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NCLEX Practice Exam for Medical Surgical Nursing 3 (PM)
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Question 1
Clara, a burn client, receives a temporary heterograft (pig skin) on some of her burns. These grafts will:
A
Debride necrotic epithelium
B
Frequently be used concurrently with topical antimicrobials.
C
Relieve pain and promote rapid epithelialization
D
Be sutured in place for better adherence
Question 1 Explanation:
The graft covers nerve endings, which reduces pain and provides a framework for granulation that promotes effective healing.
Question 2
Helen is diagnosed with myasthenia gravis and pyridostigmine bromide (Mestinon) therapy is started. The Mestinon dosage is frequently changed during the first week. While the dosage is being adjusted, the nurse’s priority intervention is to:
A
Administer the medication exactly on time
B
Evaluate the client’s muscle strength hourly after medication
C
Evaluate the client’s emotional side effects between doses
D
Administer the medication with food or mild
Question 2 Explanation:
Peak response occurs 1 hour after administration and lasts up to 8 hours; the response will influence dosage levels.
Question 3
Ana, 55 years old, is admitted to the hospital to rule out pernicious anemia. A Schilling test is ordered for Ana. The nurse recognizes that the primary purpose of the Schilling test is to determine the client’s ability to:
A
Absorb vitamin B12
B
Produce vitamin B12
C
Digest vitamin B12
D
Store vitamin B12
Question 3 Explanation:
Pernicious anemia is caused by the inability to absorb vitamin B12 in the stomach due to a lack of intrinsic factor in the gastric juices. In the Schilling test, radioactive vitamin B12 is administered and its absorption and excretion can be ascertained through the urine.
Question 4
Clara is a 37-year old cook. She is admitted for treatment of partial and full-thickness burns of her entire right lower extremity and the anterior portion of her right upper extremity. Her respiratory status is compromised, and she is in pain and anxious. Performing an immediate appraisal, using the rule of nines, the nurse estimates the percent of Clara’s body surface that is burned is:
A
18 %
B
4.5%
C
9%
D
22.5%
Question 4 Explanation:
The entire right lower extremity is 18% the anterior portion of the right upper extremity is 4.5% giving a total of 22.5%
Question 5
When doing colostomy irrigation at home, a client with colostomy should be instructed to report to his physician :
A
Abdominal cramps during fluid inflow
B
Inability to complete the procedure in half an hour
C
Difficulty in inserting the irrigating tube
D
Passage of flatus during expulsion of feces
Question 5 Explanation:
Difficulty of inserting the irrigating tube indicates stenosis of the stoma and should be reported to the physician. Abdominal cramps and passage of flatus can be expected during colostomy irrigations. The procedure may take longer than half an hour.
Question 6
The meal pattern that would probably be most appropriate for a client recovering from GI bleeding is:
A
A flexible plan according to his appetite
B
Regular meals and snacks to limit gastric discomfort
C
Three large meals large enough to supply adequate energy.
D
Limited food and fluid intake when he has pain
Question 6 Explanation:
Presence of food in the stomach at regular intervals interacts with HCl limiting acid mucosal irritation. Mucosal irritation can lead to bleeding.
Question 7
Oxygen 3L/min by nasal cannula is prescribed for Joey who is admitted to the hospital for chest pain. The nurse institutes safety precautions in the room because oxygen:
A
Supports combustion
B
Has unstable properties
C
Converts to an alternate form of matter
D
Is flammable
Question 7 Explanation:
The nurse should know that Oxygen is necessary to produce fire, thus precautionary measures are important regarding its use.
Question 8
During and 8 hour shift, Mario drinks two 6 oz. cups of tea and vomits 125 ml of fluid. During this 8 hour period, his fluid balance would be:
A
+55 ml
B
+137 ml
C
+235 ml
D
+485 ml
Question 8 Explanation:
The client’s intake was 360 ml (6oz x 30 ml) and loss was 125 ml of fluid; loss is subtracted from intake
Question 9
Joey asks the nurse why he is receiving the injection of Morphine after he was hospitalized for severe anginal pain. The nurse replies that it:
A
Relieves pain and decreases level of anxiety
B
Decreases anxiety
C
Dilates coronary blood vessels
D
Will help prevent erratic heart beats
Question 9 Explanation:
Morphine is a specific central nervous system depressant used to relieve the pain associated with myocardial infarction. It also decreases anxiety and apprehension and prevents cardiogenic shock by decreasing myocardial oxygen demand.
Question 10
The initial nursing goal for a client with myasthenia gravis during the diagnostic phase of her hospitalization would be to:
A
Facilitate psychologic adjustment
B
Maintain the present muscle strength
C
Prepare for the appearance of myasthenic crisis
D
Develop a teaching plan
Question 10 Explanation:
Until diagnosis is confirmed, primary goal should be to maintain adequate activity and prevent muscle atrophy
Question 11
The physician orders on a client with CHF a cardiac glycoside, a vasodilator, and furosemide (Lasix). The nurse understands Lasix exerts is effects in the:
A
Ascending limb of the loop of Henle
B
Collecting duct
C
Glomerulus of the nephron
D
Distal tubule
Question 11 Explanation:
This is the site of action of Lasix being a potent loop diuretic.
Question 12
Myra is ordered laboratory tests after she is admitted to the hospital for angina. The isoenzyme test that is the most reliable early indicator of myocardial insult is:
A
AST
B
CK-MB
C
SGPT
D
LDH
Question 12 Explanation:
The cardiac marker, Creatinine phosphokinase (CPK) isoenzyme levels, especially the MB sub-unit which is cardio-specific, begin to rise in 3-6 hours, peak in 12-18 hours and are elevated 48 hours after the occurrence of the infarct. They are therefore most reliable in assisting with early diagnosis. The cardiac markers elevate as a result of myocardial tissue damage.
Question 13
Twenty-four hours after TURP surgery, the client tells the nurse he has lower abdominal discomfort. The nurse notes that the catheter drainage has stopped. The nurse’s initial action should be to:
A
Notify the physician
B
Remove the catheter
C
Milk the catheter tubing
D
Irrigate the catheter with saline
Question 13 Explanation:
Milking the tubing will usually dislodge the plug and will not harm the client. A physician’s order is not necessary for a nurse to check catheter patency.
Question 14
A client with multiple injury following a vehicular accident is transferred to the critical care unit. He begins to complain of increased abdominal pain in the left upper quadrant. A ruptured spleen is diagnosed and he is scheduled for emergency splenectomy. In preparing the client for surgery, the nurse should emphasize in his teaching plan the:
A
Risk of the procedure with his other injuries
B
Complete safety of the procedure
C
Presence of abdominal drains for several days after surgery
D
Expectation of postoperative bleeding
Question 14 Explanation:
Drains are usually inserted into the splenic bed to facilitate removal of fluid in the area that could lead to abscess formation.
Question 15
In the early postoperative period following a transurethral surgery, the most common complication the nurse should observe for is:
A
Sepsis
B
Urinary retention with overflow
C
Leakage around the catheter
D
Hemorrhage
Question 15 Explanation:
After transurethral surgery, hemorrhage is common because of venous oozing and bleeding from many small arteries in the prostatic bed.
Question 16
A client with burns on the chest has periodic episodes of dyspnea. The position that would provide for the greatest respiratory capacity would be the:
A
Orthopneic position
B
Supine position
C
Sims’ position
D
Semi-fowler’s position
Question 16 Explanation:
The orthopneic position lowers the diaphragm and provides for maximal thoracic expansion
Question 17
When observing an ostomate do a return demonstration of the colostomy irrigation, the nurse notes that he needs more teaching if he:
A
Lubricates the tip of the catheter before inserting it into the stoma
B
Hangs the bag on a clothes hook on the bathroom door during fluid insertion
C
Discontinues the insertion of fluid after only 500 ml of fluid has been instilled
D
Stops the flow of fluid when he feels uncomfortable
Question 17 Explanation:
The irrigation bag should be hung 12-18 inches above the level of the stoma; a clothes hook is too high which can create increase pressure and sudden intestinal distention and cause abdominal discomfort to the patient.
Question 18
The physician orders non-weight bearing with crutches for Joy, who had surgery for a fractured hip. The most important activity to facilitate walking with crutches before ambulation begun is:
A
Using the trapeze frequently for pull-ups to strengthen the biceps muscles
B
Doing isometric exercises on the unaffected leg
C
Exercising the triceps, finger flexors, and elbow extensors
D
Sitting up at the edge of the bed to help strengthen back muscles
Question 18 Explanation:
These sets of muscles are used when walking with crutches and therefore need strengthening prior to ambulation.
Question 19
Ana is diagnosed to have Pernicious anemia. The physician orders 0.2 mg of Cyanocobalamin (Vitamin B12) IM. Available is a vial of the drug labeled 1 ml= 100 mcg. The nurse should administer:
A
1.0 ml
B
2.0 ml
C
0.5 ml
D
1.5 ml
Question 19 Explanation:
First convert milligrams to micrograms and then use ratio and proportion (0.2 mg= 200 mcg) 200 mcg : 100 mcg= X ml : ml 100 X= 200 X = 2 ml. Inject 2 ml. to give 0.2 mg of Cyanocobalamin.
Question 20
The nurse is assisting in planning care for a client with a diagnosis of immune deficiency. The nurse would incorporate which of the ff. as a priority in the plan of care?
A
encouraging discussion about lifestyle changes
B
protecting the client from infection
C
providing emotional support to decrease fear
D
identifying factors that decreased the immune function
Question 20 Explanation:
Immunodeficiency is an absent or depressed immune response that increases susceptibility to infection. So it is the nurse’s primary responsibility to protect the patient from infection.
Question 21
Eddie, 40 years old, is brought to the emergency room after the crash of his private plane. He has suffered multiple crushing wounds of the chest, abdomen and legs. It is feared his leg may have to be amputated. When Eddie arrives in the emergency room, the assessment that assume the greatest priority are:
A
Quality of respirations and presence of pulsesQuality of respirations and presence of pulses
B
Pain, Respiratory rate and blood pressure
C
Abdominal contusions and other wounds
D
Level of consciousness and pupil size
Question 21 Explanation:
Respiratory and cardiovascular functions are essential for oxygenation. These are top priorities to trauma management. Basic life functions must be maintained or reestablished
Question 22
In dealing with a dying client who is in the denial stage of grief, the best nursing approach is to:
A
Reassure the client that everything will be okay
B
Allow the denial but be available to discuss death
C
Leave the client alone to discuss the loss
D
Agree with and encourage the client’s denial
Question 22 Explanation:
This does not take away the client’s only way of coping, and it permits future movement through the grieving process when the client is ready. Dying clients move through the different stages of grieving and the nurse must be ready to intervene in all these stages.
Question 23
A client has been in a coma for 2 months. The nurse understands that to prevent the effects of shearing force on the skin, the head of the bed should be at an angle of:
A
60 degrees
B
30 degrees
C
45 degrees
D
90 degrees
Question 23 Explanation:
Shearing force occurs when 2 surfaces move against each other; when the bed is at an angle greater than 30 degrees, the torso tends to slide and causes this phenomenon. Shearing forces are good contributory factors of pressure sores.
Question 24
Twenty four hours after admission for an Acute MI, Jose’s temperature is noted at 39.3 C. The nurse monitors him for other adaptations related to the pyrexia, including:
A
Shortness of breath
B
Chest pain
C
Elevated blood pressure
D
Increased pulse rate
Question 24 Explanation:
Fever causes an increase in the body’s metabolism, which results in an increase in oxygen consumption and demand. This need for oxygen increases the heart rate, which is reflected in the increased pulse rate. Increased BP, chest pain and shortness of breath are not typically noted in fever.
Question 25
When preparing to teach a client with colostomy how to irrigate his colostomy, the nurse should plan to perform the procedure:
A
When the client would have normally had a bowel movement
B
At least 2 hours before visitors arrive
C
After the client accepts he had a bowel movement
D
Before breakfast and morning care
Question 25 Explanation:
Irrigation should be performed at the time the client normally defecated before the colostomy to maintain continuity in lifestyle and usual bowel function/habit.
Question 26
Following prostate surgery, the retention catheter is secured to the client’s leg causing slight traction of the inflatable balloon against the prostatic fossa. This is done to:
A
Limit discomfort
B
Promote urinary drainage
C
Provide hemostasis
D
Reduce bladder spasms
Question 26 Explanation:
The pressure of the balloon against the small blood vessels of the prostate creates a tampon-like effect that causes them to constrict thereby preventing bleeding.
Question 27
Dennis receives a blood transfusion and develops flank pain, chills, fever and hematuria. The nurse recognizes that Dennis is probably experiencing:
A
A hemolytic transfusion reaction
B
A pyrogenic transfusion reaction
C
An allergic transfusion reaction
D
An anaphylactic transfusion reaction
Question 27 Explanation:
This non-judgmentally on the part of the nurse points out the client’s behavior.This results from a recipient’s antibodies that are incompatible with transfused RBC’s; also called type II hypersensitivity; these signs result from RBC hemolysis, agglutination, and capillary plugging that can damage renal function, thus the flank pain and hematuria and the other manifestations.
Question 28
The nurse performs full range of motion on a bedridden client’s extremities. When putting his ankle through range of motion, the nurse must perform:
A
Dorsiflexion, plantar flexion, eversion and inversion
B
Abduction, flexion, adduction and extension
C
Pronation, supination, rotation, and extension
D
Flexion, extension and left and right rotation
Question 28 Explanation:
These movements include all possible range of motion for the ankle joint
Question 29
Thrombus formation is a danger for all postoperative clients. The nurse should act independently to prevent this complication by:
A
Massaging gently the legs with lotion
B
Encouraging adequate fluids
C
Performing active-assistive leg exercises
D
Applying elastic stockings
Question 29 Explanation:
Inactivity causes venous stasis, hypercoagulability, and external pressure against the veins, all of which lead to thrombus formation. Early ambulation or exercise of the lower extremities reduces the occurrence of this phenomenon
Question 30
A client’s exopthalmos continues inspite of thyroidectomy for Grave’s Disease. The nurse teaches her how to reduce discomfort and prevent corneal ulceration. The nurse recognizes that the client understands the teaching when she says: “I should:
A
Avoid moving my extra-ocular muscles
B
Avoid using a sleeping mask at night
C
Avoid excessive blinking
D
Elevate the head of my bed at night
Question 30 Explanation:
The mask may irritate or scratch the eye if the client turns and lies on it during the night.
Question 31
The nurse applies mafenide acetate (Sulfamylon cream) to Clara, who has second and third degree burns on the right upper and lower extremities, as ordered by the physician. This medication will:
A
Provide chemical debridement
B
Prevent scar tissue formation
C
Relieve pain from the burn
D
Inhibit bacterial growth
Question 31 Explanation:
Sulfamylon is effective against a wide variety of gram positive and gram negative organisms including anaerobes
Question 32
Lucy is admitted to the surgical unit for a subtotal thyroidectomy. She is diagnosed with Grave’s Disease. When assessing Lucy, the nurse would expect to find:
A
Lethargy, weight gain, and forgetfulness
B
Weight loss, exopthalmos and restlessness
C
Constipation, dry skin, and weight gain
D
Weight loss, protruding eyeballs, and lethargy
Question 32 Explanation:
Classic signs associated with hyperthyroidism are weight loss and restlessness because of increased basal metabolic rate. Exopthalmos is due to peribulbar edema.
Question 33
After the acute phase of congestive heart failure, the nurse should expect the dietary management of the client to include the restriction of:
A
Potassium
B
Sodium
C
Magnesium
D
Calcium
Question 33 Explanation:
Restriction of sodium reduces the amount of water retention that reduces the cardiac workload
Question 34
Jose, who is admitted to the hospital for chest pain, asks the nurse, “Is it still possible for me to have another heart attack if I watch my diet religiously and avoid stress?” The most appropriate initial response would be for the nurse to:
A
Suggest he discuss his feelings of vulnerability with his physician.
B
Tell him that he certainly needs to be especially careful about his diet and lifestyle.
C
Avoid giving him direct information and help him explore his feelings
D
Recognize that he is frightened and suggest he talk with the psychiatrist or counselor.
Question 34 Explanation:
To help the patient verbalize and explore his feelings, the nurse must reflect and analyze the feelings that are implied in the client’s question. The focus should be on collecting data to minister to the client’s psychosocial needs.
Question 35
To promote continued improvement in the respiratory status of a client following chest tube removal after a chest surgery for multiple rib fracture, the nurse should:
A
Encourage frequent coughing and deep breathing
B
Encourage bed rest with active and passive range of motion exercises
C
Continue observing for dyspnea and crepitus
D
Turn him from side to side at least every 2 hours
Question 35 Explanation:
This nursing action prevents atelectasis and collection of respiratory secretions and promotes adequate ventilation and gas exchange.
Question 36
The laboratory results of the client with leukemia indicate bone marrow depression. The nurse should encourage the client to:
A
Drink citrus juices frequently for nourishment
B
Sleep with the head of his bed slightly elevated
C
Use a soft toothbrush and electric razor
D
Increase his activity level and ambulate frequently
Question 36 Explanation:
Suppression of red bone marrow increases bleeding susceptibility associated with thrombocytopenia, decreased platelets. Anemia and leucopenia are the two other problems noted with bone marrow depression.
Question 37
Helen, a client with myasthenia gravis, begins to experience increased difficulty in swallowing. To prevent aspiration of food, the nursing action that would be most effective would be to:
A
Change her diet order from soft foods to clear liquids
B
Place an emergency tracheostomy set in her room
C
Coordinate her meal schedule with the peak effect of her medication, Mestinon
D
Assess her respiratory status before and after meals
Question 37 Explanation:
Dysphagia should be minimized during peak effect of Mestinon, thereby decreasing the probability of aspiration. Mestinon can increase her muscle strength including her ability to swallow.
Question 38
An early finding in the EKG of a client with an infarcted mycardium would be:
A
Flattened T waves
B
Absence of P wave
C
Disappearance of Q waves
D
Elevated ST segments
Question 38 Explanation:
This is a typical early finding after a myocardial infarct because of the altered contractility of the heart. The other choices are not typical of MI.
Question 39
Routine postoperative IV fluids are designed to supply hydration and electrolyte and only limited energy. Because 1 L of a 5% dextrose solution contains 50 g of sugar, 3 L per day would apply approximately:
A
400 Kilocalories
B
1000 Kilocalories
C
600 Kilocalories
D
800 Kilocalories
Question 39 Explanation:
Carbohydrates provide 4 kcal/ gram; therefore 3L x 50 g/L x 4 kcal/g = 600 kcal; only about a third of the basal energy need.
Question 40
A client jokes about his leukemia even though he is becoming sicker and weaker. The nurse’s most therapeutic response would be:
A
“He who laughs on the outside, cries on the inside.”
B
“Does it help you to joke about your illness?”
C
“Why are you always laughing?”
D
“Your laugher is a cover for your fear.”
Question 40 Explanation:
This non-judgmentally on the part of the nurse points out the client’s behavior.
Question 41
An unconscious client is admitted to the ICU, IV fluids are started and a Foley catheter is inserted. With an indwelling catheter, urinary infection is a potential danger. The nurse can best plan to avoid this problem by:
A
Maintaining the ordered hydration
B
Assessing urine specific gravity
C
Emptying the drainage bag frequently
D
Collecting a weekly urine specimen
Question 41 Explanation:
Promoting hydration, maintains urine production at a higher rate, which flushes the bladder and prevents urinary stasis and possible infection
Question 42
Rene, age 62, is scheduled for a TURP after being diagnosed with a Benign Prostatic Hyperplasia (BPH). As part of the preoperative teaching, the nurse should tell the client that after surgery:
A
Urinary drainage will be dependent on a urethral catheter for 24 hours
B
His ability to perform sexually will be permanently impaired
C
Frequency and burning on urination will last while the cystotomy tube is in place
D
Urinary control may be permanently lost to some degree
Question 42 Explanation:
An indwelling urethral catheter is used, because surgical trauma can cause urinary retention leading to further complications such as bleeding.
Question 43
Eddie, a plane crash victim, undergoes endotracheal intubation and positive pressure ventilation. The most immediate nursing intervention for him at this time would be to:
A
Facilitate his verbal communication
B
Prepare him for emergency surgery
C
Maintain sterility of the ventilation system
D
Assess his response to the equipment
Question 43 Explanation:
It is a primary nursing responsibility to evaluate effect of interventions done to the client. Nothing is achieved if the equipment is working and the client is not responding
Question 44
The transurethral resection of the prostate is performed on a client with BPH. Following surgery, nursing care should include:
A
Maintaining patency of a three-way Foley catheter for cystoclysis
B
Changing the abdominal dressing
C
Maintaining patency of the cystotomy tube
D
Observing for hemorrhage and wound infection
Question 44 Explanation:
Patency of the catheter promotes bladder decompression, which prevents distention and bleeding. Continuous flow of fluid through the bladder limits clot formation and promotes hemostasis
Question 45
Joey is a 46 year-old radio technician who is admitted because of mild chest pain. He is 5 feet, 8 inches tall and weighs 190 pounds. He is diagnosed with a myocardial infarct. Morphine sulfate, Diazepam (Valium) and Lidocaine are prescribed.
The physician orders 8 mg of Morphine Sulfate to be given IV. The vial on hand is labeled 1 ml/ 10 mg. The nurse should administer:
A
8 minims
B
12 minims
C
15 minims
D
10 minims
Question 45 Explanation:
Using ratio and proportion 8 mg/10 mg = X minims/15 minims 10 X= 120 X = 12 minims The nurse will administer 12 minims intravenously equivalent to 8mg Morphine Sulfate
Question 46
The day after her surgery Joy asks the nurse how she might lose weight. Before answering her question, the nurse should bear in mind that long-term weight loss best occurs when:
A
Exercise is part of the program
B
Fats are controlled in the diet
C
Eating habits are altered
D
Carbohydrates are regulated
Question 46 Explanation:
For weight reduction to occur and be maintained, a new dietary program, with a balance of foods from the basic four food groups, must be established and continued
Question 47
A client undergoes below the knee amputation following a vehicular accident. Three days postoperatively, the client is refusing to eat, talk or perform any rehabilitative activities. The best initial nursing approach would be to:
A
Appear cheerful and non-critical regardless of his response to attempts at intervention
B
Accept and acknowledge that his withdrawal is an initially normal and necessary part of grieving
C
Emphasize repeatedly that with as prosthesis, he will be able to return to his normal lifestyle
D
Give him explanations of why there is a need to quickly increase his activity
Question 47 Explanation:
The withdrawal provides time for the client to assimilate what has occurred and integrate the change in the body image. Acceptance of the client’s behavior is an important factor in the nurse’s intervention.
Question 48
Lucy undergoes Subtotal Thyroidectomy for Grave’s Disease. In planning for the client’s return from the OR, the nurse would consider that in a subtotal thyroidectomy:
A
A small part of the gland is left intact
B
The entire thyroid gland is removed
C
One parathyroid gland is also removed
D
A portion of the thyroid and four parathyroids are removed
Question 48 Explanation:
Remaining thyroid tissue may provide enough hormone for normal function. Total thyroidectomy is generally done in clients with Thyroid Ca.
Question 49
Mr. Ong weighs 210 lbs on admission to the hospital. After 2 days of diuretic therapy he weighs 205.5 lbs. The nurse could estimate that the amount of fluid he has lost is:
A
1.0 L
B
3.5 L
C
0.5 L
D
2.0 L
Question 49 Explanation:
One liter of fluid weighs approximately 2.2 lbs. Therefore a 4.5 lbs weight loss equals approximately 2 Liters.
Question 50
Forty-eight hours after a burn injury, the physician orders for the client 2 liters of IV fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide:
A
32 gtt/min
B
28 gtt/min
C
36 gtt/min
D
18 gtt/min
Question 50 Explanation:
This is the correct flow rate; multiply the amount to be infused (2000 ml) by the drop factor (10) and divide the result by the amount of time in minutes (12 hours x 60 minutes)
Question 51
Joy, an obese 32 year old, is admitted to the hospital after an automobile accident. She has a fractured hip and is brought to the OR for surgery.
After surgery Joy is to receive a piggy-back of Clindamycin phosphate (Cleocin) 300 mg in 50 ml of D5W. The piggyback is to infuse in 20 minutes. The drop factor of the IV set is 10 gtt/ml. The nurse should set the piggyback to flow at:
A
45 gtt/min
B
30 gtt/min
C
35 gtt/min
D
25 gtt/min
Question 51 Explanation:
To get the correct flow rate: multiply the amount to be infused (50 ml) by the drop factor (10) and divide the result by the amount of time in minutes (20)
Question 52
A chest tube with water seal drainage is inserted to a client following a multiple chest injury. A few hours later, the client’s chest tube seems to be obstructed. The most appropriate nursing action would be to
A
Arrange for a stat Chest x-ray film.
B
Prepare for chest tube removal
C
Milk the tube toward the collection container as ordered
D
Clam the tube immediately
Question 52 Explanation:
This assists in moving blood, fluid or air, which may be obstructing drainage, toward the collection chamber
Question 53
Mr. Ong is admitted to the hospital with a diagnosis of Left-sided CHF. In the assessment, the nurse should expect to find:
A
Jugular vein distention
B
Dyspnea on exertion
C
Extensive peripheral edema
D
Crushing chest pain
Question 53 Explanation:
Pulmonary congestion and edema occur because of fluid extravasation from the pulmonary capillary bed, resulting in difficult breathing. Left-sided heart failure creates a backward effect on the pulmonary system that leads to pulmonary congestion.
Question 54
The diet ordered for a client with CHF permits him to have a 190 g of carbohydrates, 90 g of fat and 100 g of protein. The nurse understands that this diet contains approximately:
A
2200 calories
B
2000 calories
C
1600 calories
D
2800 calories
Question 54 Explanation:
There are 9 calories in each gram of fat and 4 calories in each gram of carbohydrate and protein
Question 55
Mr. Ong, a client with CHF, has been receiving a cardiac glycoside, a diuretic, and a vasodilator drug. His apical pulse rate is 44 and he is on bed rest. The nurse concludes that his pulse rate is most likely the result of the:
A
Cardiac glycoside
B
Vasodilator
C
Diuretic
D
Bed-rest regimen
Question 55 Explanation:
A cardiac glycoside such as digitalis increases force of cardiac contraction, decreases the conduction speed of impulses within the myocardium and slows the heart rate.
Question 56
Jose, who had a myocardial infarction 2 days earlier, has been complaining to the nurse about issues related to his hospital stay. The best initial nursing response would be to:
A
Refocus the conversation on his fears, frustrations and anger about his condition
B
Explain how his being upset dangerously disturbs his need for rest
C
Attempt to explain the purpose of different hospital routines
D
Allow him to release his feelings and then leave him alone to allow him to regain his composure
Question 56 Explanation:
This provides the opportunity for the client to verbalize feelings underlying behavior and helpful in relieving anxiety. Anxiety can be a stressor which can activate the sympathoadrenal response causing the release of catecholamines that can increase cardiac contractility and workload that can further increase myocardial oxygen demand.
Question 57
When a post-thyroidectomy client returns from surgery the nurse assesses her for unilateral injury of the laryngeal nerve every 30 to 60 minutes by:
A
Asking her to state her name out loud
B
Observing for signs of tetany
C
Palpating the side of her neck for blood seepage
D
hecking her throat for swelling
Question 57 Explanation:
If the recurrent laryngeal nerve is damaged during surgery, the client will be hoarse and have difficult speaking.
Question 58
The key factor in accurately assessing how body image changes will be dealt with by the client is the:
A
Extent of body change present
B
Suddenness of the change
C
Obviousness of the change
D
Client’s perception of the change
Question 58 Explanation:
It is not reality, but the client’s feeling about the change that is the most important determinant of the ability to cope. The client should be encouraged to his feelings.
Question 59
The nurse would know that a post-TURP client understood his discharge teaching when he says “I should:”
A
Attempt to void every 3 hours when I’m awake
B
Avoid vigorous exercise for 6 months after surgery
C
Get out of bed into a chair for several hours daily
D
Call the physician if my urinary stream decreases
Question 59 Explanation:
Urethral mucosa in the prostatic area is destroyed during surgery and strictures my form with healing that causes partial or even complete ueinary obstruction.
Question 60
The nurse teaches Joy, an obese client, the value of aerobic exercises in her weight reduction program. The nurse would know that this teaching was effective when Joy says that exercise will:
A
Increase her lean body mass
B
Decrease her appetite
C
Lower her metabolic rate
D
Raise her heart rate
Question 60 Explanation:
Increased exercise builds skeletal muscle mass and reduces excess fatty tissue.
Question 61
Arthur Cruz, a 45 year old artist, has recently had an abdominoperineal resection and colostomy. Mr. Cruz accuses the nurse of being uncomfortable during a dressing change, because his “wound looks terrible.” The nurse recognizes that the client is using the defense mechanism known as:
A
Sublimation
B
Intellectualization
C
Projection
D
Reaction Formation
Question 61 Explanation:
Projection is the attribution of unacceptable feelings and emotions to others which may indicate the patients nonacceptance of his condition.
Question 62
In the evaluation of a client’s response to fluid replacement therapy, the observation that indicates adequate tissue perfusion to vital organs is:
A
Pulse rates of 120 and 110 in a 15 minute period
B
Urinary output is 30 ml in an hour
C
Central venous pressure reading of 2 cm H2O
D
Blood pressure readings of 50/30 and 70/40 within 30 minutes
Question 62 Explanation:
A rate of 30 ml/hr is considered adequate for perfusion of kidney, heart and brain.
Question 63
The nurse recognizes that a client understood the demonstration of crutch walking when she places her weight on:
A
Her axillary regions
B
The palms of her hands
C
Both feet placed wide apart
D
The palms and axillary regions
Question 63 Explanation:
The palms should bear the client’s weight to avoid damage to the nerves in the axilla (brachial plexus)
Question 64
A client with colostomy refuses to allow his wife to see the incision or stoma and ignores most of his dietary instructions. The nurse on assessing this data, can assume that the client is experiencing:
A
Impotency due to the surgery and needs sexual counseling
B
A difficult time accepting reality and is in a state of denial.
C
Suicide thoughts and should be seen by psychiatrist
D
A reaction formation to his recent altered body image.
Question 64 Explanation:
As long as no one else confirms the presence of the stoma and the client does not need to adhere to a prescribed regimen, the client’s denial is supported
Question 65
Jude develops GI bleeding and is admitted to the hospital. An important etiologic clue for the nurse to explore while taking his history would be:
A
His working patterns
B
Any recent foreign travel
C
The medications he has been taking
D
His usual dietary pattern
Question 65 Explanation:
Some medications, such as aspirin and prednisone, irritate the stomach lining and may cause bleeding with prolonged use
Question 66
The most significant initial nursing observations that need to be made about a client with myasthenia include:
A
Ability to smile an to close her eyelids
B
Ability to chew and speak distinctly
C
Degree of anxiety about her diagnosis
D
Respiratory exchange and ability to swallow
Question 66 Explanation:
Muscle weakness can lead to respiratory failure that will require emergency intervention and inability to swallow may lead to aspiration
Question 67
On a post-thyroidectomy client’s discharge, the nurse teaches her to observe for signs of surgically induced hypothyroidism. The nurse would know that the client understands the teaching when she states she should notify the physician if she develops:
A
Progressive weight loss
B
Dry skin and fatigue
C
Insomnia and excitability
D
Intolerance to heat
Question 67 Explanation:
Dry skin is most likely caused by decreased glandular function and fatigue caused by decreased metabolic rate. Body functions and metabolism are decreased in hypothyroidism.
Question 68
Before a post- thyroidectomy client returns to her room from the OR, the nurse plans to set up emergency equipment, which should include:
A
An airway and rebreathing mask
B
Two ampules of sodium bicarbonate
C
A tracheostomy set and oxygen
D
A crash cart with bed board
Question 68 Explanation:
Acute respiratory obstruction in the post-operative period can result from edema, subcutaneous bleeding that presses on the trachea, nerve damage, or tetany.
Question 69
The nurse knows that a client with Pernicious Anemia understands the teaching regarding the vitamin B12 injections when she states that she must take it:
A
Until her symptoms subside
B
For the rest of her life
C
During exacerbations of anemia
D
When she feels fatigued
Question 69 Explanation:
Since the intrinsic factor does not return to gastric secretions even with therapy, B12 injections will be required for the remainder of the client’s life.
Question 70
Health teachings to be given to a client with Pernicious Anemia regarding her therapeutic regimen concerning Vit. B12 will include:
A
Oral tablets of Vitamin B12 will control her symptoms
B
IM injections once a month will maintain control
C
Weekly Z-track injections provide needed control
D
IM injections are required for daily control
Question 70 Explanation:
Deep IM injections bypass B12 absorption defect in the stomach due to lack of intrinsic factor, the transport carrier component of gastric juices. A monthly dose is usually sufficient since it is stored in active body tissues such as the liver, kidney, heart, muscles, blood and bone marrow
Question 71
Larry is diagnosed as having myelocytic leukemia and is admitted to the hospital for chemotherapy. Larry discusses his recent diagnosis of leukemia by referring to statistical facts and figures. The nurse recognizes that Larry is using the defense mechanism known as:
A
Intellectualization
B
Sublimation
C
Projection
D
Reaction formation
Question 71 Explanation:
People use defense mechanisms to cope with stressful events. Intellectualization is the use of reasoning and thought processes to avoid the emotional upsets.
Question 72
Jane, a 20- year old college student is admiited to the hospital with a tentative diagnosis of myasthenia gravis. She is scheduled to have a series of diagnostic studies for myasthenia gravis, including a Tensilon test. In preparing her for this procedure, the nurse explains that her response to the medication will confirm the diagnosis if Tensilon produces:
A
Brief exaggeration of symptoms
B
Symptomatic improvement of just the ptosis
C
Prolonged symptomatic improvement
D
Rapid but brief symptomatic improvement
Question 72 Explanation:
Tensilon acts systemically to increase muscle strength; with a peak effect in 30 seconds, It lasts several minutes.
Question 73
A client with a history of recurrent GI bleeding is admitted to the hospital for a gastrectomy. Following surgery, the client has a nasogastric tube to low continuous suction. He begins to hyperventilate. The nurse should be aware that this pattern will alter his arterial blood gases by:
A
Decreasing PO2
B
Increasing HCO3
C
Decreasing pH
D
Decreasing PCO2
Question 73 Explanation:
Hyperventilation results in the increased elimination of carbon dioxide from the blood that can lead to respiratory alkalosis.
Question 74
The nurse would know that dietary teaching had been effective for a client with colostomy when he states that he will eat:
A
Bland foods so that his intestines do not become irritated
B
Soft foods that are more easily digested and absorbed by the large intestines
C
Everything he ate before the operation but will avoid those foods that cause gas
D
Food low in fiber so that there is less stool
Question 74 Explanation:
There is no special diets for clients with colostomy. These clients can eat a regular diet. Only gas-forming foods that cause distention and discomfort should be avoided.
Question 75
The observation that indicates a desired response to thoracostomy drainage of a client with chest injury is:
A
Crepitus detected on palpation of chest
B
Increased breath sounds
C
Increased respiratory rate
D
Constant bubbling in the drainage chamber
Question 75 Explanation:
The chest tube normalizes intrathoracic pressure and restores negative intra-pleural pressure, drains fluid and air from the pleural space, and improves pulmonary function
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NCLEX Practice Exam for Medical Surgical Nursing 3 (EM)
Choose the letter of the correct answer. You got 75 minutes to finish the exam .Good luck!
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Congratulations - you have completed NCLEX Practice Exam for Medical Surgical Nursing 3 (EM).
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Your answers are highlighted below.
Question 1
Lucy is admitted to the surgical unit for a subtotal thyroidectomy. She is diagnosed with Grave’s Disease. When assessing Lucy, the nurse would expect to find:
A
Constipation, dry skin, and weight gain
B
Lethargy, weight gain, and forgetfulness
C
Weight loss, protruding eyeballs, and lethargy
D
Weight loss, exopthalmos and restlessness
Question 1 Explanation:
Classic signs associated with hyperthyroidism are weight loss and restlessness because of increased basal metabolic rate. Exopthalmos is due to peribulbar edema.
Question 2
The most significant initial nursing observations that need to be made about a client with myasthenia include:
A
Respiratory exchange and ability to swallow
B
Ability to smile an to close her eyelids
C
Degree of anxiety about her diagnosis
D
Ability to chew and speak distinctly
Question 2 Explanation:
Muscle weakness can lead to respiratory failure that will require emergency intervention and inability to swallow may lead to aspiration
Question 3
Mr. Ong weighs 210 lbs on admission to the hospital. After 2 days of diuretic therapy he weighs 205.5 lbs. The nurse could estimate that the amount of fluid he has lost is:
A
0.5 L
B
1.0 L
C
3.5 L
D
2.0 L
Question 3 Explanation:
One liter of fluid weighs approximately 2.2 lbs. Therefore a 4.5 lbs weight loss equals approximately 2 Liters.
Question 4
A client with colostomy refuses to allow his wife to see the incision or stoma and ignores most of his dietary instructions. The nurse on assessing this data, can assume that the client is experiencing:
A
Suicide thoughts and should be seen by psychiatrist
B
Impotency due to the surgery and needs sexual counseling
C
A reaction formation to his recent altered body image.
D
A difficult time accepting reality and is in a state of denial.
Question 4 Explanation:
As long as no one else confirms the presence of the stoma and the client does not need to adhere to a prescribed regimen, the client’s denial is supported
Question 5
Rene, age 62, is scheduled for a TURP after being diagnosed with a Benign Prostatic Hyperplasia (BPH). As part of the preoperative teaching, the nurse should tell the client that after surgery:
A
His ability to perform sexually will be permanently impaired
B
Urinary drainage will be dependent on a urethral catheter for 24 hours
C
Frequency and burning on urination will last while the cystotomy tube is in place
D
Urinary control may be permanently lost to some degree
Question 5 Explanation:
An indwelling urethral catheter is used, because surgical trauma can cause urinary retention leading to further complications such as bleeding.
Question 6
Joey asks the nurse why he is receiving the injection of Morphine after he was hospitalized for severe anginal pain. The nurse replies that it:
A
Dilates coronary blood vessels
B
Relieves pain and decreases level of anxiety
C
Decreases anxiety
D
Will help prevent erratic heart beats
Question 6 Explanation:
Morphine is a specific central nervous system depressant used to relieve the pain associated with myocardial infarction. It also decreases anxiety and apprehension and prevents cardiogenic shock by decreasing myocardial oxygen demand.
Question 7
Health teachings to be given to a client with Pernicious Anemia regarding her therapeutic regimen concerning Vit. B12 will include:
A
IM injections once a month will maintain control
B
IM injections are required for daily control
C
Oral tablets of Vitamin B12 will control her symptoms
D
Weekly Z-track injections provide needed control
Question 7 Explanation:
Deep IM injections bypass B12 absorption defect in the stomach due to lack of intrinsic factor, the transport carrier component of gastric juices. A monthly dose is usually sufficient since it is stored in active body tissues such as the liver, kidney, heart, muscles, blood and bone marrow
Question 8
An early finding in the EKG of a client with an infarcted mycardium would be:
A
Elevated ST segments
B
Disappearance of Q waves
C
Absence of P wave
D
Flattened T waves
Question 8 Explanation:
This is a typical early finding after a myocardial infarct because of the altered contractility of the heart. The other choices are not typical of MI.
Question 9
The nurse is assisting in planning care for a client with a diagnosis of immune deficiency. The nurse would incorporate which of the ff. as a priority in the plan of care?
A
identifying factors that decreased the immune function
B
encouraging discussion about lifestyle changes
C
providing emotional support to decrease fear
D
protecting the client from infection
Question 9 Explanation:
Immunodeficiency is an absent or depressed immune response that increases susceptibility to infection. So it is the nurse’s primary responsibility to protect the patient from infection.
Question 10
The nurse would know that a post-TURP client understood his discharge teaching when he says “I should:”
A
Avoid vigorous exercise for 6 months after surgery
B
Call the physician if my urinary stream decreases
C
Attempt to void every 3 hours when I’m awake
D
Get out of bed into a chair for several hours daily
Question 10 Explanation:
Urethral mucosa in the prostatic area is destroyed during surgery and strictures my form with healing that causes partial or even complete ueinary obstruction.
Question 11
A chest tube with water seal drainage is inserted to a client following a multiple chest injury. A few hours later, the client’s chest tube seems to be obstructed. The most appropriate nursing action would be to
A
Milk the tube toward the collection container as ordered
B
Arrange for a stat Chest x-ray film.
C
Clam the tube immediately
D
Prepare for chest tube removal
Question 11 Explanation:
This assists in moving blood, fluid or air, which may be obstructing drainage, toward the collection chamber
Question 12
Eddie, a plane crash victim, undergoes endotracheal intubation and positive pressure ventilation. The most immediate nursing intervention for him at this time would be to:
A
Assess his response to the equipment
B
Maintain sterility of the ventilation system
C
Facilitate his verbal communication
D
Prepare him for emergency surgery
Question 12 Explanation:
It is a primary nursing responsibility to evaluate effect of interventions done to the client. Nothing is achieved if the equipment is working and the client is not responding
Question 13
Before a post- thyroidectomy client returns to her room from the OR, the nurse plans to set up emergency equipment, which should include:
A
An airway and rebreathing mask
B
Two ampules of sodium bicarbonate
C
A tracheostomy set and oxygen
D
A crash cart with bed board
Question 13 Explanation:
Acute respiratory obstruction in the post-operative period can result from edema, subcutaneous bleeding that presses on the trachea, nerve damage, or tetany.
Question 14
In the evaluation of a client’s response to fluid replacement therapy, the observation that indicates adequate tissue perfusion to vital organs is:
A
Blood pressure readings of 50/30 and 70/40 within 30 minutes
B
Central venous pressure reading of 2 cm H2O
C
Pulse rates of 120 and 110 in a 15 minute period
D
Urinary output is 30 ml in an hour
Question 14 Explanation:
A rate of 30 ml/hr is considered adequate for perfusion of kidney, heart and brain.
Question 15
Jose, who is admitted to the hospital for chest pain, asks the nurse, “Is it still possible for me to have another heart attack if I watch my diet religiously and avoid stress?” The most appropriate initial response would be for the nurse to:
A
Tell him that he certainly needs to be especially careful about his diet and lifestyle.
B
Recognize that he is frightened and suggest he talk with the psychiatrist or counselor.
C
Suggest he discuss his feelings of vulnerability with his physician.
D
Avoid giving him direct information and help him explore his feelings
Question 15 Explanation:
To help the patient verbalize and explore his feelings, the nurse must reflect and analyze the feelings that are implied in the client’s question. The focus should be on collecting data to minister to the client’s psychosocial needs.
Question 16
On a post-thyroidectomy client’s discharge, the nurse teaches her to observe for signs of surgically induced hypothyroidism. The nurse would know that the client understands the teaching when she states she should notify the physician if she develops:
A
Progressive weight loss
B
Insomnia and excitability
C
Dry skin and fatigue
D
Intolerance to heat
Question 16 Explanation:
Dry skin is most likely caused by decreased glandular function and fatigue caused by decreased metabolic rate. Body functions and metabolism are decreased in hypothyroidism.
Question 17
The physician orders on a client with CHF a cardiac glycoside, a vasodilator, and furosemide (Lasix). The nurse understands Lasix exerts is effects in the:
A
Collecting duct
B
Glomerulus of the nephron
C
Distal tubule
D
Ascending limb of the loop of Henle
Question 17 Explanation:
This is the site of action of Lasix being a potent loop diuretic.
Question 18
Jude develops GI bleeding and is admitted to the hospital. An important etiologic clue for the nurse to explore while taking his history would be:
A
His working patterns
B
Any recent foreign travel
C
His usual dietary pattern
D
The medications he has been taking
Question 18 Explanation:
Some medications, such as aspirin and prednisone, irritate the stomach lining and may cause bleeding with prolonged use
Question 19
The initial nursing goal for a client with myasthenia gravis during the diagnostic phase of her hospitalization would be to:
A
Maintain the present muscle strength
B
Prepare for the appearance of myasthenic crisis
C
Develop a teaching plan
D
Facilitate psychologic adjustment
Question 19 Explanation:
Until diagnosis is confirmed, primary goal should be to maintain adequate activity and prevent muscle atrophy
Question 20
A client’s exopthalmos continues inspite of thyroidectomy for Grave’s Disease. The nurse teaches her how to reduce discomfort and prevent corneal ulceration. The nurse recognizes that the client understands the teaching when she says: “I should:
A
Avoid moving my extra-ocular muscles
B
Avoid using a sleeping mask at night
C
Elevate the head of my bed at night
D
Avoid excessive blinking
Question 20 Explanation:
The mask may irritate or scratch the eye if the client turns and lies on it during the night.
Question 21
When doing colostomy irrigation at home, a client with colostomy should be instructed to report to his physician :
A
Inability to complete the procedure in half an hour
B
Abdominal cramps during fluid inflow
C
Passage of flatus during expulsion of feces
D
Difficulty in inserting the irrigating tube
Question 21 Explanation:
Difficulty of inserting the irrigating tube indicates stenosis of the stoma and should be reported to the physician. Abdominal cramps and passage of flatus can be expected during colostomy irrigations. The procedure may take longer than half an hour.
Question 22
Helen is diagnosed with myasthenia gravis and pyridostigmine bromide (Mestinon) therapy is started. The Mestinon dosage is frequently changed during the first week. While the dosage is being adjusted, the nurse’s priority intervention is to:
A
Evaluate the client’s emotional side effects between doses
B
Administer the medication with food or mild
C
Administer the medication exactly on time
D
Evaluate the client’s muscle strength hourly after medication
Question 22 Explanation:
Peak response occurs 1 hour after administration and lasts up to 8 hours; the response will influence dosage levels.
Question 23
Clara, a burn client, receives a temporary heterograft (pig skin) on some of her burns. These grafts will:
A
Frequently be used concurrently with topical antimicrobials.
B
Relieve pain and promote rapid epithelialization
C
Debride necrotic epithelium
D
Be sutured in place for better adherence
Question 23 Explanation:
The graft covers nerve endings, which reduces pain and provides a framework for granulation that promotes effective healing.
Question 24
The nurse performs full range of motion on a bedridden client’s extremities. When putting his ankle through range of motion, the nurse must perform:
A
Abduction, flexion, adduction and extension
B
Flexion, extension and left and right rotation
C
Dorsiflexion, plantar flexion, eversion and inversion
D
Pronation, supination, rotation, and extension
Question 24 Explanation:
These movements include all possible range of motion for the ankle joint
Question 25
The observation that indicates a desired response to thoracostomy drainage of a client with chest injury is:
A
Increased respiratory rate
B
Constant bubbling in the drainage chamber
C
Crepitus detected on palpation of chest
D
Increased breath sounds
Question 25 Explanation:
The chest tube normalizes intrathoracic pressure and restores negative intra-pleural pressure, drains fluid and air from the pleural space, and improves pulmonary function
Question 26
Mr. Ong is admitted to the hospital with a diagnosis of Left-sided CHF. In the assessment, the nurse should expect to find:
A
Crushing chest pain
B
Extensive peripheral edema
C
Dyspnea on exertion
D
Jugular vein distention
Question 26 Explanation:
Pulmonary congestion and edema occur because of fluid extravasation from the pulmonary capillary bed, resulting in difficult breathing. Left-sided heart failure creates a backward effect on the pulmonary system that leads to pulmonary congestion.
Question 27
An unconscious client is admitted to the ICU, IV fluids are started and a Foley catheter is inserted. With an indwelling catheter, urinary infection is a potential danger. The nurse can best plan to avoid this problem by:
A
Collecting a weekly urine specimen
B
Maintaining the ordered hydration
C
Emptying the drainage bag frequently
D
Assessing urine specific gravity
Question 27 Explanation:
Promoting hydration, maintains urine production at a higher rate, which flushes the bladder and prevents urinary stasis and possible infection
Question 28
Myra is ordered laboratory tests after she is admitted to the hospital for angina. The isoenzyme test that is the most reliable early indicator of myocardial insult is:
A
SGPT
B
AST
C
CK-MB
D
LDH
Question 28 Explanation:
The cardiac marker, Creatinine phosphokinase (CPK) isoenzyme levels, especially the MB sub-unit which is cardio-specific, begin to rise in 3-6 hours, peak in 12-18 hours and are elevated 48 hours after the occurrence of the infarct. They are therefore most reliable in assisting with early diagnosis. The cardiac markers elevate as a result of myocardial tissue damage.
Question 29
Joy, an obese 32 year old, is admitted to the hospital after an automobile accident. She has a fractured hip and is brought to the OR for surgery.
After surgery Joy is to receive a piggy-back of Clindamycin phosphate (Cleocin) 300 mg in 50 ml of D5W. The piggyback is to infuse in 20 minutes. The drop factor of the IV set is 10 gtt/ml. The nurse should set the piggyback to flow at:
A
25 gtt/min
B
30 gtt/min
C
45 gtt/min
D
35 gtt/min
Question 29 Explanation:
To get the correct flow rate: multiply the amount to be infused (50 ml) by the drop factor (10) and divide the result by the amount of time in minutes (20)
Question 30
In dealing with a dying client who is in the denial stage of grief, the best nursing approach is to:
A
Leave the client alone to discuss the loss
B
Agree with and encourage the client’s denial
C
Allow the denial but be available to discuss death
D
Reassure the client that everything will be okay
Question 30 Explanation:
This does not take away the client’s only way of coping, and it permits future movement through the grieving process when the client is ready. Dying clients move through the different stages of grieving and the nurse must be ready to intervene in all these stages.
Question 31
The nurse teaches Joy, an obese client, the value of aerobic exercises in her weight reduction program. The nurse would know that this teaching was effective when Joy says that exercise will:
A
Lower her metabolic rate
B
Decrease her appetite
C
Raise her heart rate
D
Increase her lean body mass
Question 31 Explanation:
Increased exercise builds skeletal muscle mass and reduces excess fatty tissue.
Question 32
In the early postoperative period following a transurethral surgery, the most common complication the nurse should observe for is:
A
Urinary retention with overflow
B
Leakage around the catheter
C
Hemorrhage
D
Sepsis
Question 32 Explanation:
After transurethral surgery, hemorrhage is common because of venous oozing and bleeding from many small arteries in the prostatic bed.
Question 33
Ana, 55 years old, is admitted to the hospital to rule out pernicious anemia. A Schilling test is ordered for Ana. The nurse recognizes that the primary purpose of the Schilling test is to determine the client’s ability to:
A
Absorb vitamin B12
B
Store vitamin B12
C
Produce vitamin B12
D
Digest vitamin B12
Question 33 Explanation:
Pernicious anemia is caused by the inability to absorb vitamin B12 in the stomach due to a lack of intrinsic factor in the gastric juices. In the Schilling test, radioactive vitamin B12 is administered and its absorption and excretion can be ascertained through the urine.
Question 34
Helen, a client with myasthenia gravis, begins to experience increased difficulty in swallowing. To prevent aspiration of food, the nursing action that would be most effective would be to:
A
Place an emergency tracheostomy set in her room
B
Assess her respiratory status before and after meals
C
Change her diet order from soft foods to clear liquids
D
Coordinate her meal schedule with the peak effect of her medication, Mestinon
Question 34 Explanation:
Dysphagia should be minimized during peak effect of Mestinon, thereby decreasing the probability of aspiration. Mestinon can increase her muscle strength including her ability to swallow.
Question 35
Jane, a 20- year old college student is admiited to the hospital with a tentative diagnosis of myasthenia gravis. She is scheduled to have a series of diagnostic studies for myasthenia gravis, including a Tensilon test. In preparing her for this procedure, the nurse explains that her response to the medication will confirm the diagnosis if Tensilon produces:
A
Symptomatic improvement of just the ptosis
B
Prolonged symptomatic improvement
C
Rapid but brief symptomatic improvement
D
Brief exaggeration of symptoms
Question 35 Explanation:
Tensilon acts systemically to increase muscle strength; with a peak effect in 30 seconds, It lasts several minutes.
Question 36
The nurse recognizes that a client understood the demonstration of crutch walking when she places her weight on:
A
Her axillary regions
B
The palms of her hands
C
Both feet placed wide apart
D
The palms and axillary regions
Question 36 Explanation:
The palms should bear the client’s weight to avoid damage to the nerves in the axilla (brachial plexus)
Question 37
A client jokes about his leukemia even though he is becoming sicker and weaker. The nurse’s most therapeutic response would be:
A
“Your laugher is a cover for your fear.”
B
“Does it help you to joke about your illness?”
C
“Why are you always laughing?”
D
“He who laughs on the outside, cries on the inside.”
Question 37 Explanation:
This non-judgmentally on the part of the nurse points out the client’s behavior.
Question 38
During and 8 hour shift, Mario drinks two 6 oz. cups of tea and vomits 125 ml of fluid. During this 8 hour period, his fluid balance would be:
A
+137 ml
B
+235 ml
C
+55 ml
D
+485 ml
Question 38 Explanation:
The client’s intake was 360 ml (6oz x 30 ml) and loss was 125 ml of fluid; loss is subtracted from intake
Question 39
The day after her surgery Joy asks the nurse how she might lose weight. Before answering her question, the nurse should bear in mind that long-term weight loss best occurs when:
A
Fats are controlled in the diet
B
Carbohydrates are regulated
C
Exercise is part of the program
D
Eating habits are altered
Question 39 Explanation:
For weight reduction to occur and be maintained, a new dietary program, with a balance of foods from the basic four food groups, must be established and continued
Question 40
The meal pattern that would probably be most appropriate for a client recovering from GI bleeding is:
A
A flexible plan according to his appetite
B
Limited food and fluid intake when he has pain
C
Regular meals and snacks to limit gastric discomfort
D
Three large meals large enough to supply adequate energy.
Question 40 Explanation:
Presence of food in the stomach at regular intervals interacts with HCl limiting acid mucosal irritation. Mucosal irritation can lead to bleeding.
Question 41
The physician orders non-weight bearing with crutches for Joy, who had surgery for a fractured hip. The most important activity to facilitate walking with crutches before ambulation begun is:
A
Exercising the triceps, finger flexors, and elbow extensors
B
Using the trapeze frequently for pull-ups to strengthen the biceps muscles
C
Doing isometric exercises on the unaffected leg
D
Sitting up at the edge of the bed to help strengthen back muscles
Question 41 Explanation:
These sets of muscles are used when walking with crutches and therefore need strengthening prior to ambulation.
Question 42
Oxygen 3L/min by nasal cannula is prescribed for Joey who is admitted to the hospital for chest pain. The nurse institutes safety precautions in the room because oxygen:
A
Is flammable
B
Converts to an alternate form of matter
C
Has unstable properties
D
Supports combustion
Question 42 Explanation:
The nurse should know that Oxygen is necessary to produce fire, thus precautionary measures are important regarding its use.
Question 43
The nurse would know that dietary teaching had been effective for a client with colostomy when he states that he will eat:
A
Food low in fiber so that there is less stool
B
Soft foods that are more easily digested and absorbed by the large intestines
C
Everything he ate before the operation but will avoid those foods that cause gas
D
Bland foods so that his intestines do not become irritated
Question 43 Explanation:
There is no special diets for clients with colostomy. These clients can eat a regular diet. Only gas-forming foods that cause distention and discomfort should be avoided.
Question 44
When preparing to teach a client with colostomy how to irrigate his colostomy, the nurse should plan to perform the procedure:
A
At least 2 hours before visitors arrive
B
When the client would have normally had a bowel movement
C
Before breakfast and morning care
D
After the client accepts he had a bowel movement
Question 44 Explanation:
Irrigation should be performed at the time the client normally defecated before the colostomy to maintain continuity in lifestyle and usual bowel function/habit.
Question 45
Eddie, 40 years old, is brought to the emergency room after the crash of his private plane. He has suffered multiple crushing wounds of the chest, abdomen and legs. It is feared his leg may have to be amputated. When Eddie arrives in the emergency room, the assessment that assume the greatest priority are:
A
Pain, Respiratory rate and blood pressure
B
Quality of respirations and presence of pulsesQuality of respirations and presence of pulses
C
Level of consciousness and pupil size
D
Abdominal contusions and other wounds
Question 45 Explanation:
Respiratory and cardiovascular functions are essential for oxygenation. These are top priorities to trauma management. Basic life functions must be maintained or reestablished
Question 46
The diet ordered for a client with CHF permits him to have a 190 g of carbohydrates, 90 g of fat and 100 g of protein. The nurse understands that this diet contains approximately:
A
2000 calories
B
1600 calories
C
2800 calories
D
2200 calories
Question 46 Explanation:
There are 9 calories in each gram of fat and 4 calories in each gram of carbohydrate and protein
Question 47
After the acute phase of congestive heart failure, the nurse should expect the dietary management of the client to include the restriction of:
A
Sodium
B
Magnesium
C
Calcium
D
Potassium
Question 47 Explanation:
Restriction of sodium reduces the amount of water retention that reduces the cardiac workload
Question 48
The nurse knows that a client with Pernicious Anemia understands the teaching regarding the vitamin B12 injections when she states that she must take it:
A
During exacerbations of anemia
B
For the rest of her life
C
When she feels fatigued
D
Until her symptoms subside
Question 48 Explanation:
Since the intrinsic factor does not return to gastric secretions even with therapy, B12 injections will be required for the remainder of the client’s life.
Question 49
A client has been in a coma for 2 months. The nurse understands that to prevent the effects of shearing force on the skin, the head of the bed should be at an angle of:
A
30 degrees
B
60 degrees
C
90 degrees
D
45 degrees
Question 49 Explanation:
Shearing force occurs when 2 surfaces move against each other; when the bed is at an angle greater than 30 degrees, the torso tends to slide and causes this phenomenon. Shearing forces are good contributory factors of pressure sores.
Question 50
Jose, who had a myocardial infarction 2 days earlier, has been complaining to the nurse about issues related to his hospital stay. The best initial nursing response would be to:
A
Refocus the conversation on his fears, frustrations and anger about his condition
B
Attempt to explain the purpose of different hospital routines
C
Explain how his being upset dangerously disturbs his need for rest
D
Allow him to release his feelings and then leave him alone to allow him to regain his composure
Question 50 Explanation:
This provides the opportunity for the client to verbalize feelings underlying behavior and helpful in relieving anxiety. Anxiety can be a stressor which can activate the sympathoadrenal response causing the release of catecholamines that can increase cardiac contractility and workload that can further increase myocardial oxygen demand.
Question 51
Lucy undergoes Subtotal Thyroidectomy for Grave’s Disease. In planning for the client’s return from the OR, the nurse would consider that in a subtotal thyroidectomy:
A
One parathyroid gland is also removed
B
A portion of the thyroid and four parathyroids are removed
C
The entire thyroid gland is removed
D
A small part of the gland is left intact
Question 51 Explanation:
Remaining thyroid tissue may provide enough hormone for normal function. Total thyroidectomy is generally done in clients with Thyroid Ca.
Question 52
A client with burns on the chest has periodic episodes of dyspnea. The position that would provide for the greatest respiratory capacity would be the:
A
Sims’ position
B
Semi-fowler’s position
C
Orthopneic position
D
Supine position
Question 52 Explanation:
The orthopneic position lowers the diaphragm and provides for maximal thoracic expansion
Question 53
The laboratory results of the client with leukemia indicate bone marrow depression. The nurse should encourage the client to:
A
Increase his activity level and ambulate frequently
B
Drink citrus juices frequently for nourishment
C
Use a soft toothbrush and electric razor
D
Sleep with the head of his bed slightly elevated
Question 53 Explanation:
Suppression of red bone marrow increases bleeding susceptibility associated with thrombocytopenia, decreased platelets. Anemia and leucopenia are the two other problems noted with bone marrow depression.
Question 54
Arthur Cruz, a 45 year old artist, has recently had an abdominoperineal resection and colostomy. Mr. Cruz accuses the nurse of being uncomfortable during a dressing change, because his “wound looks terrible.” The nurse recognizes that the client is using the defense mechanism known as:
A
Intellectualization
B
Projection
C
Sublimation
D
Reaction Formation
Question 54 Explanation:
Projection is the attribution of unacceptable feelings and emotions to others which may indicate the patients nonacceptance of his condition.
Question 55
Ana is diagnosed to have Pernicious anemia. The physician orders 0.2 mg of Cyanocobalamin (Vitamin B12) IM. Available is a vial of the drug labeled 1 ml= 100 mcg. The nurse should administer:
A
0.5 ml
B
1.0 ml
C
1.5 ml
D
2.0 ml
Question 55 Explanation:
First convert milligrams to micrograms and then use ratio and proportion (0.2 mg= 200 mcg) 200 mcg : 100 mcg= X ml : ml 100 X= 200 X = 2 ml. Inject 2 ml. to give 0.2 mg of Cyanocobalamin.
Question 56
Joey is a 46 year-old radio technician who is admitted because of mild chest pain. He is 5 feet, 8 inches tall and weighs 190 pounds. He is diagnosed with a myocardial infarct. Morphine sulfate, Diazepam (Valium) and Lidocaine are prescribed.
The physician orders 8 mg of Morphine Sulfate to be given IV. The vial on hand is labeled 1 ml/ 10 mg. The nurse should administer:
A
10 minims
B
12 minims
C
15 minims
D
8 minims
Question 56 Explanation:
Using ratio and proportion 8 mg/10 mg = X minims/15 minims 10 X= 120 X = 12 minims The nurse will administer 12 minims intravenously equivalent to 8mg Morphine Sulfate
Question 57
Dennis receives a blood transfusion and develops flank pain, chills, fever and hematuria. The nurse recognizes that Dennis is probably experiencing:
A
An allergic transfusion reaction
B
A hemolytic transfusion reaction
C
A pyrogenic transfusion reaction
D
An anaphylactic transfusion reaction
Question 57 Explanation:
This non-judgmentally on the part of the nurse points out the client’s behavior.This results from a recipient’s antibodies that are incompatible with transfused RBC’s; also called type II hypersensitivity; these signs result from RBC hemolysis, agglutination, and capillary plugging that can damage renal function, thus the flank pain and hematuria and the other manifestations.
Question 58
Clara is a 37-year old cook. She is admitted for treatment of partial and full-thickness burns of her entire right lower extremity and the anterior portion of her right upper extremity. Her respiratory status is compromised, and she is in pain and anxious. Performing an immediate appraisal, using the rule of nines, the nurse estimates the percent of Clara’s body surface that is burned is:
A
9%
B
18 %
C
22.5%
D
4.5%
Question 58 Explanation:
The entire right lower extremity is 18% the anterior portion of the right upper extremity is 4.5% giving a total of 22.5%
Question 59
The transurethral resection of the prostate is performed on a client with BPH. Following surgery, nursing care should include:
A
Maintaining patency of a three-way Foley catheter for cystoclysis
B
Observing for hemorrhage and wound infection
C
Maintaining patency of the cystotomy tube
D
Changing the abdominal dressing
Question 59 Explanation:
Patency of the catheter promotes bladder decompression, which prevents distention and bleeding. Continuous flow of fluid through the bladder limits clot formation and promotes hemostasis
Question 60
Mr. Ong, a client with CHF, has been receiving a cardiac glycoside, a diuretic, and a vasodilator drug. His apical pulse rate is 44 and he is on bed rest. The nurse concludes that his pulse rate is most likely the result of the:
A
Diuretic
B
Cardiac glycoside
C
Vasodilator
D
Bed-rest regimen
Question 60 Explanation:
A cardiac glycoside such as digitalis increases force of cardiac contraction, decreases the conduction speed of impulses within the myocardium and slows the heart rate.
Question 61
When observing an ostomate do a return demonstration of the colostomy irrigation, the nurse notes that he needs more teaching if he:
A
Discontinues the insertion of fluid after only 500 ml of fluid has been instilled
B
Stops the flow of fluid when he feels uncomfortable
C
Hangs the bag on a clothes hook on the bathroom door during fluid insertion
D
Lubricates the tip of the catheter before inserting it into the stoma
Question 61 Explanation:
The irrigation bag should be hung 12-18 inches above the level of the stoma; a clothes hook is too high which can create increase pressure and sudden intestinal distention and cause abdominal discomfort to the patient.
Question 62
Thrombus formation is a danger for all postoperative clients. The nurse should act independently to prevent this complication by:
A
Performing active-assistive leg exercises
B
Applying elastic stockings
C
Massaging gently the legs with lotion
D
Encouraging adequate fluids
Question 62 Explanation:
Inactivity causes venous stasis, hypercoagulability, and external pressure against the veins, all of which lead to thrombus formation. Early ambulation or exercise of the lower extremities reduces the occurrence of this phenomenon
Question 63
Twenty four hours after admission for an Acute MI, Jose’s temperature is noted at 39.3 C. The nurse monitors him for other adaptations related to the pyrexia, including:
A
Chest pain
B
Elevated blood pressure
C
Increased pulse rate
D
Shortness of breath
Question 63 Explanation:
Fever causes an increase in the body’s metabolism, which results in an increase in oxygen consumption and demand. This need for oxygen increases the heart rate, which is reflected in the increased pulse rate. Increased BP, chest pain and shortness of breath are not typically noted in fever.
Question 64
The nurse applies mafenide acetate (Sulfamylon cream) to Clara, who has second and third degree burns on the right upper and lower extremities, as ordered by the physician. This medication will:
A
Provide chemical debridement
B
Relieve pain from the burn
C
Inhibit bacterial growth
D
Prevent scar tissue formation
Question 64 Explanation:
Sulfamylon is effective against a wide variety of gram positive and gram negative organisms including anaerobes
Question 65
Following prostate surgery, the retention catheter is secured to the client’s leg causing slight traction of the inflatable balloon against the prostatic fossa. This is done to:
A
Limit discomfort
B
Reduce bladder spasms
C
Provide hemostasis
D
Promote urinary drainage
Question 65 Explanation:
The pressure of the balloon against the small blood vessels of the prostate creates a tampon-like effect that causes them to constrict thereby preventing bleeding.
Question 66
A client with multiple injury following a vehicular accident is transferred to the critical care unit. He begins to complain of increased abdominal pain in the left upper quadrant. A ruptured spleen is diagnosed and he is scheduled for emergency splenectomy. In preparing the client for surgery, the nurse should emphasize in his teaching plan the:
A
Presence of abdominal drains for several days after surgery
B
Expectation of postoperative bleeding
C
Complete safety of the procedure
D
Risk of the procedure with his other injuries
Question 66 Explanation:
Drains are usually inserted into the splenic bed to facilitate removal of fluid in the area that could lead to abscess formation.
Question 67
Larry is diagnosed as having myelocytic leukemia and is admitted to the hospital for chemotherapy. Larry discusses his recent diagnosis of leukemia by referring to statistical facts and figures. The nurse recognizes that Larry is using the defense mechanism known as:
A
Projection
B
Intellectualization
C
Reaction formation
D
Sublimation
Question 67 Explanation:
People use defense mechanisms to cope with stressful events. Intellectualization is the use of reasoning and thought processes to avoid the emotional upsets.
Question 68
Routine postoperative IV fluids are designed to supply hydration and electrolyte and only limited energy. Because 1 L of a 5% dextrose solution contains 50 g of sugar, 3 L per day would apply approximately:
A
1000 Kilocalories
B
600 Kilocalories
C
400 Kilocalories
D
800 Kilocalories
Question 68 Explanation:
Carbohydrates provide 4 kcal/ gram; therefore 3L x 50 g/L x 4 kcal/g = 600 kcal; only about a third of the basal energy need.
Question 69
A client with a history of recurrent GI bleeding is admitted to the hospital for a gastrectomy. Following surgery, the client has a nasogastric tube to low continuous suction. He begins to hyperventilate. The nurse should be aware that this pattern will alter his arterial blood gases by:
A
Decreasing PO2
B
Increasing HCO3
C
Decreasing pH
D
Decreasing PCO2
Question 69 Explanation:
Hyperventilation results in the increased elimination of carbon dioxide from the blood that can lead to respiratory alkalosis.
Question 70
To promote continued improvement in the respiratory status of a client following chest tube removal after a chest surgery for multiple rib fracture, the nurse should:
A
Encourage bed rest with active and passive range of motion exercises
B
Continue observing for dyspnea and crepitus
C
Turn him from side to side at least every 2 hours
D
Encourage frequent coughing and deep breathing
Question 70 Explanation:
This nursing action prevents atelectasis and collection of respiratory secretions and promotes adequate ventilation and gas exchange.
Question 71
Twenty-four hours after TURP surgery, the client tells the nurse he has lower abdominal discomfort. The nurse notes that the catheter drainage has stopped. The nurse’s initial action should be to:
A
Milk the catheter tubing
B
Irrigate the catheter with saline
C
Remove the catheter
D
Notify the physician
Question 71 Explanation:
Milking the tubing will usually dislodge the plug and will not harm the client. A physician’s order is not necessary for a nurse to check catheter patency.
Question 72
A client undergoes below the knee amputation following a vehicular accident. Three days postoperatively, the client is refusing to eat, talk or perform any rehabilitative activities. The best initial nursing approach would be to:
A
Accept and acknowledge that his withdrawal is an initially normal and necessary part of grieving
B
Give him explanations of why there is a need to quickly increase his activity
C
Emphasize repeatedly that with as prosthesis, he will be able to return to his normal lifestyle
D
Appear cheerful and non-critical regardless of his response to attempts at intervention
Question 72 Explanation:
The withdrawal provides time for the client to assimilate what has occurred and integrate the change in the body image. Acceptance of the client’s behavior is an important factor in the nurse’s intervention.
Question 73
The key factor in accurately assessing how body image changes will be dealt with by the client is the:
A
Extent of body change present
B
Obviousness of the change
C
Client’s perception of the change
D
Suddenness of the change
Question 73 Explanation:
It is not reality, but the client’s feeling about the change that is the most important determinant of the ability to cope. The client should be encouraged to his feelings.
Question 74
When a post-thyroidectomy client returns from surgery the nurse assesses her for unilateral injury of the laryngeal nerve every 30 to 60 minutes by:
A
Asking her to state her name out loud
B
hecking her throat for swelling
C
Palpating the side of her neck for blood seepage
D
Observing for signs of tetany
Question 74 Explanation:
If the recurrent laryngeal nerve is damaged during surgery, the client will be hoarse and have difficult speaking.
Question 75
Forty-eight hours after a burn injury, the physician orders for the client 2 liters of IV fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide:
A
32 gtt/min
B
36 gtt/min
C
18 gtt/min
D
28 gtt/min
Question 75 Explanation:
This is the correct flow rate; multiply the amount to be infused (2000 ml) by the drop factor (10) and divide the result by the amount of time in minutes (12 hours x 60 minutes)
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1. The nurse is assisting in planning care for a client with a diagnosis of immune deficiency. The nurse would incorporate which of the ff. as a priority in the plan of care?
providing emotional support to decrease fear
protecting the client from infection
encouraging discussion about lifestyle changes
.identifying factors that decreased the immune function
2. Joy, an obese 32 year old, is admitted to the hospital after an automobile accident. She has a fractured hip and is brought to the OR for surgery.
After surgery Joy is to receive a piggy-back of Clindamycin phosphate (Cleocin) 300 mg in 50 ml of D5W. The piggyback is to infuse in 20 minutes. The drop factor of the IV set is 10 gtt/ml. The nurse should set the piggyback to flow at:
25 gtt/min
30 gtt/min
5 gtt/min
45 gtt/min
3. The day after her surgery Joy asks the nurse how she might lose weight. Before answering her question, the nurse should bear in mind that long-term weight loss best occurs when:
Fats are controlled in the diet
Eating habits are altered
Carbohydrates are regulated
Exercise is part of the program
4. The nurse teaches Joy, an obese client, the value of aerobic exercises in her weight reduction program. The nurse would know that this teaching was effective when Joy says that exercise will:
Increase her lean body mass
Lower her metabolic rate
Decrease her appetite
Raise her heart rate
5. The physician orders non-weight bearing with crutches for Joy, who had surgery for a fractured hip. The most important activity to facilitate walking with crutches before ambulation begun is:
Exercising the triceps, finger flexors, and elbow extensors
Sitting up at the edge of the bed to help strengthen back muscles
Doing isometric exercises on the unaffected leg
Using the trapeze frequently for pull-ups to strengthen the biceps muscles
6. The nurse recognizes that a client understood the demonstration of crutch walking when she places her weight on:
The palms and axillary regions
Both feet placed wide apart
The palms of her hands
Her axillary regions
7. Joey is a 46 year-old radio technician who is admitted because of mild chest pain. He is 5 feet, 8 inches tall and weighs 190 pounds. He is diagnosed with a myocardial infarct. Morphine sulfate, Diazepam (Valium) and Lidocaine are prescribed.
The physician orders 8 mg of Morphine Sulfate to be given IV. The vial on hand is labeled 1 ml/ 10 mg. The nurse should administer:
8 minims
10 minims
12 minims
15 minims
8. Joey asks the nurse why he is receiving the injection of Morphine after he was hospitalized for severe anginal pain. The nurse replies that it:
Will help prevent erratic heart beats
Relieves pain and decreases level of anxiety
Decreases anxiety
Dilates coronary blood vessels
9. Oxygen 3L/min by nasal cannula is prescribed for Joey who is admitted to the hospital for chest pain. The nurse institutes safety precautions in the room because oxygen:
Converts to an alternate form of matter
Has unstable properties
Supports combustion
Is flammable
10. Myra is ordered laboratory tests after she is admitted to the hospital for angina. The isoenzyme test that is the most reliable early indicator of myocardial insult is:
SGPT
LDH
CK-MB
AST
11. An early finding in the EKG of a client with an infarcted mycardium would be:
Disappearance of Q waves
Elevated ST segments
Absence of P wave
Flattened T waves
12. Jose, who had a myocardial infarction 2 days earlier, has been complaining to the nurse about issues related to his hospital stay. The best initial nursing response would be to:
Allow him to release his feelings and then leave him alone to allow him to regain his composure
Refocus the conversation on his fears, frustrations and anger about his condition
Explain how his being upset dangerously disturbs his need for rest
Attempt to explain the purpose of different hospital routines
13. Twenty four hours after admission for an Acute MI, Jose’s temperature is noted at 39.3 C. The nurse monitors him for other adaptations related to the pyrexia, including:
Shortness of breath
Chest pain
Elevated blood pressure
Increased pulse rate
14. Jose, who is admitted to the hospital for chest pain, asks the nurse, “Is it still possible for me to have another heart attack if I watch my diet religiously and avoid stress?” The most appropriate initial response would be for the nurse to:
Suggest he discuss his feelings of vulnerability with his physician.
Tell him that he certainly needs to be especially careful about his diet and lifestyle.
Avoid giving him direct information and help him explore his feelings
Recognize that he is frightened and suggest he talk with the psychiatrist or counselor.
15. Ana, 55 years old, is admitted to the hospital to rule out pernicious anemia. A Schilling test is ordered for Ana. The nurse recognizes that the primary purpose of the Schilling test is to determine the client’s ability to:
Store vitamin B12
Digest vitamin B12
Absorb vitamin B12
Produce vitamin B12
16. Ana is diagnosed to have Pernicious anemia. The physician orders 0.2 mg of Cyanocobalamin (Vitamin B12) IM. Available is a vial of the drug labeled 1 ml= 100 mcg. The nurse should administer:
0.5 ml
1.0 ml
1.5 ml
2.0 ml
17. Health teachings to be given to a client with Pernicious Anemia regarding her therapeutic regimen concerning Vit. B12 will include:
Oral tablets of Vitamin B12 will control her symptoms
IM injections are required for daily control
IM injections once a month will maintain control
Weekly Z-track injections provide needed control
18. The nurse knows that a client with Pernicious Anemia understands the teaching regarding the vitamin B12 injections when she states that she must take it:
When she feels fatigued
During exacerbations of anemia
Until her symptoms subside
For the rest of her life
19. Arthur Cruz, a 45 year old artist, has recently had an abdominoperineal resection and colostomy. Mr. Cruz accuses the nurse of being uncomfortable during a dressing change, because his “wound looks terrible.” The nurse recognizes that the client is using the defense mechanism known as:
Reaction Formation
Sublimation
Intellectualization
Projection
20. When preparing to teach a client with colostomy how to irrigate his colostomy, the nurse should plan to perform the procedure:
When the client would have normally had a bowel movement
After the client accepts he had a bowel movement
Before breakfast and morning care
At least 2 hours before visitors arrive
21. When observing an ostomate do a return demonstration of the colostomy irrigation, the nurse notes that he needs more teaching if he:
Stops the flow of fluid when he feels uncomfortable
Lubricates the tip of the catheter before inserting it into the stoma
Hangs the bag on a clothes hook on the bathroom door during fluid insertion
Discontinues the insertion of fluid after only 500 ml of fluid has been instilled
22. When doing colostomy irrigation at home, a client with colostomy should be instructed to report to his physician :
Abdominal cramps during fluid inflow
Difficulty in inserting the irrigating tube
Passage of flatus during expulsion of feces
Inability to complete the procedure in half an hour
23. A client with colostomy refuses to allow his wife to see the incision or stoma and ignores most of his dietary instructions. The nurse on assessing this data, can assume that the client is experiencing:
A reaction formation to his recent altered body image.
A difficult time accepting reality and is in a state of denial.
Impotency due to the surgery and needs sexual counseling
Suicide thoughts and should be seen by psychiatrist
24. The nurse would know that dietary teaching had been effective for a client with colostomy when he states that he will eat:
Food low in fiber so that there is less stool
Everything he ate before the operation but will avoid those foods that cause gas
Bland foods so that his intestines do not become irritated
Soft foods that are more easily digested and absorbed by the large intestines
25. Eddie, 40 years old, is brought to the emergency room after the crash of his private plane. He has suffered multiple crushing wounds of the chest, abdomen and legs. It is feared his leg may have to be amputated. When Eddie arrives in the emergency room, the assessment that assume the greatest priority are:
Level of consciousness and pupil size
Abdominal contusions and other wounds
Pain, Respiratory rate and blood pressure
Quality of respirations and presence of pulsesQuality of respirations and presence of pulses
26. Eddie, a plane crash victim, undergoes endotracheal intubation and positive pressure ventilation. The most immediate nursing intervention for him at this time would be to:
Facilitate his verbal communication
Maintain sterility of the ventilation system
Assess his response to the equipment
Prepare him for emergency surgery
27. A chest tube with water seal drainage is inserted to a client following a multiple chest injury. A few hours later, the client’s chest tube seems to be obstructed. The most appropriate nursing action would be to
Prepare for chest tube removal
Milk the tube toward the collection container as ordered
Arrange for a stat Chest x-ray film.
Clam the tube immediately
28. The observation that indicates a desired response to thoracostomy drainage of a client with chest injury is:
Increased breath sounds
Constant bubbling in the drainage chamber
Crepitus detected on palpation of chest
Increased respiratory rate
29. In the evaluation of a client’s response to fluid replacement therapy, the observation that indicates adequate tissue perfusion to vital organs is:
Urinary output is 30 ml in an hour
Central venous pressure reading of 2 cm H2O
Pulse rates of 120 and 110 in a 15 minute period
Blood pressure readings of 50/30 and 70/40 within 30 minutes
30. A client with multiple injury following a vehicular accident is transferred to the critical care unit. He begins to complain of increased abdominal pain in the left upper quadrant. A ruptured spleen is diagnosed and he is scheduled for emergency splenectomy. In preparing the client for surgery, the nurse should emphasize in his teaching plan the:
Complete safety of the procedure
Expectation of postoperative bleeding
Risk of the procedure with his other injuries
Presence of abdominal drains for several days after surgery
31. To promote continued improvement in the respiratory status of a client following chest tube removal after a chest surgery for multiple rib fracture, the nurse should:
Encourage bed rest with active and passive range of motion exercises
Encourage frequent coughing and deep breathing
Turn him from side to side at least every 2 hours
Continue observing for dyspnea and crepitus
32. A client undergoes below the knee amputation following a vehicular accident. Three days postoperatively, the client is refusing to eat, talk or perform any rehabilitative activities. The best initial nursing approach would be to:
Give him explanations of why there is a need to quickly increase his activity
Emphasize repeatedly that with as prosthesis, he will be able to return to his normal lifestyle
Appear cheerful and non-critical regardless of his response to attempts at intervention
Accept and acknowledge that his withdrawal is an initially normal and necessary part of grieving
33. The key factor in accurately assessing how body image changes will be dealt with by the client is the:
Extent of body change present
Suddenness of the change
Obviousness of the change
Client’s perception of the change
34. Larry is diagnosed as having myelocytic leukemia and is admitted to the hospital for chemotherapy. Larry discusses his recent diagnosis of leukemia by referring to statistical facts and figures. The nurse recognizes that Larry is using the defense mechanism known as:
Reaction formation
Sublimation
Intellectualization
Projection
35. The laboratory results of the client with leukemia indicate bone marrow depression. The nurse should encourage the client to:
Increase his activity level and ambulate frequently
Sleep with the head of his bed slightly elevated
Drink citrus juices frequently for nourishment
Use a soft toothbrush and electric razor
36. Dennis receives a blood transfusion and develops flank pain, chills, fever and hematuria. The nurse recognizes that Dennis is probably experiencing:
An anaphylactic transfusion reaction
An allergic transfusion reaction
A hemolytic transfusion reaction
A pyrogenic transfusion reaction
37. A client jokes about his leukemia even though he is becoming sicker and weaker. The nurse’s most therapeutic response would be:
“Your laugher is a cover for your fear.”
“He who laughs on the outside, cries on the inside.”
“Why are you always laughing?”
“Does it help you to joke about your illness?”
38. In dealing with a dying client who is in the denial stage of grief, the best nursing approach is to:
Agree with and encourage the client’s denial
Reassure the client that everything will be okay
Allow the denial but be available to discuss death
Leave the client alone to discuss the loss
39. During and 8 hour shift, Mario drinks two 6 oz. cups of tea and vomits 125 ml of fluid. During this 8 hour period, his fluid balance would be:
+55 ml
+137 ml
+235 ml
+485 ml
40. Mr. Ong is admitted to the hospital with a diagnosis of Left-sided CHF. In the assessment, the nurse should expect to find:
Crushing chest pain
Dyspnea on exertion
Extensive peripheral edema
Jugular vein distention
41. The physician orders on a client with CHF a cardiac glycoside, a vasodilator, and furosemide (Lasix). The nurse understands Lasix exerts is effects in the:
Distal tubule
Collecting duct
Glomerulus of the nephron
Ascending limb of the loop of Henle
42. Mr. Ong weighs 210 lbs on admission to the hospital. After 2 days of diuretic therapy he weighs 205.5 lbs. The nurse could estimate that the amount of fluid he has lost is:
0.5 L
1.0 L
2.0 L
3.5 L
43. Mr. Ong, a client with CHF, has been receiving a cardiac glycoside, a diuretic, and a vasodilator drug. His apical pulse rate is 44 and he is on bed rest. The nurse concludes that his pulse rate is most likely the result of the:
Diuretic
Vasodilator
Bed-rest regimen
Cardiac glycoside
44. The diet ordered for a client with CHF permits him to have a 190 g of carbohydrates, 90 g of fat and 100 g of protein. The nurse understands that this diet contains approximately:
2200 calories
2000 calories
2800 calories
1600 calories
45. After the acute phase of congestive heart failure, the nurse should expect the dietary management of the client to include the restriction of:
Magnesium
Sodium
Potassium
Calcium
46. Jude develops GI bleeding and is admitted to the hospital. An important etiologic clue for the nurse to explore while taking his history would be:
The medications he has been taking
Any recent foreign travel
His usual dietary pattern
His working patterns
47. The meal pattern that would probably be most appropriate for a client recovering from GI bleeding is:
Three large meals large enough to supply adequate energy.
Regular meals and snacks to limit gastric discomfort
Limited food and fluid intake when he has pain
A flexible plan according to his appetite
48. A client with a history of recurrent GI bleeding is admitted to the hospital for a gastrectomy. Following surgery, the client has a nasogastric tube to low continuous suction. He begins to hyperventilate. The nurse should be aware that this pattern will alter his arterial blood gases by:
Increasing HCO3
Decreasing PCO2
Decreasing pH
Decreasing PO2
49. Routine postoperative IV fluids are designed to supply hydration and electrolyte and only limited energy. Because 1 L of a 5% dextrose solution contains 50 g of sugar, 3 L per day would apply approximately:
400 Kilocalories
600 Kilocalories
800 Kilocalories
1000 Kilocalories
50. Thrombus formation is a danger for all postoperative clients. The nurse should act independently to prevent this complication by:
Encouraging adequate fluids
Applying elastic stockings
Massaging gently the legs with lotion
Performing active-assistive leg exercises
51. An unconscious client is admitted to the ICU, IV fluids are started and a Foley catheter is inserted. With an indwelling catheter, urinary infection is a potential danger. The nurse can best plan to avoid this problem by:
Emptying the drainage bag frequently
Collecting a weekly urine specimen
Maintaining the ordered hydration
Assessing urine specific gravity
52. The nurse performs full range of motion on a bedridden client’s extremities. When putting his ankle through range of motion, the nurse must perform:
Flexion, extension and left and right rotation
Abduction, flexion, adduction and extension
Pronation, supination, rotation, and extension
Dorsiflexion, plantar flexion, eversion and inversion
53. A client has been in a coma for 2 months. The nurse understands that to prevent the effects of shearing force on the skin, the head of the bed should be at an angle of:
30 degrees
45 degrees
60 degrees
90 degrees
54. Rene, age 62, is scheduled for a TURP after being diagnosed with a Benign Prostatic Hyperplasia (BPH). As part of the preoperative teaching, the nurse should tell the client that after surgery:
Urinary control may be permanently lost to some degree
Urinary drainage will be dependent on a urethral catheter for 24 hours
Frequency and burning on urination will last while the cystotomy tube is in place
His ability to perform sexually will be permanently impaired
55. The transurethral resection of the prostate is performed on a client with BPH. Following surgery, nursing care should include:
Changing the abdominal dressing
Maintaining patency of the cystotomy tube
Maintaining patency of a three-way Foley catheter for cystoclysis
Observing for hemorrhage and wound infection
56. In the early postoperative period following a transurethral surgery, the most common complication the nurse should observe for is:
Sepsis
Hemorrhage
Leakage around the catheter
Urinary retention with overflow
57. Following prostate surgery, the retention catheter is secured to the client’s leg causing slight traction of the inflatable balloon against the prostatic fossa. This is done to:
Limit discomfort
Provide hemostasis
Reduce bladder spasms
Promote urinary drainage
58. Twenty-four hours after TURP surgery, the client tells the nurse he has lower abdominal discomfort. The nurse notes that the catheter drainage has stopped. The nurse’s initial action should be to:
Irrigate the catheter with saline
Milk the catheter tubing
Remove the catheter
Notify the physician
59. The nurse would know that a post-TURP client understood his discharge teaching when he says “I should:”
Get out of bed into a chair for several hours daily
Call the physician if my urinary stream decreases
Attempt to void every 3 hours when I’m awake
Avoid vigorous exercise for 6 months after surgery
60. Lucy is admitted to the surgical unit for a subtotal thyroidectomy. She is diagnosed with Grave’s Disease. When assessing Lucy, the nurse would expect to find:
Lethargy, weight gain, and forgetfulness
Weight loss, protruding eyeballs, and lethargy
Weight loss, exopthalmos and restlessness
Constipation, dry skin, and weight gain
61. Lucy undergoes Subtotal Thyroidectomy for Grave’s Disease. In planning for the client’s return from the OR, the nurse would consider that in a subtotal thyroidectomy:
The entire thyroid gland is removed
A small part of the gland is left intact
One parathyroid gland is also removed
A portion of the thyroid and four parathyroids are removed
62. Before a post- thyroidectomy client returns to her room from the OR, the nurse plans to set up emergency equipment, which should include:
A crash cart with bed board
A tracheostomy set and oxygen
An airway and rebreathing mask
Two ampules of sodium bicarbonate
63. When a post-thyroidectomy client returns from surgery the nurse assesses her for unilateral injury of the laryngeal nerve every 30 to 60 minutes by:
Observing for signs of tetany
Checking her throat for swelling
Asking her to state her name out loud
Palpating the side of her neck for blood seepage
64. On a post-thyroidectomy client’s discharge, the nurse teaches her to observe for signs of surgically induced hypothyroidism. The nurse would know that the client understands the teaching when she states she should notify the physician if she develops:
Intolerance to heat
Dry skin and fatigue
Progressive weight loss
Insomnia and excitability
65. A client’s exopthalmos continues inspite of thyroidectomy for Grave’s Disease. The nurse teaches her how to reduce discomfort and prevent corneal ulceration. The nurse recognizes that the client understands the teaching when she says: “I should:
Elevate the head of my bed at night
Avoid moving my extra-ocular muscles
Avoid using a sleeping mask at night
Avoid excessive blinking
66. Clara is a 37-year old cook. She is admitted for treatment of partial and full-thickness burns of her entire right lower extremity and the anterior portion of her right upper extremity. Her respiratory status is compromised, and she is in pain and anxious. Performing an immediate appraisal, using the rule of nines, the nurse estimates the percent of Clara’s body surface that is burned is:
4.5%
9%
18 %
22.5%
67. The nurse applies mafenide acetate (Sulfamylon cream) to Clara, who has second and third degree burns on the right upper and lower extremities, as ordered by the physician. This medication will:
Inhibit bacterial growth
Relieve pain from the burn
Prevent scar tissue formation
Provide chemical debridement
68. Forty-eight hours after a burn injury, the physician orders for the client 2 liters of IV fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide:
18 gtt/min
28 gtt/min
32 gtt/min
36 gtt/min
69. Clara, a burn client, receives a temporary heterograft (pig skin) on some of her burns. These grafts will:
Debride necrotic epithelium
Be sutured in place for better adherence
Relieve pain and promote rapid epithelialization
Frequently be used concurrently with topical antimicrobials.
70. A client with burns on the chest has periodic episodes of dyspnea. The position that would provide for the greatest respiratory capacity would be the:
Semi-fowler’s position
Sims’ position
Orthopneic position
Supine position
71. Jane, a 20- year old college student is admiited to the hospital with a tentative diagnosis of myasthenia gravis. She is scheduled to have a series of diagnostic studies for myasthenia gravis, including a Tensilon test. In preparing her for this procedure, the nurse explains that her response to the medication will confirm the diagnosis if Tensilon produces:
Brief exaggeration of symptoms
Prolonged symptomatic improvement
Rapid but brief symptomatic improvement
Symptomatic improvement of just the ptosis
72. The initial nursing goal for a client with myasthenia gravis during the diagnostic phase of her hospitalization would be to:
Develop a teaching plan
Facilitate psychologic adjustment
Maintain the present muscle strength
Prepare for the appearance of myasthenic crisis
73. The most significant initial nursing observations that need to be made about a client with myasthenia include:
Ability to chew and speak distinctly
Degree of anxiety about her diagnosis
Ability to smile an to close her eyelids
Respiratory exchange and ability to swallow
74. Helen is diagnosed with myasthenia gravis and pyridostigmine bromide (Mestinon) therapy is started. The Mestinon dosage is frequently changed during the first week. While the dosage is being adjusted, the nurse’s priority intervention is to:
Administer the medication exactly on time
Administer the medication with food or mild
Evaluate the client’s muscle strength hourly after medication
Evaluate the client’s emotional side effects between doses
75. Helen, a client with myasthenia gravis, begins to experience increased difficulty in swallowing. To prevent aspiration of food, the nursing action that would be most effective would be to:
Change her diet order from soft foods to clear liquids
Place an emergency tracheostomy set in her room
Assess her respiratory status before and after meals
Coordinate her meal schedule with the peak effect of her medication, Mestinon
Answers and Rationales
Answer: (B) protecting the client from infection. Immunodeficiency is an absent or depressed immune response that increases susceptibility to infection. So it is the nurse’s primary responsibility to protect the patient from infection.
Answer: (A) 25 gtt/min . To get the correct flow rate: multiply the amount to be infused (50 ml) by the drop factor (10) and divide the result by the amount of time in minutes (20)
Answer: (B) Eating habits are altered . For weight reduction to occur and be maintained, a new dietary program, with a balance of foods from the basic four food groups, must be established and continued
Answer: (A) Increase her lean body mass . Increased exercise builds skeletal muscle mass and reduces excess fatty tissue.
Answer: (A) Exercising the triceps, finger flexors, and elbow extensors . These sets of muscles are used when walking with crutches and therefore need strengthening prior to ambulation.
Answer: (C) The palms of her hands .The palms should bear the client’s weight to avoid damage to the nerves in the axilla (brachial plexus)
Answer: (C) 12 minims . Using ratio and proportion 8 mg/10 mg = X minims/15 minims 10 X= 120 X = 12 minims The nurse will administer 12 minims intravenously equivalent to 8mg Morphine Sulfate
Answer: (B) Relieves pain and decreases level of anxiety. Morphine is a specific central nervous system depressant used to relieve the pain associated with myocardial infarction. It also decreases anxiety and apprehension and prevents cardiogenic shock by decreasing myocardial oxygen demand.
Answer: (C) Supports combustion. The nurse should know that Oxygen is necessary to produce fire, thus precautionary measures are important regarding its use.
Answer: (C) CK-MB. The cardiac marker, Creatinine phosphokinase (CPK) isoenzyme levels, especially the MB sub-unit which is cardio-specific, begin to rise in 3-6 hours, peak in 12-18 hours and are elevated 48 hours after the occurrence of the infarct. They are therefore most reliable in assisting with early diagnosis. The cardiac markers elevate as a result of myocardial tissue damage.
Answer: (B) Elevated STsegments . This is a typical early finding after a myocardial infarct because of the altered contractility of the heart. The other choices are not typical of MI.
Answer: (B) Refocus the conversation on his fears, frustrations and anger about his condition . This provides the opportunity for the client to verbalize feelings underlying behavior and helpful in relieving anxiety. Anxiety can be a stressor which can activate the sympathoadrenal response causing the release of catecholamines that can increase cardiac contractility and workload that can further increase myocardial oxygen demand.
Answer: (D) Increased pulse rate . Fever causes an increase in the body’s metabolism, which results in an increase in oxygen consumption and demand. This need for oxygen increases the heart rate, which is reflected in the increased pulse rate. Increased BP, chest pain and shortness of breath are not typically noted in fever.
Answer: (C) Avoid giving him direct information and help him explore his feelings . To help the patient verbalize and explore his feelings, the nurse must reflect and analyze the feelings that are implied in the client’s question. The focus should be on collecting data to minister to the client’s psychosocial needs.
Answer: (C) Absorb vitamin B12 . Pernicious anemia is caused by the inability to absorb vitamin B12 in the stomach due to a lack of intrinsic factor in the gastric juices. In the Schilling test, radioactive vitamin B12 is administered and its absorption and excretion can be ascertained through the urine.
Answer: (D) 2.0 ml . First convert milligrams to micrograms and then use ratio and proportion (0.2 mg= 200 mcg) 200 mcg : 100 mcg= X ml : ml 100 X= 200 X = 2 ml. Inject 2 ml. to give 0.2 mg of Cyanocobalamin.
Answer: (C) IM injections once a month will maintain control . Deep IM injections bypass B12 absorption defect in the stomach due to lack of intrinsic factor, the transport carrier component of gastric juices. A monthly dose is usually sufficient since it is stored in active body tissues such as the liver, kidney, heart, muscles, blood and bone marrow
Answer: (D) For the rest of her life . Since the intrinsic factor does not return to gastric secretions even with therapy, B12 injections will be required for the remainder of the client’s life.
Answer: (D) Projection. Projection is the attribution of unacceptable feelings and emotions to others which may indicate the patients nonacceptance of his condition.
Answer: (A) When the client would have normally had a bowel movement . Irrigation should be performed at the time the client normally defecated before the colostomy to maintain continuity in lifestyle and usual bowel function/habit.
Answer: (C) Hangs the bag on a clothes hook on the bathroom door during fluid insertion . The irrigation bag should be hung 12-18 inches above the level of the stoma; a clothes hook is too high which can create increase pressure and sudden intestinal distention and cause abdominal discomfort to the patient.
Answer: (B) Difficulty in inserting the irrigating tube . Difficulty of inserting the irrigating tube indicates stenosis of the stoma and should be reported to the physician. Abdominal cramps and passage of flatus can be expected during colostomy irrigations. The procedure may take longer than half an hour.
Answer: (B) A difficult time accepting reality and is in a state of denial. As long as no one else confirms the presence of the stoma and the client does not need to adhere to a prescribed regimen, the client’s denial is supported
Answer: (B) Everything he ate before the operation but will avoid those foods that cause gas . There is no special diets for clients with colostomy. These clients can eat a regular diet. Only gas-forming foods that cause distention and discomfort should be avoided.
Answer: (D) Quality of respirations and presence of pulsesQuality of respirations and presence of pulses . Respiratory and cardiovascular functions are essential for oxygenation. These are top priorities to trauma management. Basic life functions must be maintained or reestablished
Answer: (C) Assess his response to the equipment . It is a primary nursing responsibility to evaluate effect of interventions done to the client. Nothing is achieved if the equipment is working and the client is not responding
Answer: (B) Milk the tube toward the collection container as ordered . This assists in moving blood, fluid or air, which may be obstructing drainage, toward the collection chamber
Answer: (A) Increased breath sounds . The chest tube normalizes intrathoracic pressure and restores negative intra-pleural pressure, drains fluid and air from the pleural space, and improves pulmonary function
Answer: (A) Urinary output is 30 ml in an hour . A rate of 30 ml/hr is considered adequate for perfusion of kidney, heart and brain.
Answer: (D) Presence of abdominal drains for several days after surgery . Drains are usually inserted into the splenic bed to facilitate removal of fluid in the area that could lead to abscess formation.
Answer: (B) Encourage frequent coughing and deep breathing . This nursing action prevents atelectasis and collection of respiratory secretions and promotes adequate ventilation and gas exchange.
Answer: (D) Accept and acknowledge that his withdrawal is an initially normal and necessary part of grieving . The withdrawal provides time for the client to assimilate what has occurred and integrate the change in the body image. Acceptance of the client’s behavior is an important factor in the nurse’s intervention.
Answer: (D) Client’s perception of the change . It is not reality, but the client’s feeling about the change that is the most important determinant of the ability to cope. The client should be encouraged to his feelings.
Answer: (C) Intellectualization . People use defense mechanisms to cope with stressful events. Intellectualization is the use of reasoning and thought processes to avoid the emotional upsets.
Answer: (D) Use a soft toothbrush and electric razor . Suppression of red bone marrow increases bleeding susceptibility associated with thrombocytopenia, decreased platelets. Anemia and leucopenia are the two other problems noted with bone marrow depression.
Answer: (C) A hemolytic transfusion reaction . This results from a recipient’s antibodies that are incompatible with transfused RBC’s; also called type II hypersensitivity; these signs result from RBC hemolysis, agglutination, and capillary plugging that can damage renal function, thus the flank pain and hematuria and the other manifestations.
Answer: (D) “Does it help you to joke about your illness?” . This non-judgmentally on the part of the nurse points out the client’s behavior.
Answer: (C) Allow the denial but be available to discuss death . This does not take away the client’s only way of coping, and it permits future movement through the grieving process when the client is ready. Dying clients move through the different stages of grieving and the nurse must be ready to intervene in all these stages.
Answer: (C) +235 ml . The client’s intake was 360 ml (6oz x 30 ml) and loss was 125 ml of fluid; loss is subtracted from intake
Answer: (B) Dyspnea on exertion . Pulmonary congestion and edema occur because of fluid extravasation from the pulmonary capillary bed, resulting in difficult breathing. Left-sided heart failure creates a backward effect on the pulmonary system that leads to pulmonary congestion.
Answer: (D) Ascending limb of the loop of Henle . This is the site of action of Lasix being a potent loop diuretic.
Answer: (C) 2.0 L . One liter of fluid weighs approximately 2.2 lbs. Therefore a 4.5 lbs weight loss equals approximately 2 Liters.
Answer: (D) Cardiac glycoside . A cardiac glycoside such as digitalis increases force of cardiac contraction, decreases the conduction speed of impulses within the myocardium and slows the heart rate.
Answer: (B) 2000 calories . There are 9 calories in each gram of fat and 4 calories in each gram of carbohydrate and protein
Answer: (B) Sodium . Restriction of sodium reduces the amount of water retention that reduces the cardiac workload
Answer: (A) The medications he has been taking . Some medications, such as aspirin and prednisone, irritate the stomach lining and may cause bleeding with prolonged use
Answer: (B) Regular meals and snacks to limit gastric discomfort . Presence of food in the stomach at regular intervals interacts with HCl limiting acid mucosal irritation. Mucosal irritation can lead to bleeding.
Answer: (B) Decreasing PCO2 . Hyperventilation results in the increased elimination of carbon dioxide from the blood that can lead to respiratory alkalosis.
Answer: (B) 600 Kilocalories . Carbohydrates provide 4 kcal/ gram; therefore 3L x 50 g/L x 4 kcal/g = 600 kcal; only about a third of the basal energy need.
Answer: (D) Performing active-assistive leg exercises . Inactivity causes venous stasis, hypercoagulability, and external pressure against the veins, all of which lead to thrombus formation. Early ambulation or exercise of the lower extremities reduces the occurrence of this phenomenon
Answer: (C) Maintaining the ordered hydration . Promoting hydration, maintains urine production at a higher rate, which flushes the bladder and prevents urinary stasis and possible infection
Answer: (D) Dorsiflexion, plantar flexion, eversion and inversion . These movements include all possible range of motion for the ankle joint
Answer: (A) 30 degrees . Shearing force occurs when 2 surfaces move against each other; when the bed is at an angle greater than 30 degrees, the torso tends to slide and causes this phenomenon. Shearing forces are good contributory factors of pressure sores.
Answer: (B) Urinary drainage will be dependent on a urethral catheter for 24 hours . An indwelling urethral catheter is used, because surgical trauma can cause urinary retention leading to further complications such as bleeding.
Answer: (C) Maintaining patency of a three-way Foley catheter for cystoclysis . Patency of the catheter promotes bladder decompression, which prevents distention and bleeding. Continuous flow of fluid through the bladder limits clot formation and promotes hemostasis
Answer: (B) Hemorrhage . After transurethral surgery, hemorrhage is common because of venous oozing and bleeding from many small arteries in the prostatic bed.
Answer: (B) Provide hemostasis . The pressure of the balloon against the small blood vessels of the prostate creates a tampon-like effect that causes them to constrict thereby preventing bleeding.
Answer: (B) Milk the catheter tubing . Milking the tubing will usually dislodge the plug and will not harm the client. A physician’s order is not necessary for a nurse to check catheter patency.
Answer: (B) Call the physician if my urinary stream decreases . Urethral mucosa in the prostatic area is destroyed during surgery and strictures my form with healing that causes partial or even complete ueinary obstruction.
Answer: (C) Weight loss, exopthalmos and restlessness . Classic signs associated with hyperthyroidism are weight loss and restlessness because of increased basal metabolic rate. Exopthalmos is due to peribulbar edema.
Answer: (B) A small part of the gland is left intact . Remaining thyroid tissue may provide enough hormone for normal function. Total thyroidectomy is generally done in clients with Thyroid Ca.
Answer: (B) A tracheostomy set and oxygen . Acute respiratory obstruction in the post-operative period can result from edema, subcutaneous bleeding that presses on the trachea, nerve damage, or tetany.
Answer: (C) Asking her to state her name out loud . If the recurrent laryngeal nerve is damaged during surgery, the client will be hoarse and have difficult speaking.
Answer: (B) Dry skin and fatigue . Dry skin is most likely caused by decreased glandular function and fatigue caused by decreased metabolic rate. Body functions and metabolism are decreased in hypothyroidism.
Answer: (C) Avoid using a sleeping mask at night . The mask may irritate or scratch the eye if the client turns and lies on it during the night.
Answer: (D) 22.5% . The entire right lower extremity is 18% the anterior portion of the right upper extremity is 4.5% giving a total of 22.5%
Answer: (A) Inhibit bacterial growth . Sulfamylon is effective against a wide variety of gram positive and gram negative organisms including anaerobes
Answer: (B) 28 gtt/min . This is the correct flow rate; multiply the amount to be infused (2000 ml) by the drop factor (10) and divide the result by the amount of time in minutes (12 hours x 60 minutes)
Answer: (C) Relieve pain and promote rapid epithelialization . The graft covers nerve endings, which reduces pain and provides a framework for granulation that promotes effective healing.
Answer: (C) Orthopneic position . The orthopneic position lowers the diaphragm and provides for maximal thoracic expansion
Answer: (C) Rapid but brief symptomatic improvement . Tensilon acts systemically to increase muscle strength; with a peak effect in 30 seconds, It lasts several minutes.
Answer: (C) Maintain the present muscle strength . Until diagnosis is confirmed, primary goal should be to maintain adequate activity and prevent muscle atrophy
Answer: (D) Respiratory exchange and ability to swallow . Muscle weakness can lead to respiratory failure that will require emergency intervention and inability to swallow may lead to aspiration
Answer: (C) Evaluate the client’s muscle strength hourly after medication Peak response occurs 1 hour after administration and lasts up to 8 hours; the response will influence dosage levels.
Answer: (D) Coordinate her meal schedule with the peak effect of her medication, Mestinon . Dysphagia should be minimized during peak effect of Mestinon, thereby decreasing the probability of aspiration. Mestinon can increase her muscle strength including her ability to swallow.