcal/kg/day and 1 to 2 g/kg/day of amino acids. For a 60-kg patient, the number of calories should be 1800 to 3600 kcal/day, and amino acids should be 60 to 120 g/day.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 248

TOP:   NURSING PROCESS: Nursing Intervention

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort: Nutrition

 

  1. The nurse is caring for a patient who is receiving total parenteral nutrition (TPN). The patient reports nausea, headache, and thirst. The nurse will contact the provider to discuss
a. giving acetaminophen for headache pain.
b. obtaining a serum glucose level.
c. ordering an antiemetic to prevent vomiting.
d. starting intravenous isotonic dextrose.

 

 

ANS:  B

This patient shows signs of hyperglycemia, which is a common adverse effect of TPN. The nurse should request an order for serum glucose. Symptoms should not be treated without first determining the underlying cause. Isotonic dextrose is given to prevent hypoglycemia.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 249

TOP:   NURSING PROCESS: Nursing Intervention

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort: Nutrition

 

  1. The nurse is caring for a patient who is receiving total parenteral nutrition (TPN) and notes that the patient becomes dyspneic when transferring from the bed to a chair. The nurse auscultates rales in both lungs. Which action will the nurse take next?
a. Ask the patient to perform the Valsalva maneuver.
b. Decrease the TPN rate and request an order for a diuretic medication.
c. Obtain an order for a chest radiograph and an antibiotic.
d. Stop the TPN and request an order for intravenous isotonic dextrose.

 

 

ANS:  B

The patient who is being treated with TPN and has dyspnea and rales is experiencing fluid overload. The nurse should slow the rate of the TPN and request an order for a diuretic. Patients perform the Valsalva maneuver during bag changes to help prevent pulmonary emboli. Patients receiving TPN are not necessarily at risk for aspiration pneumonia. Intravenous isotonic dextrose is given after sudden interruption of TPN to prevent hypoglycemia.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 249

TOP:   NURSING PROCESS: Evaluation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort: Nutrition

 

  1. The nurse is caring for a patient who is being treated with total parenteral nutrition (TPN). The patient is experiencing chest pain, and the nurse observes shortness of breath and coughing along with cyanosis. The nurse understands that this patient is most likely experiencing which condition?
a. Air embolism
b. Pneumonia
c. Pneumothorax
d. Pulmonary edema

 

 

ANS:  A

Patients receiving TPN are at risk for air embolism and will report chest pain and be dyspneic with coughing and cyanosis. Patients with pneumonia will have cough and either adventitious breath sounds or diminished breath sounds. Patients with pneumothorax will have unilateral absent breath sounds and respiratory distress. Patients with pulmonary edema will have crackles and dyspnea.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 249

TOP:   NURSING PROCESS: Assessment

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort: Nutrition

 

  1. A patient receiving total parenteral nutrition (TPN) begins having cough and dyspnea. The nurse auscultates rales and notes neck vein engorgement and weight gain. The nurse suspects that the patient is experiencing which condition?
a. Air embolism
b. Fluid overload
c. Pneumonia
d. Pneumothorax

 

 

ANS:  B

This patient shows signs of overload, characterized by pulmonary edema with cough and dyspnea, neck vein engorgement, and weight gain.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 249

TOP:   NURSING PROCESS: Assessment

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort: Nutrition

 

  1. The nurse assumes care for a patient who is being treated with enteral feeding. When performing the initial assessment, the nurse finds the patient supine and asleep. The nurse will perform which action?
a. Elevate the head of the bed 30 degrees.
b. Flush the tubing with water.
c. Position the patient to the left side.
d. Temporarily discontinue the infusion.

 

 

ANS:  A

When administering an enteral feeding, the nurse should elevate the head of the patient’s bed 30 degrees.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 246

TOP:   NURSING PROCESS: Nursing Intervention

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort: Nutrition

 

MULTIPLE RESPONSE

 

  1. Patients with which conditions would benefit from enteral feedings? (Select all that apply.)
a. Burns of face, chest, and neck
b. Cerebral palsy with severe dysphagia
c. Crohn’s disease
d. Facial fractures
e. Gluten enteropathy
f. Stroke

 

 

ANS:  B, D, F

Patients with an intact, functioning gastrointestinal tract will benefit from enteral nutrition. Patients with extensive burns will need total parenteral nutrition (TPN) to prevent negative nitrogen balance. Patients with Crohn’s disease and gluten enteropathy have malabsorption problems and will need TPN.

 

DIF:    COGNITIVE LEVEL: Applying (Application)                REF:   Page 244

TOP:   NURSING PROCESS: Assessment

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort: Nutrition