Nursing Process Test Questions

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The physician orders cystoscopy and random biopsies of the bladder for a client who reports painless hematuria. Test results reveal carcinoma in situ in several bladder regions. To treat bladder cancer, the client will have a series of intravesical instillations of bacillus Calmette-Guerin (BCG), administered 1 week apart. When teaching the client about BCG, the nurse should mention that this drug commonly causes:

  • A. Renal calculi
  • B. Hematuria
  • C. Delayed ejaculation
  • D. Impotence
Correct Answer: B

Rationale: The correct answer is B: Hematuria. Bacillus Calmette-Guerin (BCG) is commonly used in the treatment of bladder cancer. It works by stimulating the immune system to attack and destroy cancer cells in the bladder. One of the common side effects of BCG instillations is hematuria, which is the presence of blood in the urine. This can occur due to irritation of the bladder lining by the BCG solution, leading to inflammation and bleeding. It is important for the nurse to educate the client about this potential side effect so they are aware of what to expect during treatment.

A: Renal calculi - BCG therapy is not commonly associated with the formation of renal calculi.
C: Delayed ejaculation - Delayed ejaculation is not a common side effect of BCG therapy.
D: Impotence - Impotence is not a common side effect of BCG therapy.

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Which action by the nurse is appropriate?

  • A. Observe the patient for abnormal bleeding.
  • B. Notify the physician and expect an order to increase the warfarin dose.
  • C. Advise the patient to double today’s dose of warfarin.
  • D. Administer Vit. K per protocol.
Correct Answer: A

Rationale: The correct answer is A because observing the patient for abnormal bleeding is an appropriate action to monitor for potential complications of warfarin therapy. This aligns with the nursing role in assessing and monitoring patient responses to treatment.

B is incorrect as increasing warfarin dose without physician order can lead to adverse effects. C is incorrect as altering the dose without medical advice can be dangerous. D is incorrect as administering Vitamin K would counteract the effects of warfarin, which is used to prevent blood clotting.

Which intervention is appropriate for the nurse caring for a client in severe pain receiving a continuous I.V. infusion of morphine?

  • A. Assisting with a naloxone challenge test before therapy begins
  • B. Discontinuing the drug immediately if signs of dependence appear
  • C. Changing the administration route to P.O. if the client can tolerate fluids
  • D. Obtaining baseline vital signs before administering the first dose
Correct Answer: D

Rationale: The correct answer is D: Obtaining baseline vital signs before administering the first dose. This intervention is crucial to establish the client's baseline condition before starting morphine therapy. Baseline vital signs provide a comparison for monitoring the client's response to the medication and detecting any adverse effects. This step ensures the nurse can identify and address any potential complications promptly.

Other choices are incorrect:
A: Assisting with a naloxone challenge test before therapy begins - Naloxone challenge test is used to diagnose opioid dependence, not appropriate for monitoring pain management.
B: Discontinuing the drug immediately if signs of dependence appear - Abrupt discontinuation can lead to withdrawal symptoms and should be managed gradually.
C: Changing the administration route to P.O. if the client can tolerate fluids - Changing the route of administration should be based on clinical indications, not solely on the client's ability to tolerate fluids.

A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The physician begins the client on cyanocobalamin (Betalin-12), 100mcg IM daily. Which substance influences Vitamin B12 absorption?

  • A. Intrinsic factor
  • B. Histamine
  • C. Hydrochloric acid
  • D. Liver enzyme
Correct Answer: A

Rationale: Step 1: Vitamin B12 is absorbed in the small intestine with the help of intrinsic factor produced by parietal cells in the stomach.
Step 2: Intrinsic factor binds to vitamin B12, forming a complex that is then absorbed in the ileum.
Step 3: If intrinsic factor is lacking (as seen in pernicious anemia), vitamin B12 absorption is impaired, leading to megaloblastic anemia.
Step 4: Administering cyanocobalamin bypasses the need for intrinsic factor.
Step 5: Thus, intrinsic factor influences Vitamin B12 absorption. Other choices (B, C, D) do not play a direct role in Vitamin B12 absorption.

A client who is receiving cyclosporine (Sandimmune) must practice good oral hygiene, including regular brushing and flossing of the teeth, to minimize gingival hyperplasia during long-term therapy with certain drugs. Which of the following drug falls into this category?

  • A. Procainamide (Pronestyl)
  • B. Phenytoin (Dilantin)
  • C. Azathioprine (Imuran)
  • D. Allopurinol (Zyloprim)
Correct Answer: B

Rationale: The correct answer is B: Phenytoin (Dilantin). Phenytoin is known to cause gingival hyperplasia as a side effect, which can be minimized with good oral hygiene practices. Procainamide, Azathioprine, and Allopurinol are not associated with gingival hyperplasia. Therefore, the client receiving cyclosporine should focus on practicing good oral hygiene specifically when taking Phenytoin to minimize the risk of developing gingival hyperplasia.

The nurse knows that Parkinson’s disease a progressive neurologic disorder is characterized by:

  • A. Bradykinesia
  • B. Tremor
  • C. Muscle rigidity
  • D. All of the above
Correct Answer: D

Rationale: The correct answer is D. Parkinson's disease is characterized by bradykinesia, tremor, and muscle rigidity. Bradykinesia refers to slowness of movement, tremor involves involuntary shaking, and muscle rigidity causes stiffness and resistance to movement. These three symptoms are commonly known as the classic triad of Parkinson's disease. Therefore, selecting "All of the above" (D) is the correct choice as it encompasses all the key features of Parkinson's disease. Choices A, B, and C individually are incorrect because they do not fully capture the comprehensive presentation of symptoms in Parkinson's disease.

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