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Implementation # 2
Questions Answers and Clinical Reasoning
1. To prevent infection when obtaining a sterile urine specimen from a patient's
indwelling urinary catheter, the nurse should:
A. aspirate urine from the tubing port, using a sterile syringe and needle
B. disconnect the catheter from the tubing and obtain urine
C. open the drainage bag and pour out some urine
D. wear sterile gloves when obtaining urine
2. Which action should the nurse take first when preparing to administer a
blood transfusion. ?
A. Arrange for typing and crossmatching of the patient's blood
B. Compare the patient's identification wristband with the tag on the unit of
blood
C. Start an I.V. infusion of normal saline solution
D. Measure the patient's vital signs
3. A preschool-age child with sickle cell anemia is admitted to the health care
facility in vaso-occlusive crisis after developing a fever and joint pain. What is
the nurse's highest priority when caring for this child?
A. Providing fluids
B. Maintaining protective isolation
C. Applying cool compresses to affected joints
D. Administering antipyretics, as prescribed
4. A child, age 5, is hospitalized for treatment of Kawasaki disease. Which
nursing action would best identify potential complications of this disease?
A. Auscultating breath sounds
B. Instituting cardiac monitoring
C. Monitoring blood pressure
D. Assessing the skin daily
5. The nurse must administer an oral medication to a 3-year-old child. The best
way for the nurse to proceed is by saying:
A. "It's time for you to take your medicine right now."
B. "If you take your medicine now, you'll go home sooner."
C. "Here's your medicine. Would you like apple juice or grape drink after?"
D. "See how Jimmy took his medicine? He's a good boy. Now it's your turn."
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6. A woman becomes increasingly afraid of riding in elevators. One morning, she
experiences shortness of breath, palpitations, dizziness, and trembling while
in an elevator. A doctor can find no physiological basis for these symptoms
and refers her to a psychiatric clinical nurse specialist for outpatient
counseling sessions. Which of the following is most likely to reduce the
patient's anxiety level?
A. Psychoanalytically oriented psychotherapy
B. Group psychotherapy
C. Systematic desensitization
D. Referral for evaluation for electroconvulsive therapy
7. The nurse in a psychiatric inpatient unit is caring for a patient with obsessivecompulsive disorder. As part of the patient's treatment, the psychiatrist
orders lorazepam (Ativan), 1 mg P.O. t.i.d. During lorazepam therapy, the
nurse should remind the patient to:
A. avoid caffeine
B. avoid aged cheeses
C. stay out of the sun
D. maintain an adequate salt intake
8. A patient with Alzheimer's disease says, "I'm so afraid. Where am I? Where is
my family?" How should the nurse respond?
A. "You are in the hospital and you're safe here. Your family will return at 10
o'clock--that's 1 hour from now."
B. "You know where you are. You were admitted here 2 weeks ago. Don't
worry, your family will be back soon."
C. "Why do you keep asking the same questions over and over?"
D. "The name of the hospital is on the sign over the door. Let's go read it
again."
9. Before the nurse administers the first dose of lithium (Lithonate) to a patient,
she reviews information about the drug. Which statement accurately
describes the metabolism and excretion of lithium?
A. It is metabolized in the liver and excreted in the feces.
B. It is metabolized and excreted by the kidneys.
C. It is not metabolized and is excreted unchanged by the kidneys.
D. It is metabolized in the liver and excreted by the kidneys.
10. A patient is in the eighth month of pregnancy. To enhance cardiac output and
renal function, the nurse should advise her to use which body position?
A. Right lateral
B. Left lateral
C. Supine
D. Semi-Fowler's
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11. The nurse is providing dietary teaching to a pregnant patient. To help meet
the patient's iron needs, the nurse should advise her to eat:
A. grains and milk
B. tomatoes and fish
C. eggs and citrus fruit
D. spinach and beef
12. Before discharge, which instruction should the nurse give to a patient
receiving flecainide (Tambocor) to reduce the risk of congestive heart failure?
A. "Limit your fluid intake."
B. "Take a diuretic before going to bed."
C. "Limit your potassium intake."
D. "Have your serum electrolyte levels measured weekly."
13. Which nursing intervention is most appropriate for a patient with multiple
myeloma?
A. Monitoring respiratory status
B. Balancing rest and activity
C. Restricting fluid intake
D. Preventing bone injury
14. A patient is scheduled to undergo a left hemicolectomy for colorectal cancer.
The doctor prescribes phenobarbital sodium (Luminal), 100 mg I.M. 60
minutes before surgery for sedation. Which statement accurately describes
administration of phenobarbital sodium?
A. The preferred route of administration for this drug is I.M.
B. This drug can be mixed and given with other medications.
C. This drug should be used within 24 hours after opening.
D. This drug should be injected into a large muscle mass.
15. At a health fair, a woman, age 43, with a family history of osteoporosis asks
the nurse how much calcium she should consume. The nurse tells her that the
recommended daily calcium intake for premenopausal women is:
A. 250 to 500 mg
B. 600 to 800 mg
C. 1,000 to 1,200 mg
D. 1,500 to 2,000 mg
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Implementation # 2 ~ Answers and Clinical Reasoning
Question
1. The nurse is obtaining a sterile urine specimen from a patient's indwelling urinary
catheter. To prevent infection, the nurse should:
THE CORRECT ANSWER IS: A. aspirate urine from the tubing port, using a sterile
syringe and needle.
CLINICAL REASONING: To obtain urine properly, the nurse should aspirate it from a
port, using a sterile syringe after cleaning the port. Opening a closed urine-drainage
system, as in options B and C, would increase the risk of urinary tract infection.
Although standard precautions specify wearing gloves during contact with body fluids,
sterile gloves are not necessary.
NURSING INTERVENTION : PATIENT NEED : Safe, effective care environment
TAXONOMY:
2. The nurse is preparing to administer a blood transfusion. Which action should the
nurse take first?
THE CORRECT ANSWER IS: A. Arrange for typing and crossmatching of the patient's
blood.
CLINICAL REASONING: The nurse first arranges for typing and crossmatching of the
patient's blood to ensure compatibility with donor blood. The other options, although
appropriate when preparing to administer a blood transfusion, come later.
NURISNG INTERVENTION : Implementation
PATIENT NEEDS: Safe, effective care environment TAXONOMY : Knowledge
Question
3. A preschool-age child with sickle cell anemia is admitted to the health care facility in
vaso-occlusive crisis after developing a fever and joint pain. What is the nurse's
highest priority when caring for this child?
THE CORRECT ANSWER IS: A. Providing fluids.
CLINICAL REASONING: During a vaso-occlusive crisis, sickle-shaped red blood cells
(RBCs) clump together and obstruct blood vessels, causing ischemia and tissue
damage. Providing I.V. and oral fluids promotes hemodilution, which aids the free flow
of RBCs through blood vessels. The patient must be kept away from known infection
sources but does not require protective isolation. Warm compresses may be applied to
painful joints to promote comfort; cool compresses would cause vasoconstriction,
which exacerbates sickling. Antipyretics may be administered to reduce fever but do
not play a crucial role in resolving the crisis.
NURISNG INTERVENTION : Implementation
PATIENT NEEDS : Physiological integrity
TAXONOMY : Evaluation
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4. A child, age 5, is hospitalized for treatment of Kawasaki disease. Which nursing action
would best identify potential complications of this disease?
THE CORRECT ANSWER IS: B. Instituting cardiac monitoring
CLINICAL REASONING: Kawasaki disease sometimes causes cardiac complications,
including arrhythmias. Instituting cardiac monitoring is crucial in detecting such
complications. Auscultating breath sounds, monitoring blood pressure, and assessing
the skin daily are important but to a lesser degree.
NURSING INTERVENTIO : Implementation
PATIENT NEEDS : Physiological integrity
TAXONOMY : Application
Question
5. The nurse must administer an oral medication to a 3-year-old child. The best way for
the nurse to proceed is by saying:
THE CORRECT ANSWER IS: C. "Here's your medicine. Would you like apple juice or
grape drink after?"
RATIONALES: Involving the child promotes cooperation, and permitting the child to make
choices provides a sense of control. Telling a child to take the medicine "right now" could
provoke a negative response. Promising that the child will go home sooner could decrease
the child's trust in nurses and doctors. Comparing one child with another would not
encourage cooperation.
NURSING INTERVENTION : Implementation
PATIENT NEEDS : Safe, effective care environment
TAXONOMY : Evaluation
Question
6. A woman becomes increasingly afraid of riding in elevators. One morning, she
experiences shortness of breath, palpitations, dizziness, and trembling while in an
elevator. A doctor can find no physiological basis for these symptoms and refers her to
a psychiatric clinical nurse specialist for outpatient counseling sessions. Which of the
following is most likely to reduce the patient's anxiety level?
THE CORRECT ANSWER IS: C. Systematic desensitization
RATIONALES: Phobias commonly are viewed as learned responses to anxiety that can
be unlearned through certain techniques, such as behavior modification. Systematic
desensitization, a form of behavior modification, attempts to reduce anxiety and
thereby eradicate the phobia through gradual exposure to anxiety-producing stimuli.
Psychoanalytically oriented therapy also may be effective in this situation but requires
years of treatment. Group psychotherapy could be used as an adjunct treatment to
increase the patient's self-esteem and reduce generalized anxiety. Electroconvulsive
therapy is reserved primarily for patients with severe depression or psychosis who
respond poorly to other treatments. It is rarely indicated for phobic disorders.
NURSING INTERVENTION : Implementation
PATIENT NEEDS : Psychosocial integrity
TAXONOMY : Evaluation
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7. The nurse in a psychiatric inpatient unit is caring for a patient with obsessivecompulsive disorder. As part of the patient's treatment, the psychiatrist orders
lorazepam (Ativan), 1 mg P.O. t.i.d. During lorazepam therapy, the nurse should
remind the patient to:
THE CORRECT ANSWER IS: A. avoid caffeine
RATIONALES: Ingesting 500 mg or more of caffeine can significantly alter the anxiolytic
effects of lorazepam. Other dietary restrictions are unnecessary. Staying out of the sun or
using sunscreens is required when taking phenothiazines. An adequate salt intake is
necessary for patients receiving lithium.
NURSING INTERVENTION : Implementation
PATIENT NEEDS : Physiological integrity
TAXONOMY : Knowledge
Question
8. A patient with Alzheimer's disease says, "I'm so afraid. Where am I? Where is my
family?" How should the nurse respond?
THE CORRECT ANSWER IS: A. "You are in the hospital and you're safe here. Your family
will return at 10 o'clock--that's 1 hour from now."
RATIONALES: Providing the specific information requested comforts and reassures the
patient, who is lost and confused, and promotes orientation. The nurse should not
assume that a patient with Alzheimer's disease will remember being admitted to the
hospital (option B) and should supply specific information about when the family will
visit. The nurse should not scold or infantilize the patient (option C) or assume that
the patient will remember the name of the hospital after seeing the sign (option D).
NURSING INTERVENTION : Implementation
PATIENT NEEDS : Psychosocial integrity
TAXONOMY : Comprehension
Question
9. Before the nurse administers the first dose of lithium (Lithonate) to a patient, she
reviews information about the drug. Which statement accurately describes the
metabolism and excretion of lithium?
THE CORRECT ANSWER IS: C. It is not metabolized and is excreted unchanged by the
kidneys.
RATIONALES: Lithium is not metabolized and is excreted unchanged by the kidneys.
NURSING INTERVENTION : Implementation
PATIENT NEEDS : Physiological integrity
TAXONOMY : Analysis
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Question
10. A patient is in the eighth month of pregnancy. To enhance cardiac output and renal
function, the nurse should advise her to use which body position?
THE CORRECT ANSWER IS: B. Left lateral
RATIONALES: The left lateral position shifts the enlarged uterus away from the vena
cava and aorta, enhancing cardiac output, kidney perfusion, and kidney function. The
right lateral and semi-Fowler positions do not alleviate pressure of the enlarged uterus
on the vena cava. The supine position reduces sodium and water excretion because
the enlarged uterus compresses the vena cava and aorta; this decreases cardiac
output, leading to decreased renal blood flow, which in turn impairs kidney function.
NURSING INTERVENTION : Implementation
PATIENT NEEDS : Health promotion and maintenance
TAXONOMY : Knowledge
Question
11. The nurse is providing dietary teaching to a pregnant patient. To help meet the
patient's iron needs, the nurse should advise her to eat:
THE CORRECT ANSWER IS: D. spinach and beef
RATIONALES: Common food sources of iron include spinach, beef, liver, prunes, pork,
broccoli, legumes, and whole wheat breads and cereals. Grains are good sources of
carbohydrates; milk is high in vitamin D; and fish, eggs, and calcium are high in
protein. Tomatoes and citrus fruits are high in vitamins A and C.
NURSING INTERVENTIONS : Implementation
PATIENT NEEDS : Physiological integrity
TAXONOMY : Knowledge
Question
12. Before discharge, which instruction should the nurse give to a patient receiving
flecainide (Tambocor) to reduce the risk of congestive heart failure?
THE CORRECT ANSWER IS: A. "Limit your fluid intake."
RATIONALES: The nurse should tell the patient receiving flecainide to limit fluid intake.
The patient should not take a diuretic unless prescribed by the doctor; if prescribed,
the diuretic should be taken early in the day to prevent nocturia. Sodium (not
potassium) should be limited because excessive sodium intake causes water retention.
The patient's electrolyte levels do not need to be measured weekly.
NURSING INTERVENTION : Implementation
PATIENT NEEDS : Health promotion and maintenance
TAXONOMY : Comprehension
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Question
13. Which nursing intervention is most appropriate for a patient with multiple myeloma?
THE CORRECT ANSWER IS: D. Preventing bone injury
RATIONALES: When caring for a patient with multiple myeloma, the nurse should
focus on relieving pain, preventing bone injury and infection, and maintaining
hydration. Monitoring respiratory status and balancing rest and activity are
appropriate interventions for any patient. To prevent such complications as
pyelonephritis and renal calculi, the nurse should keep the patient well hydrated--not
restrict his fluid intake.
NURSING INTERVENTION : Implementation
PATIENT NEEDS : Safe, effective care environment
TAXONOMY : Application
Question
14. A patient is scheduled to undergo a left hemicolectomy for colorectal cancer. The
doctor prescribes phenobarbital sodium (Luminal), 100 mg I.M. 60 minutes before
surgery for sedation. Which statement accurately describes administration of
phenobarbital sodium?
THE CORRECT ANSWER IS: D. This drug should be injected into a large muscle mass.
RATIONALES: Phenobarbital sodium should be injected into a large muscle mass. The
I.M. route of administration is usually avoided because the alkalinity of the soluble
preparations causes pain and necrosis at the injection site. Barbiturates are involved in
many drug interactions, so the drug should not be mixed and given with other
medications. The drug solution should be used within 30 minutes after opening to
minimize deterioration.
NURSING INTERVENTION : Implementation
PATIENT NEEDS : Physiological integrity
TAXONOMY : Analysis
Question
15. At a health fair, a woman, age 43, with a family history of osteoporosis asks the nurse
how much calcium she should consume. The nurse tells her that the recommended
daily calcium intake for premenopausal women is:
THE CORRECT ANSWER IS: C. 1,000 to 1,200 mg.
RATIONALES: Most authorities recommend that premenopausal women consume
1,000 to 1,200 mg of calcium daily. Less than 1,000 mg may not provide adequate
protection against osteoporosis; more than 1,200 mg is not necessary and may be
harmful.
NUSING INTERVENTION : Implementation
PATIENT NEEDS : Health promotion and maintenance
TAXONOMY : Knowledge
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