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Medical-Surgical Nursing Exam 2 (PM)
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Question 1
Kenneth who has diagnosed with uremic syndrome has the potential to develop complications. Which among the following complications should the nurse anticipates:
A
An elevated hematocrit level
B
Hypotension
C
Flapping hand tremors
D
Hypokalemia
Question 1 Explanation:
Elevation of uremic waste products causes irritation of the nerves, resulting in flapping hand tremors.
Question 2
A 65 year old female is experiencing flare up of pruritus. Which of the client’s action could aggravate the cause of flare ups?
A
Using clothes made from 100% cotton
B
Increasing fluid intake
C
Sleeping in cool and humidified environment
D
Daily baths with fragrant soap
Question 2 Explanation:
The use of fragrant soap is very drying to skin hence causing the pruritus.
Question 3
Lydia is scheduled for elective splenectomy. Before the clients goes to surgery, the nurse in charge final assessment would be:
A
signed consent
B
vital signs
C
empty bladder
D
name band
Question 3 Explanation:
An elective procedure is scheduled in advance so that all preparations can be completed ahead of time. The vital signs are the final check that must be completed before the client leaves the room so that continuity of care and assessment is provided for.
Question 4
Nurse Hazel teaches the client with angina about common expected side effects of nitroglycerin including:
A
headache
B
shortness of breath
C
stomach cramps
D
high blood pressure
Question 4 Explanation:
Because of its widespread vasodilating effects, nitroglycerin often produces side effects such as headache, hypotension and dizziness.
Question 5
A male client has undergone spinal surgery, the nurse should:
A
Observe the client’s bowel movement and voiding patterns
B
Assess the client’s feet for sensation and circulation
C
Log-roll the client to prone position
D
Encourage client to drink plenty of fluids
Question 5 Explanation:
Alteration in sensation and circulation indicates damage to the spinal cord, if these occurs notify physician immediately.
Question 6
Which of the following complications associated with tracheostomy tube?
A
Acute respiratory distress syndrome (ARDS)
B
Damage to laryngeal nerves
C
Increased cardiac output
D
Increased blood pressure
Question 6 Explanation:
Tracheostomy tube has several potential complications including bleeding, infection and laryngeal nerve damage.
Question 7
A client has been diagnosed with hypertension. The nurse priority nursing diagnosis would be:
A
Impaired skin integrity
B
Pain
C
Ineffective health maintenance
D
Deficient fluid volume
Question 7 Explanation:
Managing hypertension is the priority for the client with hypertension. Clients with hypertension frequently do not experience pain, deficient volume, or impaired skin integrity. It is the asymptomatic nature of hypertension that makes it so difficult to treat.
Question 8
Nurse Maureen would expect the a client with mitral stenosis would demonstrate symptoms associated with congestion in the:
A
Superior vena cava
B
Aorta
C
Right atrium
D
Pulmonary
Question 8 Explanation:
When mitral stenosis is present, the left atrium has difficulty emptying its contents into the left ventricle because there is no valve to prevent back ward flow into the pulmonary vein, the pulmonary circulation is under pressure.
Question 9
A male client with tuberculosis asks Nurse Brian how long the chemotherapy must be continued. Nurse Brian’s accurate reply would be:
A
6 to 12 months
B
3 to 5 months
C
3 years and more
D
1 to 3 weeks
Question 9 Explanation:
Tubercle bacillus is a drug resistant organism and takes a long time to be eradicated. Usually a combination of three drugs is used for minimum of 6 months and at least six months beyond culture conversion.
Question 10
Karina a client with myasthenia gravis is to receive immunosuppressive therapy. The nurse understands that this therapy is effective because it:
A
Promotes the removal of antibodies that impair the transmission of impulses
B
Inhibits the breakdown of acetylcholine at the neuromuscular junction.
C
Stimulates the production of acetylcholine at the neuromuscular junction.
D
Decreases the production of autoantibodies that attack the acetylcholine receptors.
Question 10 Explanation:
Steroids decrease the body’s immune response thus decreasing the production of antibodies that attack the acetylcholine receptors at the neuromuscular junction
Question 11
After a long leg cast is removed, the male client should:
A
Put leg through full range of motion twice daily
B
Report any discomfort or stiffness to the physician
C
Cleanse the leg by scrubbing with a brisk motion
D
Elevate the leg when sitting for long periods of time.
Question 11 Explanation:
Elevation will help control the edema that usually occurs.
Question 12
What is the peak age range in acquiring acute lymphocytic leukemia (ALL)?
A
40 to 50 years
B
20 to 30 years
C
4 to 12 years.
D
60 60 70 years
Question 12 Explanation:
The peak incidence of Acute Lymphocytic Leukemia (ALL) is 4 years of age. It is uncommon after 15 years of age.
Question 13
A client has undergone laryngectomy. The immediate nursing priority would be:
A
Monitor for signs of infection
B
Keep trachea free of secretions
C
Promote means of communication
D
Provide emotional support
Question 13 Explanation:
Patent airway is the most priority; therefore removal of secretions is necessary.
Question 14
Halfway through the administration of blood, the female client complains of lumbar pain. After stopping the infusion Nurse Hazel should:
A
Notify the blood bank
B
Obtain vital signs.
C
Increase the flow of normal saline
D
Assess the pain further
Question 14 Explanation:
The blood must be stopped at once, and then normal saline should be infused to keep the line patent and maintain blood volume.
Question 15
Marco who was diagnosed with brain tumor was scheduled for craniotomy. In preventing the development of cerebral edema after surgery, the nurse should expect the use of:
A
Antihypertensive
B
Diuretics
C
Steroids
D
Anticonvulsants
Question 15 Explanation:
Glucocorticoids (steroids) are used for their anti-inflammatory action, which decreases the development of edema.
Question 16
Which of the following represents a significant risk immediately after surgery for repair of aortic aneurysm?
A
Potential electrolyte balance
B
Potential alteration in renal perfusion
C
Potential ineffective coping
D
Potential wound infection
Question 16 Explanation:
There is a potential alteration in renal perfusion manifested by decreased urine output. The altered renal perfusion may be related to renal artery embolism, prolonged hypotension, or prolonged aortic cross-clamping during the surgery.
Question 17
Nurse Maureen knows that the positive diagnosis for HIV infection is made based on which of the following:
A
A history of high risk sexual behaviors.
B
Evidence of extreme weight loss and high fever
C
Identification of an associated opportunistic infection
D
Positive ELISA and western blot tests
Question 17 Explanation:
These tests confirm the presence of HIV antibodies that occur in response to the presence of the human immunodeficiency virus (HIV).
Question 18
Karen has been diagnosed with aplastic anemia. The nurse monitors for changes in which of the following physiologic functions?
A
Intake and out put
B
Bleeding tendencies
C
Peripheral sensation
D
Bowel function
Question 18 Explanation:
Aplastic anemia decreases the bone marrow production of RBC’s, white blood cells, and platelets. The client is at risk for bruising and bleeding tendencies.
Question 19
Which of the following signs and symptoms would Nurse Maureen include in teaching plan as an early manifestation of laryngeal cancer?
A
Stomatitis
B
Airway obstruction
C
Hoarseness
D
Dysphagia
Question 19 Explanation:
Early warning signs of laryngeal cancer can vary depending on tumor location. Hoarseness lasting 2 weeks should be evaluated because it is one of the most common warning signs.
Question 20
A client has undergone with penile implant. After 24 hrs of surgery, the client’s scrotum was edematous and painful. The nurse should:
A
Assist the client with sitz bath
B
Elevate the scrotum using a soft support
C
Prepare for a possible incision and drainage.
D
Apply war soaks in the scrotum
Question 20 Explanation:
Elevation increases lymphatic drainage, reducing edema and pain.
Question 21
Which of the following stage the carcinogen is irreversible?
A
Regression stage
B
Promotion stage
C
Progression stage
D
Initiation stage
Question 21 Explanation:
Progression stage is the change of tumor from the preneoplastic state or low degree of malignancy to a fast growing tumor that cannot be reversed.
Question 22
A male client’s left tibia was fractured in an automobile accident, and a cast is applied. To assess for damage to major blood vessels from the fracture tibia, the nurse in charge should monitor the client for:
A
Increased skin temperature of the foot
B
Prolonged reperfusion of the toes after blanching
C
Swelling of the left thigh
D
Increased blood pressure
Question 22 Explanation:
Damage to blood vessels may decrease the circulatory perfusion of the toes, this would indicate the lack of blood supply to the extremity.
Question 23
While performing a physical assessment of a male client with gout of the great toe, Nurse Vivian should assess for additional tophi (urate deposits) on the:
A
Abdomen
B
Ears
C
Face
D
Buttocks
Question 23 Explanation:
Uric acid has a low solubility, it tends to precipitate and form deposits at various sites where blood flow is least active, including cartilaginous tissue such as the ears.
Question 24
Mang Jose with rheumatoid arthritis states, “the only time I am without pain is when I lie in bed perfectly still”. During the convalescent stage, the nurse in charge with Mang Jose should encourage:
A
Range of motion exercises twice daily
B
Continued immobility until pain subsides
C
Flexion exercises three times daily
D
Active joint flexion and extension
Question 24 Explanation:
Active exercises, alternating extension, flexion, abduction, and adduction, mobilize exudates in the joints relieves stiffness and pain.
Question 25
Nurse Jon assesses vital signs on a client undergone epidural anesthesia. Which of the following would the nurse assess next?
A
Bladder distension
B
Headache
C
Ability to move legs
D
Dizziness
Question 25 Explanation:
The last area to return sensation is in the perineal area, and the nurse in charge should monitor the client for distended bladder.
Question 26
Nurse Anna is aware that early adaptation of client with renal carcinoma is:
A
intermittent hematuria
B
Nausea and vomiting
C
flank pain
D
weight gain
Question 26 Explanation:
Intermittent pain is the classic sign of renal carcinoma. It is primarily due to capillary erosion by the cancerous growth.
Question 27
Nurse Katrina should anticipate that all of the following drugs may be used in the attempt to control the symptoms of Meniere’s disease except:
A
Diuretics
B
Antiemetics
C
Antihistamines
D
Glucocorticoids
Question 27 Explanation:
Glucocorticoids play no significant role in disease treatment.
Question 28
Atropine sulfate (Atropine) is contraindicated in all but one of the following client?
A
A client with bowel obstruction
B
A client with glaucoma
C
A client with U.T.I
D
A client with high blood
Question 28 Explanation:
Atropine sulfate is contraindicated with glaucoma patients because it increases intraocular pressure.
Question 29
Among the following clients, which among them is high risk for potential hazards from the surgical experience?
A
33-year-old client
B
15-year-old client
C
49-year-old client
D
67-year-old client
Question 29 Explanation:
A 67 year old client is greater risk because the older adult client is more likely to have a less-effective immune system.
Question 30
A female client is receiving IV Mannitol. An assessment specific to safe administration of the said drug is:
A
Weighing daily
B
Level of consciousness q4h
C
Urine output hourly
D
Vital signs q4h
Question 30 Explanation:
The osmotic diuretic mannitol is contraindicated in the presence of inadequate renal function or heart failure because it increases the intravascular volume that must be filtered and excreted by the kidney.
Question 31
Patricia a 20 year old college student withdiabetes mellitus requests additional information about the advantages of using a pen like insulindelivery devices. The nurse explains that the advantages of these devices over syringes includes:
A
Accurate dose delivery
B
Shorter injection time
C
Use of smaller gauge needle.
D
Lower cost with reusable insulin cartridges
Question 31 Explanation:
These devices are more accurate because they are easily to used and have improved adherence in insulin regimens by young people because the medication can be administered discreetly.
Question 32
A client is admitted to the hospital with benign prostatic hyperplasia, the nurse most relevant assessment would be:
A
Distention of the lower abdomen
B
Urethral discharge
C
Flank pain radiating in the groin
D
Perineal edema
Question 32 Explanation:
This indicates that the bladder is distended with urine, therefore palpable.
Question 33
A client has been diagnosed with Disseminated Intravascular Coagulation (DIC). Which of the following is contraindicated with the client?
A
Treating the underlying cause
B
Administering Coumadin
C
Replacing depleted blood products
D
Administering Heparin
Question 33 Explanation:
Disseminated Intravascular Coagulation (DIC) has not been found to respond to oral anticoagulants such as Coumadin.
Question 34
What is the priority nursing assessment in the first 24 hours after admission of the client with thrombotic CVA?
A
cholesterol level
B
Pupil size and papillary response
C
Echocardiogram
D
Bowel sounds
Question 34 Explanation:
It is crucial to monitor the pupil size and papillary response to indicate changes around the cranial nerves.
Question 35
A client is experiencing spinal shock. Nurse Myrna should expect the function of the bladder to be which of the following?
A
Uncontrolled
B
Atonic
C
Normal
D
Spastic
Question 35 Explanation:
In spinal shock, the bladder becomes completely atonic and will continue to fill unless the client is catheterized.
Question 36
The nurse is aware the early indicator of hypoxia in the unconscious client is:
A
Restlessness
B
Increased respirations
C
Cyanosis
D
Hypertension
Question 36 Explanation:
Restlessness is an early indicator of hypoxia. The nurse should suspect hypoxia in unconscious client who suddenly becomes restless.
Question 37
Nurse Katrina would recognize that the demonstration of crutch walking with tripod gait was understood when the client places weight on the:
A
Palms of the hand
B
Palms of the hands and axillary regions
C
Feet, which are set apart
D
Axillary regions
Question 37 Explanation:
The palms should bear the client’s weight to avoid damage to the nerves in the axilla.
Question 38
An 83-year-old woman has several ecchymotic areas on her right arm. The bruises are probably caused by:
A
increased capillary fragility and permeability
B
increased blood supply to the skin
C
elder abuse
D
self inflicted injury
Question 38 Explanation:
Aging process involves increased capillary fragility and permeability. Older adults have a decreased amount of subcutaneous fat and cause an increased incidence of bruise like lesions caused by collection of extravascular blood in loosely structured dermis.
Question 39
Nurse Maureen is aware that a client who has been diagnosed with chronic renal failure recognizes an adequate amount of high-biologic-value protein when the food the client selected from the menu was:
A
Apple juice
B
Whole wheat bread
C
Raw carrots
D
Cottage cheese
Question 39 Explanation:
One cup of cottage cheese contains approximately 225 calories, 27 g of protein, 9 g of fat, 30 mg cholesterol, and 6 g of carbohydrate. Proteins of high biologic value (HBV) contain optimal levels of amino acids essential for life.
Question 40
Nurse Faith should recognize that fluid shift in an client with burn injury results from increase in the:
A
Total volume of intravascular plasma
B
Permeability of capillary walls
C
Total volume of circulating whole blood
D
Permeability of kidney tubules
Question 40 Explanation:
In burn, the capillaries and small vessels dilate, and cell damage cause the release of a histamine-like substance. The substance causes the capillary walls to become more permeable and significant quantities of fluid are lost.
Question 41
Marina with acute renal failure moves into the diuretic phase after one week of therapy. During this phase the client must be assessed for signs ofdeveloping:
A
renal failure
B
hyperkalemia
C
Hypovolemia
D
metabolic acidosis
Question 41 Explanation:
In the diuretic phase fluid retained during the oliguric phase is excreted and may reach 3 to 5 liters daily, hypovolemia may occur and fluids should be replaced.
Question 42
Nurse Josie should instruct the client to eat which of the following foods to obtain the best supply of Vitamin B12?
A
Broccoli
B
Grains
C
vegetables
D
dairy products
Question 42 Explanation:
Good source of vitamin B12 are dairy products and meats.
Question 43
Among the following components thorough pain assessment, which is the most significant?
A
Intensity
B
Causing factors
C
Cause
D
Effect
Question 43 Explanation:
Intensity is the major indicative of severity of pain and it is important for the evaluation of the treatment.
Question 44
Nurse Judith obtains a specimen of clear nasal drainage from a client with a head injury. Which of the following tests differentiates mucus from cerebrospinal fluid (CSF)?
A
Specific gravity
B
Microorganism
C
Glucose
D
Protein
Question 44 Explanation:
The constituents of CSF are similar to those of blood plasma. An examination for glucose content is done to determine whether a body fluid is a mucus or a CSF. A CSF normally contains glucose.
Question 45
A 22 year old client suffered from his first tonic-clonic seizure. Upon awakening the client asks the nurse, “What caused me to have a seizure? Which of the following would the nurse include in the primary cause of tonic clonic seizures in adults more the 20 years?
A
Epilepsy
B
Congenital defect
C
Head trauma
D
Electrolyte imbalance
Question 45 Explanation:
Trauma is one of the primary cause of brain damage and seizure activity in adults. Other common causes of seizure activity in adults include neoplasms, withdrawal from drugs and alcohol, and vascular disease.
Question 46
Marie with acute lymphocytic leukemia suffers from nausea and headache. These clinical manifestations may indicate all of the following except
A
gastric distension
B
effects of radiation
C
meningeal irritation
D
chemotherapy side effects
Question 46 Explanation:
Acute Lymphocytic Leukemia (ALL) does not cause gastric distention. It does invade the central nervous system, and clients experience headaches and vomiting from meningeal irritation.
Question 47
Nurse hazel receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following?
A
Myocardial damage
B
Hypertension
C
Cancer
D
Liver disease
Question 47 Explanation:
Detection of myoglobin is a diagnostic tool to determine whether myocardial damage has occurred.
Question 48
The following are lipid abnormalities. Which of the following is a risk factor for the development of atherosclerosis and PVD?
A
Low levels of LDL cholesterol.
B
Low concentration triglycerides
C
High levels of high density lipid (HDL) cholesterol
D
High levels of low density lipid (LDL) cholesterol
Question 48 Explanation:
An increased in LDL cholesterol concentration has been documented at risk factor for the development of atherosclerosis. LDL cholesterol is not broken down into the liver but is deposited into the wall of the blood vessels.
Question 49
Which of the following findings is the best indication that fluid replacement for the client with hypovolemic shock is adequate?
A
Urine output greater than 30ml/hr
B
Systolic blood pressure greater than 110 mmhg
C
Respiratory rate of 21 breaths/minute
D
Diastolic blood pressure greater than 90 mmhg
Question 49 Explanation:
Urine output provides the most sensitive indication of the client’s response to therapy for hypovolemic shock. Urine output should be consistently greater than 30 to 35 mL/hr.
Question 50
Nurse Linda is preparing a client with multiple sclerosis for discharge from the hospital to home. Which of the following instruction is most appropriate?
A
“Practice using the mechanical aids that you will need when future disabilities arise”.
B
“You will need to accept the necessity for a quiet and inactive lifestyle”.
C
“Keep active, use stress reduction strategies, and avoid fatigue.
D
“Follow good health habits to change the course of the disease”.
Question 50 Explanation:
The nurse most positive approach is to encourage the client with multiple sclerosis to stay active, use stress reduction techniques and avoid fatigue because it is important to support the immune system while remaining active.
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Medical-Surgical Nursing Exam 2 (EM)
Choose the letter of the correct answer. You got 50 minutes to finish the exam .Good luck!
Start
Congratulations - you have completed Medical-Surgical Nursing Exam 2 (EM).
You scored %%SCORE%% out of %%TOTAL%%.
Your performance has been rated as %%RATING%%
Your answers are highlighted below.
Question 1
Nurse Maureen would expect the a client with mitral stenosis would demonstrate symptoms associated with congestion in the:
A
Aorta
B
Superior vena cava
C
Right atrium
D
Pulmonary
Question 1 Explanation:
When mitral stenosis is present, the left atrium has difficulty emptying its contents into the left ventricle because there is no valve to prevent back ward flow into the pulmonary vein, the pulmonary circulation is under pressure.
Question 2
Nurse Maureen knows that the positive diagnosis for HIV infection is made based on which of the following:
A
Identification of an associated opportunistic infection
B
Evidence of extreme weight loss and high fever
C
A history of high risk sexual behaviors.
D
Positive ELISA and western blot tests
Question 2 Explanation:
These tests confirm the presence of HIV antibodies that occur in response to the presence of the human immunodeficiency virus (HIV).
Question 3
A client has undergone with penile implant. After 24 hrs of surgery, the client’s scrotum was edematous and painful. The nurse should:
A
Elevate the scrotum using a soft support
B
Prepare for a possible incision and drainage.
C
Assist the client with sitz bath
D
Apply war soaks in the scrotum
Question 3 Explanation:
Elevation increases lymphatic drainage, reducing edema and pain.
Question 4
After a long leg cast is removed, the male client should:
A
Put leg through full range of motion twice daily
B
Cleanse the leg by scrubbing with a brisk motion
C
Elevate the leg when sitting for long periods of time.
D
Report any discomfort or stiffness to the physician
Question 4 Explanation:
Elevation will help control the edema that usually occurs.
Question 5
Kenneth who has diagnosed with uremic syndrome has the potential to develop complications. Which among the following complications should the nurse anticipates:
A
Hypokalemia
B
Hypotension
C
An elevated hematocrit level
D
Flapping hand tremors
Question 5 Explanation:
Elevation of uremic waste products causes irritation of the nerves, resulting in flapping hand tremors.
Question 6
The nurse is aware the early indicator of hypoxia in the unconscious client is:
A
Increased respirations
B
Restlessness
C
Hypertension
D
Cyanosis
Question 6 Explanation:
Restlessness is an early indicator of hypoxia. The nurse should suspect hypoxia in unconscious client who suddenly becomes restless.
Question 7
Karina a client with myasthenia gravis is to receive immunosuppressive therapy. The nurse understands that this therapy is effective because it:
A
Promotes the removal of antibodies that impair the transmission of impulses
B
Inhibits the breakdown of acetylcholine at the neuromuscular junction.
C
Decreases the production of autoantibodies that attack the acetylcholine receptors.
D
Stimulates the production of acetylcholine at the neuromuscular junction.
Question 7 Explanation:
Steroids decrease the body’s immune response thus decreasing the production of antibodies that attack the acetylcholine receptors at the neuromuscular junction
Question 8
Which of the following signs and symptoms would Nurse Maureen include in teaching plan as an early manifestation of laryngeal cancer?
A
Hoarseness
B
Airway obstruction
C
Stomatitis
D
Dysphagia
Question 8 Explanation:
Early warning signs of laryngeal cancer can vary depending on tumor location. Hoarseness lasting 2 weeks should be evaluated because it is one of the most common warning signs.
Question 9
A client is experiencing spinal shock. Nurse Myrna should expect the function of the bladder to be which of the following?
A
Normal
B
Atonic
C
Spastic
D
Uncontrolled
Question 9 Explanation:
In spinal shock, the bladder becomes completely atonic and will continue to fill unless the client is catheterized.
Question 10
Nurse Anna is aware that early adaptation of client with renal carcinoma is:
A
flank pain
B
Nausea and vomiting
C
intermittent hematuria
D
weight gain
Question 10 Explanation:
Intermittent pain is the classic sign of renal carcinoma. It is primarily due to capillary erosion by the cancerous growth.
Question 11
Among the following clients, which among them is high risk for potential hazards from the surgical experience?
A
67-year-old client
B
33-year-old client
C
15-year-old client
D
49-year-old client
Question 11 Explanation:
A 67 year old client is greater risk because the older adult client is more likely to have a less-effective immune system.
Question 12
Atropine sulfate (Atropine) is contraindicated in all but one of the following client?
A
A client with glaucoma
B
A client with high blood
C
A client with bowel obstruction
D
A client with U.T.I
Question 12 Explanation:
Atropine sulfate is contraindicated with glaucoma patients because it increases intraocular pressure.
Question 13
A female client is receiving IV Mannitol. An assessment specific to safe administration of the said drug is:
A
Vital signs q4h
B
Level of consciousness q4h
C
Weighing daily
D
Urine output hourly
Question 13 Explanation:
The osmotic diuretic mannitol is contraindicated in the presence of inadequate renal function or heart failure because it increases the intravascular volume that must be filtered and excreted by the kidney.
Question 14
Nurse Hazel teaches the client with angina about common expected side effects of nitroglycerin including:
A
high blood pressure
B
stomach cramps
C
headache
D
shortness of breath
Question 14 Explanation:
Because of its widespread vasodilating effects, nitroglycerin often produces side effects such as headache, hypotension and dizziness.
Question 15
Lydia is scheduled for elective splenectomy. Before the clients goes to surgery, the nurse in charge final assessment would be:
A
vital signs
B
signed consent
C
empty bladder
D
name band
Question 15 Explanation:
An elective procedure is scheduled in advance so that all preparations can be completed ahead of time. The vital signs are the final check that must be completed before the client leaves the room so that continuity of care and assessment is provided for.
Question 16
Which of the following complications associated with tracheostomy tube?
A
Increased blood pressure
B
Acute respiratory distress syndrome (ARDS)
C
Damage to laryngeal nerves
D
Increased cardiac output
Question 16 Explanation:
Tracheostomy tube has several potential complications including bleeding, infection and laryngeal nerve damage.
Question 17
A 65 year old female is experiencing flare up of pruritus. Which of the client’s action could aggravate the cause of flare ups?
A
Sleeping in cool and humidified environment
B
Using clothes made from 100% cotton
C
Increasing fluid intake
D
Daily baths with fragrant soap
Question 17 Explanation:
The use of fragrant soap is very drying to skin hence causing the pruritus.
Question 18
Nurse Josie should instruct the client to eat which of the following foods to obtain the best supply of Vitamin B12?
A
dairy products
B
vegetables
C
Broccoli
D
Grains
Question 18 Explanation:
Good source of vitamin B12 are dairy products and meats.
Question 19
Nurse Judith obtains a specimen of clear nasal drainage from a client with a head injury. Which of the following tests differentiates mucus from cerebrospinal fluid (CSF)?
A
Glucose
B
Specific gravity
C
Protein
D
Microorganism
Question 19 Explanation:
The constituents of CSF are similar to those of blood plasma. An examination for glucose content is done to determine whether a body fluid is a mucus or a CSF. A CSF normally contains glucose.
Question 20
Among the following components thorough pain assessment, which is the most significant?
A
Intensity
B
Cause
C
Effect
D
Causing factors
Question 20 Explanation:
Intensity is the major indicative of severity of pain and it is important for the evaluation of the treatment.
Question 21
Nurse Jon assesses vital signs on a client undergone epidural anesthesia. Which of the following would the nurse assess next?
A
Ability to move legs
B
Dizziness
C
Headache
D
Bladder distension
Question 21 Explanation:
The last area to return sensation is in the perineal area, and the nurse in charge should monitor the client for distended bladder.
Question 22
Nurse Katrina would recognize that the demonstration of crutch walking with tripod gait was understood when the client places weight on the:
A
Feet, which are set apart
B
Palms of the hands and axillary regions
C
Axillary regions
D
Palms of the hand
Question 22 Explanation:
The palms should bear the client’s weight to avoid damage to the nerves in the axilla.
Question 23
Which of the following represents a significant risk immediately after surgery for repair of aortic aneurysm?
A
Potential wound infection
B
Potential electrolyte balance
C
Potential ineffective coping
D
Potential alteration in renal perfusion
Question 23 Explanation:
There is a potential alteration in renal perfusion manifested by decreased urine output. The altered renal perfusion may be related to renal artery embolism, prolonged hypotension, or prolonged aortic cross-clamping during the surgery.
Question 24
Karen has been diagnosed with aplastic anemia. The nurse monitors for changes in which of the following physiologic functions?
A
Peripheral sensation
B
Bleeding tendencies
C
Bowel function
D
Intake and out put
Question 24 Explanation:
Aplastic anemia decreases the bone marrow production of RBC’s, white blood cells, and platelets. The client is at risk for bruising and bleeding tendencies.
Question 25
Nurse hazel receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following?
A
Cancer
B
Myocardial damage
C
Liver disease
D
Hypertension
Question 25 Explanation:
Detection of myoglobin is a diagnostic tool to determine whether myocardial damage has occurred.
Question 26
A client has been diagnosed with Disseminated Intravascular Coagulation (DIC). Which of the following is contraindicated with the client?
A
Replacing depleted blood products
B
Treating the underlying cause
C
Administering Heparin
D
Administering Coumadin
Question 26 Explanation:
Disseminated Intravascular Coagulation (DIC) has not been found to respond to oral anticoagulants such as Coumadin.
Question 27
Nurse Katrina should anticipate that all of the following drugs may be used in the attempt to control the symptoms of Meniere’s disease except:
A
Antiemetics
B
Glucocorticoids
C
Diuretics
D
Antihistamines
Question 27 Explanation:
Glucocorticoids play no significant role in disease treatment.
Question 28
A male client has undergone spinal surgery, the nurse should:
A
Assess the client’s feet for sensation and circulation
B
Encourage client to drink plenty of fluids
C
Observe the client’s bowel movement and voiding patterns
D
Log-roll the client to prone position
Question 28 Explanation:
Alteration in sensation and circulation indicates damage to the spinal cord, if these occurs notify physician immediately.
Question 29
Halfway through the administration of blood, the female client complains of lumbar pain. After stopping the infusion Nurse Hazel should:
A
Increase the flow of normal saline
B
Obtain vital signs.
C
Assess the pain further
D
Notify the blood bank
Question 29 Explanation:
The blood must be stopped at once, and then normal saline should be infused to keep the line patent and maintain blood volume.
Question 30
A 22 year old client suffered from his first tonic-clonic seizure. Upon awakening the client asks the nurse, “What caused me to have a seizure? Which of the following would the nurse include in the primary cause of tonic clonic seizures in adults more the 20 years?
A
Head trauma
B
Electrolyte imbalance
C
Congenital defect
D
Epilepsy
Question 30 Explanation:
Trauma is one of the primary cause of brain damage and seizure activity in adults. Other common causes of seizure activity in adults include neoplasms, withdrawal from drugs and alcohol, and vascular disease.
Question 31
Which of the following stage the carcinogen is irreversible?
A
Promotion stage
B
Progression stage
C
Regression stage
D
Initiation stage
Question 31 Explanation:
Progression stage is the change of tumor from the preneoplastic state or low degree of malignancy to a fast growing tumor that cannot be reversed.
Question 32
A male client’s left tibia was fractured in an automobile accident, and a cast is applied. To assess for damage to major blood vessels from the fracture tibia, the nurse in charge should monitor the client for:
A
Increased blood pressure
B
Increased skin temperature of the foot
C
Swelling of the left thigh
D
Prolonged reperfusion of the toes after blanching
Question 32 Explanation:
Damage to blood vessels may decrease the circulatory perfusion of the toes, this would indicate the lack of blood supply to the extremity.
Question 33
The following are lipid abnormalities. Which of the following is a risk factor for the development of atherosclerosis and PVD?
A
High levels of high density lipid (HDL) cholesterol
B
Low levels of LDL cholesterol.
C
High levels of low density lipid (LDL) cholesterol
D
Low concentration triglycerides
Question 33 Explanation:
An increased in LDL cholesterol concentration has been documented at risk factor for the development of atherosclerosis. LDL cholesterol is not broken down into the liver but is deposited into the wall of the blood vessels.
Question 34
Patricia a 20 year old college student withdiabetes mellitus requests additional information about the advantages of using a pen like insulindelivery devices. The nurse explains that the advantages of these devices over syringes includes:
A
Use of smaller gauge needle.
B
Accurate dose delivery
C
Shorter injection time
D
Lower cost with reusable insulin cartridges
Question 34 Explanation:
These devices are more accurate because they are easily to used and have improved adherence in insulin regimens by young people because the medication can be administered discreetly.
Question 35
Nurse Maureen is aware that a client who has been diagnosed with chronic renal failure recognizes an adequate amount of high-biologic-value protein when the food the client selected from the menu was:
A
Raw carrots
B
Cottage cheese
C
Whole wheat bread
D
Apple juice
Question 35 Explanation:
One cup of cottage cheese contains approximately 225 calories, 27 g of protein, 9 g of fat, 30 mg cholesterol, and 6 g of carbohydrate. Proteins of high biologic value (HBV) contain optimal levels of amino acids essential for life.
Question 36
A male client with tuberculosis asks Nurse Brian how long the chemotherapy must be continued. Nurse Brian’s accurate reply would be:
A
1 to 3 weeks
B
3 to 5 months
C
6 to 12 months
D
3 years and more
Question 36 Explanation:
Tubercle bacillus is a drug resistant organism and takes a long time to be eradicated. Usually a combination of three drugs is used for minimum of 6 months and at least six months beyond culture conversion.
Question 37
A client is admitted to the hospital with benign prostatic hyperplasia, the nurse most relevant assessment would be:
A
Distention of the lower abdomen
B
Flank pain radiating in the groin
C
Urethral discharge
D
Perineal edema
Question 37 Explanation:
This indicates that the bladder is distended with urine, therefore palpable.
Question 38
What is the priority nursing assessment in the first 24 hours after admission of the client with thrombotic CVA?
A
Bowel sounds
B
Echocardiogram
C
Pupil size and papillary response
D
cholesterol level
Question 38 Explanation:
It is crucial to monitor the pupil size and papillary response to indicate changes around the cranial nerves.
Question 39
A client has undergone laryngectomy. The immediate nursing priority would be:
A
Keep trachea free of secretions
B
Monitor for signs of infection
C
Provide emotional support
D
Promote means of communication
Question 39 Explanation:
Patent airway is the most priority; therefore removal of secretions is necessary.
Question 40
While performing a physical assessment of a male client with gout of the great toe, Nurse Vivian should assess for additional tophi (urate deposits) on the:
A
Ears
B
Abdomen
C
Face
D
Buttocks
Question 40 Explanation:
Uric acid has a low solubility, it tends to precipitate and form deposits at various sites where blood flow is least active, including cartilaginous tissue such as the ears.
Question 41
An 83-year-old woman has several ecchymotic areas on her right arm. The bruises are probably caused by:
A
increased capillary fragility and permeability
B
increased blood supply to the skin
C
self inflicted injury
D
elder abuse
Question 41 Explanation:
Aging process involves increased capillary fragility and permeability. Older adults have a decreased amount of subcutaneous fat and cause an increased incidence of bruise like lesions caused by collection of extravascular blood in loosely structured dermis.
Question 42
Marina with acute renal failure moves into the diuretic phase after one week of therapy. During this phase the client must be assessed for signs ofdeveloping:
A
metabolic acidosis
B
hyperkalemia
C
renal failure
D
Hypovolemia
Question 42 Explanation:
In the diuretic phase fluid retained during the oliguric phase is excreted and may reach 3 to 5 liters daily, hypovolemia may occur and fluids should be replaced.
Question 43
Marie with acute lymphocytic leukemia suffers from nausea and headache. These clinical manifestations may indicate all of the following except
A
chemotherapy side effects
B
gastric distension
C
meningeal irritation
D
effects of radiation
Question 43 Explanation:
Acute Lymphocytic Leukemia (ALL) does not cause gastric distention. It does invade the central nervous system, and clients experience headaches and vomiting from meningeal irritation.
Question 44
Nurse Linda is preparing a client with multiple sclerosis for discharge from the hospital to home. Which of the following instruction is most appropriate?
A
“Follow good health habits to change the course of the disease”.
B
“Keep active, use stress reduction strategies, and avoid fatigue.
C
“You will need to accept the necessity for a quiet and inactive lifestyle”.
D
“Practice using the mechanical aids that you will need when future disabilities arise”.
Question 44 Explanation:
The nurse most positive approach is to encourage the client with multiple sclerosis to stay active, use stress reduction techniques and avoid fatigue because it is important to support the immune system while remaining active.
Question 45
A client has been diagnosed with hypertension. The nurse priority nursing diagnosis would be:
A
Pain
B
Impaired skin integrity
C
Ineffective health maintenance
D
Deficient fluid volume
Question 45 Explanation:
Managing hypertension is the priority for the client with hypertension. Clients with hypertension frequently do not experience pain, deficient volume, or impaired skin integrity. It is the asymptomatic nature of hypertension that makes it so difficult to treat.
Question 46
Marco who was diagnosed with brain tumor was scheduled for craniotomy. In preventing the development of cerebral edema after surgery, the nurse should expect the use of:
A
Steroids
B
Antihypertensive
C
Diuretics
D
Anticonvulsants
Question 46 Explanation:
Glucocorticoids (steroids) are used for their anti-inflammatory action, which decreases the development of edema.
Question 47
What is the peak age range in acquiring acute lymphocytic leukemia (ALL)?
A
4 to 12 years.
B
40 to 50 years
C
60 60 70 years
D
20 to 30 years
Question 47 Explanation:
The peak incidence of Acute Lymphocytic Leukemia (ALL) is 4 years of age. It is uncommon after 15 years of age.
Question 48
Nurse Faith should recognize that fluid shift in an client with burn injury results from increase in the:
A
Permeability of capillary walls
B
Total volume of intravascular plasma
C
Total volume of circulating whole blood
D
Permeability of kidney tubules
Question 48 Explanation:
In burn, the capillaries and small vessels dilate, and cell damage cause the release of a histamine-like substance. The substance causes the capillary walls to become more permeable and significant quantities of fluid are lost.
Question 49
Which of the following findings is the best indication that fluid replacement for the client with hypovolemic shock is adequate?
A
Diastolic blood pressure greater than 90 mmhg
B
Systolic blood pressure greater than 110 mmhg
C
Urine output greater than 30ml/hr
D
Respiratory rate of 21 breaths/minute
Question 49 Explanation:
Urine output provides the most sensitive indication of the client’s response to therapy for hypovolemic shock. Urine output should be consistently greater than 30 to 35 mL/hr.
Question 50
Mang Jose with rheumatoid arthritis states, “the only time I am without pain is when I lie in bed perfectly still”. During the convalescent stage, the nurse in charge with Mang Jose should encourage:
A
Range of motion exercises twice daily
B
Active joint flexion and extension
C
Flexion exercises three times daily
D
Continued immobility until pain subsides
Question 50 Explanation:
Active exercises, alternating extension, flexion, abduction, and adduction, mobilize exudates in the joints relieves stiffness and pain.
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1. Marco who was diagnosed with brain tumor was scheduled for craniotomy. In preventing the development of cerebral edema after surgery, the nurse should expect the use of:
Diuretics
Antihypertensive
Steroids
Anticonvulsants
2. Halfway through the administration of blood, the female client complains of lumbar pain. After stopping the infusion Nurse Hazel should:
Increase the flow of normal saline
Assess the pain further
Notify the blood bank
Obtain vital signs.
3. Nurse Maureen knows that the positive diagnosis for HIV infection is made based on which of the following:
A history of high risk sexual behaviors.
Positive ELISA and western blot tests
Identification of an associated opportunistic infection
Evidence of extreme weight loss and high fever
4. Nurse Maureen is aware that a client who has been diagnosed with chronic renal failure recognizes an adequate amount of high-biologic-value protein when the food the client selected from the menu was:
Raw carrots
Apple juice
Whole wheat bread
Cottage cheese
5. Kenneth who has diagnosed with uremic syndrome has the potential to develop complications. Which among the following complications should the nurse anticipates:
Flapping hand tremors
An elevated hematocrit level
Hypotension
Hypokalemia
6. A client is admitted to the hospital with benign prostatic hyperplasia, the nurse most relevant assessment would be:
Flank pain radiating in the groin
Distention of the lower abdomen
Perineal edema
Urethral discharge
7. A client has undergone with penile implant. After 24 hrs of surgery, the client’s scrotum was edematous and painful. The nurse should:
Assist the client with sitz bath
Apply war soaks in the scrotum
Elevate the scrotum using a soft support
Prepare for a possible incision and drainage.
8. Nurse hazel receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following?
Liver disease
Myocardial damage
Hypertension
Cancer
9. Nurse Maureen would expect the a client with mitral stenosis would demonstrate symptoms associated with congestion in the:
Right atrium
Superior vena cava
Aorta
Pulmonary
10. A client has been diagnosed with hypertension. The nurse priority nursing diagnosis would be:
Ineffective health maintenance
Impaired skin integrity
Deficient fluid volume
Pain
11. Nurse Hazel teaches the client with angina about common expected side effects of nitroglycerin including:
high blood pressure
stomach cramps
headache
shortness of breath
12. The following are lipid abnormalities. Which of the following is a risk factor for the development of atherosclerosis and PVD?
High levels of low density lipid (LDL) cholesterol
High levels of high density lipid (HDL) cholesterol
Low concentration triglycerides
Low levels of LDL cholesterol.
13. Which of the following represents a significant risk immediately after surgery for repair of aortic aneurysm?
Potential wound infection
Potential ineffective coping
Potential electrolyte balance
Potential alteration in renal perfusion
14. Nurse Josie should instruct the client to eat which of the following foods to obtain the best supply of Vitamin B12?
dairy products
vegetables
Grains
Broccoli
15. Karen has been diagnosed with aplastic anemia. The nurse monitors for changes in which of the following physiologic functions?
Bowel function
Peripheral sensation
Bleeding tendencies
Intake and out put
16. Lydia is scheduled for elective splenectomy. Before the clients goes to surgery, the nurse in charge final assessment would be:
signed consent
vital signs
name band
empty bladder
17. What is the peak age range in acquiring acute lymphocytic leukemia (ALL)?
4 to 12 years.
20 to 30 years
40 to 50 years
60 60 70 years
18. Marie with acute lymphocytic leukemia suffers from nausea and headache. These clinical manifestations may indicate all of the following except
effects of radiation
chemotherapy side effects
meningeal irritation
gastric distension
19. A client has been diagnosed with Disseminated Intravascular Coagulation (DIC). Which of the following is contraindicated with the client?
Administering Heparin
Administering Coumadin
Treating the underlying cause
Replacing depleted blood products
20. Which of the following findings is the best indication that fluid replacement for the client with hypovolemic shock is adequate?
Urine output greater than 30ml/hr
Respiratory rate of 21 breaths/minute
Diastolic blood pressure greater than 90 mmhg
Systolic blood pressure greater than 110 mmhg
21. Which of the following signs and symptoms would Nurse Maureen include in teaching plan as an early manifestation of laryngeal cancer?
Stomatitis
Airway obstruction
Hoarseness
Dysphagia
22. Karina a client with myasthenia gravis is to receive immunosuppressive therapy. The nurse understands that this therapy is effective because it:
Promotes the removal of antibodies that impair the transmission of impulses
Stimulates the production of acetylcholine at the neuromuscular junction.
Decreases the production of autoantibodies that attack the acetylcholine receptors.
Inhibits the breakdown of acetylcholine at the neuromuscular junction.
23. A female client is receiving IV Mannitol. An assessment specific to safe administration of the said drug is:
Vital signs q4h
Weighing daily
Urine output hourly
Level of consciousness q4h
24. Patricia a 20 year old college student with diabetes mellitus requests additional information about the advantages of using a pen like insulin deliverydevices. The nurse explains that the advantages of these devices over syringes includes:
Accurate dose delivery
Shorter injection time
Lower cost with reusable insulin cartridges
Use of smaller gauge needle.
25. A male client’s left tibia was fractured in an automobile accident, and a cast is applied. To assess for damage to major blood vessels from the fracture tibia, the nurse in charge should monitor the client for:
Swelling of the left thigh
Increased skin temperature of the foot
Prolonged reperfusion of the toes after blanching
Increased blood pressure
26. After a long leg cast is removed, the male client should:
Cleanse the leg by scrubbing with a brisk motion
Put leg through full range of motion twice daily
Report any discomfort or stiffness to the physician
Elevate the leg when sitting for long periods of time.
27. While performing a physical assessment of a male client with gout of the great toe, Nurse Vivian should assess for additional tophi (urate deposits) on the:
Buttocks
Ears
Face
Abdomen
28. Nurse Katrina would recognize that the demonstration of crutch walking with tripod gait was understood when the client places weight on the:
Palms of the hands and axillary regions
Palms of the hand
Axillary regions
Feet, which are set apart
29. Mang Jose with rheumatoid arthritis states, “the only time I am without pain is when I lie in bed perfectly still”. During the convalescent stage, the nurse in charge with Mang Jose should encourage:
Active joint flexion and extension
Continued immobility until pain subsides
Range of motion exercises twice daily
Flexion exercises three times daily
30. A male client has undergone spinal surgery, the nurse should:
Observe the client’s bowel movement and voiding patterns
Log-roll the client to prone position
Assess the client’s feet for sensation and circulation
Encourage client to drink plenty of fluids
31. Marina with acute renal failure moves into the diuretic phase after one week of therapy. During this phase the client must be assessed for signs ofdeveloping:
Hypovolemia
renal failure
metabolic acidosis
hyperkalemia
32. Nurse Judith obtains a specimen of clear nasal drainage from a client with a head injury. Which of the following tests differentiates mucus from cerebrospinal fluid (CSF)?
Protein
Specific gravity
Glucose
Microorganism
33. A 22 year old client suffered from his first tonic-clonic seizure. Upon awakening the client asks the nurse, “What caused me to have a seizure? Which of the following would the nurse include in the primary cause of tonic clonic seizures in adults more the 20 years?
Electrolyte imbalance
Head trauma
Epilepsy
Congenital defect
34. What is the priority nursing assessment in the first 24 hours after admission of the client with thrombotic CVA?
Pupil size and papillary response
cholesterol level
Echocardiogram
Bowel sounds
35. Nurse Linda is preparing a client with multiple sclerosis for discharge from the hospital to home. Which of the following instruction is most appropriate?
“Practice using the mechanical aids that you will need when future disabilities arise”.
“Follow good health habits to change the course of the disease”.
“Keep active, use stress reduction strategies, and avoid fatigue.
“You will need to accept the necessity for a quiet and inactive lifestyle”.
36. The nurse is aware the early indicator of hypoxia in the unconscious client is:
Cyanosis
Increased respirations
Hypertension
Restlessness
37. A client is experiencing spinal shock. Nurse Myrna should expect the function of the bladder to be which of the following?
Normal
Atonic
Spastic
Uncontrolled
38. Which of the following stage the carcinogen is irreversible?
Progression stage
Initiation stage
Regression stage
Promotion stage
39. Among the following components thorough pain assessment, which is the most significant?
Effect
Cause
Causing factors
Intensity
40. A 65 year old female is experiencing flare up of pruritus. Which of the client’s action could aggravate the cause of flare ups?
Sleeping in cool and humidified environment
Daily baths with fragrant soap
Using clothes made from 100% cotton
Increasing fluid intake
41. Atropine sulfate (Atropine) is contraindicated in all but one of the following client?
A client with high blood
A client with bowel obstruction
A client with glaucoma
A client with U.T.I
42. Among the following clients, which among them is high risk for potential hazards from the surgical experience?
67-year-old client
49-year-old client
33-year-old client
15-year-old client
43. Nurse Jon assesses vital signs on a client undergone epidural anesthesia. Which of the following would the nurse assess next?
Headache
Bladder distension
Dizziness
Ability to move legs
44. Nurse Katrina should anticipate that all of the following drugs may be used in the attempt to control the symptoms of Meniere’s disease except:
Antiemetics
Diuretics
Antihistamines
Glucocorticoids
45. Which of the following complications associated with tracheostomy tube?
Increased cardiac output
Acute respiratory distress syndrome (ARDS)
Increased blood pressure
Damage to laryngeal nerves
46. Nurse Faith should recognize that fluid shift in an client with burn injury results from increase in the:
Total volume of circulating whole blood
Total volume of intravascular plasma
Permeability of capillary walls
Permeability of kidney tubules
47. An 83-year-old woman has several ecchymotic areas on her right arm. The bruises are probably caused by:
increased capillary fragility and permeability
increased blood supply to the skin
self inflicted injury
elder abuse
48. Nurse Anna is aware that early adaptation of client with renal carcinoma is:
Nausea and vomiting
flank pain
weight gain
intermittent hematuria
49. A male client with tuberculosis asks Nurse Brian how long the chemotherapy must be continued. Nurse Brian’s accurate reply would be:
1 to 3 weeks
6 to 12 months
3 to 5 months
3 years and more
50. A client has undergone laryngectomy. The immediate nursing priority would be:
Keep trachea free of secretions
Monitor for signs of infection
Provide emotional support
Promote means of communication
Answers and Rationales
C. Glucocorticoids (steroids) are used for their anti-inflammatory action, which decreases the development of edema.
A. The blood must be stopped at once, and then normal saline should be infused to keep the line patent and maintain blood volume.
B. These tests confirm the presence of HIV antibodies that occur in response to the presence of the human immunodeficiency virus (HIV).
D. One cup of cottage cheese contains approximately 225 calories, 27 g of protein, 9 g of fat, 30 mg cholesterol, and 6 g of carbohydrate. Proteins of high biologic value (HBV) contain optimal levels of amino acids essential for life.
A. Elevation of uremic waste products causes irritation of the nerves, resulting in flapping hand tremors.
B. This indicates that the bladder is distended with urine, therefore palpable.
C. Elevation increases lymphatic drainage, reducing edema and pain.
B. Detection of myoglobin is a diagnostic tool to determine whether myocardial damage has occurred.
D. When mitral stenosis is present, the left atrium has difficulty emptying its contents into the left ventricle because there is no valve to prevent back ward flow into the pulmonary vein, the pulmonary circulation is under pressure.
A. Managing hypertension is the priority for the client with hypertension. Clients with hypertension frequently do not experience pain, deficient volume, or impaired skin integrity. It is the asymptomatic nature of hypertension that makes it so difficult to treat.
C. Because of its widespread vasodilating effects, nitroglycerin often produces side effects such as headache, hypotension and dizziness.
A. An increased in LDL cholesterol concentration has been documented at risk factor for the development of atherosclerosis. LDL cholesterol is not broken down into the liver but is deposited into the wall of the blood vessels.
D. There is a potential alteration in renal perfusion manifested by decreased urine output. The altered renal perfusion may be related to renal arteryembolism, prolonged hypotension, or prolonged aortic cross-clamping during the surgery.
A. Good source of vitamin B12 are dairy products and meats.
C. Aplastic anemia decreases the bone marrow production of RBC’s, white blood cells, and platelets. The client is at risk for bruising and bleeding tendencies.
B. An elective procedure is scheduled in advance so that all preparations can be completed ahead of time. The vital signs are the final check that must be completed before the client leaves the room so that continuity of care and assessment is provided for.
A. The peak incidence of Acute Lymphocytic Leukemia (ALL) is 4 years of age. It is uncommon after 15 years of age.
D. Acute Lymphocytic Leukemia (ALL) does not cause gastric distention. It does invade the central nervous system, and clients experience headaches and vomiting from meningeal irritation.
B. Disseminated Intravascular Coagulation (DIC) has not been found to respond to oral anticoagulants such as Coumadin.
A. Urine output provides the most sensitive indication of the client’s response to therapy for hypovolemic shock. Urine output should be consistently greater than 30 to 35 mL/hr.
C. Early warning signs of laryngeal cancer can vary depending on tumor location. Hoarseness lasting 2 weeks should be evaluated because it is one of the most common warning signs.
C. Steroids decrease the body’s immune response thus decreasing the production of antibodies that attack the acetylcholine receptors at the neuromuscular junction
C. The osmotic diuretic mannitol is contraindicated in the presence of inadequate renal function or heart failure because it increases the intravascular volume that must be filtered and excreted by the kidney.
A. These devices are more accurate because they are easily to used and have improved adherence in insulin regimens by young people because the medication can be administered discreetly.
C. Damage to blood vessels may decrease the circulatory perfusion of the toes, this would indicate the lack of blood supply to the extremity.
D. Elevation will help control the edema that usually occurs.
B. Uric acid has a low solubility, it tends to precipitate and form deposits at various sites where blood flow is least active, including cartilaginous tissue such as the ears.
B. The palms should bear the client’s weight to avoid damage to the nerves in the axilla.
A. Active exercises, alternating extension, flexion, abduction, and adduction, mobilize exudates in the joints relieves stiffness and pain.
C. Alteration in sensation and circulation indicates damage to the spinal cord, if these occurs notify physician immediately.
A. In the diuretic phase fluid retained during the oliguric phase is excreted and may reach 3 to 5 liters daily, hypovolemia may occur and fluids should be replaced.
C. The constituents of CSF are similar to those of blood plasma. An examination for glucose content is done to determine whether a body fluid is a mucus or a CSF. A CSF normally contains glucose.
B. Trauma is one of the primary cause of brain damage and seizure activity in adults. Other common causes of seizure activity in adults include neoplasms, withdrawal from drugs and alcohol, and vascular disease.
A. It is crucial to monitor the pupil size and papillary response to indicate changes around the cranial nerves.
C. The nurse most positive approach is to encourage the client with multiple sclerosis to stay active, use stress reduction techniques and avoid fatigue because it is important to support the immune system while remaining active.
D. Restlessness is an early indicator of hypoxia. The nurse should suspect hypoxia in unconscious client who suddenly becomes restless.
B. In spinal shock, the bladder becomes completely atonic and will continue to fill unless the client is catheterized.
A. Progression stage is the change of tumor from the preneoplastic state or low degree of malignancy to a fast growing tumor that cannot be reversed.
D. Intensity is the major indicative of severity of pain and it is important for the evaluation of the treatment.
B. The use of fragrant soap is very drying to skin hence causing the pruritus.
C. Atropine sulfate is contraindicated with glaucoma patients because it increases intraocular pressure.
A. A 67 year old client is greater risk because the older adult client is more likely to have a less-effective immune system.
B. The last area to return sensation is in the perineal area, and the nurse in charge should monitor the client for distended bladder.
D. Glucocorticoids play no significant role in disease treatment.
D. Tracheostomy tube has several potential complications including bleeding, infection and laryngeal nerve damage.
C. In burn, the capillaries and small vessels dilate, and cell damage cause the release of a histamine-like substance. The substance causes the capillary walls to become more permeable and significant quantities of fluid are lost.
A. Aging process involves increased capillary fragility and permeability. Older adults have a decreased amount of subcutaneous fat and cause an increased incidence of bruise like lesions caused by collection of extravascular blood in loosely structured dermis.
D. Intermittent pain is the classic sign of renal carcinoma. It is primarily due to capillary erosion by the cancerous growth.
B. Tubercle bacillus is a drug resistant organism and takes a long time to be eradicated. Usually a combination of three drugs is used for minimum of 6 months and at least six months beyond culture conversion.
A. Patent airway is the most priority; therefore removal of secretions is necessary.