a nurse is orally administering alendronate fosamax a bisphosphonate drug the patient is largely bed bound and being treated for osteoporosis what nur a nurse is orally administering alendronate fosamax a bisphosphonate drug the patient is largely bed bound and being treated for osteoporosis what nur
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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: Sit the head of the bed up for 30 minutes after administration

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. While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child’s developmental needs?

Correct answer: “I understand the need to use those new skills.”

Rationale: The correct answer is: “I understand the need to use those new skills.” This response indicates that the mother recognizes the importance of allowing the toddler to practice and develop new skills, supporting autonomy and exploration. Setting limits, protecting from falls, and intending to keep control go against the toddler's developmental needs. Toddlers at this stage require opportunities to explore, practice new skills, and gain independence to foster healthy development.

3. Who is most likely to arrange the discharge of a patient to their own home, a nursing home, or an assisted living facility?

Correct answer: C: A social worker

Rationale: Social workers play a crucial role in arranging patient discharges to suitable facilities. They collaborate with healthcare professionals to ensure that patients are transitioned to the most appropriate setting post-hospitalization. Social workers focus on the holistic needs of patients, including their social and emotional well-being, to facilitate a smooth continuum of care. Choices A, B, and D do not typically have the primary responsibility for arranging patient discharges to various facilities.

4. A client diagnosed with sexual dysfunction states, 'Well, I guess my sex life is over.' Which response would the nurse use as a reply?

Correct answer: 'You are concerned about your sex life?'

Rationale: The response 'You are concerned about your sex life?' explores the meaning of the statement and allows further expression of concern. It shows empathy and encourages the client to elaborate on their feelings. Choice A, 'I’m sorry to hear that,' does not prompt the client to share more about their concerns and may close off communication. Choice B, 'Oh, you have a lot of good years left,' lacks empathy and understanding of the client's emotions, diverting the focus from the client's feelings. Choice D, 'Have you asked your primary health care provider about that?' shifts the responsibility away from the nurse and may not address the client's emotional needs, potentially making them feel dismissed or embarrassed to seek help.

5. A client is in need of hemodialysis for end-stage renal failure. The physician has inserted an AV fistula. Which of the following nursing interventions is appropriate when caring for this access site?

Correct answer: Assess for a bruit or thrill at the site of the fistula

Rationale: When caring for an AV fistula used for hemodialysis, it is important to assess for a bruit (a humming sound) or thrill (a vibrating sensation) at the site of the fistula. These indicate proper blood flow through the fistula, ensuring it is patent and suitable for hemodialysis. Assessing for clotting in fistula tubing (Choice A) is not a routine nursing intervention for AV fistulas. Applying a dressing over the fistula site (Choice B) is not necessary as the site needs to be accessible for hemodialysis. Assessing circulation proximal to the fistula site (Choice D) is important but not specific to caring for the access site of an AV fistula.

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