Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The client diagnosed with vitamin B12 deficiency presents to the outpatient department for the follow-up evaluation. Which nursing assessment finding indicates that the treatment has been effective? The client:
A. Has gained 2 pounds and has pink buccal mucosa
While gaining weight and having pink buccal mucosa can be signs of overall improved health, they are not specific indicators of effective treatment for vitamin B12 deficiency¹².
B. No longer has paresthesia of the hands and feet
Paresthesia (a sensation of tingling, tickling, pricking, or burning of a person's skin) of the hands and feet is a common symptom of vitamin B12 deficiency¹². If the client no longer has this symptom, it could indicate that the treatment for vitamin B12 deficiency has been effective¹².
C. Realizes eating more iron fortified cereals
Eating more iron-fortified cereals can contribute to overall nutritional health, but it's not directly related to the treatment of vitamin B12 deficiency¹².
D. Has stopped drinking any alcoholic beverages
While stopping alcohol consumption can improve overall health, it's not a specific indicator of effective treatment for vitamin B12 deficiency¹²..
This question is an excerpt from Nurse Dive's nursing test bank - Ati Med Surg Nursing 200 Proctored Exam. Take the full exam now
Full Explanation
Choice A reason: While gaining weight and having pink buccal mucosa can be signs of overall improved health, they are not specific indicators of effective treatment for vitamin B12 deficiency¹².
Choice B reason: Paresthesia (a sensation of tingling, tickling, pricking, or burning of a person's skin) of the hands and feet is a common symptom of vitamin B12 deficiency¹². If the client no longer has this symptom, it could indicate that the treatment for vitamin B12 deficiency has been effective¹².
Choice C reason: Eating more iron-fortified cereals can contribute to overall nutritional health, but it's not directly related to the treatment of vitamin B12 deficiency¹².
Choice D reason: While stopping alcohol consumption can improve overall health, it's not a specific indicator of effective treatment for vitamin B12 deficiency¹²..
Similar Questions
A client is scheduled to receive atenolol 25 mg PO and diltiazem 60 mg PO at 0800. The nurse assesses the client's heart rate as 45 beats/minute and irregular. What is the best nursing action at this time?
A. Document the pulse rate and administer the medications as prescribed
This is not the best nursing action. Documenting the pulse rate and administering the medications as prescribed may be harmful to the client. Atenolol and diltiazem are both medications that lower the blood pressure and the heart rate. Atenolol is a beta blocker that blocks the effects of adrenaline on the heart and blood vessels. Diltiazem is a calcium channel blocker that relaxes the muscles of the heart and blood vessels. Giving both medications to a client who already has a low and irregular heart rate may cause further bradycardia, which is a heart rate below 60 beats/minute, or arrhythmia, which is an abnormal heart rhythm. The nurse should check the parameters and the contraindications for the medications before administering them.
B. Assess for chest pain and administer atenolol if pain free
This is not the best nursing action. Assessing for chest pain and administering atenolol if pain free may not be appropriate for the client. Chest pain can be a sign of angina or myocardial infarction, which are conditions where the blood flow to the heart is reduced or blocked. Atenolol can help relieve chest pain by reducing the oxygen demand of the heart, but it can also lower the heart rate and the blood pressure. The client already has a low and irregular heart rate, which may indicate a problem with the electrical conduction of the heart. The nurse should not give atenolol without checking the pulse rate and the blood pressure, and consulting the health care provider.
C. Hold the atenolol and administer the diltiazem
This is the best nursing action. Holding the atenolol and administering the diltiazem is the most appropriate for the client. Atenolol can lower the heart rate and the blood pressure, which may worsen the client's condition. The nurse should hold the atenolol and notify the health care provider of the client's pulse rate and rhythm. Diltiazem can also lower the heart rate and the blood pressure, but it can also help regulate the heart rhythm by slowing down the electrical impulses in the heart. The nurse should administer the diltiazem as prescribed, and monitor the client's vital signs and cardiac status.
D. Withhold the medications and reassess the heart rate in 30 minutes
This is not the best nursing action. Withholding the medications and reassessing the heart rate in 30 minutes may delay the treatment and the care of the client. The client has a low and irregular heart rate, which may indicate a serious cardiac problem that needs immediate attention. The nurse should not wait for 30 minutes to reassess the heart rate, but rather act promptly and notify the health care provider. The nurse should also administer the diltiazem as prescribed, unless there is a specific reason to withhold it.
Full Explanation
Choice A reason: This is not the best nursing action. Documenting the pulse rate and administering the medications as prescribed may be harmful to the client. Atenolol and diltiazem are both medications that lower the blood pressure and the heart rate. Atenolol is a beta blocker that blocks the effects of adrenaline on the heart and blood vessels. Diltiazem is a calcium channel blocker that relaxes the muscles of the heart and blood vessels. Giving both medications to a client who already has a low and irregular heart rate may cause further bradycardia, which is a heart rate below 60 beats/minute, or arrhythmia, which is an abnormal heart rhythm. The nurse should check the parameters and the contraindications for the medications before administering them.
Choice B reason: This is not the best nursing action. Assessing for chest pain and administering atenolol if pain free may not be appropriate for the client. Chest pain can be a sign of angina or myocardial infarction, which are conditions where the blood flow to the heart is reduced or blocked. Atenolol can help relieve chest pain by reducing the oxygen demand of the heart, but it can also lower the heart rate and the blood pressure. The client already has a low and irregular heart rate, which may indicate a problem with the electrical conduction of the heart. The nurse should not give atenolol without checking the pulse rate and the blood pressure, and consulting the health care provider.
Choice C reason: This is the best nursing action. Holding the atenolol and administering the diltiazem is the most appropriate for the client. Atenolol can lower the heart rate and the blood pressure, which may worsen the client's condition. The nurse should hold the atenolol and notify the health care provider of the client's pulse rate and rhythm. Diltiazem can also lower the heart rate and the blood pressure, but it can also help regulate the heart rhythm by slowing down the electrical impulses in the heart. The nurse should administer the diltiazem as prescribed, and monitor the client's vital signs and cardiac status.
Choice D reason: This is not the best nursing action. Withholding the medications and reassessing the heart rate in 30 minutes may delay the treatment and the care of the client. The client has a low and irregular heart rate, which may indicate a serious cardiac problem that needs immediate attention. The nurse should not wait for 30 minutes to reassess the heart rate, but rather act promptly and notify the health care provider. The nurse should also administer the diltiazem as prescribed, unless there is a specific reason to withhold it.
The nurse is caring for a client who is discharged with a prescription for amlodipine. The client should be instructed to self-monitor for:
A. A decrease in urination
This is not a correct answer. A decrease in urination is not a common side effect of amlodipine. Amlodipine is a calcium channel blocker that lowers the blood pressure and relaxes the blood vessels. Amlodipine does not affect the kidney function or the urine output, unless there is an underlying renal problem or a drug interaction. The client should monitor their urination, but not expect a decrease.
B. An increase in lower extremity edema
This is the correct answer. An increase in lower extremity edema is a common side effect of amlodipine. Amlodipine can cause fluid retention and swelling in the legs, ankles, or feet. This is due to the dilation of the blood vessels and the leakage of fluid into the tissues. The client should monitor their weight and the size of their lower extremities, and report any significant changes to their health care provider. The client may also elevate their legs, wear compression stockings, or take diuretics to reduce the edema.
C. Tachycardia during exercise
This is not a correct answer. Tachycardia during exercise is not a common side effect of amlodipine. Amlodipine can lower the heart rate and the cardiac output, which can reduce the oxygen demand of the heart. Amlodipine does not cause an increase in the heart rate, unless there is an underlying cardiac problem or a drug interaction. The client should monitor their pulse and blood pressure, but not expect tachycardia.
D. An increase in bowel motility
This is not a correct answer. An increase in bowel motility is not a common side effect of amlodipine. Amlodipine does not affect the gastrointestinal system or the digestion, unless there is an allergic reaction or a drug interaction. Amlodipine can cause some gastrointestinal side effects, such as nausea, abdominal pain, or constipation, but not an increase in bowel motility. The client should monitor their bowel movements, but not expect an increase.
Full Explanation
Choice A reason: This is not a correct answer. A decrease in urination is not a common side effect of amlodipine. Amlodipine is a calcium channel blocker that lowers the blood pressure and relaxes the blood vessels. Amlodipine does not affect the kidney function or the urine output, unless there is an underlying renal problem or a drug interaction. The client should monitor their urination, but not expect a decrease.
Choice B reason: This is the correct answer. An increase in lower extremity edema is a common side effect of amlodipine. Amlodipine can cause fluid retention and swelling in the legs, ankles, or feet. This is due to the dilation of the blood vessels and the leakage of fluid into the tissues. The client should monitor their weight and the size of their lower extremities, and report any significant changes to their health care provider. The client may also elevate their legs, wear compression stockings, or take diuretics to reduce the edema.
Choice C reason: This is not a correct answer. Tachycardia during exercise is not a common side effect of amlodipine. Amlodipine can lower the heart rate and the cardiac output, which can reduce the oxygen demand of the heart. Amlodipine does not cause an increase in the heart rate, unless there is an underlying cardiac problem or a drug interaction. The client should monitor their pulse and blood pressure, but not expect tachycardia.
Choice D reason: This is not a correct answer. An increase in bowel motility is not a common side effect of amlodipine. Amlodipine does not affect the gastrointestinal system or the digestion, unless there is an allergic reaction or a drug interaction. Amlodipine can cause some gastrointestinal side effects, such as nausea, abdominal pain, or constipation, but not an increase in bowel motility. The client should monitor their bowel movements, but not expect an increase.
Choice A reason: This is not a correct answer. A decrease in urination is not a common side effect of amlodipine. Amlodipine is a calcium channel blocker that lowers the blood pressure and relaxes the blood vessels. Amlodipine does not affect the kidney function or the urine output, unless there is an underlying renal problem or a drug interaction. The client should monitor their urination, but not expect a decrease.
Choice B reason: This is the correct answer. An increase in lower extremity edema is a common side effect of amlodipine. Amlodipine can cause fluid retention and swelling in the legs, ankles, or feet. This is due to the dilation of the blood vessels and the leakage of fluid into the tissues. The client should monitor their weight and the size of their lower extremities, and report any significant changes to their health care provider. The client may also elevate their legs, wear compression stockings, or take diuretics to reduce the edema.
Choice C reason: This is not a correct answer. Tachycardia during exercise is not a common side effect of amlodipine. Amlodipine can lower the heart rate and the cardiac output, which can reduce the oxygen demand of the heart. Amlodipine does not cause an increase in the heart rate, unless there is an underlying cardiac problem or a drug interaction. The client should monitor their pulse and blood pressure, but not expect tachycardia.
Choice D reason: This is not a correct answer. An increase in bowel motility is not a common side effect of amlodipine. Amlodipine does not affect the gastrointestinal system or the digestion, unless there is an allergic reaction or a drug interaction. Amlodipine can cause some gastrointestinal side effects, such as nausea, abdominal pain, or constipation, but not an increase in bowel motility. The client should monitor their bowel movements, but not expect an increase.
The nurse is reviewing the laboratory data of a client diagnosed with coronary artery disease. Which set of laboratory results indicates a need for client teaching regarding dietary modifications?
A. Cholesterol 200 mg/dL; HDL 35 mg/dL; triglycerides 190 mg/dL
This option is not correct because the cholesterol level is within the normal range of less than 200 mg/dL¹, the HDL level is slightly low but not too far from the recommended level of over 40 mg/dL for men and over 50 mg/dL for women¹, and the triglyceride level is also within the normal range of less than 150 mg/dL¹. Therefore, this set of laboratory results does not indicate a need for dietary modifications.
B. Cholesterol 120 mg/dL; HDL 50 mg/dL; triglycerides 140 mg/dL
This option is not correct because the cholesterol level is low, the HDL level is high, and the triglyceride level is normal. These are all desirable results that reflect a low risk of coronary artery disease¹. Therefore, this set of laboratory results does not indicate a need for dietary modifications.
C. Cholesterol 180 mg/dL; HDL 40 mg/dL; triglycerides 220 mg/dL
This option is correct because the cholesterol level is high, the HDL level is low, and the triglyceride level is high. These are all unfavorable results that reflect a high risk of coronary artery disease¹. High cholesterol and triglycerides can lead to plaque buildup in the arteries, which can cause atherosclerosis and reduce blood flow to the heart². Low HDL can also increase the risk of heart disease because it does not help remove LDL (bad cholesterol) from the arteries². Therefore, this set of laboratory results indicates a need for dietary modifications, such as reducing saturated and trans fats, increasing fiber, and limiting alcohol³.
D. Cholesterol 165 mg/dL; HDL 54 mg/dL; triglycerides 160 mg/dL
This option is not correct because the cholesterol level is normal, the HDL level is high, and the triglyceride level is normal. These are all desirable results that reflect a low risk of coronary artery disease¹. Therefore, this set of laboratory results does not indicate a need for dietary modifications..
Full Explanation
Choice A reason: This option is not correct because the cholesterol level is within the normal range of less than 200 mg/dL¹, the HDL level is slightly low but not too far from the recommended level of over 40 mg/dL for men and over 50 mg/dL for women¹, and the triglyceride level is also within the normal range of less than 150 mg/dL¹. Therefore, this set of laboratory results does not indicate a need for dietary modifications.
Choice B reason: This option is not correct because the cholesterol level is low, the HDL level is high, and the triglyceride level is normal. These are all desirable results that reflect a low risk of coronary artery disease¹. Therefore, this set of laboratory results does not indicate a need for dietary modifications.
Choice C reason: This option is correct because the cholesterol level is high, the HDL level is low, and the triglyceride level is high. These are all unfavorable results that reflect a high risk of coronary artery disease¹. High cholesterol and triglycerides can lead to plaque buildup in the arteries, which can cause atherosclerosis and reduce blood flow to the heart². Low HDL can also increase the risk of heart disease because it does not help remove LDL (bad cholesterol) from the arteries². Therefore, this set of laboratory results indicates a need for dietary modifications, such as reducing saturated and trans fats, increasing fiber, and limiting alcohol³.
Choice D reason: This option is not correct because the cholesterol level is normal, the HDL level is high, and the triglyceride level is normal. These are all desirable results that reflect a low risk of coronary artery disease¹. Therefore, this set of laboratory results does not indicate a need for dietary modifications..