1. A 65-year-old patient with pneumonia is receiving garamycin (Gentamicin). It would be MOST important for a nurse to monitor which of the following laboratory values in this patient?
(A) Hemoglobin and hematocrit. (B) BUN and creatinine. (C) Platelet count and clotting time. (D) Sodium and potassium.
2. A 22-year-old man is admitted to the hospital with complaints of fatigue and weight loss. Physical examination reveals pallor and multiple bruises on his arms and legs. The results of the patients tests reveal acute lymphocytic leukemia and thrombocytopenia. Which of the following nursing diagnoses MOST accurately reflects his condition?
(A) Potential for injury. (B) Self-care deficit. (C) Potential for self-harm. (D) Alteration in comfort.
3. To enhance the percutaneous absorption of nitroglycerine ointment, it would be MOST important for the nurse to select a site that is
(A) muscular. (B) near the heart. (C) non-hairy. (D) over a bony prominence.
4. A man is admitted to the Telemetry Unit for evaluation of complaints of chest pain. Eight hours after admission, the patient goes into ventricular fibrillation. The physician defibrillates the patient. The nurse understands that the purpose of defibrillation is to:
(A) increase cardiac contractility and cardiac output. (B) cause asystole so the normal pacemaker can recapture. (C) reduce cardiac ischemia and acidosis. (D) provide energy for depleted myocardial cells.
5. A patient is to receive 3,000 ml of 0.9% NaCl IV in 24 hours. The intravenous set delivers 15 drops per milliliter. The nurse should regulate the flow rate so that the patient receives how many drops of fluid per minute?
(A) 21 (B) 28 (C) 31 (D) 42
ANSWERS AND RATIONALE
1. The correct answer is B.
Question: Which lab values should you monitor for a patient receiving Gentamicin?
Needed Info: Gentamicin: broad spectrum antibiotic. Side effects: neuromuscular blockage, ototoxic to eighth cranial nerve (tinnitus, vertigo, ataxia, nystagmus, hearing loss), nephrotoxic. Nursing responsibilities: monitor renal function, force fluids, monitor hearing acuity. Draw blood for peak levels 1 hr. after IM and 30 min – 1 hr. after IV infusion, draw blood for trough just before next dose.
(A) Hemoglobin and hematocrit — can cause anemia; less common (B) BUN and creatinine — CORRECT: nephrotoxic; will see proteinuria, oliguria, hematuria, thirst, increased BUN, decreased creatine clearance (C) Platelet count and clotting time — do not usually change (D) Sodium and potassium — hypokalemia infrequent problem
2. The correct answer is A.
Question: What nursing diagnosis is seen with acute lymphocytic leukemia and thromocytopenia?
Needed Info: Thromocytopenia: decreased platelet count increases the patient’s risk for injury, normal count: 200,000-400,000 per mm3. Leukemia: group of malignant disorders involving overproduction of immature leukocytes in bone marrow. This shuts down normal bone marrow production of erythrocytes, platelets, normal leukocytes. Causes anemia, leukopenia, and thrombocytopenia leading to infection and hemorrhage. Symptoms: pallor of nail beds and conjunctiva, petechiae (small hemorrhagic spot on skin), tachycardia, dyspnea, weight loss, fatigue. Treatment: chemotherapy, antibiotics, blood transfusions, bone marrow transplantation. Nursing responsibilities: private room, no raw fruits or vegs, small frequent meals, O2, good skin care.
(A) Potential for injury — CORRECT: low platelet increases risk of bleeding from even minor injuries. Safety measures: shave with an electric razor, use soft tooth brush, avoid SQ or IM meds and invasive procedures (urinary drainage catheter or a nasogastric tube), side-rails up, remove sharp objects, frequently assess for signs of bleeding, bruising, hemorrhage. (B) Self-care deficit — may feel weak, doesn’t address condition (C) Potential for self-harm — implies risk for purposeful self-injury, not given any info, assumption (D) Alteration in comfort — patient is not comfortable, and comfort measures would address problem
3. The correct answer is C.
Question: What is the best site for nitroglycerine ointment?
Strategy: Think about each site.
Needed Info: Nitroglycerine: used in treatment of angina pectoris to reduce ischemia and relieve pain by decreasing myocardial oxygen consumption; dilates veins and arteries. Side effects: throbbing headache, flushing, hypotension, tachycardia. Nursing responsibilities: teach appropriate administration, storage, expected pain relief, side effects. Ointment applied to skin; sites rotated to avoid skin irritaion. Prolonged effect up to 24 hours.
(A) muscular — not most important (B) near the heart — not most important (C) non-hairy — CORRECT: skin site free of hair will increase absorption; avoid distal part of extremities due to less than maximal absorption (D) over a bony prominence — most important is that the site be non-hairy
4. The correct answer is B.
Question: Why is a patient defibrillated?
Strategy: Think about each answer choice.
Needed Info: Defibrillation: produces asystole of heart to provide opportunity for natural pacemaker (SA node) to resume as pacer of heart activity.
(A) increase cardiac contractility and cardiac output — inaccurate (B) cause asystole so the normal pacemaker can recapture — CORRECT: allows SA node to resume as pacer of heart activity (C) reduce cardiac ischemia and acidosis — inaccurate (D) provide energy for depleted myocardial cells — inaccurate
5. The correct answer is C.
Question: How should you regulate the IV flow rate?
Strategy: Use formula and avoid making math errors.
Needed Info: total volume x the drop factor divided by the total time in minutes.
(A) 21 — inaccurate (B) 28 — inaccurate (C) 31 — CORRECT: 3,000 x 15 divided by 24 x 60 (D) 42 — inaccurate