Question 1

The nurse applies a fentanyl transdermal patch to the client for the first time. Shortly after application, the client is experiencing pain. Which nursing action is most appropriate?

Accepted Answer

Answer reason: Transdermal fentanyl has a delayed onset because the medication must be absorbed through the skin and build a therapeutic depot before providing steady analgesia. Breakthrough pain soon after the first patch is expected and should be treated with an immediate-release opioid per PRN orders while the patch begins working. Replacing the patch does not solve the delayed onset and risks dosing errors or excessive opioid exposure once absorption catches up. Rubbing the patch can increase absorption unpredictably and raise overdose risk, and requesting a higher dose immediately is inappropriate before assessing steady-state response and safety (e.g., sedation/respiratory status).

Question 2

The nurse teaches the client with erectile dysfunction about the use of alprostadil via subcutaneous penile injection. Which statement indicates the client needs further teaching?

Accepted Answer

Answer reason:  Alprostadil (intracavernosal injection therapy) is intended to produce an erection that can persist long enough for intercourse, and the key safety teaching is to monitor duration because prolonged erection/priapism is a serious adverse effect. Saying it “won’t last long” reflects misunderstanding of the expected outcome and could delay recognition of an abnormally prolonged erection that requires urgent evaluation. Proper teaching includes anticipated onset (often within minutes and generally within about 5–20 minutes) and that the effect may last up to about an hour, varying by dose and patient response. Sterile technique and reporting systemic symptoms such as dizziness (possible hypotension/vasovagal response) are appropriate education points.

Question 3

The HCP prescribes amoxicillin for the 8-month-old with acute otitis media that has not resolved- Which statement to the parents is correct regarding the primary purpose of amoxicillin?

Accepted Answer

Answer reason:  Amoxicillin’s primary therapeutic purpose in acute otitis media is to eradicate susceptible bacterial pathogens causing the infection. Treating the underlying infection helps resolve middle-ear inflammation and prevents complications or persistence/recurrence. Fever and pain may improve as the infection clears, but these are symptomatic effects and are typically managed with antipyretics/analgesics rather than being the antibiotic’s primary action. Reducing Eustachian tube edema is not the main effect of an antibiotic and would relate more to anti-inflammatory/decongestant strategies (with limited pediatric indications).

Question 4

The 16-year-old is taking acyclovir. Which statement, if made by the adolescent, should indicate to the nurse that the medication is having the desired therapeutic effect?

Accepted Answer

Answer reason:  Acyclovir is an antiviral used to treat herpes simplex virus infections by inhibiting viral replication, which reduces the severity and duration of outbreaks. Improvement in painful vesicular/ulcerative genital lesions is the expected therapeutic outcome when treating genital herpes. Vaginal odor and green discharge are more consistent with bacterial vaginosis or trichomoniasis/cervicitis, which are not treated with acyclovir. Menstrual cycle regularity is unrelated to this medication’s antiviral effect.

Question 5

A client diagnosed with acute lymphocytic leukemia is about to begin chemotherapy. The nurse recognizes that further teaching is necessary when the client makes which statement?

Accepted Answer

Answer reason:  Chemotherapy commonly causes systemic adverse effects because it targets rapidly dividing cells, not just malignant cells. Nausea/vomiting, mucositis, fatigue, and infection risk can occur early in treatment depending on the specific regimen and the client’s baseline condition, so assuming there will be no illness reflects misunderstanding. Teaching should set realistic expectations and emphasize symptom reporting and supportive care strategies. In contrast, remission induction is a standard initial goal of therapy for acute leukemias.

Question 6

A client with suspected myasthenia gravis is to undergo a Tensilon test. The client asks if the Tensilon can be used to treat myasthenia gravis. The best response by the nurse is?

Accepted Answer

Answer reason: Edrophonium (Tensilon) is a very short-acting acetylcholinesterase inhibitor used primarily to diagnose myasthenia gravis by producing transient improvement in muscle strength. Because its effect lasts only minutes, it is not suitable as maintenance therapy, which requires longer-acting agents like pyridostigmine. Immunosuppression is not a mechanism-based effect of edrophonium and reflects confusion with immunomodulating therapies sometimes used in MG. While cholinergic adverse effects can occur, they are not the main reason it is not used for long-term treatment.

Question 7

A client who was hospitalized for pulmonary embolism is being discharged on warfarin (Coumadin) therapy. The client asks the nurse to explain how warfarin works. The best response by the nurse is?

Accepted Answer

Answer reason:  Warfarin is an anticoagulant that decreases synthesis of vitamin K–dependent clotting factors, thereby reducing the blood’s ability to form new clots and preventing extension of existing clots. This is the key teaching point for discharge because it sets expectations for therapeutic effect and bleeding risk monitoring. It does not lyse clots; clot dissolution is performed by thrombolytics and the body’s fibrinolytic system over time. It also does not directly lower blood pressure or mechanically prevent venous stasis, which are addressed through other interventions (e.g., mobility, compression).

Question 8

A client is diagnosed with diabetes type 1. The nurse reviews the prescribed insulin regimen of regular insulin and NPH insulin with the client to be administered subcutaneously each morning. The nurse determines that teaching was effective when the client states that the onset of regular insulin begins at what point after administration?

Accepted Answer

Answer reason: This timing is clinically important for coordinating meal intake to reduce postprandial hyperglycemia while avoiding early hypoglycemia. “Within 5 minutes” corresponds to rapid-acting analogs (e.g., lispro/aspart), not regular insulin. “4 to 8 hours” aligns more with onset/peak characteristics of longer-acting preparations and would be unsafe teaching for regular insulin meal planning.

Question 9

When providing information about treatments for diabetes insipidus to parents, a nurse explains the use of nasal spray and injections. Which indication might deter a parent from choosing nasal spray treatment?

Accepted Answer

Answer reason: Desmopressin for diabetes insipidus can be delivered via intranasal or injectable routes, but the intranasal route is limited by the child’s developmental ability and reliable nasal absorption. Infants cannot consistently coordinate or tolerate intranasal administration, and nasal congestion or small nares further makes dosing unreliable, so this limitation can drive families toward injections. Typical dosing intervals for intranasal desmopressin are not as frequent as every 2 to 4 hours, making that distractor inconsistent with standard therapy expectations. “Measurements are too difficult” is not a defining clinical limitation because dosing is provided in standardized units with caregiver teaching.

Question 10

A client with a dependent personality disorder is taking fluoxetine (Prozac) for depression. Which instruction is included in client teaching?

Accepted Answer

Answer reason: SSRIs have a delayed onset of antidepressant benefit because downstream receptor and neurotransmission changes take time. Teaching the expected time course supports adherence and prevents premature discontinuation due to perceived lack of effect. PRN dosing is unsafe and ineffective with SSRIs because they require steady daily dosing, and alcohol should be avoided rather than restricted to certain types. Sleep disturbance can occur with fluoxetine, but the key universal teaching point tested is delayed therapeutic onset.

Question 11

The nurse is caring for the postoperative client. The nurse should determine that which HCP order is specifically written to prevent thrombophlebitis and pulmonary embolism?

Accepted Answer

Answer reason: Postoperative venous thromboembolism prevention is achieved with pharmacologic anticoagulation to reduce clot formation in immobile or hypercoagulable patients. Low-molecular-weight heparin provides effective prophylaxis against deep vein thrombosis and subsequent pulmonary embolism when ordered at a standard preventive dose. Dangling/early mobility helps but is not as specifically targeted as anticoagulant prophylaxis and may be inappropriate depending on surgery and stability. Deep breathing and coughing primarily prevent atelectasis and pneumonia, and opioid analgesia addresses pain rather than thromboembolic risk.

Question 12

The client diagnosed with a seizure disorder is prescribed phenytoin (Dilantin), an anticonvulsant. Which statement indicates the client needs more teaching concerning this medication?

Accepted Answer

Answer reason:  Phenytoin patient teaching emphasizes expected therapeutic monitoring and prevention of common adverse effects rather than harmless body-fluid color changes. Orange urine is a classic benign effect of medications like rifampin/phenazopyridine, not a typical expected effect of phenytoin, so this statement reflects misinformation. Appropriate teaching includes regular serum level checks due to a narrow therapeutic index and nonlinear kinetics. Good oral hygiene is also important because gingival hyperplasia is a known adverse effect, making that statement appropriate rather than concerning.

Question 13

Nitroglycerin is ordered for an elderly client who is having an episode of chest pain. Which is a correct statement regarding the use of nitroglycerin spray instead of nitroglycerin tablets in this age group?

Accepted Answer

Answer reason: Sublingual nitroglycerin requires rapid dissolution and absorption through oral mucosa to relieve ischemic chest pain quickly. Older adults commonly have reduced salivary flow and drier oral mucosa, which can delay tablet dissolution and slow onset of effect. The spray bypasses the need for the tablet to dissolve, helping provide more reliable, rapid delivery in this group. Increased absorption and longer duration are not the key advantages of the spray; the clinical benefit is faster, more dependable onset.

Question 14

The home health care nurse is assessing a client. During the assessment, the client tells the nurse that the doctor has recently prescribed nystatin (Mycostatin). The nurse determines that further teaching is not necessary when the client states?

Accepted Answer

Answer reason:  Nystatin used for oral candidiasis is a topical-acting oral suspension that should contact the oral mucosa and then be swallowed, and timing around meals helps maximize mucosal exposure while still allowing eating. Splitting the dose so part is taken before and part after meals maintains contact time and helps cover the oral cavity when food intake might otherwise wash the medication away. Taking it only after meals can reduce pre-meal mucosal coating, while taking it only before meals may be cleared quickly by eating and drinking. The statement about dividing the dose indicates correct understanding of administration timing to optimize therapeutic effect.

Question 15

The nurse is caring for the client diagnosed with cirrhosis. After completing discharge education, the nurse recognizes the need for further teaching when the client makes which statement?

Accepted Answer

Answer reason:  In cirrhosis, nonselective beta-blockers are primarily used to lower portal venous pressure and reduce the risk of esophageal variceal bleeding rather than to treat systemic hypertension. This statement reflects a misunderstanding of the medication’s main therapeutic purpose in liver disease and therefore signals a need for more teaching. By contrast, stopping alcohol and conserving energy are appropriate lifestyle measures in cirrhosis. Diuretics such as furosemide can be part of ascites management to decrease excess fluid, often alongside other therapies and monitoring.

Question 16

Ciprofloxacin is prescribed for the client to treat a UTI. Which information should the nurse stress when teaching the client about the medication?

Accepted Answer

Answer reason: Fluoroquinolones chelate with polyvalent cations (e.g., calcium, magnesium, iron), which significantly reduces GI absorption and can cause treatment failure. Separating calcium supplements from the antibiotic by a time interval minimizes this interaction and helps ensure therapeutic drug levels for UTI eradication. A key distractor is dairy: while cation-containing products can interfere, the safer, high-yield teaching point is to separate the antibiotic from calcium-containing supplements/antacids rather than implying all dairy must be avoided. Antidiarrheals are not routinely recommended without assessment because antibiotic-associated diarrhea may represent C. difficile and requires prompt evaluation rather than self-treatment.

Question 17

The newborn is to receive phytonadione. Which statement, if made by the newborn’s mother, indicates that she understands the nurse’s teaching about the medication?

Accepted Answer

Answer reason:  Newborns have low vitamin K stores and immature gut flora, which reduces production of vitamin K–dependent clotting factors and increases risk for vitamin K deficiency bleeding. Phytonadione (vitamin K1) is given prophylactically shortly after birth to promote clotting factor activation and prevent hemorrhage. Jaundice prevention is not its purpose; jaundice is more related to bilirubin metabolism and hemolysis. Eye protection from gonorrhea/chlamydia is provided by ophthalmic antibiotic ointment, not vitamin K, and the standard route is typically intramuscular rather than oral by dropper.

Question 18

Prior to assisting with an external cephalic version on the client who is 38 weeks’ gestation, the nurse is preparing to administer terbutaline sulfate subcutaneously. Which explanation about the medication should the nurse provide to the client?

Accepted Answer

Answer reason: External cephalic version is facilitated by temporarily reducing uterine tone to allow the fetus to be turned more easily and with less resistance. Terbutaline is a beta-2 adrenergic agonist that produces smooth muscle relaxation, including relaxation of the myometrium, so its expected outcome is uterine relaxation. Common effects are maternal tachycardia, tremor, and palpitations rather than sedation. It is used as a tocolytic and therefore opposes, not stimulates, labor contractions.

Question 19

The child is prescribed hydrocortisone ointment 1% for treatment of atopic dermatitis. Which statement by the child's parent indicates understanding of the intended effect of the topical corticosteroid?

Accepted Answer

Answer reason: Topical corticosteroids are used in atopic dermatitis primarily for their anti-inflammatory effects, which reduces erythema, swelling, and immune-mediated skin irritation. By calming the inflammatory response, they also reduce pruritus indirectly and allow the skin barrier to recover. Ointment bases can be occlusive and help retain moisture, but the medication’s intended therapeutic action is not to “moisten” or “dry” the skin. Options emphasizing drying are inconsistent with eczema management, where maintaining hydration is important.

Question 20

The client being treated for opiate dependence is receiving a buprenorphine/naloxone combination. The nurse understands that the reason for adding naloxone to the treatment with buprenorphine is for what effect?

Accepted Answer

Answer reason: The key principle is that adding an opioid antagonist to an opioid agonist/partial agonist combination is meant to deter misuse, especially by injection. Naloxone has minimal effect when taken as prescribed sublingually, but if the combination is misused parenterally it rapidly antagonizes opioid receptors and can precipitate acute withdrawal symptoms. This aversive effect reduces the reinforcing “high” and discourages diversion/abuse of the medication. The other choices do not reflect naloxone’s purpose; it is not a nutritional supplement and does not reduce buprenorphine’s adverse effects.

Question 21

At discharge, the nurse documents that the client taking lithium has an accurate understanding of self-care. On which client statement should the nurse base this judgment?

Accepted Answer

Answer reason: Lithium is handled by the kidneys similarly to sodium, so low sodium intake or dehydration increases renal reabsorption and raises the risk of toxicity. Maintaining a consistent dietary sodium intake and adequate daily fluids helps keep lithium levels stable and reduces toxicity risk. Taking it on an empty stomach is not required and may worsen GI upset; it can be taken with food if needed. Routine serum monitoring is important, but a fixed “every 2 weeks” schedule is not universally correct long-term and depends on treatment phase and stability.

Question 22

The nurse instructs the parents of an infant diagnosed with hypothyroidism on how to count the infant’s pulse. The parents ask the nurse what they should do if the pulse rate is above the provided parameters. What is the best response by the nurse?

Accepted Answer

Answer reason: A pulse above set parameters suggests possible overtreatment with thyroid hormone, which can produce tachycardia and other signs of excessive dosing in infants. The safest nursing guidance is to stop the next dose and promptly notify the prescriber so the child can be assessed and the dose adjusted if needed. Administering the medication despite an abnormal vital sign increases risk of worsening cardiovascular effects. Doubling the next dose is unsafe and can precipitate toxicity, while delaying with a nap does not address the potential adverse drug effect.

Question 23

The client newly diagnosed with epilepsy who works in an office asks the nurse, “What can I do to prevent having seizures?” Which statement is the nurse’s best response?

Accepted Answer

Answer reason:  Therapeutic drug monitoring is a key prevention strategy in epilepsy because maintaining antiepileptic medication levels in the therapeutic range helps reduce breakthrough seizures and guides safe dose adjustments. Regular serum levels are especially important early in therapy, when dosing is being titrated, adherence is being assessed, and potential interactions or toxicity need to be detected. Sleep deprivation is a common seizure trigger, so recommending only 4 hours is unsafe and increases risk. Office tasks like making copies or lighting changes are not universally necessary and only apply to select cases (e.g., photosensitive epilepsy), making them less broadly appropriate than medication monitoring.

Question 24

Which statement by the client indicates proper knowledge of the use of the medication phenazopyridine hydrochloride (Pyridium)?

Accepted Answer

Answer reason: Phenazopyridine is a urinary tract analgesic that provides symptomatic relief (dysuria, urgency) but does not treat the underlying infection. A key expected effect is orange/red discoloration of urine and the potential to stain contact lenses and fabrics, so recognizing this indicates correct teaching. The statement about the infection being gone in 24 hours reflects misunderstanding because an antibiotic is required to eradicate bacteria. Calling it an antibiotic and focusing on allergy also shows incorrect knowledge of the drug’s purpose.

Question 25

Clients diagnosed with Alzheimer’s disease respond to cholinergic medications. Why do these medications help these clients?

Accepted Answer

Answer reason: Alzheimer’s disease features a deficit of central cholinergic neurotransmission that correlates with impaired memory and cognition. Cholinergic therapies used in Alzheimer’s (typically acetylcholinesterase inhibitors) increase synaptic acetylcholine availability in the CNS, which can modestly improve or stabilize cognitive symptoms. The other options emphasize peripheral autonomic effects (parasympathetic/sympathetic balance or vasodilation), which are not the primary mechanism for cognitive benefit and are more relevant to side effects. Therefore, the best rationale is increasing acetylcholine levels in the brain.

Question 26

A client receives rabies immunization after being bitten by a bat. Which statement is correct?

Accepted Answer

Answer reason: Active immunity is generated by the client’s own immune system after exposure to an antigen, so protective antibodies are not immediate and rise over time. Vaccine administration stimulates this endogenous antibody production, and immune response can be assessed indirectly with antibody titers. By contrast, rabies immune globulin is passive immunity because it provides ready-made antibodies for immediate, short-term protection without requiring the client to mount the initial response. Therefore the statement describing delayed development and titer measurement best reflects the active immune response expected after vaccination.

Question 27

Warfarin (Coumadin) works by obstructing certain clotting factors in the clotting cascade. Which information is correct regarding this mechanism of action?

Accepted Answer

Answer reason: Warfarin produces anticoagulation by inhibiting vitamin K epoxide reductase in the liver, which prevents regeneration of reduced (active) vitamin K. Without active vitamin K, hepatic gamma-carboxylation of vitamin K–dependent clotting factors (II, VII, IX, X) and proteins C and S is impaired, so the factors produced are functionally ineffective. This matches the concept of reduced vitamin K activity at the sites where clotting factors are synthesized (the liver). Calcium binding is central to parts of the coagulation cascade but is not warfarin’s target; vitamin D and magnesium are unrelated to its anticoagulant mechanism.

Question 28

The medication hyaluronidase is sometimes added to the fluid used for subcutaneous therapy (hypodermoclysis). What is the action of this medication?

Accepted Answer

Answer reason: Hyaluronidase works by breaking down hyaluronic acid in connective tissue, which decreases the viscosity of interstitial “cement” and increases tissue permeability. In hypodermoclysis, this promotes faster and more uniform dispersion of subcutaneous fluids into the surrounding tissues, improving systemic absorption. It does not function as a local anesthetic, so it is not primarily used to reduce injection-site pain. It also does not prevent allergic reactions or infections; standard aseptic technique and monitoring are required for those risks.

Question 29

The nurse is caring for a frail, elderly client. At the client care conference, the family asks if it is safe for him to receive narcotics for pain. The nurse is aware that the client is receiving hydromorphone hydrochloride (Dilaudid) for pain. What is the most appropriate response for the nurse to give the family?

Accepted Answer

Answer reason: In frail older adults, opioid selection and teaching should emphasize pharmacokinetics and safety, since reduced renal/hepatic reserve increases risk of prolonged sedation and toxicity. Hydromorphone is often considered a safer opioid choice than agents with active metabolites that can build up and cause neurotoxicity in renal impairment, making it less likely to accumulate compared with some alternatives. The statement about “no problems with breathing” is unsafe because all opioids can cause respiratory depression and require monitoring. The “not as strong as morphine” and “similar to methamphetamine” statements are incorrect and do not address the family’s safety concern appropriately.

Question 30

The client with ulcerative colitis is started on sulfasalazine. The nurse overheats the client talking with family members about sulfasalazine and recognizes the need for more teaching when the client makes which statement?

Accepted Answer

Answer reason:  Ulcerative colitis is a chronic inflammatory bowel disease characterized by periods of remission and exacerbation, not a condition that is typically “cured” by maintenance medication alone. Sulfasalazine (a 5-ASA compound) is used to reduce colonic inflammation and maintain remission, thereby decreasing symptoms and helping prevent flares. Expecting a definitive cure after a fixed time frame reflects a misunderstanding of realistic treatment outcomes and the long-term nature of the disease. This misconception could lead to nonadherence once symptoms improve, increasing the risk of relapse and complications.

Question 31

The nurse administers a calcium channel blocker to the 10-year-old experiencing fatigue and dependent edema from HP. The child's baseline BP is 108/65 mm Hg. Which finding best indicates that the medication has had the desired therapeutic effect?

Accepted Answer

Answer reason: Calcium channel blockers lower systemic vascular resistance by relaxing vascular smooth muscle, so the most direct indicator of therapeutic effect in hypertension is a reduction in blood pressure from baseline. A measurable decrease in BP after administration reflects the intended hemodynamic response and improved afterload control. Increased urine output is not a primary or expected immediate effect of calcium channel blockade and could be influenced by many non-treatment factors. Improved exercise tolerance and resolution of clubbing would not be expected as a prompt, specific outcome of this medication and are less reliable for evaluating response.

Question 32

The parent of the overweight 12-year-old is diagnosed with type 2 DM. The child, who is at risk for developing type 2 DM, is prescribed metformin. What should be the nurse’s understanding of the use of metformin in high-risk children?

Accepted Answer

Answer reason: Metformin primarily improves insulin sensitivity and decreases hepatic glucose production, which helps counter early insulin resistance seen in overweight, high-risk youth. By improving glycemic control and reducing insulin demand, it can delay progression from impaired glucose tolerance to overt type 2 diabetes in some high-risk individuals. It does not “restore” pancreatic insulin production; beta-cell dysfunction may progress despite therapy. It is not used as primary therapy for type 1 diabetes because that condition requires insulin replacement, and it does not decrease insulin sensitivity.

Question 33

The child with leukemia is being discharged after an initial chemotherapy treatment. The nurse is teaching the parents about the. allopurinol the child will continue to take at home- How should the nurse describe the most important purpose of allopurinol for this child?

Accepted Answer

Answer reason: Allopurinol inhibits xanthine oxidase, lowering new uric acid formation and thereby reducing renal crystal deposition. The key nursing teaching point is prevention of renal complications rather than symptom relief. Options about insomnia or treating an acute gout flare do not reflect the primary prophylactic indication in a child receiving chemotherapy.

Question 34

The adolescent receiving chemotherapy for treatment of Hodgkin's lymphoma is to receive tilgrastim. Which statement should reflect the nurse’s thinking about filgrastim?

Accepted Answer

Answer reason: Filgrastim is a granulocyte colony-stimulating factor (G-CSF) used to prevent or treat chemotherapy-induced neutropenia by stimulating the bone marrow to produce and mature neutrophils. This directly supports infection-risk reduction during periods of myelosuppression, which is the key expected therapeutic outcome nurses monitor for. It does not increase RBC production (that is the role of erythropoietin-stimulating agents) and it is not an antineoplastic drug. Options describing inhibition of DNA synthesis/replication reflect mechanisms of certain chemotherapy agents, not hematopoietic growth factors.

Question 35

The nurse completes teaching insulin administration to the parent of the toddler newly diagnosed with type 1 DM. The nurse concludes that the teaching was successful when the parent makes which statement?

Accepted Answer

Answer reason:  Rapid-acting insulin teaching centers on onset/peak so caregivers can coordinate dosing with meals and recognize hypoglycemia risk windows. Lispro has a very fast onset (about 10–15 minutes) and a relatively early peak (roughly 30–90 minutes), matching the expected pharmacodynamics. NPH is intermediate-acting and is not restricted to only nighttime dosing, so that statement reflects incorrect timing education. Mixing or “adding” long-acting detemir into a lispro pen is inappropriate because long-acting insulins are not mixed and are administered separately, and injection-site rotation should include multiple appropriate sites rather than only buttocks.

Question 36

The nurse is caring for the child from Italy. The child is crying, and the interpreter is stating that the child has extreme pain. What should be the nurse’s priority?

Accepted Answer

Answer reason: Safe, effective pain management starts with an objective assessment using a validated, age-appropriate tool, especially when there is a language barrier. A standardized scale helps quantify severity, guides medication selection and dosing decisions, and provides a baseline to evaluate response after interventions. Administering an opioid without first assessing pain level and sedation/respiratory risk bypasses a key nursing step and may be unsafe or lead to inadequate treatment. Using the child’s mother as the communicator is less reliable than proper assessment supported by an interpreter and can increase risk of misinterpretation. Changing the prescription is premature until pain is assessed and initial interventions and reassessment demonstrate inadequate control.

Question 37

A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who is receiving Retrovir (zidovudine). The client asked the nurse, “How does this drug work?” The nurse determines that teaching was effective when the client makes which statement?

Accepted Answer

Answer reason:  Zidovudine is a nucleoside reverse transcriptase inhibitor that blocks HIV reverse transcriptase, reducing viral replication rather than eradicating the virus. This leads to decreased viral load and helps preserve immune function, which is the practical “how it works” explanation clients should understand. Saying it “kills” HIV is inaccurate because antiretrovirals do not eliminate the virus from the body. Taking zidovudine does not guarantee the person cannot transmit HIV, and effective treatment generally requires combination antiretroviral therapy rather than a single drug.

Question 38

A client who has recently experienced a thromboembolic stroke is now stable and will begin warfarin. The client asks the nurse why the treatment was ordered. The best response by the nurse would be?

Accepted Answer

Answer reason: Cardioembolic strokes commonly arise from clot formation in the atria with atrial fibrillation, and anticoagulation is used to prevent additional emboli from forming and traveling to the brain. Warfarin specifically reduces vitamin K–dependent clotting factors, lowering the risk of recurrent embolic stroke when the source is atrial thrombus risk from dysrhythmia. It is not used as a universal standard for all ischemic stroke subtypes because antiplatelet therapy is preferred for many non-cardioembolic causes. Cost/availability and “few side effects” are not appropriate rationales, given significant bleeding risk and need for INR monitoring.

Question 39

A client with new-onset seizures of unknown cause is started on phenytoin (Dilantin), 750 mg i.v. now and 100 mg by mouth, three times a day. The nurse understands that the i.v. loading dose was given for what reason?

Accepted Answer

Answer reason: In acute seizure management, promptly attaining effective antiepileptic levels helps reduce early recurrence risk while the maintenance oral regimen is started. Phenytoin’s IV loading provides immediate systemic levels, whereas oral maintenance alone would take longer to build to a therapeutic range. The other options describe unrelated goals (CSF targeting, surgical avoidance, secretion reduction) and do not reflect the pharmacokinetic purpose of loading doses.

Question 40

A 55-year-old female client, who is in cardiac rehabilitation, tells a nurse that she’s unable to make love to her husband because she often feels fatigued and has a sense of doom. What is the most appropriate information for the nurse to provide?

Accepted Answer

Answer reason: Sexual activity increases myocardial oxygen demand and can precipitate angina-like symptoms in clients with coronary artery disease, so pre-emptive strategies that reduce cardiac workload are appropriate teaching during cardiac rehab. Nitroglycerin decreases preload and dilates coronary vessels, helping prevent or relieve ischemia associated with exertion, including intercourse. The client’s fatigue and “sense of doom” can be anginal equivalents, so providing a concrete, evidence-based action to reduce ischemic risk is safer than simply advising avoidance. Telling her to abstain offers no risk-reduction plan and may worsen anxiety and relationship stress. Alternative sexual methods may help with energy conservation, but they do not directly address possible exertional ischemia as effectively as appropriate nitroglycerin use guidance.

Question 41

The client undergoing detoxification from chronic alcohol abuse is to receive phenobarbital 120 mg IM and promethazine 50 mg IM. Which explanation by the nurse about using this medication combination is correct?

Accepted Answer

Answer reason:  Both medications depress the central nervous system, so their effects are additive when given together. In alcohol withdrawal/detoxification, enhancing sedation can help reduce agitation and promote rest while the barbiturate provides anticonvulsant/sedative benefit. Promethazine’s antihistamine/antiemetic properties do not reliably “prevent” a phenobarbital allergy, making that rationale incorrect. The combination also does not reduce sedation; instead it increases risk for excessive sedation and respiratory depression, which is the key teaching point.

Question 42

A client is awake and alert following maxillofacial surgery and complains of pain, rating it as a 9 on a scale of 1 to 10. He has orders for meperidine (Demerol) 50 mg and hydroxyzine (Vistaril) 50 mg, every 4 hours as needed. When assessing the client 20 minutes after the first dose, he reports his pain as 6. Two hours later, he reports his pain as 8. What is the priority nursing judgment?

Accepted Answer

Answer reason: Postoperative pain management should achieve sustained, acceptable relief with an appropriate regimen and reassessment when the response is inadequate. This client had only partial, short-lived relief (9 to 6 at 20 minutes) with worsening pain again to 8 by 2 hours, indicating the current PRN combination is not providing effective ongoing analgesia. The nurse’s priority judgment is to communicate the inadequate effect and request a different plan (e.g., alternative opioid, different dosing interval/route, or multimodal therapy) rather than assuming nonadherence or simply increasing dose without provider evaluation. Hydroxyzine is typically used as an adjunct for anxiety/nausea and does not commonly antagonize opioid analgesia; the key issue is ineffective pain control requiring a change in orders.

Question 43

The nurse collects the following assessment data on the client who has no known health problems: BP 135/89 mm Hg; BMI 23; waist circumference 34 inches; serum creatinine 0.9 mg/dL; serum potassium 4.0 mEq/L; LDL cholesterol 200 mg/dL; HDL cholesterol 25 mg/dL; and triglycerides 180 mg/dL. Which intervention should the nurse anticipate?

Accepted Answer

Answer reason: Statins are first-line therapy because they most effectively reduce LDL and lower the risk of future MI and stroke. Diet-only strategies would be insufficient for this degree of dyslipidemia, especially with an LDL this high. A thiazide is not indicated because the BP is only borderline and there is no diagnosis requiring diuretic therapy, and a low-potassium restriction is inappropriate with a normal potassium level.

Question 44

The nurse administers 15 units of glargine insulin at 2100 hours to the client when the client's fingerstick blood glucose reading is 110 mg/dL. At 2300, an NA reports that an evening snack was not given because the client was sleeping. Which instruction by the nurse is most appropriate?

Accepted Answer

Answer reason:  Basal insulin glargine provides relatively steady insulin coverage with minimal peak effect, so it is not routinely paired with a mandatory bedtime snack solely to prevent nocturnal hypoglycemia. With a bedtime glucose of 110 mg/dL and no symptoms reported, the priority is avoiding unnecessary waking/feeding that could disrupt sleep and add unneeded carbohydrates. A common safety practice is to reserve snacks for patients on intermediate/short-acting insulin or those with low/declining bedtime glucose or a history of nocturnal hypoglycemia. Escalating to the provider or instructing delayed “check when awake” actions is less appropriate than reinforcing correct understanding of glargine’s expected action and typical nursing care.

Question 45

The nurse is preparing to administer amitriptyline 10 mg orally to the client diagnosed with IBS. The client asks, “Why am I receiving this? I don’t feel depressed.” Which response by the nurse is best?

Accepted Answer

Answer reason:  Low-dose tricyclic antidepressants are used in IBS for neuromodulation, reducing visceral hypersensitivity and pain signaling along the gut–brain axis even when depression is not present. This response accurately explains the therapeutic purpose and expected outcome in patient-centered, nonjudgmental language. Option A is inappropriate because it makes an assumption about depression and does not educate about the IBS indication. Option C is incorrect and potentially misleading because anticholinergic effects more commonly worsen constipation and are not given to “prevent” it.

Question 46

Following a THR, the client asks the nurse, “Why am I receiving enoxaparin? With my last hip surgery, I was given a heparin injection.” What is the nurse’s best response?

Accepted Answer

Answer reason:  Low-molecular-weight heparins provide predictable anticoagulation for postoperative DVT prophylaxis and have a longer duration of action than unfractionated heparin. This explains why it may be chosen after a total hip replacement, allowing less frequent dosing while maintaining prophylactic effect. The claim that it “doesn’t affect laboratory results” is inaccurate because anticoagulation can still influence labs and bleeding risk remains clinically relevant. It is also not given orally, so the oral-administration statement is incorrect.

Question 47

The HCP recommends tamoxifen for the female client because she is at high risk for developing breast cancer. The client asks the nurse to explain how this drug will help avoid developing breast cancer. Which information about tamoxifen should be the basis for the nurse’s response?

Accepted Answer

Answer reason: Tamoxifen is a selective estrogen receptor modulator that competitively blocks estrogen’s stimulatory effects in breast tissue, reducing estrogen-driven cellular proliferation. In high-risk clients, this receptor blockade lowers the incidence of developing estrogen receptor–positive breast cancer and is also used to treat existing hormone receptor–positive disease. This mechanism-based explanation directly answers how the medication helps prevent breast cancer rather than describing nonspecific anti-inflammatory effects. A key counseling point is that it is not “minimal side effects” prophylaxis and it can increase (not decrease) endometrial cancer risk, making those distractors incorrect.

Question 48

The client, who had been prescribed sildenafil 2 weeks ago for erectile dysfunction, calls the clinic to report that nothing happens, despite taking sildenafil orally and waiting for his erection to develop. Which fact should the nurse consider before responding to the client?

Accepted Answer

Answer reason: Sildenafil enhances the normal erectile response by inhibiting PDE-5 and increasing cGMP in response to nitric oxide release, so it requires sexual arousal to initiate the pathway. A client who takes the medication and simply “waits” without stimulation may perceive it as not working even when the drug is effective. This makes education about expected action and proper use the most relevant nursing consideration before responding. Food effects are more classically emphasized with other PDE-5 inhibitors, and the other statements are factually incorrect.

Question 49

The postpartum client, who just delivered a full-term infant, tells the nurse she is concerned about her Rh-negative status. She says that she received Rho(D) immune globulin (RhoGAM) during her pregnancy, and she wonders if she is going to need it again. Which statement, if made by the nurse, is correct?

Accepted Answer

Answer reason: Postpartum Rh(D) immune globulin is used to prevent maternal sensitization when an Rh-negative mother is exposed to Rh-positive fetal red blood cells at delivery. The need for the postpartum dose depends on the infant’s Rh status (and fetomaternal hemorrhage assessment when indicated), not merely on having received antenatal prophylaxis. If the newborn is Rh-negative, there is no Rh(D) antigen exposure risk and prophylaxis is not required. Antenatal dosing does not provide lifelong protection and does not eliminate the standard postpartum decision based on the baby’s blood type.

Question 50

The 11-year-old with type 1 DM is learning to use insulin pens for basal-bolus insulin therapy with both a very-long-acting insulin and rapid-acting insulin. Which action by the child should indicate to the nurse that additional teaching is needed?

Accepted Answer

Answer reason: Basal-bolus therapy uses long-acting insulin to provide baseline coverage independent of meals and rapid-acting insulin to cover carbohydrate intake and correct hyperglycemia. Insulin glargine is a long-acting basal insulin and is not used for mealtime carbohydrate coverage because it does not match postprandial glucose rises. Using the basal pen for lunch carbs indicates misunderstanding of which insulin is appropriate for meals and increases risk for postprandial hyperglycemia with later hypoglycemia. Rapid-acting lispro is the appropriate choice for carbohydrate coverage at meals, while glargine is administered as scheduled basal dosing.

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