Medical-Surgical Nursing Exam 5

Practice Mode

Welcome to your Medical-Surgical Nursing Exam 5! This exam is carefully curated to help you consolidate your knowledge and gain deeper understanding on the topic.

 

βœ” Exam Details

  • Number of Questions: 50 items
  • Mode: Practice Mode

βœ” Exam Instructions

  1. Practice Mode: This mode aims to facilitate effective learning and review.
  2. Instant Feedback: After each question, the correct answer along with an explanation will be revealed. This is to help you understand the reasoning behind the correct answer, helping to reinforce your learning.
  3. Time Limit: There is no time limit for this exam. Take your time to understand each question and the corresponding choices.

βœ” Tips For Success

  • Read each question carefully. Take your time and don't rush.
  • Understand the rationale behind each answer. This will not only help you during this exam, but also assist in reinforcing your learning.
  • Don't be discouraged by incorrect answers. Use them as an opportunity to learn and improve.
  • Take breaks if you need them. It's not a race, and your understanding is what's most important.
  • Keep a positive attitude and believe in your ability to succeed.

Remember, this exam is not just a test of your knowledge, but also an opportunity to enhance your understanding and skills. Enjoy the learning journey!

 

Click 'Start Exam' when you're ready to begin. Best of luck!

πŸ’‘ Hint

The optimal position after a femur neck fracture aims to provide stability and minimize discomfort. The correct answer involves a specific movement of the hip joint that helps maintain an appropriate alignment.

1 / 50

1. Following a fracture of the femur neck, the nurse should be aware that the recommended position for the patient's hip is:

πŸ’‘ Hint

An empathetic response that acknowledges the patient's feelings and encourages them to further elaborate on their concerns will help provide the necessary emotional support.

2 / 50

2. You are encouraging your patient, who is scheduled for a major cancer operation, to express her fears. She says, "I am afraid to go through with it." The most appropriate response is:

πŸ’‘ Hint

Consider the level of care needed in each category and which one corresponds to the least amount of therapy and observation for the patients.

3 / 50

3. In a patient classification system, which category represents patients requiring minimal therapy and less frequent observation?

πŸ’‘ Hint

Before a surgery involving the gastrointestinal or urinary system, it is essential to prepare the area to minimize the risk of infection and complications. The correct answer involves a common preoperative practice for such procedures.

4 / 50

4. Prior to a cystectomy and ileal conduit procedure for a client diagnosed with bladder cancer, the nurse should plan to:

πŸ’‘ Hint

Consider the potential complications that can arise after an amputation, and how certain positions may help prevent these issues from developing.

5 / 50

5. An adult underwent a left above-the-knee amputation two weeks ago. The nurse positions the patient in a prone position three times a day for which reason?

πŸ’‘ Hint

Ear canal irrigation is typically employed to address a common issue involving the accumulation of a natural substance in the ear. This issue may obstruct the ear canal and affect hearing.

6 / 50

6. For which of the following conditions would ear canal irrigation be considered an appropriate intervention?

πŸ’‘ Hint

Consider which intervention can help manage the localized response to the injection and provide relief from the discomfort experienced by the client.

7 / 50

7. A client experiences a burning sensation and discomfort at the injection site after receiving an intramuscular injection. Which nursing intervention would be most appropriate in this situation?

πŸ’‘ Hint

An empathetic response should focus on acknowledging the client's feelings and needs, while opening up a conversation about their concerns.

8 / 50

8. A 56-year-old male client informs the office nurse that his wife does not allow him to change his colostomy bag himself. Which response by the nurse demonstrates an understanding of the situation?

πŸ’‘ Hint

Postoperative care often involves measures to prevent complications associated with the specific surgical procedure. Consider the physical processes involved in each of the options and their potential impact on a prostatectomy patient.

9 / 50

9. When nursing a patient during the initial stages of recovery following a prostatectomy, which intervention should take precedence?

πŸ’‘ Hint

To assess a patient's nutritional health, it is crucial to focus on the data that provides a comprehensive understanding of their body composition and nutritional status.

10 / 50

10. A 27-year-old adult is admitted for treatment of Crohn's disease. Which of the following factors is most important for the nurse to consider when evaluating the patient's nutritional health?

πŸ’‘ Hint

Consider medications that primarily target the cardiovascular system and could potentially impact sexual function.

11 / 50

11. A male client brings a list of his prescribed medications to the clinic. During the initial assessment, he reports experiencing delayed ejaculation. Which drug class is linked to this issue?

πŸ’‘ Hint

Think about the emotional impact of dealing with a serious illness. The highest priority nursing diagnosis should address the patient's psychological well-being, which can significantly affect their overall health and treatment outcomes.

12 / 50

12. For a patient diagnosed with Kaposi's sarcoma and experiencing the following nursing diagnoses, which one should be prioritized by the nurse?

πŸ’‘ Hint

Consider the potential for accidents or falls in a home environment. The correct answer involves a common household item that can easily cause slips or trips when using crutches.

13 / 50

13. When evaluating a client's home environment for safe crutch usage, which factor presents the most significant risk?

πŸ’‘ Hint

The Rule of Nines divides the body into regions, each representing a multiple of nine percent. Consider the percentages for the anterior trunk, upper extremities, and lower extremities.

14 / 50

14. Using the Rule of Nines, estimate the total percentage of body surface area burned for Marlon, who has second and third-degree burns on his anterior trunk, both front upper extremities, and both entire lower extremities.

πŸ’‘ Hint

Consider the immediate postoperative risks associated with general anesthesia and which nursing diagnosis addresses a life-threatening concern.

15 / 50

15. A client who has undergone surgery under general anesthesia returns postoperatively. Which nursing diagnosis holds the highest priority for this patient?

πŸ’‘ Hint

Sterile technique aims to minimize contamination risk. Consider which direction will best maintain sterility while opening the package.

16 / 50

16. When opening a sterile package from the central supply, which direction should the nurse unfold the first flap?

πŸ’‘ Hint

Consider how hearing loss might affect a child's ability to engage with their surroundings and how this could influence their overall behavior and interest in their environment.

17 / 50

17. Children with undiagnosed hearing loss are most likely to display which of the following behaviors?

πŸ’‘ Hint

Consider the potential complications related to an external shunt. The most serious problem involves a life-threatening condition that can result from rapid loss of blood.

18 / 50

18. For clients requiring hemodialysis, an external shunt may be used to access a vein and an artery. The most severe issue associated with an external shunt is:

πŸ’‘ Hint

Consider the location of the maxillary sinuses in relation to the facial structure to determine the correct area for palpation.

19 / 50

19. When preparing to palpate a client's maxillary sinus, the nurse should place their hands:

πŸ’‘ Hint

The Trendelenburg position involves placing the patient with their head lower than their feet. Consider how this position affects the distribution of internal organs and their relation to the diaphragm.

20 / 50

20. A patient has been positioned in the Trendelenburg position. The nurse understands that the effects of this position on the patient include:

πŸ’‘ Hint

Consider which condition may be worsened by elevating the patient's legs and lowering their head, as in the modified Trendelenburg position.

21 / 50

21. A man involved in a motor vehicle accident is going into shock. Prior to positioning the patient in a modified Trendelenburg position, the nurse should assess the patient for:

πŸ’‘ Hint

Post-surgery care should focus on promoting healing and preventing complications. Consider which action might expose the surgical site to potential risks or delay the healing process.

22 / 50

22. A client has recently undergone ear surgery. Which of the following actions would be unsuitable when planning their care?

πŸ’‘ Hint

Consider the therapeutic effects of heat application, particularly when targeting muscles and soft tissue, and its ability to address specific symptoms of chronic lower back pain.

23 / 50

23. An adult with chronic lower back pain receives hot packs three times a week. The nurse understands that this treatment is administered for which primary purpose?

πŸ’‘ Hint

Reflect on the typical symptoms that would be present when a person's airway is entirely blocked. The correct answer involves a crucial reflex that would be hindered due to the obstruction.

24 / 50

24. Which observation is indicative of a fully obstructed airway?

πŸ’‘ Hint

Consider which method would provide the necessary support to maintain the legs' alignment and prevent external rotation while the patient is lying supine.

25 / 50

25. To prevent external rotation of the legs in an adult patient who is supine, the nurse should:

πŸ’‘ Hint

Neostigmine is a medication that specifically targets a particular enzyme in the body, ultimately affecting the communication between nerves and muscles. Consider the role of this enzyme in nerve signaling.

26 / 50

26. A client with myasthenia gravis has been receiving Neostigmine (Prostigmin). The mechanism of action for this drug is:

πŸ’‘ Hint

Prior to a pelvic examination, it is essential to ensure the patient's comfort and optimal examination conditions. Consider which step would help achieve this before the exam begins.

27 / 50

27. A woman is scheduled for a pelvic examination. What should the nurse instruct the patient to do first?

πŸ’‘ Hint

TPN is a comprehensive nutritional solution intended to provide all essential nutrients when oral or enteral nutrition is not feasible.

28 / 50

28. An adult patient is prescribed Total Parenteral Nutrition (TPN). Which component is least likely to be included in the solution?

πŸ’‘ Hint

When dealing with acute injuries, consider the immediate physiological effects of cold application and how it can help address the initial symptoms.

29 / 50

29. A man has sustained a sprained ankle. The physician is likely to recommend applying cold to the affected area in order to:

πŸ’‘ Hint

A tepid sponge bath should be comfortable and help lower the patient's fever without causing discomfort or shock. Consider the temperature range that would be most suitable for this purpose.

30 / 50

30. An adult requires a tepid sponge bath to reduce their fever. At which temperature should the nurse prepare the water?

πŸ’‘ Hint

The most appropriate questions in this situation should avoid judgment or blame, focusing instead on gathering relevant information and understanding the client's condition.

31 / 50

31. The nurse is assessing a male client admitted for treatment of alcoholism. Which question is the least appropriate for the nurse to ask?

πŸ’‘ Hint

Consider which communication method is the most common and allows for direct interaction, enabling you to assess their hearing capabilities firsthand.

32 / 50

32. Hearing loss is a prevalent condition observed in elderly individuals, but it can also affect children. In order to evaluate the hearing impairment of a 70-year-old individual, which communication method should be employed initially?

πŸ’‘ Hint

An infiltration involves the unintentional administration of fluids into surrounding tissue instead of the intended vein. Think about the symptoms that could arise due to the fluid's presence in the tissue.

33 / 50

33. The nurse is monitoring a patient receiving intravenous (IV) fluids. Which observation best suggests that the IV has infiltrated?

πŸ’‘ Hint

Think about the client's ability to lip-read and which method allows them to understand speech more effectively by observing the speaker's lips.

34 / 50

34. During your routine rounds, you learn that a client in the ICU uses a respirator and relies on lip-reading for communication. To establish a relationship with this client, the most effective communication method would be:

πŸ’‘ Hint

Consider the recommendations for skin cancer prevention and sun protection. The correct answer involves a common misconception about a particular method of achieving a tan, which still carries risks for skin damage and cancer recurrence.

35 / 50

35. Which statement, if made by a patient who has had basal cell carcinoma removed, suggests that the nurse should provide additional guidance?

πŸ’‘ Hint

The most therapeutic response from the nurse should encourage open communication and empower the patient to make informed decisions about their treatment.

36 / 50

36. A patient diagnosed with metastatic kidney cancer is advised by the physician to have the kidney removed. The patient asks the nurse, β€œWhat should I do?” Which of the following responses by the nurse would be most helpful?

πŸ’‘ Hint

Collaborating with the healthcare team can help ensure that the patient receives consistent and comprehensive information about their upcoming surgery.

37 / 50

37. A registered nurse working in the preoperative area of the operating room notices that a client is scheduled for a partial mastectomy and axillary lymph node removal the following week. To ensure that the client is well-informed about her surgery, the nurse should:

πŸ’‘ Hint

Consider how to manage a patient's pain and discomfort during the debridement process.

38 / 50

38. Due to suffering second-degree burns, Marlon was admitted to the hospital. Prior to debriding a second-degree burn on the left lower leg, which of the following actions should the nurse perform?

πŸ’‘ Hint

Consider the various conditions listed and their relevance to testicular cancer risk. The correct answer involves a developmental abnormality that may contribute to an increased likelihood of developing the disease.

39 / 50

39. Which condition, reported by a 20-year-old male patient to a nurse, would suggest an increased risk for developing testicular cancer?

πŸ’‘ Hint

Non-narcotic analgesics have a specific effect on a certain class of compounds that play a key role in the generation of pain and inflammation in the body.

40 / 50

40. A client is being administered ASA (aspirin). The nurse recognizes that the primary mechanism of action for non-narcotic analgesics is their capacity to:

πŸ’‘ Hint

For a stage II pressure ulcer, the ideal dressing should promote a moist healing environment while allowing for gas exchange and preventing the entry of bacteria.

41 / 50

41. The nurse needs to apply a dressing to a stage II pressure ulcer. Which of the following dressings is the most appropriate?

πŸ’‘ Hint

Intramedullary nailing is a technique used to stabilize certain types of fractures. The correct answer involves a specific part of the femur that can benefit from this procedure.

42 / 50

42. Intramedullary nailing is employed as a treatment for which of the following conditions?

πŸ’‘ Hint

An empathetic and supportive response would encourage the patient to express their feelings and concerns, allowing for open communication and emotional support.

43 / 50

43. A patient diagnosed with a terminal illness confides in you, saying, "I'm really scared. Am I dying?" What is the most appropriate response?

πŸ’‘ Hint

Medical asepsis focuses on reducing the spread of pathogens, particularly when dealing with potentially contagious conditions. Consider which practice provides additional protection when caring for patients with such conditions.

44 / 50

44. Which of the following actions demonstrates the correct technique for medical asepsis?

πŸ’‘ Hint

Addressing the patient's concerns and providing information can be an essential part of promoting patient-centered care.

45 / 50

45. A 40-year-old patient admitted with an acute myocardial infarction requests to view his chart. What is the nurse's initial action?

πŸ’‘ Hint

Metabolic acidosis is often caused by an accumulation of acids in the body or a loss of bicarbonate. Consider which of these conditions is not directly linked to these processes.

46 / 50

46. The nurse is attending to a patient with arterial blood gas results indicative of metabolic acidosis. Which of the following is least likely to result in metabolic acidosis?

πŸ’‘ Hint

Consider the level of assistance and complexity of treatments needed for patients within each category. The correct option refers to a high degree of care and support in almost all aspects of the patient's daily life, often involving specialized medical equipment and constant monitoring.

47 / 50

47. In a patient classification system, which category denotes that a patient requires thorough supervision, comprehensive assistance in most activities, and frequent administration of intricate treatments and medications?

πŸ’‘ Hint

In emergency situations, it is crucial to follow established safety protocols and prioritize alerting others to the potential danger.

48 / 50

48. Upon discovering a fire in a room, what is the most appropriate initial action for the nurse to take?

πŸ’‘ Hint

TPN provides a high concentration of glucose, which can affect blood sugar levels. Additionally, consider the possible impact of TPN on electrolyte balance, specifically potassium.

49 / 50

49. The nurse attending to an adult patient receiving Total Parenteral Nutrition (TPN) should be vigilant for which metabolic complications?

πŸ’‘ Hint

A low-sodium diet should focus on minimizing the intake of processed and canned foods, utilizing natural flavor enhancers like herbs and spices, and seeking professional guidance when needed.

50 / 50

50. An 83-year-old widow is hospitalized for treatment of chronic renal disease and is now ready for discharge. The doctor has prescribed a high carbohydrate, low-protein, low-sodium diet. The patient's supportive family, with whom she lives, has requested assistance in planning low-sodium meals. Which of the following options best represents the pre-discharge information the nurse should provide to the client's family regarding a low-sodium diet?

Exam Mode

Welcome to your Medical-Surgical Nursing Exam 5! This exam is carefully designed to provide you with a realistic test-taking experience, preparing you for the pressures of an actual nursing exam.

 

βœ” Exam Details

  • Number of Questions: 50 items
  • Mode: Exam Mode

βœ” Exam Instructions

  1. Exam Mode: This mode is intended to simulate the environment of an actual exam. Questions and choices will be presented one at a time.
  2. Time Limit: Each question must be answered within 90 seconds. The entire exam should be completed within 75 minutes.
  3. Feedback and Grading: Upon completion of the exam, you will be able to see your grade and the correct answers to all questions. This will allow you to evaluate your performance and understand areas for improvement.

βœ” Tips For Success

  • Read each question carefully. You have 90 seconds per question, so make sure you understand the question before selecting your answer.
  • Pace yourself. Remember, you have 75 minutes in total, so try to maintain a steady rhythm.
  • Focus on one question at a time. Try not to worry about the questions to come.
  • Stay calm under pressure. Use your knowledge and trust your instincts.
  • Remember, it's not just about the score, but about the learning process.

This exam is not only a measurement of your current understanding, but also a valuable learning tool to prepare you for your future nursing career. Click 'Start Exam' when you're ready to begin. Good luck!

1 / 50

1. A client who has undergone surgery under general anesthesia returns postoperatively. Which nursing diagnosis holds the highest priority for this patient?

2 / 50

2. A patient has been positioned in the Trendelenburg position. The nurse understands that the effects of this position on the patient include:

3 / 50

3. When evaluating a client's home environment for safe crutch usage, which factor presents the most significant risk?

4 / 50

4. The nurse is monitoring a patient receiving intravenous (IV) fluids. Which observation best suggests that the IV has infiltrated?

5 / 50

5. Which statement, if made by a patient who has had basal cell carcinoma removed, suggests that the nurse should provide additional guidance?

6 / 50

6. Intramedullary nailing is employed as a treatment for which of the following conditions?

7 / 50

7. To prevent external rotation of the legs in an adult patient who is supine, the nurse should:

8 / 50

8. A client with myasthenia gravis has been receiving Neostigmine (Prostigmin). The mechanism of action for this drug is:

9 / 50

9. Upon discovering a fire in a room, what is the most appropriate initial action for the nurse to take?

10 / 50

10. For a patient diagnosed with Kaposi's sarcoma and experiencing the following nursing diagnoses, which one should be prioritized by the nurse?

11 / 50

11. You are encouraging your patient, who is scheduled for a major cancer operation, to express her fears. She says, "I am afraid to go through with it." The most appropriate response is:

12 / 50

12. A client is being administered ASA (aspirin). The nurse recognizes that the primary mechanism of action for non-narcotic analgesics is their capacity to:

13 / 50

13. An adult underwent a left above-the-knee amputation two weeks ago. The nurse positions the patient in a prone position three times a day for which reason?

14 / 50

14. Children with undiagnosed hearing loss are most likely to display which of the following behaviors?

15 / 50

15. A client has recently undergone ear surgery. Which of the following actions would be unsuitable when planning their care?

16 / 50

16. In a patient classification system, which category represents patients requiring minimal therapy and less frequent observation?

17 / 50

17. Due to suffering second-degree burns, Marlon was admitted to the hospital. Prior to debriding a second-degree burn on the left lower leg, which of the following actions should the nurse perform?

18 / 50

18. Hearing loss is a prevalent condition observed in elderly individuals, but it can also affect children. In order to evaluate the hearing impairment of a 70-year-old individual, which communication method should be employed initially?

19 / 50

19. For clients requiring hemodialysis, an external shunt may be used to access a vein and an artery. The most severe issue associated with an external shunt is:

20 / 50

20. A client experiences a burning sensation and discomfort at the injection site after receiving an intramuscular injection. Which nursing intervention would be most appropriate in this situation?

21 / 50

21. When nursing a patient during the initial stages of recovery following a prostatectomy, which intervention should take precedence?

22 / 50

22. Using the Rule of Nines, estimate the total percentage of body surface area burned for Marlon, who has second and third-degree burns on his anterior trunk, both front upper extremities, and both entire lower extremities.

23 / 50

23. A 27-year-old adult is admitted for treatment of Crohn's disease. Which of the following factors is most important for the nurse to consider when evaluating the patient's nutritional health?

24 / 50

24. A male client brings a list of his prescribed medications to the clinic. During the initial assessment, he reports experiencing delayed ejaculation. Which drug class is linked to this issue?

25 / 50

25. The nurse is attending to a patient with arterial blood gas results indicative of metabolic acidosis. Which of the following is least likely to result in metabolic acidosis?

26 / 50

26. The nurse is assessing a male client admitted for treatment of alcoholism. Which question is the least appropriate for the nurse to ask?

27 / 50

27. An adult with chronic lower back pain receives hot packs three times a week. The nurse understands that this treatment is administered for which primary purpose?

28 / 50

28. A 40-year-old patient admitted with an acute myocardial infarction requests to view his chart. What is the nurse's initial action?

29 / 50

29. The nurse needs to apply a dressing to a stage II pressure ulcer. Which of the following dressings is the most appropriate?

30 / 50

30. An adult patient is prescribed Total Parenteral Nutrition (TPN). Which component is least likely to be included in the solution?

31 / 50

31. When opening a sterile package from the central supply, which direction should the nurse unfold the first flap?

32 / 50

32. A registered nurse working in the preoperative area of the operating room notices that a client is scheduled for a partial mastectomy and axillary lymph node removal the following week. To ensure that the client is well-informed about her surgery, the nurse should:

33 / 50

33. During your routine rounds, you learn that a client in the ICU uses a respirator and relies on lip-reading for communication. To establish a relationship with this client, the most effective communication method would be:

34 / 50

34. For which of the following conditions would ear canal irrigation be considered an appropriate intervention?

35 / 50

35. A man has sustained a sprained ankle. The physician is likely to recommend applying cold to the affected area in order to:

36 / 50

36. Prior to a cystectomy and ileal conduit procedure for a client diagnosed with bladder cancer, the nurse should plan to:

37 / 50

37. An 83-year-old widow is hospitalized for treatment of chronic renal disease and is now ready for discharge. The doctor has prescribed a high carbohydrate, low-protein, low-sodium diet. The patient's supportive family, with whom she lives, has requested assistance in planning low-sodium meals. Which of the following options best represents the pre-discharge information the nurse should provide to the client's family regarding a low-sodium diet?

38 / 50

38. A patient diagnosed with metastatic kidney cancer is advised by the physician to have the kidney removed. The patient asks the nurse, β€œWhat should I do?” Which of the following responses by the nurse would be most helpful?

39 / 50

39. Following a fracture of the femur neck, the nurse should be aware that the recommended position for the patient's hip is:

40 / 50

40. Which observation is indicative of a fully obstructed airway?

41 / 50

41. Which condition, reported by a 20-year-old male patient to a nurse, would suggest an increased risk for developing testicular cancer?

42 / 50

42. An adult requires a tepid sponge bath to reduce their fever. At which temperature should the nurse prepare the water?

43 / 50

43. The nurse attending to an adult patient receiving Total Parenteral Nutrition (TPN) should be vigilant for which metabolic complications?

44 / 50

44. Which of the following actions demonstrates the correct technique for medical asepsis?

45 / 50

45. In a patient classification system, which category denotes that a patient requires thorough supervision, comprehensive assistance in most activities, and frequent administration of intricate treatments and medications?

46 / 50

46. A patient diagnosed with a terminal illness confides in you, saying, "I'm really scared. Am I dying?" What is the most appropriate response?

47 / 50

47. A woman is scheduled for a pelvic examination. What should the nurse instruct the patient to do first?

48 / 50

48. A man involved in a motor vehicle accident is going into shock. Prior to positioning the patient in a modified Trendelenburg position, the nurse should assess the patient for:

49 / 50

49. When preparing to palpate a client's maxillary sinus, the nurse should place their hands:

50 / 50

50. A 56-year-old male client informs the office nurse that his wife does not allow him to change his colostomy bag himself. Which response by the nurse demonstrates an understanding of the situation?

Text Mode

Text ModeΒ – Text version of the exam

Questions

1. A 40-year-old patient admitted with an acute myocardial infarction requests to view his chart. What is the nurse’s initial action?

A. Inquire if the patient has any concerns regarding his care.
B. Seek approval from the supervisor and physician.
C. Offer the patient a blank chart for review.
D. Inform the patient that he is not allowed to access his chart.

2. A registered nurse working in the preoperative area of the operating room notices that a client is scheduled for a partial mastectomy and axillary lymph node removal the following week. To ensure that the client is well-informed about her surgery, the nurse should:

A. Communicate with the nursing staff at the physician’s office to determine what the client has been taught and her level of understanding.
B. Entrust the postoperative nurses with patient education, as the patient may be too anxious before surgery.
C. Ensure that the post-anesthesia recovery unit nurses are aware of what to teach the patient prior to discharge.
D. Assume that the patient is already fully informed about her surgery.

3. A male client brings a list of his prescribed medications to the clinic. During the initial assessment, he reports experiencing delayed ejaculation. Which drug class is linked to this issue?

A. Antibiotics
B. Anticoagulants
C. Steroids
D. Antihypertensives

Situation: Due to suffering second-degree burns, Marlon was admitted to the hospital.

4. Prior to debriding a second-degree burn on the left lower leg, which of the following actions should the nurse perform?

A. Administer intravenous acyclovir (Zovirax).
B. Apply Lindane (Kwell) to the impacted area.
C. Position the affected leg in a dependent manner.
D. Provide the patient with a narcotic analgesic.

5. Using the Rule of Nines, estimate the total percentage of body surface area burned for Marlon, who has second and third-degree burns on his anterior trunk, both front upper extremities, and both entire lower extremities.

A. Approximately 60%
B. Approximately 70%
C. Approximately 90%
D. Approximately 50%

Situation: Hearing loss is a prevalent condition observed in elderly individuals, but it can also affect children.

6. In order to evaluate the hearing impairment of a 70-year-old individual, which communication method should be employed initially?

A. Inquire about the client through a family member.
B. Provide the client with a written message.
C. Utilize verbal communication and observe their response.
D. Communicate with the client using sign language.

7. During your routine rounds, you learn that a client in the ICU uses a respirator and relies on lip-reading for communication. To establish a relationship with this client, the most effective communication method would be:

A. Speaking with accompanying gestures.
B. Employing a basic “charades” approach or strategy.
C. Speaking softly and using a low tone.
D. Speaking slowly and audibly.

8. A client has recently undergone ear surgery. Which of the following actions would be unsuitable when planning their care?

A. Assisting the client with walking at least 24 hours after surgery.
B. Administering antiemetics and analgesics as prescribed.
C. Encouraging the patient to swim in a pool the day after surgery.
D. Instructing the patient to avoid sneezing, coughing, and nose blowing.

9. For which of the following conditions would ear canal irrigation be considered an appropriate intervention?

A. Impacted cerumen.
B. Tympanic membrane perforation.
C. Acoustic neuroma.
D. Foreign body in the ear canal.

10. Children with undiagnosed hearing loss are most likely to display which of the following behaviors?

A. Hyperactivity.
B. Hand gestures while speaking.
C. Indifference and lack of interest in the environment.
D. Decreased appetite.

Situation. Therapeutic communication is a fundamental tool in the nursing profession, and the situation presented below highlights the need to enhance communication skills.

11. A patient diagnosed with a terminal illness confides in you, saying, “I’m really scared. Am I dying?” What is the most appropriate response?

A. “I’m sure you are scared; other clients in your situation feel the same way.”
B. “You will be alright, don’t worry.”
C. “Tell me about what you think.”
D. “You should be careful not to let your family know you’re scared.”

12. The nurse is assessing a male client admitted for treatment of alcoholism. Which question is the least appropriate for the nurse to ask?

A. “What other drugs do you use?”
B. “Why do you drink so much?”
C. “Have you tried to quit drinking before?”
D. “How much do you drink?”

13. A 56-year-old male client informs the office nurse that his wife does not allow him to change his colostomy bag himself. Which response by the nurse demonstrates an understanding of the situation?

A. “Do you think your wife might benefit from counseling?”
B. “Your wife’s need to help you is a reality you should accept.”
C. “Your wife is not allowing you to be independent. Let’s talk about how we can help you gain more control over your care.”
D. “You feel you need privacy when changing your colostomy?”

14. An 83-year-old widow is hospitalized for treatment of chronic renal disease and is now ready for discharge. The doctor has prescribed a high carbohydrate, low-protein, low-sodium diet. The patient’s supportive family, with whom she lives, has requested assistance in planning low-sodium meals. Which of the following options best represents the pre-discharge information the nurse should provide to the client’s family regarding a low-sodium diet?

A. Use potassium salts as a substitute for table salt when cooking and seasoning foods, read labels on packaged foods to determine sodium content, and avoid salty snacks.
B. Avoid canned and processed foods, refrain from using salt replacements, use herbs and spices as substitutes for salt in cooking and seasoning foods, and consult a dietitian for assistance.
C. Avoid dining at restaurants, thoroughly soak vegetables before cooking to remove sodium, exclude all canned foods, and remove salt shakers from the table.
D. Eliminate all carbohydrates and focus on high-protein meals without added salt.

15. You are encouraging your patient, who is scheduled for a major cancer operation, to express her fears. She says, “I am afraid to go through with it.” The most appropriate response is:

A. “Don’t worry, you are in good hands.”
B. “I know how you feel about your condition.”
C. “Let us ask your doctor about your operation.”
D. “It’s normal to feel scared before a major surgery. What specifically are you afraid of?”

16. The nurse is attending to a patient with arterial blood gas results indicative of metabolic acidosis. Which of the following is least likely to result in metabolic acidosis?

A. Reduced serum potassium levels.
B. Kidney failure
C. Heart attack
D. Diabetic ketoacidosis

17. The nurse is monitoring a patient receiving intravenous (IV) fluids. Which observation best suggests that the IV has infiltrated?

A. Coolness surrounding the insertion site.
B. Inflammation near the insertion site.
C. Alteration in flow rate.
D. Discomfort at the site.

18 A 27-year-old adult is admitted for treatment of Crohn’s disease. Which of the following factors is most important for the nurse to consider when evaluating the patient’s nutritional health?

A. Frequency of headaches.
B. Results of anthropometric measurements.
C. Occurrence of facial redness.
D. Evidence of bleeding gums.

19. A client is being administered ASA (aspirin). The nurse recognizes that the primary mechanism of action for non-narcotic analgesics is their capacity to:

A. Directly influences the central nervous system.
B. Focus on the pain-inducing properties of kinins.
C. Inhibit the synthesis of prostaglandins.
D. Increase endorphin levels in the brain.

20. The nurse attending to an adult patient receiving Total Parenteral Nutrition (TPN) should be vigilant for which metabolic complications?

A. Hyperglycemia and Hyperkalemia.
B. Hypoglycemia and Hypercalcemia.
C. Hyperglycemia and Hypokalemia.
D. Hyperkalemia and Hypercalcemia.

21. An adult patient is prescribed Total Parenteral Nutrition (TPN). Which component is least likely to be included in the solution?

A. Amino acids
B. 10% dextrose
C. Trace minerals
D. None of the choices

22. A man has sustained a sprained ankle. The physician is likely to recommend applying cold to the affected area in order to:

A. Alleviate pain and manage bleeding.
B. Facilitate the absorption of edema.
C. Lower the body’s overall temperature.
D. Enhance circulation to the region.

23. An adult requires a tepid sponge bath to reduce their fever. At which temperature should the nurse prepare the water?

A. 105Β°F (40.5Β°C)
B. 65Β°F (18.3Β°C)
C. 120Β°F (48.9Β°C)
D. 90Β°F (32.2Β°C)

24. An adult with chronic lower back pain receives hot packs three times a week. The nurse understands that this treatment is administered for which primary purpose?

A. To enhance the patient’s overall circulation.
B. To aid in clearing debris from the affected area.
C. To alleviate muscle spasms and encourage muscle relaxation.
D. To maintain the patient’s warmth and increase their body temperature.

25. In a patient classification system, which category represents patients requiring minimal therapy and less frequent observation?

A. Minimal care (Category 1)
B. Moderate care (Category 2)
C. Maximum care (Category 3)
D. Intensive care (Category 4)

26. The nurse needs to apply a dressing to a stage II pressure ulcer. Which of the following dressings is the most appropriate?

A. Moisture vapor permeable dressing
B. Dry gauze dressing
C. Wet-to-dry dressing
D. Wet gauze dressing

27. A patient has been positioned in the Trendelenburg position. The nurse understands that the effects of this position on the patient include:

A. Reduced intracranial pressure.
B. Enhanced blood flow to the feet.
C. Increased pressure on the diaphragm.
D. Lowered blood pressure.

28. A man involved in a motor vehicle accident is going into shock. Prior to positioning the patient in a modified Trendelenburg position, the nurse should assess the patient for:

A. Thrombophlebitis
B. Air embolism
C. Head injury
D. Long bone fracture

29. Upon discovering a fire in a room, what is the most appropriate initial action for the nurse to take?

A. Retrieve a fire extinguisher and extinguish the fire.
B. Attempt to remove any burning items from the room.
C. Activate the fire alarm or notify the operator, based on the institution’s protocol.
D. Close all windows and doors, and turn off any oxygen or electrical appliances.

30. When opening a sterile package from the central supply, which direction should the nurse unfold the first flap?

A. Away from the nurse.
B. Open the package with both hands simultaneously.
C. Toward the nurse.
D. Direction does not matter as long as the nurse touches only the outside edge.

31. Which of the following actions demonstrates the correct technique for medical asepsis?

A. Changing hospital linens weekly.
B. Wearing gloves for all client contact.
C. Wearing a gown while caring for a 1-year-old child with infectious diarrhea.
D. Using alcohol-based hand sanitizers instead of handwashing.

32. An adult underwent a left above-the-knee amputation two weeks ago. The nurse positions the patient in a prone position three times a day for which reason?

A. Prevents flexion contractures.
B. Facilitates better blood flow to the heart.
C. Ensures proper fit of the prosthesis.
D. Promotes wound dehiscence.

33. A woman is scheduled for a pelvic examination. What should the nurse instruct the patient to do first?

A. Gather all necessary equipment for the examination.
B. Use the restroom and void, saving a sample.
C. Remove all clothing, including socks and shoes.
D. Drink a large glass of water before the exam.

34. To prevent external rotation of the legs in an adult patient who is supine, the nurse should:

A. Position a pillow directly under the patient’s knees.
B. Lower the patient’s legs so that they are below the hips.
C. Utilize a trochanter roll alongside the patient’s upper thighs.
D. Instruct the patient to maintain their legs in an adducted position.

35. When preparing to palpate a client’s maxillary sinus, the nurse should place their hands:

A. Over the temporal area.
B. On the forehead.
C. On the bridge of the nose.
D. Below the cheekbones.

36. A client who has undergone surgery under general anesthesia returns postoperatively. Which nursing diagnosis holds the highest priority for this patient?

A. Fluid volume deficit related to fluid and blood loss from surgery.
B. Risk for aspiration related to anesthesia.
C. Altered body image related to surgical incisions.
D. Pain related to the surgery.

37. A client experiences a burning sensation and discomfort at the injection site after receiving an intramuscular injection. Which nursing intervention would be most appropriate in this situation?

A. Place a warm compress on the site to promote vasodilation.
B. Apply a cold compress to minimize swelling.
C. Advise the client to contract their gluteal muscles to enhance drug absorption.
D. Elevate the affected extremity.

38. In a patient classification system, which category denotes that a patient requires thorough supervision, comprehensive assistance in most activities, and frequent administration of intricate treatments and medications?

A. Minimal Care (Category 1)
B. Moderate Care (Category 2)
C. Maximum Care (Category 3)
D. Intensive Care (Category 4)

39. Which observation is indicative of a fully obstructed airway?

A. Incapacity to cough.
B. Strident crowing sounds during speech attempts.
C. Prolonged, deep breaths.
D. Audible wheezing upon auscultation.

40. When evaluating a client’s home environment for safe crutch usage, which factor presents the most significant risk?

A. Loose rugs
B. A 4-year-old cocker spaniel.
C. High noise levels.
D. Small snack tables.

41. For a patient diagnosed with Kaposi’s sarcoma and experiencing the following nursing diagnoses, which one should be prioritized by the nurse?

A. Despair, related to lack of control over disease progression.
B. Ineffective coping, related to loss of personal boundaries.
C. Impaired cognitive function, related to lesion presence.
D. Compromised self-care, related to noncompliance.

42. Which statement, if made by a patient who has had basal cell carcinoma removed, suggests that the nurse should provide additional guidance?

A. β€œI will wear a wide-brimmed hat when I am in the sun.”
B. β€œI will use tanning booths instead of sunbathing from now on.”
C. β€œI will use sunscreen with a sun protection factor (SPF) of at least 15.”
D. β€œI will avoid sun exposure between 10:00 AM and 2:00 PM.”

43. A patient diagnosed with metastatic kidney cancer is advised by the physician to have the kidney removed. The patient asks the nurse, β€œWhat should I do?” Which of the following responses by the nurse would be most helpful?

A. β€œI recommend getting a second opinion before undergoing surgery.”
B. β€œLet’s discuss the available options.”
C. β€œYou should adhere to the doctor’s recommendation.”
D. β€œWhat does your family want you to do?”

44. Which condition, reported by a 20-year-old male patient to a nurse, would suggest an increased risk for developing testicular cancer?

A. Hydrocele
B. Undescended testicle
C. Acne
D. Genital herpes

45. Prior to a cystectomy and ileal conduit procedure for a client diagnosed with bladder cancer, the nurse should plan to:

A. Administer prescribed cleansing enemas and laxatives.
B. Instruct on the process of stoma irrigation.
C. Restrict fluid intake for 24 hours.
D. Give antibiotics to avert infection.

46. For clients requiring hemodialysis, an external shunt may be used to access a vein and an artery. The most severe issue associated with an external shunt is:

A. Nerve injury.
B. Vessel sclerosis.
C. Bloodstream infection.
D. Exsanguination

47. When nursing a patient during the initial stages of recovery following a prostatectomy, which intervention should take precedence?

A. Encourage the patient to urinate in a standing position.
B. Advise the patient to avoid straining during defecation.
C. Utilize a bulb syringe to draw urine from the retention catheter.
D. Inform the primary healthcare provider if the patient fails to urinate before sleep.

48. Intramedullary nailing is employed as a treatment for which of the following conditions?

A. Slipped epiphysis of the femur.
B. Fracture of the femur shaft.
C. Fracture of the femur neck.
D. Osteoporosis of the femur.

49. Following a fracture of the femur neck, the nurse should be aware that the recommended position for the patient’s hip is:

A. Slight abduction
B. Moderate flexion
C. Extension
D. Slight adduction

50. A client with myasthenia gravis has been receiving Neostigmine (Prostigmin). The mechanism of action for this drug is:

A. Speeding up transmission along neural pathways.
B. Suppressing the sympathetic nervous system.
C. Inhibiting the function of cholinesterase.
D. Exciting the cerebral cortex.

Answers and Rationales

1. Correct answer:

A. Inquire if the patient has any concerns regarding his care. Inquiring about a patient’s concerns regarding his care is an important initial response because it can help the nurse understand the patient’s needs, worries, or potential misunderstandings. This communication can often clarify the information the patient seeks and can sometimes eliminate the need to view the chart. Also, it creates an open dialogue where the nurse can provide explanations, reassurances, and education about the patient’s condition and treatment.

Incorrect answer options:

B. Seek approval from the supervisor and physician. This option is not necessarily wrong, but it isn’t the best initial action. While some institutions may require approval for a patient to view their chart, the Health Insurance Portability and Accountability Act (HIPAA) generally allows patients the right to view and obtain a copy of their health records. However, the first step should be to understand the patient’s concerns, not to seek approval.

C. Offer the patient a blank chart for review. This is incorrect because offering a blank chart would not address the patient’s request. A blank chart does not contain any information about the patient’s health, diagnoses, or treatment, so it would not be helpful or relevant.

D. Inform the patient that he is not allowed to access his chart. This is incorrect. Under the Health Insurance Portability and Accountability Act (HIPAA), patients have the right to view and obtain a copy of their health records. This includes their charts, which contain important medical information about their diagnoses, treatments, and progress.

2. Correct answer:

A. Communicate with the nursing staff at the physician’s office to determine what the client has been taught and her level of understanding. Communication with the nursing staff at the physician’s office is crucial in this situation. This helps the nurse understand what information the client has already been provided and assess the client’s understanding of the upcoming surgery. This information will guide the nurse in providing further patient education, addressing any knowledge gaps, and alleviating any concerns or anxieties the patient may have. Effective preoperative education can improve patient outcomes and satisfaction.

Incorrect answer options:

B. Entrust the postoperative nurses with patient education, as the patient may be too anxious before surgery. This answer is not optimal because preoperative education is essential in preparing a patient for surgery and reducing anxiety. Postoperative education is also necessary but may not cover all the information the patient needs to understand before the surgery.

C. Ensure that the post-anesthesia recovery unit nurses are aware of what to teach the patient prior to discharge. While it’s important for the post-anesthesia recovery unit nurses to provide appropriate education before discharge, this doesn’t address the need for preoperative education. The patient needs to be well-informed about the surgery before it happens, not just after.

D. Assume that the patient is already fully informed about her surgery. This is incorrect because the nurse should never assume that the patient is fully informed. Even if the physician has discussed the procedure with the patient, the nurse should still verify the patient’s understanding and provide further education as necessary.

3. Correct answer:

D. Antihypertensives. Certain antihypertensive medications, particularly those in the class of selective serotonin reuptake inhibitors (SSRIs) and beta-blockers, are known to potentially cause sexual side effects such as delayed ejaculation. This is due to the physiological effects these medications have on the body, including altering neurotransmitter levels or reducing sympathetic nervous system activity, which can impact sexual function.

Incorrect answer options:

A. Antibiotics. Antibiotics are not typically associated with delayed ejaculation. These drugs are used to treat bacterial infections and work by killing bacteria or preventing them from multiplying. While they can have side effects, sexual dysfunction is not commonly one of them.

B. Anticoagulants. Anticoagulants are medications used to prevent blood clots. They do not typically cause sexual side effects such as delayed ejaculation. They work by interrupting the process involved in the formation of blood clots.

C. Steroids. Steroids can have a variety of effects on the body, but they are not typically associated with delayed ejaculation. Steroids, particularly anabolic steroids, may cause other sexual side effects, such as reduced sperm production or shrunken testicles, primarily when misused or abused.

4. Correct answer:

D. Provide the patient with a narcotic analgesic. Before debriding a burn wound, it’s crucial to medicate the patient with a narcotic analgesic. Debridement, the process of removing dead tissue from a burn, can be very painful. Thus, ensuring adequate pain relief with an analgesic prior to the procedure is necessary for patient comfort.

Incorrect answer options:

A. Administer intravenous acyclovir (Zovirax). Administering acyclovir (Zovirax) is not the best action before debridement. Acyclovir is an antiviral medication used to treat herpes simplex and varicella-zoster viruses. It is not typically used in the management of burns unless there is a specific indication (e.g., the patient has a concurrent viral infection).

B. Apply Lindane (Kwell) to the impacted area. Lindane (Kwell) is a medication used to treat scabies and lice, and it is not typically used in burn care. Applying this medication before debridement would not provide any benefit.

C. Position the affected leg in a dependent manner. Positioning the affected leg in a dependent manner is not the most appropriate action to take before debriding a burn wound. Elevating the burned area can help reduce swelling, but it’s not the primary concern prior to debridement. Instead, ensuring the patient’s comfort through adequate pain management is a priority.

5. Correct answer:

A. Approximately 60%. The Rule of Nines is a tool used in the initial assessment of a burn patient to estimate the total body surface area (TBSA) that has been burned. In adults, this rule assigns percentages in multiples of nine to various body regions.

According to the Rule of Nines:

  • The anterior trunk is 18% of the body surface area.
  • Each entire upper extremity (front and back combined) is 9%, so the front of both upper extremities would account for about 9% (4.5% each).
  • Each entire lower extremity is 18%, so both lower extremities would account for 36% (18% each).

Adding these together, we get: 18% (anterior trunk) + 9% (both front upper extremities) + 36% (both entire lower extremities) = 63%.

However, considering the available options and rounding up to the nearest ten, the closest correct answer is approximately 60%.

Incorrect answer options:

B. Approximately 70%. This slightly overestimates the amount of body surface area that has been burned, according to the Rule of Nines.

C. Approximately 90%. This overestimates the body surface area that has been burned, according to the Rule of Nines.

D. Approximately 50%. This significantly underestimates the extent of the burns.

6. Correct answer:

C. Utilize verbal communication and observe their response. When attempting to assess a client’s hearing impairment, the nurse should first attempt to communicate verbally with the client and observe their response. This direct method provides an opportunity to understand the degree of hearing impairment and the client’s ability to understand spoken language.

Incorrect answer options:

A. Inquire about the client through a family member. While family members can provide valuable information about a client’s hearing capabilities, it’s essential to assess the client directly whenever possible. This ensures the most accurate and current information about the client’s condition.

B. Provide the client with a written message. This can be a useful technique if the individual has severe hearing loss or if verbal communication is ineffective. However, it should not be the first method employed. Additionally, this method assumes that the client can read and understand written language, which may not always be the case.

D. Communicate with the client using sign language. While sign language can be an effective communication method for some individuals with hearing impairment, not all people with hearing loss know sign language. Therefore, this method should not be the initial mode of communication unless it’s known that the client uses sign language.

7. Correct answer:

D. Speaking slowly and audibly. For a client who relies on lip-reading for communication, the nurse should speak slowly and audibly. This will enable the client to read the nurse’s lips better and understand the communication. The nurse should also maintain eye contact and ensure their mouth is visible to the client.

Incorrect answer options:

A. Speaking with accompanying gestures. While gestures can sometimes support communication, they are not a reliable primary means of communication. Gestures can be misinterpreted, and not all words or concepts have easily understandable gestures. Therefore, this method should be used as a support to verbal communication rather than the primary means of communication.

B. Employing a basic “charades” approach or strategy. This approach can be challenging and frustrating for both the nurse and the client. It may lead to misinterpretations and miscommunication. Like gestures, this should not be the primary means of communication.

C. Speaking softly and using a low tone. Speaking softly can be problematic for someone who relies on lip-reading. They may not be able to see the movements of the nurse’s lips as well, which can lead to misunderstandings. A normal or slightly louder volume (without shouting) is more appropriate.

8. Correct answer:

C. Encouraging the patient to swim in a pool the day after surgery. After ear surgery, it’s crucial to prevent water from entering the ear canal until it’s fully healed, as this can lead to infection or complications. Therefore, encouraging the patient to swim in a pool the day after surgery would be inappropriate.

Incorrect answer options:

A. Assisting the client with walking at least 24 hours after surgery. Assisting the patient with walking post-surgery is appropriate care. It helps to promote circulation and prevent complications such as deep vein thrombosis (DVT).

B. Administering antiemetics and analgesics as prescribed. Post-surgery, it’s common for patients to experience pain and nausea. Administering antiemetics and analgesics as prescribed by the physician is part of proper patient care.

D. Instructing the patient to avoid sneezing, coughing, and nose blowing. After ear surgery, patients should avoid actions that can increase pressure in the ears, like sneezing, coughing, and nose blowing. These actions can disrupt the healing process and potentially lead to complications.

9. Correct answer:

A. Impacted cerumen. Ear canal irrigation, also known as ear syringing, is commonly used to remove impacted cerumen (earwax) that can cause symptoms like pain, hearing loss, tinnitus, or vertigo. This procedure involves injecting a stream of warm water into the ear canal to loosen and wash out the cerumen.

Incorrect answer options:

B. Tympanic membrane perforation. Irrigation is contraindicated if a patient has a perforated tympanic membrane because it could lead to further injury or infection. The water could potentially enter the middle ear and lead to complications such as otitis media.

C. Acoustic neuroma. Acoustic neuroma is a benign tumor of the nerve that connects the ear to the brain. It’s not treated with ear canal irrigation but usually requires surgery, radiation therapy, or monitoring.

D. Foreign body in the ear canal. Irrigation may not be the best choice for removing a foreign body from the ear canal, especially if the object is sharp or irregularly shaped, as it could potentially cause injury. It’s also not recommended if the foreign body is an insect or something that can swell when wet. Typically, a healthcare provider will remove foreign bodies using specialized instruments.

10. Correct answer:

C. Indifference and lack of interest in the environment. Children with undiagnosed hearing loss may seem indifferent or uninterested in their environment. This is because they may not hear sounds or conversations happening around them, making it harder for them to engage with the world. This can also lead to issues with social interactions and development.

Incorrect answer options:

A. Hyperactivity. Hearing loss does not necessarily cause hyperactivity. Hyperactivity is more commonly associated with conditions like Attention Deficit Hyperactivity Disorder (ADHD).

B. Hand gestures while speaking. While some children with hearing loss may use gestures or sign language, this is more common in children who have been diagnosed and taught alternative methods of communication. An undiagnosed child may not have learned these communication methods yet.

D. Decreased appetite. Hearing loss is not typically associated with a decreased appetite. Changes in appetite can be caused by many other factors, including illness, stress, or certain medications.

11. Correct answer:

C. “Tell me about what you think.” Responding with “Tell me about what you think” invites the patient to share their feelings and fears, promoting open communication. This approach shows empathy and understanding, while respecting the patient’s emotional state.

Incorrect answer options:

A. “I’m sure you are scared; other clients in your situation feel the same way.” While this response acknowledges the patient’s fear, it may not be fully comforting. Comparing the patient’s feelings to others may seem dismissive or make the patient feel as though their fears are being minimized.

B. “You will be alright, don’t worry.” This response may seem comforting, but it may not be truthful or respectful to the patient’s condition or feelings. It’s important to be honest and supportive without providing false hope.

D. “You should be careful not to let your family know you’re scared.” This response may discourage the patient from sharing their feelings with their family or loved ones, which can lead to feelings of isolation. It’s crucial to encourage open communication and emotional support during this difficult time.

12. Correct answer:

B. “Why do you drink so much?” Asking “Why do you drink so much?” can come across as judgmental and may put the client on the defensive. Nurses should aim to create a safe, non-judgmental environment that encourages open and honest communication. It’s essential to use a respectful, empathetic approach when discussing sensitive topics like substance abuse.

Incorrect answer options:

A. “What other drugs do you use?” This is an appropriate question as it provides necessary information about possible polydrug use, which can impact the client’s treatment plan.

C. “Have you tried to quit drinking before?” This is an appropriate question as it can provide insight into the client’s past attempts at sobriety and may give the healthcare team information about what strategies have or have not worked for the client in the past.

D. “How much do you drink?” This is an appropriate question as it helps to determine the extent of the client’s alcohol consumption and potential dependence, which can inform the client’s treatment plan.

13. Correct answer:

C. “Your wife is not allowing you to be independent. Let’s talk about how we can help you gain more control over your care.” This response is respectful and empathetic, recognizing the client’s desire for independence in his care. It also opens up a discussion about strategies to improve his autonomy, which could include educating both the client and his wife about the colostomy care procedure.

Incorrect answer options:

A. “Do you think your wife might benefit from counseling?” This question could be seen as making assumptions or judgments about the wife’s mental health, which may not be relevant or helpful in this situation.

B. “Your wife’s need to help you is a reality you should accept.” This statement disregards the client’s feelings and his desire for independence. It’s not supportive of the client’s autonomy or self-efficacy.

D. “You feel you need privacy when changing your colostomy?” While this response acknowledges the client’s feelings, it doesn’t directly address the issue at hand, which is the client’s desire for independence in managing his colostomy care.

14. Correct answer:

B. Avoid canned and processed foods, refrain from using salt replacements, use herbs and spices as substitutes for salt in cooking and seasoning foods, and consult a dietitian for assistance. This is the best option as it provides a comprehensive approach to a low-sodium diet. Canned and processed foods often have high sodium content. Herbs and spices can be used as a flavorful substitute for salt. Consulting a dietitian can provide more personalized advice and meal planning. Salt replacements should be avoided, as they often contain potassium, which can be harmful to someone with chronic renal disease due to decreased renal excretion.

Incorrect answer options:

A. Use potassium salts as a substitute for table salt when cooking and seasoning foods, read labels on packaged foods to determine sodium content, and avoid salty snacks. Potassium salts should not be used as a substitute in patients with chronic renal disease as their kidneys may not be able to excrete excess potassium, which can lead to dangerous levels of potassium in the blood.

C. Avoid dining at restaurants, thoroughly soak vegetables before cooking to remove sodium, exclude all canned foods, and remove salt shakers from the table. While some of these suggestions are valid, soaking vegetables does not significantly reduce sodium content. Furthermore, dining at restaurants can be done if careful choices are made.

D. Eliminate all carbohydrates and focus on high-protein meals without added salt. A high-protein diet can increase the workload of the kidneys and is not recommended for someone with chronic renal disease. Carbohydrates should not be eliminated.

15. Correct answer:

D. “It’s normal to feel scared before a major surgery. What specifically are you afraid of?” This response validates the patient’s feelings and encourages further dialogue about her specific fears. It is therapeutic and allows the patient to explore her feelings and concerns.

Incorrect answer options:

A. “Don’t worry, you are in good hands.” While it’s important to reassure the patient about the competence of the healthcare team, this response dismisses the patient’s fears and does not allow her to express her specific concerns.

B. “I know how you feel about your condition.” This response is not appropriate as it assumes the nurse fully understands the patient’s feelings. It’s crucial not to generalize or assume the feelings of the patient.

C. “Let us ask your doctor about your operation.” While involving the doctor in the conversation can be beneficial, this response does not directly address the patient’s immediate fear or allow her to express her concerns.

16. Correct answer:

A. Reduced serum potassium levels. Reduced serum potassium levels, also known as hypokalemia, are not typically associated with the development of metabolic acidosis. While severe hypokalemia can affect the body’s acid-base balance, it does not typically cause metabolic acidosis.

Incorrect answer options:

B. Kidney failure. Kidney failure can lead to metabolic acidosis. The kidneys play a crucial role in maintaining acid-base balance by excreting hydrogen ions and reabsorbing bicarbonate. In kidney failure, this function is impaired, leading to an accumulation of acids in the body.

C. Heart attack. A heart attack, or myocardial infarction, can lead to metabolic acidosis due to tissue hypoxia and the subsequent production of lactic acid.

D. Diabetic ketoacidosis. Diabetic ketoacidosis is a serious complication of diabetes that occurs when the body produces high levels of blood acids called ketones. The condition develops when the body can’t produce enough insulin, leading to an accumulation of ketones and resulting in metabolic acidosis.

17. Correct answer:

A. Coolness surrounding the insertion site. Coolness surrounding the insertion site is a common sign of IV infiltration. Infiltration occurs when the IV fluid or medication leaks into the surrounding tissue rather than going into the vein. This can cause the skin to feel cool to the touch due to the temperature of the IV fluids.

Incorrect answer options:

B. Inflammation near the insertion site. While inflammation can occur with IV infiltration, it is not the most definitive sign. Inflammation can also be a result of infection, irritation, or an allergic reaction to the IV catheter or the medication being infused.

C. Alteration in flow rate. An alteration in the flow rate of an IV may suggest several issues, including an occluded or kinked line, a positional change in the extremity, or a pump malfunction. It is not specifically indicative of an infiltration.

D. Discomfort at the site. Discomfort at the site may suggest infiltration, but it is also a common symptom of other complications such as phlebitis (inflammation of the vein), infection, or a reaction to the medication being infused. Therefore, it is not the most definitive sign of an infiltration.

18 Correct answer:

B. Results of anthropometric measurements. Anthropometric measurements, such as height, weight, body mass index (BMI), and skinfold thickness, are often used to assess nutritional status. In the case of a patient with Crohn’s disease, these measurements can provide valuable insights into the severity of malabsorption, malnutrition, or weight loss that can occur due to chronic inflammation of the digestive tract.

Incorrect answer options:

A. Frequency of headaches. While headaches can be a symptom of various health issues, they are not directly related to nutritional status and would not provide specific information about a patient’s nutritional health, especially in the context of Crohn’s disease.

C. Occurrence of facial redness. Facial redness is not typically associated with nutritional health. It can be a symptom of many different conditions, such as rosacea, allergies, or reactions to medications or skin care products, but it is not a direct indicator of nutritional status.

D. Evidence of bleeding gums. Bleeding gums can be a sign of poor oral health, often due to gum disease or vitamin C deficiency (scurvy). While this can be an indicator of overall health, it is not the most comprehensive or direct measure of nutritional status, especially in a patient with Crohn’s disease, which can significantly affect absorption of nutrients in the digestive tract.

19. Correct answer:

C. Inhibit the synthesis of prostaglandins. Non-narcotic analgesics like aspirin primarily work by inhibiting the synthesis of prostaglandins, hormone-like substances that play a key role in inflammation and pain. Aspirin achieves this by blocking the enzyme cyclooxygenase (COX), which is involved in prostaglandin production. By doing so, aspirin helps to reduce pain and inflammation.

Incorrect answer options:

A. Directly influences the central nervous system. While some analgesics, especially opioids, do act directly on the central nervous system to relieve pain, non-narcotic analgesics like aspirin primarily work at the site of tissue injury, inhibiting prostaglandin synthesis to decrease inflammation and pain.

B. Focus on the pain-inducing properties of kinins. Kinin is a generic term for certain proteins that can induce pain and inflammation. Although some drugs may work by targeting these substances, non-narcotic analgesics like aspirin primarily work by inhibiting the synthesis of prostaglandins.

D. Increase endorphin levels in the brain. Endorphins are naturally occurring pain-relieving chemicals in the brain, often increased in response to stress or discomfort. While some drugs, like opioids, work by mimicking the effects of endorphins, non-narcotic analgesics like aspirin do not primarily act through this mechanism.

20. Correct answer:

C. Hyperglycemia and Hypokalemia. Total Parenteral Nutrition (TPN) is a form of intravenous feeding that provides patients with all of the nutrients they need when they cannot eat or absorb enough nutrients from food. TPN provides carbohydrates, proteins, fats, vitamins, minerals, and electrolytes.

  1. Hyperglycemia: TPN contains a high concentration of glucose (dextrose), which can lead to high blood sugar levels (hyperglycemia), especially in patients with diabetes or in those who cannot metabolize glucose effectively.
  2. Hypokalemia: Although TPN often contains potassium, the balance of electrolytes can be complex and individual reactions can vary. Hypokalemia is caused by the loss of potassium in the urine, which is increased by the high concentration of glucose in TPN solutions.

Incorrect answer options:

A. Hyperglycemia and Hyperkalemia: While hyperglycemia is common with TPN, hyperkalemia is not necessarily common as potassium levels can vary depending on individual patient factors.

B. Hypoglycemia and Hypercalcemia: Hypoglycemia is not common with TPN due to the high glucose content. Hypercalcemia is also not a common complication of TPN.

D. Hyperkalemia and Hypercalcemia: While hyperkalemia can potentially occur, it’s not necessarily common. Also, hypercalcemia is not typically associated with TPN.

Please note that individual patient reactions can vary, and this is why careful monitoring of all TPN patients is essential.

21. Correct answer:

D. None of the choices. All of the listed components – amino acids, dextrose, and trace minerals – are typically included in a TPN solution.

Incorrect answer options:

A. Amino acids. These are necessary for protein synthesis and repair of body tissues. Therefore, they are a crucial component of TPN solutions.

B. 10% dextrose. Dextrose provides the body with essential carbohydrates, which serve as a primary energy source. It is an important part of TPN.

C. Trace minerals. Trace minerals such as zinc, copper, manganese, and chromium are essential for various bodily functions, including enzyme activity and metabolic processes. Therefore, they are also typically included in TPN.

22. Correct answer:

A. Alleviate pain and manage bleeding. Cold application or cryotherapy is often recommended for acute injuries such as a sprained ankle. The cold can help constrict the blood vessels (vasoconstriction), which can reduce bleeding into the tissues, swelling, and inflammation, thereby alleviating pain.

Incorrect answer options:

B. Facilitate the absorption of edema. While cold application can help reduce the formation of edema by decreasing the inflammatory response, it does not directly facilitate the absorption of existing edema. Once edema has formed, the body’s lymphatic system will gradually absorb the fluid.

C. Lower the body’s overall temperature. Applying cold to a localized area, such as a sprained ankle, does not significantly affect the body’s overall temperature. Cold application in this context is used for its local effects, not systemic effects.

D. Enhance circulation to the region. Cold application actually constricts blood vessels in the applied area, reducing circulation temporarily. This is beneficial immediately after an injury as it can help minimize bleeding and swelling. However, after the acute phase of an injury, applying heat may be more beneficial to enhance circulation and promote healing.

23. Correct answer:

D. 90Β°F (32.2Β°C). For a tepid sponge bath, the water should be lukewarm, not cold. A temperature of 90Β°F (32.2Β°C) is generally recommended. The aim is to cool the person down gradually without causing them to shiver, which can increase their body temperature.

Incorrect answer options:

A. 105Β°F (40.5Β°C). This temperature is too high for a tepid sponge bath intended to reduce fever. The purpose of the bath is to facilitate heat loss through evaporation, and water at this temperature may not be effective in reducing the body’s temperature.

B. 65Β°F (18.3Β°C). This temperature is too cold for a tepid sponge bath. Using water that is too cold can cause the person to shiver, which can increase metabolic activity and potentially raise body temperature.

C. 120Β°F (48.9Β°C). This temperature is too high and can potentially cause burns. It is not suitable for a tepid sponge bath.

24. Correct answer:

C. To alleviate muscle spasms and encourage muscle relaxation. Heat therapy is often used in chronic pain conditions, particularly those associated with muscle tension and spasms, such as lower back pain. The heat can help relax tightened muscles and alleviate spasms, thereby reducing pain.

Incorrect answer options:

A. To enhance the patient’s overall circulation. While heat therapy does enhance local circulation by causing vasodilation, it does not significantly affect overall circulation. The primary purpose of applying heat in this case is to alleviate muscle spasms and promote relaxation, not to enhance systemic circulation.

B. To aid in clearing debris from the affected area. Heat therapy does not directly facilitate the clearance of cellular debris. This is primarily the role of the body’s immune and lymphatic systems.

D. To maintain the patient’s warmth and increase their body temperature. The primary purpose of using heat therapy in this context is not to increase the patient’s body temperature or maintain their warmth. It is used to alleviate muscle spasms and promote muscle relaxation. While heat therapy can cause a local increase in temperature, this is not its main therapeutic aim in this case.

25. Correct answer:

A. Minimal care (Category 1). In a patient classification system, patients who require minimal therapy and less frequent observation typically fall under the “minimal care” category. These patients are generally stable and their condition is not expected to change rapidly.

Incorrect answer options:

B. Moderate care (Category 2). This category usually includes patients who require more care than those in the minimal care category. They may have more complex needs, require more frequent observation, or be at a greater risk of condition changes.

C. Maximum care (Category 3). This category typically includes patients who require a significant amount of care, often due to serious illness or injury. These patients typically require very frequent or constant observation and may have complex care needs.

D. Intensive care (Category 4). This category is for patients who are critically ill and require intensive, constant care and observation. These patients often have highly complex care needs and are at high risk of rapid condition changes.

26. Correct answer:

A. Moisture vapor permeable dressing. For a stage II pressure ulcer, which involves partial-thickness skin loss, a moist wound healing environment is often recommended. Moisture vapor permeable (also known as semi-permeable) dressings allow for gas exchange while preventing excessive moisture loss. They maintain a moist environment that can promote healing and are generally recommended for shallow, clean wounds like stage II pressure ulcers.

Incorrect answer options:

B. Dry gauze dressing. Dry gauze dressing is not typically recommended for a stage II pressure ulcer because it can adhere to the wound bed and cause trauma when removed. It does not provide the moist environment needed for optimal wound healing.

C. Wet-to-dry dressing. This type of dressing is typically used for wounds that require debridement, not for clean, shallow wounds like a stage II pressure ulcer. Wet-to-dry dressing can cause damage to healthy tissue in the wound bed when removed.

D. Wet gauze dressing. While a moist environment is good for wound healing, a wet dressing can lead to tissue maceration (softening and breakdown of skin due to prolonged exposure to moisture) which can delay healing and potentially cause further damage.

27. Correct answer:

C. Increased pressure on the diaphragm. The Trendelenburg position involves positioning the patient so that the head is lower than the feet. This position can increase pressure on the diaphragm due to the shifting of abdominal contents, which may make breathing more difficult.

Incorrect answer options:

A. Reduced intracranial pressure. In the Trendelenburg position, gravity can increase blood flow to the head, which might increase, rather than decrease, intracranial pressure.

B. Enhanced blood flow to the feet. The Trendelenburg position actually decreases blood flow to the feet due to the effects of gravity. In this position, blood is more likely to pool in the upper body and head.

D. Lowered blood pressure. The Trendelenburg position does not necessarily lower blood pressure. While it might decrease blood pressure in the lower extremities due to decreased blood flow, it can increase pressure in the upper body, including the head and chest.

28. Correct answer:

C. Head injury. Before positioning a patient who is going into shock in the modified Trendelenburg position (lying flat on their back with their legs elevated), it is crucial to assess for a head injury. This position increases blood flow to the brain, which could potentially increase intracranial pressure and worsen a head injury.

Incorrect answer options:

A. Thrombophlebitis. While it’s important to be aware of potential thrombophlebitis (inflammation of a vein associated with a blood clot), it’s not the primary concern when deciding to use the modified Trendelenburg position.

B. Air embolism. An air embolism is a serious condition that needs immediate treatment, but the risk of air embolism is not directly influenced by the modified Trendelenburg position.

D. Long bone fracture. While a long bone fracture could potentially be worsened by moving the patient, it’s not the primary concern when deciding to use the modified Trendelenburg position, as this position could be beneficial by increasing blood return to the heart.

29. Correct answer:

C. Activate the fire alarm or notify the operator, based on the institution’s protocol. This step aligns with the “R” in the RACE protocol (Rescue, Alarm, Confine, Extinguish) for responding to fires in healthcare settings. Immediately alerting others to the presence of a fire is crucial for the safety of all patients, staff, and visitors in the building.

Incorrect answer options:

A. Retrieve a fire extinguisher and extinguish the fire. While extinguishing the fire is part of the RACE protocol, it’s not the first action to take. The first action should be to raise the alarm to ensure everyone in the building is aware of the danger and can begin evacuation procedures if necessary.

B. Attempt to remove any burning items from the room. This action can be risky and should not be attempted before alerting others to the fire. It’s important to prioritize human safety over property.

D. Close all windows and doors, and turn off any oxygen or electrical appliances. This is part of the “C” in the RACE protocol (Confine the fire). However, this action should be taken after raising the alarm and ensuring any patients in immediate danger have been moved to a safe location.

30. Correct answer:

A. Away from the nurse. When opening a sterile package, the first flap should be opened away from the nurse. This is to prevent the nurse’s clothing or body from coming into contact with the inside of the package, which could contaminate the sterile contents.

Incorrect answer options:

B. Open the package with both hands simultaneously. Opening the package with both hands simultaneously could potentially cause the nurse’s hands or arms to come into contact with the inside of the package, contaminating the sterile contents.

C. Toward the nurse. Opening the first flap toward the nurse could increase the risk of contamination from the nurse’s body or clothing.

D. Direction does not matter as long as the nurse touches only the outside edge. While it is true that the nurse should only touch the outside edge of the package to maintain sterility, the direction in which the package is opened does matter. Opening the first flap away from the nurse is a standard practice to minimize the risk of contamination.

31. Correct answer:

C. Wearing a gown while caring for a 1-year-old child with infectious diarrhea. This is an example of contact precautions, a strategy used to prevent the transmission of infectious agents, including those spread by direct or indirect contact with the patient or the patient’s environment. When dealing with infectious diarrhea, healthcare providers should wear personal protective equipment like gowns and gloves to prevent the spread of the pathogen.

Incorrect answer options:

A. Changing hospital linens weekly. Hospital linens should be changed more frequently than weekly, especially if they become soiled. Soiled linens can harbor infectious agents and contribute to the spread of infection.

B. Wearing gloves for all client contact. While gloves should be worn for any contact where there might be exposure to bodily fluids, they are not required for all client contact. Overuse of gloves can lead to skin irritation and can give a false sense of security, potentially leading to lax hand hygiene practices.

D. Using alcohol-based hand sanitizers instead of handwashing. While using alcohol-based hand sanitizers is an important part of hand hygiene and medical asepsis, handwashing with soap and water is necessary when hands are visibly soiled, or after caring for patients with certain infections like Clostridium difficile.

32. Correct answer:

A. Prevents flexion contractures. Positioning a patient who has had an above-the-knee amputation in a prone position several times a day can help prevent hip flexion contractures. Contractures occur when there is a shortening and hardening of muscles, tendons, or other tissue, often leading to rigidity and deformity. In this case, regular prone positioning can help maintain the range of motion and prepare the limb for a potential prosthesis.

Incorrect answer options:

B. Facilitates better blood flow to the heart. While certain positions can help with blood flow, the prone position is not specifically used for this purpose in the context of a leg amputation.

C. Ensures proper fit of the prosthesis. While preventing contractures can eventually help with the fit of a prosthesis, the positioning itself does not ensure the proper fit of the prosthesis.

D. Promotes wound dehiscence. Wound dehiscence, the separation of the edges of a surgical wound, is a complication and not a desired outcome. The prone position does not promote wound dehiscence.

33. Correct answer:

B. Use the restroom and void, saving a sample. Before a pelvic examination, the patient should be instructed to empty her bladder. This can make the examination more comfortable for the patient, and it also may be necessary for the healthcare provider to obtain a clean-catch urine sample as part of the examination.

Incorrect answer options:

A. Gather all necessary equipment for the examination. It is typically the nurse or healthcare provider’s responsibility to gather the necessary equipment for the examination, not the patient’s.

C. Remove all clothing, including socks and shoes. While the patient will need to undress from the waist down for a pelvic examination, they do not typically need to remove all clothing, including socks and shoes, unless instructed to do so by the healthcare provider.

D. Drink a large glass of water before the exam. Drinking a large glass of water before the exam could make the patient need to urinate during the exam, which could be uncomfortable. It is more common to be asked to drink water before a pelvic ultrasound, not a pelvic examination, as a full bladder can help with the visibility of the pelvic organs during an ultrasound.

34. Correct answer:

C. Utilize a trochanter roll alongside the patient’s upper thighs. A trochanter roll, which is a rolled-up towel or special device placed along the lateral side of the patient’s upper thighs, can help prevent external rotation of the legs when the patient is in a supine position. By providing support and maintaining the legs in alignment, it can help prevent musculoskeletal complications such as contractures.

Incorrect answer options:

A. Position a pillow directly under the patient’s knees. While this position can help relieve lower back discomfort, it doesn’t prevent external rotation of the legs.

B. Lower the patient’s legs so that they are below the hips. Lowering the patient’s legs below the hips doesn’t prevent external rotation. It’s more related to preventing deep vein thrombosis by promoting venous return.

D. Instruct the patient to maintain their legs in an adducted position. While this instruction could theoretically help prevent external rotation, it’s not practical for long periods and could lead to discomfort and other complications.

35. Correct answer:

D. Below the cheekbones. The maxillary sinuses are located in the cheek area just below the eyes. To palpate these sinuses, the nurse should gently press below the cheekbones. If the patient experiences pain or discomfort during this process, it may indicate inflammation or infection of the maxillary sinuses, as seen in conditions such as sinusitis.

Incorrect answer options:

A. Over the temporal area. The temporal area is located on the sides of the head near the temples, not near the maxillary sinuses.

B. On the forehead. This area corresponds to the frontal sinuses, not the maxillary sinuses.

C. On the bridge of the nose. The bridge of the nose is not the location of the maxillary sinuses. The ethmoid and sphenoid sinuses are closer to this area.

36. Correct answer:

B. Risk for aspiration related to anesthesia. Immediately after surgery under general anesthesia, the highest priority nursing diagnosis is “Risk for aspiration related to anesthesia.” General anesthesia can suppress the gag reflex and impair swallowing, which can potentially lead to aspiration. Aspiration, especially of gastric contents, can cause serious complications such as pneumonia, acute respiratory distress syndrome (ARDS), or even cardiac arrest.

Incorrect answer options:

A. Fluid volume deficit related to fluid and blood loss from surgery. Although this is an important nursing diagnosis postoperatively, it is not the highest priority immediately after general anesthesia. The patient’s fluid volume status can be managed and monitored by the healthcare team through intravenous fluids and blood products if necessary.

C. Altered body image related to surgical incisions. Although this may be a concern for the patient, it is not a high priority immediately following surgery under general anesthesia. This issue can be addressed once the patient is stable and alert.

D. Pain related to the surgery. While pain is certainly a concern postoperatively, immediate post-anesthesia care prioritizes airway management and the prevention of complications such as aspiration. Once the patient is stable and awake, pain can be assessed and managed effectively.

37. Correct answer:

B. Apply a cold compress to minimize swelling. Applying a cold compress to the injection site can help to reduce inflammation and provide relief from the burning sensation and discomfort. The cold temperature can constrict the blood vessels, which may help to minimize any swelling or inflammation at the site.

Incorrect answer options:

A. Place a warm compress on the site to promote vasodilation. While warm compresses can be beneficial for certain conditions, they may not be the best choice immediately after an injection if there’s discomfort or inflammation. Warm compresses promote vasodilation, which can increase blood flow and potentially exacerbate inflammation.

C. Advise the client to contract their gluteal muscles to enhance drug absorption. Contracting the muscles may not necessarily enhance drug absorption and could potentially cause more discomfort or pain.

D. Elevate the affected extremity. While this might be useful for conditions like sprains or injuries to reduce swelling, it may not be specifically beneficial for discomfort at an injection site.

38. Correct answer:

D. Intensive Care (Category 4): The patient classification system where patients need close attention and complete care in most activities and requires frequent and complex treatments and medications is called Intensive Care (Category 4).

Incorrect answer options:

A. Minimal Care (Category 1) is a patient classification system where patients require minimal assistance with activities of daily living and have stable vital signs.

B. Moderate Care (Category 2) is a patient classification system where patients require moderate assistance with activities of daily living and may have unstable vital signs.

C. Maximum Care (Category 3) is a patient classification system where patients require complete assistance with activities of daily living and may have unstable vital signs.

39. Correct answer:

A. Incapacity to cough. When an individual’s airway is completely obstructed, they are unable to make any sounds, including coughing, because no air can pass through the airway. This is a medical emergency and immediate intervention is required to clear the airway and restore breathing.

Incorrect answer options:

B. Strident crowing sounds during speech attempts. These sounds, also known as stridor, typically indicate a partial obstruction of the airway, often in the larynx or trachea, not a complete obstruction.

C. Prolonged, deep breaths. This type of breathing pattern is not typically associated with airway obstruction. It could be seen in various conditions, such as metabolic acidosis, but not specifically indicative of an obstructed airway.

D. Audible wheezing upon auscultation. Wheezing, a high-pitched sound produced primarily during expiration, is often associated with narrowed airways, as seen in conditions like asthma or chronic obstructive pulmonary disease (COPD), not a complete airway obstruction.

40. Correct answer:

A. Loose rugs. Loose rugs are a significant hazard when using crutches as they can easily cause a person to slip or trip, leading to falls and potential injury. It’s important to ensure that all pathways are clear and surfaces are secure to provide a safe environment for crutch usage.

Incorrect answer options:

B. A 4-year-old cocker spaniel. While pets can potentially be a risk due to their unpredictable movements, they don’t typically present as significant a risk as environmental hazards like loose rugs. However, it’s important to ensure pets are managed appropriately to minimize the risk of falls.

C. High noise levels. While high noise levels can be distracting, they are not typically a direct risk for safe crutch usage. However, it’s always important to maintain concentration and awareness when moving with crutches.

D. Small snack tables. These could present a risk if they are in the path of travel, but generally, they do not pose as significant a risk as loose rugs, which can cause immediate tripping or slipping.

41. Correct answer:

A. Despair, related to lack of control over disease progression. This nursing diagnosis is of high priority as it addresses the patient’s emotional state which can significantly impact their overall health and well-being, as well as their ability to effectively participate in treatment plans. However, in the presence of immediate life-threatening conditions, those would take priority.

Incorrect answer options:

B. Ineffective coping, related to loss of personal boundaries. While this is an important aspect to consider in a patient’s overall health, it may not be the most urgent unless it is leading to harmful behaviors or significantly impacting the patient’s mental health.

C. Impaired cognitive function, related to lesion presence. This would be prioritized if the cognitive impairment was severe enough to pose immediate safety risks or significantly interfere with the patient’s ability to participate in their care.

D. Compromised self-care, related to noncompliance. Noncompliance can be a significant issue in managing a patient’s health, but understanding the underlying cause of the noncompliance is crucial. It may be related to other factors such as despair, ineffective coping, or impaired cognitive function.

42. Correct answer:

B. β€œI will use tanning booths instead of sunbathing from now on.” Tanning booths expose the skin to ultraviolet (UV) radiation, which can increase the risk of skin cancer, including basal cell carcinoma. Using a tanning booth is not a safer alternative to sunbathing, and it is not recommended, especially for those who have had skin cancer.

Incorrect answer options:

A. β€œI will wear a wide-brimmed hat when I am in the sun.” Wearing a wide-brimmed hat can protect the face and neck from the sun and is a recommended sun-protection measure.

C. β€œI will use sunscreen with a sun protection factor (SPF) of at least 15.” Using sunscreen with an SPF of at least 15 can help protect the skin from UV radiation. However, it’s important to remember that no sunscreen can block all UV rays, and other sun-protection measures should be used as well.

D. β€œI will avoid sun exposure between 10:00 AM and 2:00 PM.” The sun’s rays are strongest between 10:00 AM and 2:00 PM, so avoiding sun exposure during these hours can help reduce the risk of skin cancer.

43. Correct answer:

B. β€œLet’s discuss the available options.” This response supports the patient’s autonomy and gives them the space to talk about their feelings and concerns. It also encourages shared decision-making, where the patient is an active participant in their own care.

Incorrect answer options:

A. β€œI recommend getting a second opinion before undergoing surgery.” This response might be helpful in some situations, but it is not the nurse’s role to suggest a second opinion without a discussion about the patient’s feelings and understanding about the recommended treatment.

C. β€œYou should adhere to the doctor’s recommendation.” While it’s important to respect the physician’s expertise, this response does not encourage patient autonomy or shared decision-making.

D. β€œWhat does your family want you to do?” While family input can be important, the primary focus should be on what the patient wants and feels comfortable with. This response might inadvertently pressure the patient to follow their family’s wishes instead of their own.

44. Correct answer:

B. Undescended testicle. Cryptorchidism, or undescended testicle, is a well-established risk factor for testicular cancer. In this condition, one or both of the testes fail to descend into the scrotum before birth. Even if the condition is corrected with surgery, the increased risk remains.

Incorrect answer options:

A. Hydrocele. A hydrocele, which is a fluid-filled sac around a testicle, is common and usually isn’t painful or harmful. While it may be associated with an underlying testicular condition, it is not a known risk factor for testicular cancer.

C. Acne. Acne is a common condition that affects the skin’s oil glands but has no known connection with testicular cancer.

D. Genital herpes. Genital herpes is a sexually transmitted infection caused by the herpes simplex virus. There is no evidence that it increases the risk of testicular cancer.

45. Correct answer:

A. Administer prescribed cleansing enemas and laxatives. Before a cystectomy and ileal conduit procedure, the bowel needs to be emptied to reduce the risk of infection and complications. This is typically achieved through the administration of prescribed cleansing enemas and laxatives. It’s like cleaning out a room before starting a renovation – you want to clear out any unnecessary items (in this case, fecal matter) to make the process smoother and reduce the risk of complications.

Incorrect answer options:

B. Instruct on the process of stoma irrigation. Stoma irrigation is a technique used to regulate bowel movements in individuals with a colostomy, not an ileal conduit. An ileal conduit is a urinary diversion, not a bowel diversion, so stoma irrigation would not be applicable in this case.

C. Restrict fluid intake for 24 hours. Fluid restriction is not typically required before a cystectomy and ileal conduit procedure. In fact, adequate hydration is important before any surgery to help prevent complications such as dehydration and thrombosis.

D. Give antibiotics to avert infection. While antibiotics may be given before surgery to prevent infection, this is not the primary nursing intervention in the preoperative care of a patient undergoing a cystectomy and ileal conduit procedure. The main focus is on bowel preparation, which includes administering prescribed cleansing enemas and laxatives.

46. Correct answer:

D. Exsanguination. An external shunt creates a direct connection between an artery and a vein, which allows for the rapid flow of blood. If the shunt becomes dislodged or ruptures, the patient can rapidly lose a large volume of blood, leading to exsanguination, a life-threatening condition.

Incorrect answer options:

A. Nerve injury. While nerve injury can occur during the placement of an external shunt, it is not the most severe issue. Any nerve injury would likely be local and would not carry the same immediate, life-threatening risk as exsanguination.

B. Vessel sclerosis. Vessel sclerosis, or hardening of the vessels, can occur over time due to the repeated puncture of the vessels for hemodialysis. However, this is a slower process and less immediately life-threatening than exsanguination.

C. Bloodstream infection. Bloodstream infections are a risk with any vascular access device, including external shunts. However, while serious, they are typically not as immediately life-threatening as exsanguination.

47. Correct answer:

B. Advise the patient to avoid straining during defecation. Following a prostatectomy, it’s crucial to avoid any unnecessary strain on the surgical site, which could disrupt the healing process or cause complications. Straining during defecation can increase abdominal and pelvic pressure, potentially leading to bleeding or damage to the surgical area. Therefore, this intervention should take precedence.

Incorrect answer options:

A. Encourage the patient to urinate in a standing position. Typically, after a prostatectomy, a urinary catheter is left in place to ensure proper bladder drainage while the patient heals. The patient will not be able to voluntarily urinate until the catheter is removed.

C. Utilize a bulb syringe to draw urine from the retention catheter. This is not a common or recommended practice. A urinary catheter, if used correctly, should drain urine by gravity into a collection bag. The bag should be kept below the level of the bladder to ensure effective drainage.

D. Inform the primary healthcare provider if the patient fails to urinate before sleep. As mentioned, a urinary catheter is usually in place following a prostatectomy, so the patient will not need to urinate independently. Any problems with urinary output will be evident by observing the amount of urine in the collection bag.

48. Correct answer:

B. Fracture of the femur shaft. Intramedullary nailing is commonly used for treating fractures of the femur shaft. This procedure involves inserting a metal rod into the marrow canal of the femur. The rod passes across the fracture to help keep it in place, allowing for healing.

Incorrect answer options:

A. Slipped epiphysis of the femur. Slipped capital femoral epiphysis (SCFE) is a condition usually affecting adolescents and involves the slipping of the head of the femur off the neck of the femur. Intramedullary nailing is not the standard treatment for this condition. Instead, it is typically managed with internal fixation using screws to secure the head of the femur and prevent further slippage.

C. Fracture of the femur neck. A femoral neck fracture is a serious injury that often requires surgical intervention. However, intramedullary nailing is not usually the preferred method of treatment, as it may not provide sufficient stability. Instead, treatments may include internal fixation with screws or a hip arthroplasty.

D. Osteoporosis of the femur. Osteoporosis is a condition characterized by reduced bone density and increased risk of fracture. Treatment for osteoporosis of the femur typically focuses on increasing bone density and reducing the risk of fracture through medication, diet, and exercise, rather than surgical intervention such as intramedullary nailing.

49. Correct answer:

A. Slight abduction. Following a femoral neck fracture, the hip is typically positioned in slight abduction to reduce the risk of hip dislocation, particularly after a hip arthroplasty (hip replacement) surgery. This position also helps to maintain the natural alignment and function of the hip joint.

Incorrect answer options:

B. Moderate flexion. Placing the hip in moderate flexion following a femoral neck fracture or surgery can increase the risk of hip dislocation and hinder the healing process. It’s important to follow the specific instructions from the healthcare provider, which usually include limiting hip flexion to 90 degrees or less.

C. Extension. While extension is not necessarily harmful, it is not the recommended position following a femoral neck fracture. The hip should typically be kept in a neutral position with slight abduction.

D. Slight adduction. Slight adduction is not recommended following a femoral neck fracture as it can increase the risk of hip dislocation. The hip should be kept in slight abduction to maintain proper alignment and joint function.

50. Correct answer:

C. Inhibiting the function of cholinesterase. Neostigmine is an anticholinesterase medication, meaning it inhibits the action of the enzyme cholinesterase. This enzyme is responsible for breaking down acetylcholine, a neurotransmitter that transmits signals in the nervous system. By inhibiting cholinesterase, neostigmine increases the amount of acetylcholine available at the neuromuscular junction, enhancing muscle strength in patients with myasthenia gravis.

Incorrect answer options:

A. Speeding up transmission along neural pathways. Neostigmine does not speed up transmission along neural pathways. Instead, it increases the availability of acetylcholine, which can facilitate neural transmission at the neuromuscular junction.

B. Suppressing the sympathetic nervous system. Neostigmine does not suppress the sympathetic nervous system. Its primary effect is on the enzyme cholinesterase and the neurotransmitter acetylcholine, neither of which are specific to the sympathetic nervous system.

D. Exciting the cerebral cortex. Neostigmine does not directly excite the cerebral cortex. Its action is primarily at the neuromuscular junction, where it increases the availability of acetylcholine by inhibiting the enzyme cholinesterase.