Text Mode – Text version of the exam
1. A female client is admitted with a diagnosis of acute renal failure. She is awake, alert, oriented, and complaining of severe back pain, nausea and vomiting and abdominal cramps. Her vital signs are blood pressure 100/70 mm Hg, pulse 110, respirations 30, and oral temperature 100.4°F (38°C). Her electrolytes are sodium 120 mEq/L, potassium 5.2 mEq/L; her urinary output for the first 8 hours is 50 ml. The client is displaying signs of which electrolyte imbalance?
2. Assessing the laboratory findings, which result would the nurse most likely expect to find in a client with chronic renal failure?
- BUN 10 to 30 mg/dl, potassium 4.0 mEq/L, creatinine 0.5 to 1.5 mg/dl
- Decreased serum calcium, blood pH 7.2, potassium 6.5 mEq/L
- BUN 15 mg/dl, increased serum calcium, creatinine l.0 mg/dl
- BUN 35 to 40 mg/dl, potassium 3.5 mEq/L, pH 7.35, decreased serum calcium
3. Treatment with hemodialysis is ordered for a client and an external shunt is created. Which nursing action would be of highest priority with regard to the external shunt?
- Heparinize it daily.
- Avoid taking blood pressure measurements or blood samples from the affected arm.
- Change the Silastic tube daily.
- Instruct the client not to use the affected arm.
4. Romeo Diaz, age 78, is admitted to the hospital with the diagnosis of benign prostatic hyperplasia (BPH). He is scheduled for a transurethral resection of the prostate (TURP). It would be inappropriate to include which of the following points in the preoperative teaching?
- TURP is the most common operation for BPH.
- Explain the purpose and function of a two-way irrigation system.
- Expect bloody urine, which will clear as healing takes place.
- He will be pain free.
5. Roxy is admitted to the hospital with a possible diagnosis of appendicitis. On physical examination, the nurse should be looking for tenderness on palpation at McBurney’s point, which is located in the
- left lower quadrant
- left upper quadrant
- right lower quadrant
- right upper quadrant
6. Mr. Valdez has undergone surgical repair of his inguinal hernia. Discharge teaching should include
- telling him to avoid heavy lifting for 4 to 6 weeks
- instructing him to have a soft bland diet for two weeks
- telling him to resume his previous daily activities without limitations
- recommending him to drink eight glasses of water daily
7. A 30-year-old homemaker fell asleep while smoking a cigarette. She sustained severe burns of the face,neck, anterior chest, and both arms and hands. Using the rule of nines, which is the best estimate of total body-surface area burned?
8. Nursing care planning is based on the knowledge that the first 24-48 hours post-burn are characterized by:
- An increase in the total volume of intracranial plasma
- Excessive renal perfusion with diuresis
- Fluid shift from interstitial space
- Fluid shift from intravascular space to the interstitial space
9. If a client has severe bums on the upper torso, which item would be a primary concern?
- Debriding and covering the wounds
- Administering antibiotics
- Frequently observing for hoarseness, stridor, and dyspnea
- Establishing a patent IV line for fluid replacement
10. Contractures are among the most serious long-term complications of severe burns. If a burn is located on the upper torso, which nursing measure would be least effective to help prevent contractures?
- Changing the location of the bed or the TV set, or both, daily
- Encouraging the client to chew gum and blow up balloons
- Avoiding the use of a pillow for sleep, or placing the head in a position of hyperextension
- Helping the client to rest in the position of maximal comfort
11. An adult is receiving Total Parenteral Nutrition (TPN). Which of the following assessment is essential?
- evaluation of the peripheral IV site
- confirmation that the tube is in the stomach
- assess the bowel sound
- fluid and electrolyte monitoring
12. Which drug would be least effective in lowering a client’s serum potassium level?
- Glucose and insulin
- Polystyrene sulfonate (Kayexalate)
- Calcium glucomite
- Aluminum hydroxide
13. A nurse is directed to administer a hypotonic intravenous solution. Looking at the following labeled solutions, she should choose
- 0.45% NaCl
- 0.9% NaCl
14. A patient is hemorrhaging from multiple trauma sites. The nurse expects that compensatory mechanisms associated with hypovolemia would cause all of the following symptoms EXCEPT
15. Maria Sison, 40 years old, single, was admitted to the hospital with a diagnosis of Breast Cancer. She was scheduled for radical mastectomy. Nursing care during the preoperative period should consist of
- assuring Maria that she will be cured of cancer
- assessing Maria’s expectations and doubts
- maintaining a cheerful and optimistic environment
- keeping Maria’s visitors to a minimum so she can have time for herself
16. Maria refuses to acknowledge that her breast was removed. She believes that her breast is intact under the dressing. The nurse should
- call the MD to change the dressing so Kathy can see the incision
- recognize that Kathy is experiencing denial, a normal stage of the grieving process
- reinforce Kathy’s belief for several days until her body can adjust to stress of surgery.
- remind Kathy that she needs to accept her diagnosis so that she can begin rehabilitation exercises.
17. A chemotherapeutic agent 5FU is ordered as an adjunct measure to surgery. Which of the ff. statements about chemotherapy is true?
- it is a local treatment affecting only tumor cells
- it affects both normal and tumor cells
- it has been proven as a complete cure for cancer
- it is often used as a palliative measure.
18. Which is an incorrect statement pertaining to the following procedures for cancer diagnostics?
- Biopsy is the removal of suspicious tissue and the only definitive method to diagnose cancer
- Ultrasonography detects tissue density changes difficult to observe by X-ray via sound waves.
- CT scanning uses magnetic fields and radio frequencies to provide cross-sectional view of tumor
- Endoscopy provides direct view of a body cavity to detect abnormality.
19. A post-operative complication of mastectomy is lymphedema. This can be prevented by
- ensuring patency of wound drainage tube
- placing the arm on the affected side in a dependent position
- restricting movement of the affected arm
- frequently elevating the arm of the affected side above the level of the heart.
20. Which statement by the client indicates to the nurse that the patient understands precautions necessary during internal radiation therapy for cancer of the cervix?
- “I should get out of bed and walk around in my room.”
- “My 7 year old twins should not come to visit me while I’m receiving treatment.”
- “I will try not to cough, because the force might make me expel the application.”
- “I know that my primary nurse has to wear one of those badges like the people in the x-ray department, but they are not necessary for anyone else who comes in here.”
21. High uric acid levels may develop in clients who are receiving chemotherapy. This is caused by:
- The inability of the kidneys to excrete the drug metabolites
- Rapid cell catabolism
- Toxic effect of the antibiotic that are given concurrently
- The altered blood ph from the acid medium of the drugs
22. Which of the following interventions would be included in the care of plan in a client with cervical implant?
- Frequent ambulation
- Unlimited visitors
- Low residue diet
- Vaginal irrigation every shift
23. Which nursing measure would avoid constriction on the affected arm immediately after mastectomy?
- Avoid BP measurement and constricting clothing on the affected arm
- Active range of motion exercises of the arms once a day.
- Discourage feeding, washing or combing with the affected arm
- Place the affected arm in a dependent position, below the level of the heart
24. A client suffering from acute renal failure has an unexpected increase in urinary output to 150ml/hr. The nurse assesses that the client has entered the second phase of acute renal failure. Nursing actions throughout this phase include observation for signs and symptoms of
- Hypervolemia, hypokalemia, and hypernatremia.
- Hypervolemia, hyperkalemia, and hypernatremia.
- Hypovolemia, wide fluctuations in serum sodium and potassium levels.
- Hypovolemia, no fluctuation in serum sodium and potassium levels.
25. An adult has just been brought in by ambulance after a motor vehicle accident. When assessing the client, the nurse would expect which of the following manifestations could have resulted from sympathetic nervous system stimulation?
- A rapid pulse and increased RR
- Decreased physiologic functioning
- Rigid posture and altered perceptual focus
- Increased awareness and attention
26. Ms. Sy undergoes surgery and the abdominal aortic aneurysm is resected and replaced with a graft. When she arrives in the RR she is still in shock. The nurse’s priority should be :
- placing her in a trendeleburg position
- putting several warm blankets on her
- monitoring her hourly urine output
- assessing her VS especially her RR
27. A major goal for the client during the first 48 hours after a severe bum is to prevent hypovolemic shock. The best indicator of adequate fluid balance during this period is
- Elevated hematocrit levels.
- Urine output of 30 to 50 ml/hr.
- Change in level of consciousness.
- Estimate of fluid loss through the burn eschar.
28. A thoracentesis is performed on a chest-injured client, and no fluid or air is found. Blood and fluids is administered intravenously (IV), but the client’s vital signs do not improve. A central venous pressure line is inserted, and the initial reading is 20 cm H^O. The most likely cause of these findings is which of the following?
- Spontaneous pneumothorax
- Ruptured diaphragm
- Pericardial tamponade
29. Intervention for a pt. who has swallowed a Muriatic Acid includes all of the following except;
- administering an irritant that will stimulate vomiting
- aspirating secretions from the pharynx if respirations are affected
- neutralizing the chemical
- washing the esophagus with large volumes of water via gastric lavage
30. Which initial nursing assessment finding would best indicate that a client has been successfully resuscitated after a cardio-respiratory arrest?
- Skin warm and dry
- Pupils equal and react to light
- Palpable carotid pulse
- Positive Babinski’s reflex
31. Chemical burn of the eye are treated with
- local anesthetics and antibacterial drops for 24 – 36 hrs.
- hot compresses applied at 15-minute intervals
- Flushing of the lids, conjunctiva and cornea with tap or preferably sterile water
- cleansing the conjunctiva with a small cotton-tipped applicator
32. The Heimlich maneuver (abdominal thrust), for acute airway obstruction, attempts to:
- Force air out of the lungs
- Increase systemic circulation
- Induce emptying of the stomach
- Put pressure on the apex of the heart
33. John, 16 years old, is brought to the ER after a vehicular accident. He is pronounced dead on arrival. When his parents arrive at the hospital, the nurse should:
- ask them to stay in the waiting area until she can spend time alone with them
- speak to both parents together and encourage them to support each other and express their emotions freely
- Speak to one parent at a time so that each can ventilate feelings of loss without upsetting the other
- ask the MD to medicate the parents so they can stay calm to deal with their son’s death.
34. An emergency treatment for an acute asthmatic attack is Adrenaline 1:1000 given hypodermically. This is given to:
- increase BP
- decrease mucosal swelling
- relax the bronchial smooth muscle
- decrease bronchial secretions
35. A nurse is performing CPR on an adult patient. When performing chest compressions, the nurse understands the correct hand placement is located over the
- upper half of the sternum
- upper third of the sternum
- lower half of the sternum
- lower third of the sternum
36. The nurse is performing an eye examination on an elderly client. The client states ‘My vision is blurred, and I don’t easily see clearly when I get into a dark room.” The nurse best response is:
- “You should be grateful you are not blind.”
- “As one ages, visual changes are noted as part of degenerative changes. This is normal.”
- “You should rest your eyes frequently.”
- “You maybe able to improve you vision if you move slowly.”
37. Which of the following activities is not encouraged in a patient after an eye surgery?
- sneezing, coughing and blowing the nose
- straining to have a bowel movement
- wearing tight shirt collars
- sexual intercourse
38. Which of the following indicates poor practice in communicating with a hearing-impaired client?
- Use appropriate hand motions
- Keep hands and other objects away from your mouth when talking to the client
- Speak clearly in a loud voice or shout to be heard
- Converse in a quiet room with minimal distractions
39. A client is to undergo lumbar puncture. Which is least important information about LP?
- Specimens obtained should be labeled in their proper sequence.
- It may be used to inject air, dye or drugs into the spinal canal.
- Assess movements and sensation in the lower extremities after the
- Force fluids before and after the procedure.
40. A client diagnosed with cerebral thrombosis is scheduled for cerebral angiography. Nursing care of the client includes the following EXCEPT
- Inform the client that a warm, flushed feeling and a salty taste may be
- Maintain pressure dressing over the site of puncture and check for
- Check pulse, color and temperature of the extremity distal to the site of
- Kept the extremity used as puncture site flexed to prevent bleeding.
41. Which is considered as the earliest sign of increased ICP that the nurse should closely observed for?
- abnormal respiratory pattern
- rising systolic and widening pulse pressure
- contralateral hemiparesis and ipsilateral dilation of the pupils
- progression from restlessness to confusion and disorientation to lethargy
42. Which is irrelevant in the pharmacologic management of a client with CVA?
- Osmotic diuretics and corticosteroids are given to decrease cerebral edema
- Anticonvulsants are given to prevent seizures
- Thrombolytics are most useful within three hours of an occlusive CVA
- Aspirin is used in the acute management of a completed stroke.
43. What would be the MOST therapeutic nursing action when a client’s expressive aphasia is severe?
- Anticipate the client wishes so she will not need to talk
- Communicate by means of questions that can be answered by the client shaking the head
- Keep us a steady flow rank to minimize silence
- Encourage the client to speak at every possible opportunity.
44. A client with head injury is confused, drowsy and has unequal pupils. Which of the following nursing diagnosis is most important at this time?
- altered level of cognitive function
- high risk for injury
- altered cerebral tissue perfusion
- sensory perceptual alteration
45. Which nursing diagnosis is of the highest priority when caring for a client with myasthenia gravis?
- High risk for injury related to muscle weakness
- Ineffective coping related to illness
- Ineffective airway clearance related to muscle weakness
46. The client has clear drainage from the nose and ears after a head injury. How can the nurse determine if the drainage is CSF?
- Measure the ph of the fluid
- Measure the specific gravity of the fluid
- Test for glucose
- Test for chlorides
47. The nurse includes the important measures for stump care in the teaching plan for a client with an amputation. Which measure would be excluded from the teaching plan?
- Wash, dry, and inspect the stump daily.
- Treat superficial abrasions and blisters promptly.
- Apply a “shrinker” bandage with tighter arms around the proximal end of the affected limb.
- Toughen the stump by pushing it against a progressively harder substance (e.g., pillow on a foot-stool).
48. A 70-year-old female comes to the clinic for a routine checkup. She is 5 feet 4 inches tall and weighs 180 pounds. Her major complaint is pain in her joints. She is retired and has had to give up her volunteer work because of her discomfort. She was told her diagnosis was osteoarthritis about 5 years ago. Which would be excluded from the clinical pathway for this client?
- Decrease the calorie count of her daily diet.
- Take warm baths when arising.
- Slide items across the floor rather than lift them.
- Place items so that it is necessary to bend or stretch to reach them.
49. A client is admitted from the emergency department with severe-pain and edema in the right foot. His diagnosis is gouty arthritis. When developing a plan of care, which action would have the highest priority?
- Apply hot compresses to the affected joints.
- Stress the importance of maintaining good posture to prevent deformities.
- Administer salicylates to minimize the inflammatory reaction.
- Ensure an intake of at least 3000 ml of fluid per day.
50. A client had a laminectomy and spinal fusion yesterday. Which statement is to be excluded from your plan of care?
- Before log rolling, place a pillow under the client’s head and a pillow between the client’s legs.
- Before log rolling, remove the pillow from under the client’s head and use no pillows between the client’s legs.
- Keep the knees slightly flexed while the client is lying in a semi-Fowler’s position in bed.
- Keep a pillow under the client’s head as needed for comfort.
Answers and Rationales
- Answer: (A) Hyponatremia . The normal serum sodium level is 135 – 145 mEq/L. The client’s serum sodium is below normal. Hyponatremia also manifests itself with abdominal cramps and nausea and vomiting
- Answer: (B) Decreased serum calcium, blood pH 7.2, potassium 6.5 mEq/L. Chronic renal failure is usually the end result of gradual tissue destruction and loss of renal function. With the loss of renal function, the kidneys ability to regulate fluid and electrolyte and acid base balance results. The serum Ca decreases as the kidneys fail to excrete phosphate, potassium and hydrogen ions are retained.
- Answer: (B) Avoid taking blood pressure measurements or blood samples from the affected arm. In the client with an external shunt, don’t use the arm with the vascular access site to take blood pressure readings, draw blood, insert IV lines, or give injections because these procedures may rupture the shunt or occlude blood flow causing damage and obstructions in the shunt.
- Answer: (D) He will be pain free. Surgical interventions involve an experience of pain for the client which can come in varying degrees. Telling the pain that he will be pain free is giving him false reassurance.
- Answer: (C) right lower quadrant . To be exact, the appendix is anatomically located at the Mc Burney’s point at the right iliac area of the right lower quadrant.
- Answer: (A) telling him to avoid heavy lifting for 4 to 6 weeks . The client should avoid lifting heavy objects and any strenuous activity for 4-6 weeks after surgery to prevent stress on the inguinal area. There is no special diet required. The fluid intake of eight glasses a day is good advice but is not a priority in this case.
- Answer: (C) 31% . Using the Rule of Nine in the estimation of total body surface burned, we allot the following: 9% – head; 9% – each upper extremity; 18%- front chest and abdomen; 18% – entire back; 18% – each lower extremity and 1% – perineum.
- Answer: (D) Fluid shift from intravascular space to the interstitial space . This period is the burn shock stage or the hypovolemic phase. Tissue injury causes vasodilation that results in increase capillary permeability making fluids shift from the intravascular to the interstitial space. This can lead to a decrease in circulating blood volume or hypovolemia which decreases renal perfusion and urine output.
- Answer: (C) Frequently observing for hoarseness, stridor, and dyspnea . Burns located in the upper torso, especially resulting from thermal injury related to fires can lead to inhalation burns. This causes swelling of the respiratory mucosa and blistering which can lead to airway obstruction manifested by hoarseness, noisy and difficult breathing. Maintaining a patent airway is a primary concern.
- Answer: (D) Helping the client to rest in the position of maximal comfort . Mobility and placing the burned areas in their functional position can help prevent contracture deformities related to burns. Pain can immobilize a client as he seeks the position where he finds less pain and provides maximal comfort. But this approach can lead to contracture deformities and other complications.
- Answer: (D) fluid and electrolyte monitoring . Total parenteral nutrition is a method of providing nutrients to the body by an IV route. The admixture is made up of proteins, carbohydrates, fats, electrolytes, vitamins, trace minerals and sterile water based on individual client needs. It is intended to improve the clients nutritional status. Because of its composition, it is important to monitor the clients fluid intake and output including electrolytes, blood glucose and weight.
- Answer: (D) Aluminum hydroxide . Aluminum hydroxide binds dietary phosphorus in the GI tract and helps treat hyperphosphatemia. All the other medications mentioned help treat hyperkalemia and its effects.
- Answer: (A) 0.45% NaCl . Hypotonic solutions like 0.45% NaCl has a lower tonicity that the blood; 0.9% NaCl and D5W are isotonic solutions with same tonicity as the blood; and D5NSS is hypertonic with a higher tonicity thab the blood.
- Answer: (A) hypertension . In hypovolemia, one of the compenasatory mechanisms is activation of the sympathetic nervous system that increases the RR & PR and helps restore the BP to maintain tissue perfusion but not cause a hypertension. The SNS stimulation constricts renal arterioles that increases release of aldosterone, decreases glomerular filtration and increases sodium & water reabsorption that leads to oliguria.
- Answer: (B) assessing Maria’s expectations and doubts . Assessing the client’s expectations and doubts will help lessen her fears and anxieties. The nurse needs to encourage the client to verbalize and to listen and correctly provide explanations when needed.
- Answer: (B) recognize that Kathy is experiencing denial, a normal stage of the grieving process . A person grieves to a loss of a significant object. The initial stage in the grieving process is denial, then anger, followed by bargaining, depression and last acceptance. The nurse should show acceptance of the patient’s feelings and encourage verbalization.
- Answer: (B) it affects both normal and tumor cells . Chemotherapeutic agents are given to destroy the actively proliferating cancer cells. But these agents cannot differentiate the abnormal actively proliferating cancer cells from those that are actively proliferating normal cells like the cells of the bone marrow, thus the effect of bone marrow depression.
- Answer: (C) CTscanning uses magnetic fields and radio frequencies to provide cross-sectional view of tumor . CT scan uses narrow beam x-ray to provide cross-sectional view. MRI uses magnetic fields and radio frequencies to detect tumors.
- Answer: (D) frequently elevating the arm of the affected side above the level of the heart. . Elevating the arm above the level of the heart promotes good venous return to the heart and good lymphatic drainage thus preventing swelling.
- Answer: (B) “My 7 year old twins should not come to visit me while I’m receiving treatment.” . Children have cells that are normally actively dividing in the process of growth. Radiation acts not only against the abnormally actively dividing cells of cancer but also on the normally dividing cells thus affecting the growth and development of the child and even causing cancer itself.
- Answer: (B) Rapid cell catabolism . One of the oncologic emergencies, the tumor lysis syndrome, is caused by the rapid destruction of large number of tumor cells. . Intracellular contents are released, including potassium and purines, into the bloodstream faster than the body can eliminate them. The purines are converted in the liver to uric acid and released into the blood causing hyperuricemia. They can precipitate in the kidneys and block the tubules causing acute renal failure.
- Answer: (C) Low residue diet . It is important for the nurse to remember that the implant be kept intact in the cervix during therapy. Mobility and vaginal irrigations are not done. A low residue diet will prevent bowel movement that could lead to dislodgement of the implant. Patient is also strictly isolated to protect other people from the radiation emissions
- Answer: (A) Avoid BP measurement and constricting clothing on the affected arm . A BP cuff constricts the blood vessels where it is applied. BP measurements should be done on the unaffected arm to ensure adequate circulation and venous and lymph drainage in the affected arm
- Answer: (C) Hypovolemia, wide fluctuations in serum sodium and potassium levels. . The second phase of ARF is the diuretic phase or high output phase. The diuresis can result in an output of up to 10L/day of dilute urine. Loss of fluids and electrolytes occur.
- Answer: (A) A rapid pulse and increased RR . The fight or flight reaction of the sympathetic nervous system occurs during stress like in a motor vehicular accident. This is manifested by increased in cardiovascular function and RR to provide the immediate needs of the body for survival.
- Answer: (D) assessing her VS especially her RR . Shock is characterized by reduced tissue and organ perfusion and eventual organ dysfunction and failure. Checking on the VS especially the RR, which detects need for oxygenation, is a priority to help detect its progress and provide for prompt management before the occurrence of complications.
- Answer: (B) Urine output of 30 to 50 ml/hr. Hypovolemia is a decreased in circulatory volume. This causes a decrease in tissue perfusion to the different organs of the body. Measuring the hourly urine output is the most quantifiable way of measuring tissue perfusion to the organs. Normal renal perfusion should produce 1ml/kg of BW/min. An output of 30-50 ml/hr is considered adequate and indicates good fluid balance.
- Answer: (D) Pericardial tamponade . Pericardial tamponade occurs when there is presence of fluid accumulation in the pericardial space that compresses on the ventricles causing a decrease in ventricular filling and stretching during diastole with a decrease in cardiac output. . This leads to right atrial and venous congestion manifested by a CVP reading above normal.
- Answer: (A) administering an irritant that will stimulate vomiting . Swallowing of corrosive substances causes severe irritation and tissue destruction of the mucous membrane of the GI tract. Measures are taken to immediately remove the toxin or reduce its absorption. For corrosive poison ingestion, such as in muriatic acid where burn or perforation of the mucosa may occur, gastric emptying procedure is immediately instituted, This includes gastric lavage and the administration of activated charcoal to absorb the poison. Administering an irritant with the concomitant vomiting to remove the swallowed poison will further cause irritation and damage to the mucosal lining of the digestive tract. Vomiting is only indicated when non-corrosive poison is swallowed.
- Answer: (C) Palpable carotid pulse . Presence of a palpable carotid pulse indicates the return of cardiac function which, together with the return of breathing, is the primary goal of CPR. Pulsations in arteries indicates blood flowing in the blood vessels with each cardiac contraction. Signs of effective tissue perfusion will be noted after.
- Answer: (C) Flushing of the lids, conjunctiva and cornea with tap or preferably sterile water . Prompt treatment of ocular chemical burns is important to prevent further damage. Immediate tap-water eye irrigation should be started on site even before transporting the patient to the nearest hospital facility. In the hospital, copious irrigation with normal saline, instillation of local anesthetic and antibiotic is done.
- Answer: (A) Force air out of the lungs . The Heimlich maneuver is used to assist a person choking on a foreign object. The pressure from the thrusts lifts the diaphragm, forces air out of the lungs and creates an artificial cough that expels the aspirated material.
- Answer: (B) speak to both parents together and encourage them to support each other and express their emotions freely . Sudden death of a family member creates a state of shock on the family. They go into a stage of denial and anger in their grieving. Assisting them with information they need to know, answering their questions and listening to them will provide the needed support for them to move on and be of support to one another.
- Answer: (C) relax the bronchial smooth muscle . Acute asthmatic attack is characterized by severe bronchospasm which can be relieved by the immediate administration of bronchodilators. Adrenaline or Epinephrine is an adrenergic agent that causes bronchial dilation by relaxing the bronchial smooth muscles.
- Answer: (C) lower half of the sternum . The exact and safe location to do cardiac compression is the lower half of the sternum. Doing it at the lower third of the sternum may cause gastric compression which can lead to a possible aspiration.
- Answer: (B) “As one ages, visual changes are noted as part of degenerative changes. This is normal.” . Aging causes less elasticity of the lens affecting accommodation leading to blurred vision. The muscles of the iris increase in stiffness and the pupils dilate slowly and less completely so that it takes the older person to adjust when going to and from light and dark environment and needs brighter light for close vision.
- Answer: (D) sexual intercourse . To reduce increases in IOP, teach the client and family about activity restrictions. Sexual intercourse can cause a sudden rise in IOP.
- Answer: (C) Speak clearly in a loud voice or shout to be heard . Shouting raises the frequency of the sound and often makes understanding the spoken words difficult. It is enough for the nurse to speak clearly and slowly.
- Answer: (D) Force fluids before and after the procedure. LP involves the removal of some amount of spinal fluid. To facilitate CSF production, the client is instructed to increase fluid intake to 3L, unless contraindicated, for 24 to 48 hrs after the procedure.
- Answer: (D) Kept the extremity used as puncture site flexed to prevent bleeding. Angiography involves the threading of a catheter through an artery which can cause trauma to the endothelial lining of the blood vessel. The platelets are attracted to the area causing thrombi formation. This is further enhanced by the slowing of blood flow caused by flexion of the affected extremity. The affected extremity must be kept straight and immobilized during the duration of the bedrest after the procedure. Ice bag can be applied intermittently to the puncture site.
- Answer: (D) progression from restlessness to confusion and disorientation to lethargy . The first major effect of increasing ICP is a decrease in cerebral perfusion causing hypoxia that produces a progressive alteration in the LOC. This is initially manifested by restlessness.
- Answer: (D) Aspirin is used in the acute management of a completed stroke. . The primary goal in the management of CVA is to improve cerebral tissue perfusion. Aspirin is a platelet deaggregator used in the prevention of recurrent or embolic stroke but is not used in the acute management of a completed stroke as it may lead to bleeding.
- Answer: (D) Encourage the client to speak at every possible opportunity. Expressive or motor aphasia is a result of damage in the Broca’s area of the frontal lobe. It is amotor speech problem in which the client generally understands what is said but is unable to communicate verbally. The patient can best he helped therefore by encouraging him to communicate and reinforce this behavior positively.
- Answer: (C) altered cerebral tissue perfusion . The observations made by the nurse clearly indicate a problem of decrease cerebral perfusion. Restoring cerebral perfusion is most important to maintain cerebral functioning and prevent further brain damage.
- Answer: (D) Ineffective airway clearance related to muscle weakness . Myasthenia gravis causes a failure in the transmission of nerve impulses at the neuromuscular junction which may be due to a weakening or decrease in acetylcholine receptor sites. This leads to sporadic, progressive weakness or abnormal fatigability of striated muscles that eventually causes loss of function. The respiratory muscles can become weak with decreased tidal volume and vital capacity making breathing and clearing the airway through coughing difficult. The respiratory muscle weakness may be severe enough to require and emergency airway and mechanical ventilation.
- Answer: (C) Test for glucose . The CSF contains a large amount of glucose which can be detected by using glucostix. A positive result with the drainage indicate CSF leakage.
- Answer: (C) Apply a “shrinker” bandage with tighter arms around the proximal end of the affected limb. The “shrinker” bandage is applied to prevent swelling of the stump. It should be applied with the distal end with the tighter arms. Applying the tighter arms at the proximal end will impair circulation and cause swelling by reducing venous flow.
- Answer: (D) Place items so that it is necessary to bend or stretch to reach them. Patients with osteoarthritis have decreased mobility caused by joint pain. Over-reaching and stretching to get an object are to be avoided as this can cause more pain and can even lead to falls. The nurse should see to it therefore that objects are within easy reach of the patient.
- Answer: (D) Ensure an intake of at least 3000 ml of fluid per day. Gouty arthritis is a metabolic disease marked by urate deposits that cause painful arthritic joints. The patient should be urged to increase his fluid intake to prevent the development of urinary uric acid stones.
- Answer: (B) Before log rolling, remove the pillow from under the client’s head and use no pillows between the client’s legs. Following a laminectomy and spinal fusion, it is important that the back of the patient be maintained in straight alignment and to support the entire vertebral column to promote complete healing.