Question

Which of the following findings indicates that hydrochlorothiazide (HCTZ) is working effectively?

Answer 1

Correct Answers:

The client's blood pressure changes from 170/88 to 136/74

Rationale :

♦ Hydrochlorothiazide (HCTZ) is a thiazide diuretic primarily prescribed for hypertension and mild fluid retention. Its effectiveness is best evaluated by a reduction in blood pressure, since this is the therapeutic goal.

♦ The drop from 170/88 to 136/74 shows a clinically significant improvement toward normal blood pressure, indicating that the medication is controlling hypertension.

♦ While HCTZ can cause mild electrolyte changes (like sodium and potassium shifts), these are side effects or expected lab changes, not the primary measure of effectiveness.

♦ Cholesterol and pulse rate are not therapeutic indicators for HCTZ, as the medication does not directly treat dyslipidemia or control heart rate.

♦ Therefore, improved blood pressure readings confirm the drug is working as intended.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Aspirin

Rationale :

◈ The MONA protocol (Morphine, Oxygen, Nitroglycerin, Aspirin) is used in the initial management of chest pain suspected to be due to myocardial ischemia.

◈ Aspirin is an antiplatelet agent that works by inhibiting platelet aggregation, which helps prevent further clot formation in the coronary arteries.

◈ This action reduces the risk of complete vessel occlusion and progression of myocardial infarction.

◈ Nitroglycerin primarily dilates coronary arteries and reduces myocardial oxygen demand, but it does not prevent clot formation.

◈ Morphine relieves pain and decreases sympathetic nervous system activity, while oxygen increases oxygen delivery, but neither plays a role in preventing clots.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Take Zyloprim if ordered and drink 2000ml of fluid/day, water is encouraged

Rationale :

💧Adequate hydration is the most important prevention strategy for kidney stones, as fluids dilute the urine and reduce the concentration of stone-forming substances.

💧Water is the best fluid choice, while sodas, colas, and milk in excess can contribute to stone risk depending on stone type.

💧Allopurinol (Zyloprim) is prescribed for uric acid stones because it reduces uric acid production, decreasing stone recurrence.

💧Foods like chocolate and nuts are high in oxalates, which can actually increase stone risk rather than prevent it.

💧Limiting fluids to 1000 mL/day and resting increases stone risk due to urinary stasis and higher solute concentration.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

2

Rationale :

Ordered dose = 80 mg
On hand = 20 mg ÷ 0.5 mL
Formula: (Dose ordered ÷ Dose on hand) × mL available
= 80 ÷ 20 × 0.5
= 4 × 0.5
= 2 mL

💉 Final Answer: 2 mL

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Call out for help, release the CPR button on the bed, and start with chest compressions.

Rationale :

💓In a full code patient who is unresponsive, pulseless, and apneic, the priority is to activate emergency response and immediately begin high-quality chest compressions.

💓Current AHA guidelines emphasize starting with chest compressions (CAB: Compressions, Airway, Breathing) rather than airway or breathing first.

💓The correct compression rate is 100–120 compressions per minute, not 80–100, to maintain adequate perfusion.

💓Confirming code status at the nurse’s station wastes valuable time and delays life-saving care.

💓Rescue breathing without compressions is ineffective in the absence of a pulse.

💓Pressing the CPR/Code button (or calling for help) ensures additional staff and equipment arrive promptly while compressions maintain circulation.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Applesauce, 7-Up and oatmeal

Rationale :

🔷After an abdominal hysterectomy, the client’s gastrointestinal tract may be sluggish due to the effects of anesthesia, opioid pain medications, and abdominal surgery.

🔷The first post-operative meal should be light, easily digested, and low in fat and fiber to minimize nausea, bloating, and the risk of ileus.

🔷Applesauce is soft, easy to swallow, and gentle on the stomach.

🔷7-Up (or other clear liquids) provides hydration and is non-irritating, helping assess tolerance to fluids before advancing.

🔷Oatmeal is a bland, soft food that is easy to digest and provides some nutrition without straining the GI system.

🔷This combination helps transition safely from clear liquids to soft foods while monitoring tolerance.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Assist the client in making a list of their favorite foods

Rationale :

🪥Unlicensed assistive personnel (UAP) can be delegated basic hygiene and comfort measures that do not require nursing judgment or specialized assessment.

🪥Helping a client swish and spit a prescribed mouthwash falls within their scope because it is similar to assisting with mouth care. The RN retains responsibility for monitoring effectiveness and tolerance, but the UAP can safely perform the task.

🪥Assessments—such as determining ability/willingness to drink through a straw, evaluating food preferences, or inspecting oral ulcerations—require nursing judgment and critical thinking, and therefore cannot be delegated.

🪥Delegation to UAP must follow the principle of tasks, not teaching, not assessment, not evaluation.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Lactulose

Rationale :

🧠In alcoholic cirrhosis, rising ammonia levels can lead to hepatic encephalopathy, which manifests as confusion, disorientation, and altered mental status.

🧠Lactulose is the treatment of choice because it reduces ammonia levels by promoting its excretion through the stool. It acidifies the colon, converting ammonia to ammonium, which cannot be reabsorbed. Frequent soft stools indicate effectiveness.

🧠Omeprazole is a proton pump inhibitor used for GERD or ulcer prevention, unrelated to ammonia reduction.

🧠Potassium chloride corrects hypokalemia but does not treat ammonia toxicity.

🧠Zyloprim (allopurinol) lowers uric acid levels in gout, not ammonia levels in liver disease.

🧠Thus, lactulose directly addresses the cause of confusion in this client by lowering toxic ammonia buildup.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

A client admitted 24 hours ago with a TIA (transient ischemic attack) who has stable vital signs

Rationale :

🛁Delegation to UAP is only safe for stable clients with predictable outcomes who need routine care such as bathing, feeding, or ambulation.

🛁A client with a TIA and stable vital signs fits this criteria, as the condition has been assessed, is non-acute, and the client is not in immediate danger.

🛁A client with low blood pressure is unstable and requires licensed nursing assessment and interventions.

🛁A client with severe pain (10/10) post-op requires nursing assessment, pain management, and monitoring, not just routine hygiene.

🛁A client just out of PACU is unstable and needs close post-anesthesia monitoring by licensed staff, not delegated care.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

GERD/peptic ulcers

Rationale :

💠Omeprazole is a proton pump inhibitor (PPI) that suppresses gastric acid secretion by inhibiting the hydrogen-potassium ATPase pump in the stomach lining.

💠It is most commonly prescribed for gastroesophageal reflux disease (GERD), peptic ulcer disease, and conditions like erosive esophagitis or Zollinger-Ellison syndrome.

💠By reducing stomach acid, it helps relieve heartburn, promote ulcer healing, and prevent recurrence.

💠Omeprazole is not used for COPD, heart failure, or hypertension, as it has no role in managing respiratory, cardiac, or vascular conditions.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

NUR 195 FINAL Summer 25 Detroit A

No.

1 :
Which of the following findings indicates that hydrochlorothiazide (HCTZ) is working effectively?

2 :
Which medication in the MONA protocol helps prevent further clot formation in a client with chest pain?

3 :
A nurse is teaching a client with a recent history of kidney stones how to prevent the formation of the stones in the future. The nurse will teach which of the following?

4 :
A client is ordered on furosemide 80mg I.M. twice a day. The vial on hand is 20mg/0.5ml. How many ml will the pt. get? Label Answer

5 :
It is 0730 and the start of a new shift. The nurse has entered the client's room and finds them unresponsive, with no respirations and no pulse. The nurse was told in report that the client is a full code. What will the nurse do?

6 :
A client had an abdominal hysterectomy this am at 0700. It is now 1700 and she is ordering her supper, which is her first post-op meal and she has an order for advance to regular diet. Which would be the best choice for the nurse to recommend?

7 :
A 26-year-old client has stomatitis (inflammation of the mouth) secondary to chemotherapy. Which task would the nurse delegate to a UAP (unlicensed ássistive personnel)?

9 :
An LPN is going to delegate a bed bath to a UAP (unlicensed personnel) on the surgical floor. Which client will the LPN delegate for the bed bath?

10 :
Which condition is omeprazole most often prescribed for?

Connect With Us

NUR 195 FINAL Summer 25 Detroit A

No.

1 : Which of the following findings indicates that hydrochlorothiazide (HCTZ) is working effectively?

2 : Which medication in the MONA protocol helps prevent further clot formation in a client with chest pain?

3 : A nurse is teaching a client with a recent history of kidney stones how to prevent the formation of the stones in the future. The nurse will teach which of the following?

4 : A client is ordered on furosemide 80mg I.M. twice a day. The vial on hand is 20mg/0.5ml. How many ml will the pt. get? Label Answer

5 : It is 0730 and the start of a new shift. The nurse has entered the client's room and finds them unresponsive, with no respirations and no pulse. The nurse was told in report that the client is a full code. What will the nurse do?

6 : A client had an abdominal hysterectomy this am at 0700. It is now 1700 and she is ordering her supper, which is her first post-op meal and she has an order for advance to regular diet. Which would be the best choice for the nurse to recommend?

7 : A 26-year-old client has stomatitis (inflammation of the mouth) secondary to chemotherapy. Which task would the nurse delegate to a UAP (unlicensed ássistive personnel)?

9 : An LPN is going to delegate a bed bath to a UAP (unlicensed personnel) on the surgical floor. Which client will the LPN delegate for the bed bath?

10 : Which condition is omeprazole most often prescribed for?

1 :
Which of the following findings indicates that hydrochlorothiazide (HCTZ) is working effectively?

2 :
Which medication in the MONA protocol helps prevent further clot formation in a client with chest pain?

3 :
A nurse is teaching a client with a recent history of kidney stones how to prevent the formation of the stones in the future. The nurse will teach which of the following?

4 :
A client is ordered on furosemide 80mg I.M. twice a day. The vial on hand is 20mg/0.5ml. How many ml will the pt. get? Label Answer

5 :
It is 0730 and the start of a new shift. The nurse has entered the client's room and finds them unresponsive, with no respirations and no pulse. The nurse was told in report that the client is a full code. What will the nurse do?

6 :
A client had an abdominal hysterectomy this am at 0700. It is now 1700 and she is ordering her supper, which is her first post-op meal and she has an order for advance to regular diet. Which would be the best choice for the nurse to recommend?

7 :
A 26-year-old client has stomatitis (inflammation of the mouth) secondary to chemotherapy. Which task would the nurse delegate to a UAP (unlicensed ássistive personnel)?

9 :
An LPN is going to delegate a bed bath to a UAP (unlicensed personnel) on the surgical floor. Which client will the LPN delegate for the bed bath?

10 :
Which condition is omeprazole most often prescribed for?