NUR 123 Exam #2 Fall 2025
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Free NUR 123 Exam #2 Fall 2025 Questions
Which nursing interventions are appropriate for a patient receiving a non-cytotoxic chemotherapy agent: biologic response modifier, Interferon, who develops a low-grade fever (99.9°F)? Select all that apply.
- Administer Tylenol
- Provide the patient with cool washcloths
- Hold the next dose
- Lower the temperature of the room
- Education on avoiding sick contacts while on the drug
Explanation
Explanation
Correct Answer:A. Administer Tylenol
B. Provide the patient with cool washcloths
E. Education on avoiding sick contacts while on the drug
Explanation
A. Administer Tylenol
Administering Tylenol (acetaminophen) is an appropriate intervention to manage a low-grade fever. Fever is a common side effect of interferon therapy, and Tylenol can help reduce the fever and provide symptomatic relief. However, the nurse should monitor the patient's temperature to ensure it does not escalate to a high fever, in which case further interventions would be needed.
B. Provide the patient with cool washcloths
Providing a cool washcloth can help lower the patient's body temperature and provide comfort during a low-grade fever. It is a non-invasive intervention that helps manage mild fever, improving the patient's comfort while preventing excessive temperature increase.
E. Education on avoiding sick contacts while on the drug
Patients receiving biologic response modifiers like interferon are often immunocompromised, making them more susceptible to infections. Educating the patient to avoid sick contacts while on the drug helps reduce the risk of infection and complications, as their immune system is suppressed during treatment.
Which complication should a patient immediately report to their provider when taking metoclopramide, a Dopamine antagonist?
- Involuntary movements of the face and neck
- Elevated blood pressure
- Dizziness when standing
- Diarrhea
Explanation
Explanation
Correct Answer:A. Involuntary movements of the face and neck
Explanation
A. Involuntary movements of the face and neck
Metoclopramide, a dopamine antagonist, can cause extrapyramidal side effects, including tardive dyskinesia, which presents as involuntary movements, especially of the face and neck. These movements may include grimacing, lip smacking, and tongue protrusion. Tardive dyskinesia is a serious, potentially irreversible condition, and patients taking metoclopramide should immediately report any signs of these involuntary movements to their provider for prompt evaluation and possible adjustment of therapy.
A healthcare provider prescribes 1000 mLs D5NS over 6 hours. The nurse calculates the flow rate for this infusion to be how many mLs per hour? Provide a numerical response rounded to a whole number.
- 200 mLs/hour
- 167 mLs/hour
- 150 mLs/hour
- 125 mLs/hour
Explanation
Explanation
Correct Answer:B. 167 mLs/hour
Explanation:
To calculate the flow rate, divide the total volume (1000 mLs) by the time (6 hours):
1000 mLs ÷ 6 hours = 166.67 mLs/hour.
Rounding to the nearest whole number gives 167 mLs/hour. Therefore, the correct flow rate is 167 mLs per hour.
The insulin order reads, "Give 10 units of NPH insulin subcutaneous every morning before breakfast." Choose the proper syringe for this injection.
- Syringe A
- Syringe B
- Syringe C
- Syringe D
Explanation
Explanation
Correct Answer:Syringe B
Explanation:
For the administration of NPH insulin, a syringe that measures in insulin units (typically U-100 syringes) should be used. Syringe B likely has the appropriate unit markings to administer exactly 10 units of NPH insulin. The other syringes may not have unit markings that would be appropriate for the required dosage, such as syringes marked in milliliters or other inappropriate units for insulin measurement.
A patient has been prescribed enfuvirtide, a Fusion Inhibitor, to treat Human Immunodeficiency Virus (HIV). What adverse reaction will the nurse monitor the patient for?
- Hypertension
- Bleeding
- Localized erythema
- Dizziness
Explanation
Explanation
Correct Answer:C. Localized erythema
Explanation
C. Localized erythema
Enfuvirtide is a fusion inhibitor used in the treatment of HIV. One of the most common side effects of enfuvirtide is localized erythema (redness) at the injection site. This reaction occurs due to the subcutaneous injection of the drug and is often associated with mild irritation or inflammation. Nurses should monitor the injection site for signs of erythema, swelling, or pain, as well as any signs of infection.
A nurse is caring for a patient who is taking raltegravir. What should the nurse do daily?
- Monitor stool color
- Monitor the sclera of the eyes
- Monitor intake and output
- Monitor the blood urea nitrogen (BUN) level
Explanation
Explanation
Correct Answer:B. Monitor the sclera of the eyes
Explanation
B. Monitor the sclera of the eyes
Raltegravir is an integrase inhibitor used for the treatment of HIV. One of the known side effects of raltegravir is hepatotoxicity, which can lead to liver damage. A common sign of liver dysfunction is jaundice, which causes the sclera (the whites of the eyes) to turn yellow. Therefore, it is important for the nurse to monitor the sclera for any signs of yellowing, which could indicate liver problems or bilirubin buildup.
Which adverse effects should a patient taking ondansetron for chemotherapy-induced nausea be instructed to watch for?
- Liver and renal damage
- Headache and diarrhea
- Dry mouth and blurred vision
- Glucose intolerance and hypokalemia
Explanation
Explanation
Correct Answer:B. Headache and diarrhea
Explanation:
Ondansetron is a 5-HT3 receptor antagonist used to prevent nausea and vomiting associated with chemotherapy. Common side effects include headache and diarrhea. Headache occurs due to the drug's effect on serotonin receptors in the brain, and diarrhea can result from its gastrointestinal side effects. These are usually mild and manageable but should be monitored by the patient during treatment.
Which of the following are common side effects and management strategies associated with the use of a scopolamine patch? (Select all that apply.)
- Use stool softeners to prevent constipation
- Avoid activities that require alertness, such as driving
- Report signs of rhinitis to your provider
- Suck on hard candy or sip fluids to help relieve dry mouth
- Stay away from crowds to prevent infection
Explanation
Explanation
Correct Answer:A. Use stool softeners to prevent constipation
B. Avoid activities that require alertness, such as driving
D. Suck on hard candy or sip fluids to help relieve dry mouth
Explanation
A. Use stool softeners to prevent constipation
Scopolamine, being an anticholinergic drug, can cause constipation due to its inhibitory effect on the parasympathetic nervous system. This can slow gastrointestinal motility. To manage this side effect, patients are often advised to use stool softeners, drink plenty of fluids, and eat a high-fiber diet to prevent constipation and ensure regular bowel movements.
B. Avoid activities that require alertness, such as driving
Scopolamine can cause side effects such as drowsiness, blurred vision, and dizziness due to its central nervous system depressant effects. These symptoms can impair a patient’s ability to perform tasks that require focus and attention, such as driving or operating machinery. Therefore, it is important for patients to avoid such activities until they are aware of how the drug affects them.
D. Suck on hard candy or sip fluids to help relieve dry mouth
Dry mouth (xerostomia) is a common side effect of scopolamine, due to its anticholinergic properties, which reduce saliva production. Patients can manage this side effect by sucking on hard candy, chewing gum, or sipping fluids regularly to keep their mouth moist and alleviate discomfort. This also helps prevent complications like difficulty swallowing and oral infections.
A nurse is preparing to administer metformin 500 mg PO BID to a patient. Which factor would contraindicate the administration of metformin to this patient?
- A history of hypertension
- Allergy to sulfonamides
- A history of renal disease
- The ingestion of carbohydrates
Explanation
Explanation
Correct Answer:C. A history of renal disease
Explanation:
Metformin is contraindicated in patients with a history of renal disease, particularly those with impaired kidney function, as it is primarily excreted through the kidneys. Renal dysfunction can lead to the accumulation of metformin in the body, increasing the risk of lactic acidosis, a rare but serious side effect. Kidney function should be assessed before initiating metformin, and it should be avoided in patients with a glomerular filtration rate (GFR) below 30 mL/min.
The nurse recognizes that endometrial cancer is a common complication in patients receiving which hormonal therapy?
- Tamoxifen
- Leuprolide
- Cetuximab
- Anastrozole
Explanation
Explanation
Correct Answer:A. Tamoxifen
Explanation
A. Tamoxifen
Tamoxifen is a selective estrogen receptor modulator (SERM) commonly used in the treatment and prevention of breast cancer, particularly in estrogen receptor-positive (ER+) cases. One of the known side effects of tamoxifen is an increased risk of endometrial cancer, as it has estrogen-like effects on the endometrium (lining of the uterus). These estrogenic effects can stimulate the growth of endometrial tissue, which can lead to hyperplasia or cancer over time, especially in postmenopausal women. Patients on tamoxifen should be monitored regularly for signs of uterine cancer, including abnormal bleeding.
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