Respiratory rate

Question 1 A nurse is caring for a patient who is in severe pain and is receiving an opioid analgesic. Which of the following would be the nurse’s priority assessments?

A) Respiratory rate, seizure activity, and electrolytes
B) Pain intensity, respiratory rate, and level of consciousness
C) Liver function studies, pain intensity, and blood glucose level
D) Respiratory rate, pain intensity, and mental status

Question 2 A nurse is caring for a patient who has been admitted with acute cocaine intoxication. Which of the following vital signs would the nurse expect to find initially when assessing the patient?

A) Blood pressure (BP): 98/50, pulse (P): 120, respirations (R): 40
B) BP: 130/88, P: 92, R: 28
C) BP: 150/90, P: 80, R: 16
D) BP: 170/98, P:110, R: 20

Question 3 A nurse is providing care for a patient who suffered extensive burns to his extremities during a recent industrial accident. Topical lidocaine gel has been ordered to be applied to the surfaces of all his burns in order to achieve adequate pain control. When considering this order, the nurse should be aware that

A) intravenous lidocaine may be preferable to topical application
B) lidocaine must be potentiated with another anesthetic in order to achieve pain control
C) pain relief is unlikely to be achieved due to the destruction of nerve endings in the burn site
D) there is a risk of systemic absorption of the lidocaine through the patient’s traumatized skin

Question 4 A patient has been prescribed zolpidem (Ambien) for short-term treatment of insomnia.Which of the following will the nurse include in a teaching plan for this patient? (Select all that apply.)

A) The drug should not be used for longer than 1 month.
B) It should be taken 1 hour to 90 minutes before going to bed
C) The drug does not cause sleepiness in the morning
D) One of the most common adverse effects of the drug is headache
E) It is available in both quick-onset and continuous-release oral forms

Question 5 A middle-aged patient was diagnosed with major depression after a suicide attempt several months ago and has failed to respond appreciably to treatment with SSRIs. As a result, his psychiatrist has prescribed phenelzine. When planning this patient’s subsequent care, what nursing diagnosis should the nurse prioritize?

A) Risk for Ineffective Peripheral Tissue Perfusion related to cardiovascular effects of phenelzine
B) Risk for Constipation related to decreased gastrointestinal peristalsis
C) Risk for Infection related to immunosuppressive effects of phenelzine
D) Risk for Injury related to drug–drug interactions or drug–nutrient interactions

Question 6 Morphine has been prescribed for a 28-year-old man with severe pain due to a back injury. The nurse will advise the patient to avoid

A) alcohol
B) vitamin C
C) fatty foods
D) dairy product

Question 7 A 62-year-old woman has been prescribed a fentanyl transdermal patch for chronic cancer pain. The patient asks the nurse how long it will take for her to experience pain relief. The nurse will instruct the patient that she should feel pain relief in approximately

A) 6 hours
B) 12 hours
C) 24 hours
D) 32 hours

Question 8 A nurse is assigned to a patient who is taking lithium. Which of the following drug serum levels would indicate that the patient is at risk for adverse effects of the drug?

A) 0.3 mEq/L
B) 0.6 mEq/L
C) 1.7 mEq/L
D) 1.2 mEq/L

Question 9 A nurse who provides care on an acute medicine unit has frequently recommended the use of nicotine replacement gum for patients who express a willingness to quit smoking during their admission or following their discharge. For which of the following patients would nicotine gum be contraindicated?

A) A patient who received treatment for kidney failure due to an overdose of acetaminophen
B) A patient whose pulmonary embolism was treated with a heparin infusion
C) A patient with a history of angina who experienced a non-ST wave myocardial infarction
D) A patient whose stage III pressure ulcer required intravenous antibiotics and a vacuum dressing

Question 10 The wife of a patient who is taking haloperidol calls the clinic and reports that her husband has taken the first dose of the drug and it is not having a therapeutic effect. An appropriate response by the nurse would be

A) “Continue the prescribed dose. It may take several days to work.”
B) “I’ll ask the nurse practitioner if the dosage can be increased.”
C) “I’ll ask the nurse practitioner if the haloperidol can be discontinued and another drug started.”
D) “I’ll report this to the nurse practitioner and see if he will add another drug to enhance the effects of the haloperidol.”

Question 11 A male patient has been brought to the emergency department during an episode of status epilepticus. Diazepam is to be administered intravenously. The nurse will be sure to