Exam Cram NCLEX-PN PRACTICE QUESTIONS with Answers 2024, Exams of Nursing

Download Exam Cram NCLEX-PN PRACTICE QUESTIONS with Answers 2024 and more Exams Nursing in PDF only on Docsity! Exam Cram NCLEX-PN PRACTICE QUESTIONS with Answers 2024 the nurse is caring for a client scheduled for removal of a pituitary tumor using the transsphenoidal approach. the nurse should be particularly alert to: A. Nasal congestion B. Abdominal Tenderness C. Muscle Tetany D. Oliguria ✔ A. Nasal congestion why? removal of the pituitary gland is usually done by transsphernoidal approach through the nose. Nasal congestion further interferes with the airway. A client with cancer is a, admitted to the oncology unit. Stat lab values revel Hgb 12.6, WBC 6500, K+1.9, uric acid 7.0, Na+136, and platelets 178,000. The nurse evaluates that the client is experiencing which of the following? A. Hypernatremia B. Hypokalemia C. Myelosuppression D. Leukocytosis ✔ B. Hypokalemia why? Hypokalemia is evident from the lab values listed. The other laboratory findings are within normal limits. making answers A,C and D incorrect A 24 year-old female client is scheduled for surgery in the morning. Which of the following is the primary responsibility of the nurse? A. taking the vital signs B. obtaining the permit C. explaining the procedure D. Checking the lab work ✔ A. taking the vital signs why? the primary responisblity of the nurse is to take the vital signs before any surgery. answers B,C and D are the responsibility of the doctor. The nurse is working in the emergency room when a client arrives with severe burns of the left arm, hands, face, and neck. which action should receive priority? A. starting an IV? B. Applying oxygen C.Obtaining blood gas D. Medicating the client foe pain ✔ B. Applying oxygen why? the client with burns to the neck needs airway assessments and supplemental oxygen, so applying oxygen is priority. the next action should be to start an IV and medicate for pain. The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instructions should be given to the client A. rest in bed after taking the medication for at least 30 mins B. Avoid rapid movements after taking the medication C. Take medication with water only D. Allow at least 1 hour between taking the medicine and taking other medications ✔ C. Take medication with water only why? Fosmax should be taken with water only. The client should also remain upright for at least 30 mins after taking the medication. The nurse is making initial rounds on a client with a C5 fracture and crutchfield thongs. Which equipment should be kept at the bedside? A. A pair of forceps B. A torque wrench C. A pair or wire cutters D. A screwdriver ✔ B. A torque wrench why? A tourque wrench is kept at the bedside to tighten and loosen the screws of crutchfield tongs. This wrench controls the amount of pressure that is placed on the screws. An infant weighs 7 pounds at birth. The excpectd weight by 1 year should be: A. 10 pounds B.12 pounds the client with diverticulitis should avoid eating foods that are gas forming and that increase abdominal discomfort, such as cooked broccoli. The nurse is caring for a new mother. The mother asks why her baby has lost weight since he was born. The best explanation of the weight loss is: A. The baby is dehydrated due to polyuria. B. The baby is hypoglycemic due to glucose. C. The baby is allergic to the formula the mother is giving him. D. The baby can lose up to 10% of weight due to meconium still, loss of extracelluar fluid, and initiation of breast-feeding. ✔ D. The baby can lose up to 10% of weight due to meconium still, loss of extraceullar fluid, and initiation of breast-feeding. why? After birth, meconium stool, loss of extracellular fluid, and initiation of breastfeeding cause the infant to lose body mass. There is no evidence to indicate dehydration, hypoglycemia, or allergy to the infant formula The nurse if caring for a client with laryngeal cancer. Which finding ascertained in the health history would not be common for this diagnosis? A. Foul breath B. Dysphagia C. Diarrhea D. Chronic hiccups ✔ C. Diarrhea why? Diarrhea is not common in clients with mouth and throat cancer A removal of the left lower lobe of the lung is performed on a client with lung cancer. Which post-operative measure would usually be included? A. Closed chest drainage B. A tracheostomy C. A mediastinal tube D. Percussion vibration and drainage ✔ A. A closed chest drainage why? The client with a lung resection will have chest tubes and a drainage-collection device. He probably will not have a tracheoostomy or mediastinal tube, and he will not have an order for percussion, vibration, or drainage. Six hours after birth, the infant is found to have an areas of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as: A. A cephalohematoma B. Molding C. Subdural hematoma D. Caput succedaneum ✔ A. A cephalohematoma why? The swelling over the right parietal area is a cephalohematoma, an area of bleeding outside the cranium. This type of hematoma does not cross the suture line because it's outside the cranium but beneath the periosteum. The nurse is assisting the RN with discharge instructions for a client with an implantable defibrillator. What discharge instruction is essential? A. "You cannot eat food prepared in a microwave." B. "You should avoid moving the should on the side of the pacemaker site for 6 weeks." C. "You should use your cellphone on your right side." D. "You will not be able to fly on a commercial airliner with the defibrillator in place." ✔ C. "You should use your cellphone on your right side." why? The client with an internal defibrilliator should learn to use any battery operated machinery on the opposite side. He should also take his pulse rate and report dizziness or fainting. A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The nurse should be most careful to monitor the client for which dysrhythmia during this procedure? A. Bradycardia B. Tachycardia C. Premature ventricular beats D. Heart block ✔ A. Bradycardia why? Suctioning can cause a vagal response and bradycardia. The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period? A. Assessment of the client's level of anxiety. B. Evaluation of the client's exercise tolerance C. Identification of peripheral pulses. D. Assessment of bowel sounds and activity. ✔ C. Identification of peripheral pulses why? The assessment that is most crucial to the client is identification of peripheral pulses because aorta is clammed during surgery. This decreases blood circulation to the kidneys and lower extremities. The nurse must also assess for the return of circulation to the lower extremities. A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in the teaching session? A. "You will be sitting for the examination procedure." B. "Portions of the procedure will cause pain or discomfort." C. "You will be given some medication to anesthetize the area." D. "you will not be able to drink fluids for 24 hours before the study." ✔ B. "Portions of the procedure will cause pain or discomfort." why? Portions of the exam are painful especially when the sample is being withdrawn so this should be included in the session with the client. The nurse is performing an assessment on a client with possible pernicious anemia. Which data would support this diagnosis? A. A weight loss of 10 pounds in 2 weeks. B. Complaints of numbness and tingling in the extremities. C. A red, beefy tongue. D. A hemoglobin level of 12.0 gm/dL ✔ C. A red, beefy tongue why? A red, beefy tongue is characteristic of a client with pernicious anemia. C. A history of minimal physical activity D. A history of the client's food intake ✔ A. A history of radiation treatment in the neck region why? Previous radiation to the neck might have damaged parathyroid glands, which are located on the thyroid gland and interfered with calcium and phosphorus regulation. A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170 meq/L. What behavioral changes would be common for this client? A. Anger B. Mania C. Depression D. Pyschosis ✔ B. Mania why? The client with serum sodium of 170 meq/L has hypernatrimia and might exhibit manic behvior. The nurse is obtaining a history of an 80 year old client. Which statement made by the client might indicate a possible fluid and electrolyte imbalance? A. "My skin is always so dry." B. "I often use laxatives for constipation." C. "I have always liked to drink ice tea." D. "I sometimes have a problem with dribbling urine." ✔ B. "I often use laxatives for constipation." why? Frequent use of laxatives can lead to diarrhea and electrolyte loss. A client visits the clinic after the death of a parent. Which statement made by the client's sister signifies abnormal grieving? A. "My sister still has episodes of crying and it's been 3 months since daddy died." B. "Sally seems to have forgotten the bad things that daddy did in his lifetime." C. "She really had a hard time after daddy's funeral. She said that she had a sense of longing." D. "Sally has not been sad at all by daddy's death. She acts like nothing has happened." ✔ D. "Sally has not been sad at all by daddy's death. She acts like nothing has happened at all." why? Abnormal grieving is exhibited by a lack of feeling sad; if the client's sister appears not to grieve, it might be abnormal grieving. This family member might be suppressing feelings of grief. The nurse recognizes that which of the following would be most appropriate to wear when providing direct care to a client with a cough? A. Mask B. Gown C. Gloves D. Shoe covers ✔ A. Mask why? If the nurse is exposed to the client with a cough, the best item to wear is a mask. If the answer had included a mask, gloves, and a gown, all would be appropriate. The nurse is caring for a client with a diagnosis of Hepatitis who is experiencing pruritis. Which would be the most appropriate nursing intervention? A. Suggest that the client take warm showers b.i.d. B. Add baby oil to the client's bath water C. Apply powder to the client's skin D. Suggest a hot water rinse after bathing. ✔ B. Add baby oil to the client's bath water why? Oil can be applied to help with the dry skin and to decrease itching, so adding baby oil to bath water is soothing to the skin. A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate? A. Blood pressure every 15 minutes B. Insertion of a levine tube C. Cardiac monitoring D. Dressing changes 2x per day ✔ B. Insertion of a levine tube why? The client with pancreatitis frequently has nausea and vomiting. Lavage is often used to decompress the stomach and rest the bowel, so the insertion of a levine tube should be anticipated. The client is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because: A. The client is at risk for evisceration B. The client will require frequent dressing changes C. The straps provide support for drains that are inserted into the incision D. No sutures or clips are used to secure the incision. ✔ B. The client will require frequent dressing changes why? Montgomery straps are used to secure dressing that require frequent dressing changes because the client with a cholescystectomy usually has a large amount of drainage on the dressing. Montgomery straps are also used for clients who are allergic to several types of tape. The physician has order that the client's medication be administered intrathecally. The nurse is aware that the medications will be administered by which method? A. Intravenously B. Rectally C. Intramuscularly D. Into the cerebrospinal fluid ✔ D. Into the cerebrospinal fluid why? Intrathecal medications are administered into the cerebrospinal fluid. This method of administering medications is reserved for the client with metastases, the client with chronic pain, or the client with cerebrospinal infections. Which client can be best assigned to the newely licensed to the Practical Nurse? A. The client receiving chemotherapy B. The client post-coronary bypass C. The client with a TURP D. The client with diverticulitis ✔ D. The client with diverticulitis why? A. Restrict her fat intake for one week before the test B. To omit creams, powders, or deodorants before the exam C. The mammography replaces the need for self breast exams D. That mammography requires higher does of radiation than an x-ray. ✔ B. To omit creams, powders, or deodorants before the exam. why? The client having the mammogram should be instructed to omit deodorants or powders beforehand because powders and deodorants can be interpreted as abnormal. Which of the following roommates would be best for the client with gastric resection? A. A client with Chron's disease B. A client with pneuomia C. A client with gastritis D. A client with phlebitis ✔ D. A client with phlebitis why? The most suitable roommate for the client with gastric resection is the client with phlebitis because phlebitis is an inflammation of the blood vessel and is not infectious. The licensed practical nurse is working with a RN and a patient care assistant. Which of the following clients should be cared for by the RN? A. A client two days post-appendectomy B. A client one week post-thyroidectomy C. A client 3 days post- splenectomy D. A client 2 days post- thoracotomy ✔ D. A client 2 days post-thoracotomy why? The most critical client should be assigned to the RN; in this case, that is the client 2 days post-thoracotomy. The LPN is observing a graduate nurse as she assess the central venous pressure. Which observation indicates that the graduate needs further teaching? A. The graduate places the client in a supine position to read the manometer B. The graduate turns the stopcock to the off position from the IV fluid to the client C. The graduate instructs the client to perform the Valsalva manuever during the CVP reading D. The graduate notes the level at the top of the meniscus ✔ C. The Graduate instructs the client to perform the Valsalva manuever during the CVP reading. why? The client should breathe normally during a central venous pressure monitor reading. Which of the following roommates would be most suitable for the client with myasthenia gravis? A. A client with hypothyroidism B. A client with Chron's disease C. A client with pylonephritis D. A client with bronchitis ✔ A. A client with hypothyroidism why? The most suitable roommate for the client with myasthenia gravis is the client with hypothyroidism because he is quiet. The nurse employed in the ER is responsible for triage for 4 clients injured in a motor vehicle accident. Which of the following clients should receive priority in care? A. A 10 year old with lacerations to the face B. A 15 year old with sternal bruising C. A 34 year old with fractured femur D. A 50 year old with dislocation of the elbow ✔ B. A 15 year old with sternal bruising why? The teenager with sternal bruising might be experiencing airway and oxygenation problems and, thus, should be seen first. The client is receiving peritoneal dialysis. If the dialysis returns cloudy the nurse should" A. Document the finding B. Send a specimen to the lab C. Strain the urine D. Obtain a complete blood count ✔ B. Send a specimen to the lab why? If the dialysate returns cloudy, infection might be present and must be evaluated The client with cirrhosis of the liver is receiving lactulose. The nurse is aware that the ratio for the order of lactulose is : A. To lower the blood glucose level B. To lower the uric acid level C. To lower ammonia level D. To lower the creatinine level ✔ C. To lower ammonia level why? Lactulose is administered to the client with cirrhosis to lower ammonia levels. The client with diabetes is preparing for discharge. During discharge teaching, the nurse assesses the client's ability to care for himself. Which statement by the client indicates a need for follow-up after discharge? A."I live by myself." B." I have trouble seeing." C. "I have a cat in the house with me." D. " I usually drive myself to the doctor." ✔ B. "I have trouble seeing" why? A client with diabetes who has trouble seeing would require follow-up after discharge. The lack of visual acuity for the client preparing and injecting insulin might require help. The client is receiving total parenteral nutrition (TPN). Which lab should be evaluated while the client is receiving TPN? A. Hemoglobin B. Creatinine C. Blood glucose D. White blood cell count ✔ C. Blood glucose why? When the client is receiving TPN, the blood glucose level should be drawn. TPN is a solution that contains large amounts of glucose. To protect herself, the nurse should wear gloves when applying a nitroglycerin patch or cream. A 25 year old male is brought to the ER with a piece of metal in his eye. Which action by the nurse is correct? A. Use a magnet to remove the object B. Rinse the eye thoroughly with saline C. Cover both eyes with paper cups D. Patch the affected eye only ✔ C. Cover both eyes with paper cups why? Covering both eyes prevents consensual movement of the affected eye. The physician has order sodium warfrin ( Coumadin) for the client with thrombophlebitis. The order should be entered to administer the medication at: A. 0900 B. 1200 C. 1700 D. 2100 ✔ C. 1700 why? Sodium warfarin is administered in the late afternoon, at approximately 1700 hours. this allows for accurate bleeding times to be drawn in the morning. The schizophrenic client has become disruptive and requires seclusion. Which staff member can institute seclusion? A. Secrurity guard B. RN C. LPN D. The nursing assistant ✔ B. RN why? The RN is the only one of these who can legally put the client in seclusion. The only other healthcare worker who is allowed to initiate seclusion is the doctor. The client is admitted with chronic obstructive pulmonary disease. Blood gases reveal a pH of 7.36, CO2 at 45, O2 at 84, HCO3 at 28. The nurse would assess the client to be in: A. Uncompensated acidosis B. Compensated alkalosis C. Compensated respiratory acidosis D. Uncompensated metabolic acidosis ✔ C. Compensated respiratory acidosis why? The client is experiencing compensated respiratory acidosis. The pH is within the normal range but is lower than 7.40, so it is on the acidic side. The CO2 level is elevated, the oxygen level is below normal, and the bicarb level is slightly elevated. In respiratory disorders, the pH will be in inverse of the CO2 and bicarb level. This means that if the pH is low, the CO2 and bicarb levels will be elevated. The nurse is assessing the client recently returned from surgery. The nurse is aware that the best way to assess pain is to: A. Take blood pressure, pulse, and temp B. Ask the client to rate his pain from 1-5 C. Watch the client's facial expression D. Ask the client if he is in pain ✔ B. Ask the client to rate his pain from 1-5 why? The best way to evaluate pain levels is to ask the client to rate his pain on a scale. The nursing is participating in a discharge teaching for the post-partal client. The nurse is aware that an effective means of managing discomfort associated with a episiotomy after discharge is: A. Promethazine B. Aspirin C. Sitz bath D. Ice bath ✔ C. Sitz bath why? A sitz bath will help with swelling and improve healing Which of the following post-op diets are most appropriate for a client who has had a hemorroidectomy? A. High fiber B. Low-residue C. Bland D. Clear liquids ✔ D. Clear liquids why? After surgery, the client will be placed o n a clear-liquid diet and progressed to a regular diet. stool softeners will be included in the plan of care, to avoid constipation. The physician has ordered a culture for the client with suspected Gonorrhea. The nurse should obtain what type of culture? A. Blood B. Nasopharyngeal secretions C. Stool D. Genital secretions ✔ D. Genital secretions why? A culture for gonorrhea is taken from the genital secretions. The culture is placed in a warm environment, where it can grow nisseria gonorrhea The nurse is caring for a client with cerebral plasy. The nurse should provide frequent rest periods because: A: Grimacing and withering movements decrease with relaxation and rest. B. Hypoactive deep tendon reflexes become more active with rest C. Stretch reflexes become more increases with rest D. Fine motor movements are improved ✔ A. Grimacing and withering movements decrease with relaxation and rest. why? Frequent rest periods help to relx tense muscles and preserve energy The nurse is making assignments for the day. Which client should be assigned to the nursing assistant? A. A client with Alzheimer's B. A client with pnuemonia The client with the appendectomy is the most stable of these clients and can be assigned to a nursing assistant. The client with bronchiolitis has an alteration in the airway, the client with periorbital cellulitis has an infection, and the client with a fracture might be an abused child. A new nursing graduate indicates in charting enteries that he is a licensed practical nurse, although he has not received the results of the licensing exam. The graduate's actions can result in what type of charge? A. Fraud B. Tort C. Malpractice D. Negligence ✔ A. Fraud why? Identifying oneself as a nurse without a license defrauds the public and can be prosecuted. A tort is a wrongful; malpractice is failing to act appropriately as a nurse or acting in a way that harm comes to the client; and negligence is failing to perform care. A client with acute leukemia develops a low white blood cell count. In addition to the institute of isolation the nurse should: A. Request that food be served with disposable utensils B. Ask the client to wear a mask when visitors are present C. Prep IV with mild soap, water, and alcohol D. Provide foods in seal single serving packages ✔ D. Provide foods in seal single serving packages why? Because the client is immune-suppressed, foods should be served in sealed containers, to avoid food contaminants. A 70 year old man who is recovering from a stroke exhibits signs of unilateral neglect. Which behavior is suggested of unilateral neglect? A. The client is observed by shaving only one side of his face B. The client is unable to distinguish between two tactile stimuli presented simultaneously C. The client is unable to complete a range a vision without turning his head side to side D. The client is unable to carry out cognitive and motor activity at the same time ✔ A. The client is observed by shaving only one side of his face why? The client with unilateral neglect will neglect one side of the body The nurse is providing discharge teaching for a client who is taking dissulfiram (Antabuse). The nurse should instruct the client to avoid eating: A. Peanuts, dates, raisins B. Figs, chocolate, eggplant C. Pickles, salad with vinaigrette dressing, and beef D. Milk, cottage cheese, ice cream ✔ C. Pickles, salad with vinaigrette dressing, beef why? The client taking antabuse should not eat or drink anything containing alcohol or vinegar A client has been receiving cyanocobalamine (B12) injections for the past 6 weeks. Which lab finding indicates that the medication is having the desired effect? A. Neutrophil count of 60% B. Basophil count of 0.5% C. Monocyte count of 2% D. Reticlocyte count of 1% ✔ D. Reticlocyte count of 1 % why? Cyanocolamine is a B12 medication that is used for pernicious anemia, and a reticulocyte count of 1% indicates that it is having the desired effect. The nurse has just received a change of shift report. Which client should the nurse assess first? A. A client 2 hours post-lobectomy with 150 cc drainage B. A client 2 days post-gastrectomy with scant drainage C. A client with pnuemonia with a oral temp of 102 F D. A client with a fractured hip in Bucks traction ✔ A. A client 2 hours post-lobectomy with 150 cc drainage why? The first client to be seen is the one who recently returned from surgery. Several clients are admitted to the ER following a three- car vehicle accident. Which clients can be assigned to share a room in the emergency department during the disaster? A. The schizophrenic client having visual and auditory hallucinations and the client with ulcerative collitis B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm C. A child whose pupils are fixed and dilated and his parents, and the client with a frontal head injury D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain ✔ B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm why? Out of all these clients, it is best to hold the pregnant client and the client with a broken arm and facial lacerations in the same room. The home health nurse is planning for the day's visits. Which client should be seen first? A. The 78 year old who had a gastrectomy 3 weeks ago with a PEG tube B. The 5 month old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension C. The 50 year old with MRSA being treated with Vancomycin via a PICC line D. The 30 year old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter ✔ D. The 30 year old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter why? The priority client is the one with multiple sclerosis who is being treated with cortisone via the central line. This client is at highest risk for complications. The nurse is found to be guilty of charting blood glucose results without actually performing the procedure. After talking to the nurse, the charge nurse should: A. Call the Board of Nursing B. File a formal reprimand C. Terminate the nurse D. Charge the nurse with a tort ✔ B. File a formal reprimand why? The action after discussing the problem with the nurse is to document the incident and file a formal reprimand. If the behavior continues or if harm has resulted to the client, the A. The client receiving linear accelerator radiation therapy for lung cancer. B. The client with a radium implant for cervical cancer C. The client who has just been administered soluble brachytherapy for thyroid cancer D. The client who returned from placement of iridium seeds for prostate cancer ✔ A. The client receiving linear accelerator radiation therapy for lung cancer why? The pregnant nurse should not be assigned to any client with radioactivity present. Therefore, the client receiving linear accelerator therapy is correct because this client travels to the radium department for therapy, and the radiation stays in the department; the client is not radioactive The client is receiving heparin for thrombophlebitis of the left lower extremity. Which of the following drugs reverses the effects of heparin? A. Cyanocoblalmine B. Protamine sulfate C. Streptokinase D. Sodium warfarin ✔ B. Protamine sulfate why? The antidote for heparin is protamine sulfate. Cyanocolbalamine is B12, Strptokinase is a thrombolytic, and sodium warfarin is an anticoagulant. The client is admitted with a BP of 210/120. Her doctor orders furosemide (Lasix) 40 mg IV stat. How should the nurse administer the prescribed furosemide to this client? A. By giving it over 1-2 minutes B. By hanging it IV piggyback C. With normal saline only D. By administering it through a venous access device ✔ A. By giving it over 1-2 minutes why? Lasix should be given approximately 1mL per minute to prevent hypotesion The physician prescribes capropril (Capoten) 25 mg po tid for the client with hypertension. Which of the following adverse reactions can occur with administration of Capoten? A. Tinnitus B. Persistent coughing C. Muscle weakness D. Diarrhea ✔ B. Persistent coughing why? A persistent cough might be related to an adverse reaction to Captoten. The doctor orders 2% nitroglycerin ointment on a 1-inch dose over 12 hours. Proper application of nitroglycerin ointment includes: A. Rotating application sites B. Limiting applications to the chest C. Rubbing it into the skin D. Covering it with a gauze dressing ✔ A. Rotating application sites why? Sites for the application of nitroglycerin should be rotated, to prevent skin irritation. It can be applied to the back and upper arms, not to the lower extremities. Lidocaine is a medication frequently ordered for the client experiencing: A. Atrial tachycardia B. Ventricular tachycardia C. Heart block D. Ventricular brachycardia ✔ B. Ventricular tachycardia why? Lidocaine is used to treat ventricular tachycardia. This medication slowly exerts an antiarrhythmic effect by increasing the electric stimulation threshold of the ventricle without depressing the force of ventricular contractions. The client is admitted to the ER with shortness of breath, anxiety, and tachycardia. His ECG reveals atrial fibrillation with a ventricular response rate of 130 beats per minute. Te doctor orders quinidne sulfate. While he is receiving quinidine, the nurse should monitor his ECG for: A. Peaked P waves B. Elevated ST segment C. Inverted T wave D. Prolonged QT interval ✔ D. Prolonged QT interval why? Quinidine can cause widened Q-T intervals and heart block. Other signs of myocardial toxicity are notched P waves and widened QRS complexes. The most common side effects are diarrhea, nausea, and vomiting. The client might experience tinnitus, veritgo, headache, visual disturbances, and confusion. The physician has prescibed tranylcypromine sulfate (Parnate) 10 mg bid. The nurse should teach the client to refrain from eating foods containing tyramine because it may cause: A. Hypertension B. Hyperthermia C. Melanoma D. Urinary retention ✔ A. Hypertension why? If the client eats foods high in tyramine, he might experience malignant hypertension. Tyramine is found in cheese, sour cream, Chianti wine, sherry, beer, pickled herring, liver, canned figs, raisins, bananas, avocados, chocolate, soy sauce, fava beans, and yeast. These episodes are treated with Regitine, and alpha-adrenergic blocking agent. The child with seizure disorder is being treated with Dilantin (phenytoin). Which of the following statements by the patient's mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy? A. "She is very irritable lately." B. "She sleeps quite a bit of the time." C. "Her gums look too big for her teeth." D. "She has gained about 10 pounds in the last 6 months." ✔ A 5 year old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery? A. Decreased appetite B. A low-grade fever C. Chest congestion D. Constant swallowing ✔ A 6 year old with cerebral palsy functions at the level of an 18 month old. Which finding would support that assessment?