a nurse is orally administering alendronate fosamax a bisphosphonate drug the patient is largely bed bound and being treated for osteoporosis what nur
Logo

Nursing Elites

NCLEX-RN

NCLEX RN Exam Review Answers

1. When orally administering alendronate (Fosamax), a bisphosphonate drug, to a largely bed-bound patient being treated for osteoporosis, what is the most important nursing consideration?

Correct answer: A

Rationale: The correct nursing consideration when administering bisphosphonates like alendronate is to sit the head of the bed up for 30 minutes after administration. Bisphosphonates are known to cause esophageal irritation, which can lead to esophagitis. By sitting upright, the patient reduces the time the medication spends in the esophagus, decreasing the risk of irritation and potential adverse effects. Giving the patient water to drink or feeding them immediately after administration can increase the risk of esophageal irritation. Assessing the patient for back pain or abdominal pain is important but not the most critical consideration during drug administration.

2. A child is diagnosed with Hirschsprung's disease. The nurse is teaching the parents about the cause of the disease. Which statement, if made by the parent, supports that teaching was successful?

Correct answer: A

Rationale: Hirschsprung's disease, also known as congenital aganglionosis or megacolon, is characterized by the absence of ganglion cells in the rectum and, sometimes, extending into the colon. Choice A correctly explains the cause of Hirschsprung's disease. Choice B is incorrect as it describes celiac disease, which is related to gluten intolerance. Choice C is inaccurate as it describes symptoms of irritable bowel syndrome, not the cause of Hirschsprung's disease. Choice D is wrong as it pertains to lactose intolerance, not Hirschsprung's disease.

3. The nurse is caring for a 2-year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects?

Correct answer: C

Rationale: The correct answer is nephrotoxicity. Calcium disodium edetate, used in chelation therapy for lead poisoning, can lead to kidney toxicity. This is an important side effect to monitor in patients undergoing this treatment. Choices A, B, and D are incorrect. Neurotoxicity, hepatomegaly, and ototoxicity are not typically associated with calcium disodium edetate therapy for lead poisoning.

4. To prevent a Valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would:

Correct answer: B

Rationale: Administering stool softeners daily as prescribed is essential to prevent straining during defecation, which can lead to a Valsalva maneuver. Straining can increase intra-abdominal pressure, hinder venous return, and elevate blood pressure, risking cardiac complications in a client recovering from a heart attack. Using a bedside commode might be useful to minimize exertion during toileting but does not directly address the risk of a Valsalva maneuver. Administering antidysrhythmics PRN is not the primary intervention for preventing a Valsalva maneuver; these medications are used to manage dysrhythmias if they occur. Keeping the client on strict bed rest is not the best option as early mobilization is encouraged in post-myocardial infarction recovery to prevent complications such as deep vein thrombosis and muscle weakness.

5. A client is being assessed for risks of a pressure ulcer by a healthcare professional. What is the best description of what may be found with an early pressure ulcer in an African American client?

Correct answer: A

Rationale: When assessing for signs of developing pressure ulcers in a client with dark skin, traditional signs like blanching may not be evident. In individuals with darker skin tones, the skin of an early pressure ulcer may present with a purple or bluish hue. This discoloration can be a crucial indicator of compromised circulation and tissue damage. Capillary refill, blanching, and tenting are more commonly used in the assessment of skin integrity and hydration levels but may not be as reliable in individuals with darker skin tones, making the purple/bluish color a key finding in this context.

Similar Questions

A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is most appropriate?
A newborn is having difficulty maintaining a temperature above 98 degrees Fahrenheit and has been placed in a warming isolette. Which action is a nursing priority?
When analyzing the results of the urinalysis collected preoperatively from a child with epispadias scheduled for surgical repair, which finding should the nurse most likely expect to note?
The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What are the priority nursing diagnoses at this time?
After an endoscopic procedure with general anesthesia, what is a priority nursing consideration for a patient in the day surgery center?

Access More Features

NCLEX RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses