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PNLE III Nursing Practice (PM)
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Question 1
A client is diagnosed with peptic ulcer. The nurse caring for the client expects the physician to order which diet?
A
Frequent feedings of clear liquids
B
Small feedings of bland food
C
NPO
D
A regular diet given frequently in small amounts
Question 1 Explanation:
Bland feedings should be given in small amounts on a frequent basis to neutralize the hydrochloric acid and to prevent overload
Question 2
A client with gangrenous foot has undergone a below-knee amputation. The nurse in the nursing care unit knows that the priority nursing intervention in the immediate post operative care of this client is:
A
Elevate the stump on a pillow for the first 24 hours
B
Apply a cone-shaped dressing
C
Position the client prone periodically
D
Encourage use of trapeze
Question 2 Explanation:
The elevation of the stump on a pillow for the first 24 hours decreases edema and increases venous return.
Question 3
The physician has given instruction to the nurse that the client can be ambulated on crutches, with no weight bearing on the affected limb. The nurse is aware that the appropriate crutch gait for the nurse to teach the client would be:
A
Tripod gait
B
Three-point gait
C
Two-point gait
D
Four-point gait
Question 3 Explanation:
The three-point gait is appropriate when weight bearing is not allowed on the affected limb. The swing-to and swing-through crutch gaits may also be used when only one leg can be used for weight bearing
Question 4
A client with multiple fractures of both lower extremities is admitted for 3 days ago and is on skeletal traction. The client is complaining of having difficulty in bowel movement. Which of the following would be the most appropriate nursing intervention?
A
Ensure maximum fluid intake (3000ml/day)
B
Put the client on the bedpan every 2 hours
C
Perform range-of-motion exercise to all extremities
D
Administer an enema
Question 4 Explanation:
The best early intervention would be to increase fluid intake, because constipation is common when activity is decreased or usual routines have been interrupted.
Question 5
The nurse encourages the client to wear compression stockings. What is the rationale behind in using compression stockings?
A
Compression stockings decreases workload on the heart
B
Compression stockings divert blood to major vessels
Compression stockings promote venous return and prevent peripheral pooling.
Question 6
Following a needle biopsy of the kidney, which assessment is an indication that the client is bleeding?
A
Urinary frequency
B
Dull, abdominal discomfort
C
Throbbing headache
D
Slow, irregular pulse
Question 6 Explanation:
An accumulation of blood from the kidney into the abdomen would manifest itself with these symptoms
Question 7
A client is rushed to the emergency room due to serious vehicle accident. The nurse is suspecting of head injury. Which of the following assessment findings would the nurse report to the physician?
A
Polyuria and dilute urinary output
B
Insomnia
C
Glasgow Coma Scale score of 13
D
CVP of 5mmHa
Question 7 Explanation:
These are symptoms of diabetes insipidus. The patient can become hypovolemic and vasopressin may reverse the Polyuria.
Question 8
A nurse is providing a discharge instruction to the client about the self-catheterization at home. Which of the following instructions would the nurse include?
A
Lubricate the catheter with Vaseline
B
Replace the catheter with a new one every 24 hour
C
Perform the Valsalva maneuver to promote insertion
D
Wash the catheter with soap and water after each use
Question 8 Explanation:
The catheter should be washed with soap and water after withdrawal and placed in a clean container. It can be reused until it is too hard or too soft for insertion. Self-care, prevention of complications, and cost-effectiveness are important in home management.
Question 9
After a right lower lobectomy on a 55-year-old client, which action should the nurse initiate when the client is transferred from the post anesthesia care unit?
A
Encourage coughing and deep breathing every 2 hours
B
Immediately administer the narcotic as ordered
C
Keep client on right side supported by pillows
D
Notify the family to report the client’s condition
Question 9 Explanation:
Coughing and deep breathing are essential for re-expansion of the lung
Question 10
The nurse is going to replace the Pleur-O-Vac attached to the client with a small, persistent left upper lobe pneumothorax with a Heimlich Flutter Valve. Which of the following is the best rationale for this?
A
Eliminate the need for a water-seal drainage
B
Prevent kinking of the tube
C
Promote air and pleural drainage
D
Eliminate the need for a dressing
Question 10 Explanation:
The Heimlich flutter valve has a one-way valve that allows air and fluid to drain. Underwater seal drainage is not necessary. This can be connected to a drainage bag for the patient’s mobility. The absence of a long drainage tubing and the presence of a one-way valve promote effective therapy
Question 11
The client with acute pancreatitis and fluid volume deficit is transferred from the ward to the ICU. Which of the following will alert the nurse?
A
Decreased pain in the fetal position
B
Urine output of 35mL/hr
C
Cardiac output of 5L/min
D
CVP of 12 mmHg
Question 11 Explanation:
C = the normal CVP is 0-8 mmHg. This value reflects hypervolemia. The right ventricular function of this client reflects fluid volume overload, and the physician should be notified.
Question 12
Mr. Stewart is in sickle cell crisis and complaining pain in the joints and difficulty of breathing. On the assessment of the nurse, his temperature is 38.1 ºC. The physician ordered Morphine sulfate via patient-controlled analgesia (PCA), and oxygen at 4L/min. A priority nursing diagnosis to Mr. Stewart is risk for infection. A nursing intervention to assist in preventing infection is:
A
Monitoring a vital signs every 2 hour
B
Enforcing a “no visitors” rule
C
Using standard precautions and medical asepsis
D
Using moist heat on painful joints
Question 12 Explanation:
Vigilant implementation of standard precautions and medical asepsis is an effective means of preventing infection
Question 13
The client is transferred to the nursing care unit from the operating room after a transurethral resection of the prostate. The client is complaining of pain in the abdomen area. The nurse suspects of bladder spasms, which of the following is the best nursing action to minimize the pain felt by the client?
A
Giving prescribed narcotics every 4 hour
B
Advising the client not to urinate around catheter
C
Intermittent catheter irrigation with saline
D
Repositioning catheter to relieve pressure
Question 13 Explanation:
The client needs to be told before surgery that the catheter causes the urge to void. Attempts to void around the catheter cause the bladder muscles to contract and result in painful spasms.
Question 14
Following nephrectomy, the nurse closely monitors the urinary output of the client. Which assessment finding is an early indicator of fluid retention in the postoperative period?
A
Periorbital edema
B
Increased specific gravity of urine
C
Daily weight gain of 2 lb or more
D
A urinary output of 50mL/hr
Question 14 Explanation:
Daily weights are taken following nephrectomy. Daily increases of 2 lb or more are indicative of fluid retention and should be reported to the physician. Intake and output records may also reflect this imbalance.
Question 15
What would be the recommended diet the nurse will implement to a client with burns of the head, face, neck and anterior chest?
A
Serve a high-fat diet, high-fiber diet
B
Serve a high-protein, high-carbohydrate diet
C
Encourage full liquid diet
D
Monitor intake to prevent weight gain
Question 15 Explanation:
A positive nitrogen balance is important for meeting metabolic needs, tissue repair, and resistance to infection. Caloric goals may be as high as 5000 calories per day.
Question 16
A 70-year-old client is brought to the emergency department with a caregiver. The client has manifestations of anorexia, wasting of muscles and multiple bruises. What nursing interventions would the nurse implement?
A
Talk to the client about the caregiver and support system
B
Check the lab data for serum albumin, hematocrit and hemoglobin
C
Complete a gastrointestinal and neurological assessment
D
Complete a police report on elder abuse
Question 16 Explanation:
Assessment and more data collection are needed. The client may have gastrointestinal or neurological problems that account for the symptoms. The anorexia could result from medications, poor dentition, or indigestion, the bruises may be attributed to ataxia, frequent falls, vertigo, or medication.
Question 17
The nurse is caring for a client who is transferred from the operating room for pneumonectomy. The nurse knows that immediately following pneumonectomy; the client should be in what position?
A
Semi-Fowler’s on the unaffected side
B
Semi-Fowler’s on the affected side
C
Supine on the unaffected side
D
Low-Fowler’s on the back
Question 17 Explanation:
This position allows maximum expansion, ventilation, and perfusion of the remaining lung.
Question 18
A male client with cirrhosis is complaining of belly pain, itchiness and his breasts are getting larger and also the abdomen. The client is so upset because of the discomfort and asks the nurse why his breast and abdomen are getting larger. Which of the following is the appropriate nursing response?
A
“Your liver is not destroying estrogen hormones that all men produce”
B
“It’s probably because you have been less physically active”
C
“It’s part of the swelling your body is experiencing”
D
“How much of a difference have you noticed”
Question 18 Explanation:
This allows the client to elaborate his concern and provides the nurse a baseline of assessment
Question 19
The nurse is going to insert a Miller-Abbott tube to the client. Before insertion of the tube, the balloon is tested for patency and capacity and then deflated. Which of the following nursing measure will ease the insertion to the tube?
A
Positioning the client in Semi-Fowler’s position
B
Warming the tube before insertion
C
Administering a sedative to reduce anxiety
D
Chilling the tube before insertion
Question 19 Explanation:
Chilling the tube before insertion assists in relieving some of the nasal discomfort. Water-soluble lubricants along with viscous lidocaine (Xylocaine) may also be used. It is usually only lightly lubricated before insertion
Question 20
The physician prescribed digoxin 0.125 mg PO qd to a client and instructed the nurse that the client is on high-potassium diet. High potassium foods are recommended in the diet of a client taking digitalis preparations because a low serum potassium has which of the following effects?
A
Promotes calcium retention
B
Potentiates the action of digoxin
C
Puts the client at risk for digitalis toxicity
D
Promotes sodium excretion
Question 20 Explanation:
Potassium influences the excitability of nerves and muscles. When potassium is low and the client is on digoxin, the risk of digoxin toxicity is increased.
Question 21
Mrs. Maupin is a professor in a prestigious university for 30 years. After lecture, she experience blurring of vision and tiredness. Mrs. Maupin is brought to the emergency department. On assessment, the nurse notes that the blood pressure of the client is 139/90. Mrs. Maupin has been diagnosed with essential hypertension and placed on medication to control her BP. Which potential nursing diagnosis will be a priority for discharge teaching?
A
Impaired physical mobility
B
Sleep Pattern disturbance
C
Fluid volume excess
D
Noncompliance
Question 21 Explanation:
Noncompliance is a major problem in the management of chronic disease. In hypertension, the client often does not feel ill and thus does not see a need to follow a treatment regimen.
Question 22
A client is admitted and has been diagnosed with bacterial (meningococcal) meningitis. The infection control registered nurse visits the staff nurse caring to the client. What statement made by the nurse reflects an understanding of the management of this client?
A
Perform skin culture on the macular popular rash
B
Respiratory isolation is necessary for 24 hours after antibiotics are started
C
Expect abnormal general muscle contractions
D
speech pattern may be altered
Question 22 Explanation:
After a minimum of 24 hours of IV antibiotics, the client is no longer considered communicable. Evaluation of the nurse’s knowledge is needed for safe care and continuity of care.
Question 23
The nurse on the night shift is making rounds in the nursing care unit. The nurse is about to enter to the client’s room when a ventilator alarm sounds, what is the first action the nurse should do?
A
Turn and position the client
B
Suction the client right away
C
Look at the client
D
Assess the lung sounds
Question 23 Explanation:
A quick look at the client can help identify the type and cause of the ventilator alarm. Disconnection of the tube from the ventilator, bronchospasm, and anxiety are some of the obvious reasons that could trigger an alarm.
Question 24
A client with a diagnosis of gastric ulcer is complaining of syncope and vertigo. What would be the initial nursing intervention by the nurse?
A
Keep the client on bed rest
B
Keep the patient on bed rest
C
Give a stat dose of Sucralfate (Carafate)
D
Monitor the client’s vital signs
Question 24 Explanation:
The priority is to maintain client’s safety. With syncope and vertigo, the client is at high risk for falling.
Question 25
A client with AIDS is scheduled for discharge. The client tells the nurse that one of his hobbies at home is gardening. What will be the discharge instruction of the nurse to the client knowing that the client is prone to toxoplasmosis?
A
Wear a mask when travelling to foreign countries
B
Wash all vegetables before cooking
C
Wear gloves when gardening
D
Avoid contact with cats and birds
Question 25 Explanation:
Toxoplasmosis is an opportunistic infection and a parasite of birds and mammals. The oocysts remain infectious in moist soil for about 1 year.
Question 26
A client is diagnosed with detached retina and scheduled for surgery. Preoperative teaching of the nurse to the client includes:
A
Semi-fowler’s position will be used to reduce pressure in the eye.
B
Eye patches may be used postoperatively
C
No eye pain is expected postoperatively
D
Return of normal vision is expected following surgery
Question 26 Explanation:
Use of eye patches may be continued postoperatively, depending on surgeon preference. This is done to achieve >90% success rate of the surgery.
Question 27
The nurse in the morning shift is making rounds in the ward. The nurse enters the client’s room and found the client in discomfort condition. The client complains of stiffness in the joints. To reduce the early morning stiffness of the joints of the client, the nurse can encourage the client to:
A
Sleep with a hot pad
B
Take a hot tub bath or shower in the morning
C
Take to aspirins before arising, and wait 15 minutes before attempting locomotion
D
Put joints through passive ROM before trying to move them actively
Question 27 Explanation:
A hot tub bath or shower in the morning helps many patients limber up and reduces the symptoms of early morning stiffness. Cold and ice packs are used to a lesser degree, though some clients state that cold decreases localized pain, particularly during acute attacks.
Question 28
Mr. Bean, a 70-year-old client is admitted in the hospital for almost one month. The nurse understands that prolonged immobilization could lead to decubitus ulcers. Which of the following would be the least appropriate nursing intervention in the prevention of decubitus?
A
Giving backrubs with alcohol
B
Use of a bed cradle
C
Frequent assessment of the skin
D
Encouraging a high-protein diet
Question 28 Explanation:
Alcohol is extremely drying and contributes to skin break down. An emollient lotion should be used.
Question 29
A client is placed on digoxin, high potassium foods are recommended in the diet of the client. Which of the following foods will the nurse give to the client?
A
Cottage cheese, cooked broccoli, and roast beef
B
Fish, green beans and cherry pie
C
Whole grain cereal, orange juice, and apricots
D
Turkey, green bean, and Italian bread
Question 29 Explanation:
These foods are high in potassium
Question 30
A nurse is completing an assessment to a client with cirrhosis. Which of the following nursing assessment is important to notify the physician?
A
Expanding ecchymosis
B
Slurred speech
C
Hematocrit of 37% and hemoglobin of 12g/dl
D
Ascites and serum albumin of 3.2 g/dl
Question 30 Explanation:
Clients with cirrhosis have already coagulation due to thrombocytopenia and vitamin K deficiency. This could be a sign of bleeding
Question 31
The nurse is going to assess the bowel sound of the client. For accurate assessment of the bowel sound, the nurse should listen for at least:
A
60 seconds
B
2 minutes
C
5 minutes
D
30 seconds
Question 31 Explanation:
Physical assessment guidelines recommend listening for atleast 2 minutes in each quadrant (and up to 5 minutes, not at least 5 minutes).
Question 32
John is diagnosed with Addison’s disease and admitted in the hospital. What would be the appropriate nursing care for John?
A
Reducing physical and emotional stress
B
Providing a low-sodium diet
C
Restricting fluids to 1500ml/day
D
Administering insulin-replacement therapy
Question 32 Explanation:
Because the client’s ability is to react to stress is decreased, maintaining a quiet environment becomes A nursing priority. Dehydration is a common problem in Addison’s disease, so close observation of the client’s hydration level is crucial. To promote optimal hydration and sodium intake, fluid intake is increased, particularly fluid containing electrolytes, such as broths, carbonated beverages, and juices.
Question 33
A client with acute bronchitis is admitted in the hospital. The nurse assigned to the client is making a plan of care regarding expectoration of thick sputum. Which nursing action is most effective?
A
Offer fluids at regular intervals
B
Place the client in a lateral position every 2 hour
C
Splint the patient’s chest with pillows when coughing
D
Use humified oxygen
Question 33 Explanation:
Fluids liquefy secretions and therefore make it easier to expectorate
Question 34
The nurse is providing a discharge instruction about the prevention of urinary stasis to a client with frequent bladder infection. Which of the following will the nurse include in the instruction?
A
Teach Kegel exercises to control bladder flow
B
Drink 3-4 quarts of fluid every day
C
Empty the bladder every 2-4 hours while awake
D
Encourage the use of coffee, tea, and colas for their diuretic effect
Question 34 Explanation:
Avoiding stasis of urine by emptying the bladder every 2-4 hours will prevent overdistention of the bladder and future urinary tract infections.
Question 35
The nurse is planning of care to a client with peptic ulcer disease. To avoid the worsening condition of the client, the nurse should carefully plan the diet of the client. Which of the following will be included in the diet regime of the client?
A
Reducing intake of high-fiber foods
B
Eating mainly bland food and milk or dairy products
C
Eating small, frequent meals and a bedtime snack
D
Eliminating intake of alcohol and coffee
Question 35 Explanation:
These substances stimulate the production of hydrochloric acid, which is detrimental in peptic ulcer disease.
Question 36
The physician ordered a low-sodium diet to the client. Which of the following food will the nurse avoid to give to the client?
A
Orange juice.
B
Ginger ale.
C
Whole milk.
D
Black coffee.
Question 36 Explanation:
Whole milk should be avoided to include in the client’s diet because it has 120 mg of sodium in 8 0z of milk.
Question 37
Mr. Smith is scheduled for an above-the-knee amputation. After the surgery he was transferred to the nursing care unit. The nurse assigned to him knows that 72 hours after the procedure the client should be positioned properly to prevent contractures. Which of the following is the best position to the client?
A
Lying on abdomen several times daily
B
Supine with stump elevated at least 30 degrees
C
Side-lying, alternating left and right sides
D
Sitting in a reclining chair twice a day
Question 37 Explanation:
At about 48-72 hours, the client must be turned onto the abdomen to prevent flexion contractures.
Question 38
The postoperative gastrectomy client is scheduled for discharge. The client asks the nurse, “When I will be allowed to eat three meals a day like the rest of my family?”. The appropriate nursing response is:
A
“You will probably have to eat six meals a day for the rest of your life.”
B
“ It varies from client to client, but generally in 6-12 months most clients can return to their previous meal patterns”
C
“Eating six meals a day can be a bother, can’t it?”
D
“Some clients can tolerate three meals a day by the time they leave the hospital. Maybe it will be a little longer for you.”
Question 38 Explanation:
In response to the question of the client, the nurse needs to provide brief, accurate information. Some clients who have had gastrectomies are able to tolerate three meals a day before discharge from the hospital. However, for the majority of clients, it takes 6-12 months before their surgically reduced stomach has stretched enough to accommodate a larger meal.
Question 39
A male client visits the clinic for check-up. The client tells the nurse that there is a yellow discharge from his penis. He also experiences a burning sensation when urinating. The nurse is suspecting of gonorrhea. What teaching is necessary for this client?
A
Women with gonorrhea are symptomatic
B
Sex partner of 3 months ago must be treated
C
Sex partner needs to be evaluated
D
Use a condom for sexual activity
Question 39 Explanation:
If infected, the sex partner must be evaluated and treated
Question 40
Before surgery, the physician ordered pentobarbital sodium (Nembutal) for the client to sleep. The night before the scheduled surgery, the nurse gave the pre-medication. One hour later the client is still unable to sleep. The nurse review the client’s chart and note the physician’s prescription with an order to repeat. What should the nurse do next?
A
Explore the client’s feelings about surgery
B
Rub the client’s back until relaxed
C
Prepare a glass of warm milk
D
Give the second dose of pentobarbital sodium
Question 40 Explanation:
Given the data, presurgical anxiety is suspected. The client needs an opportunity to talk about concerns related to surgery before further actions (which may mask the anxiety).
Question 41
The nurse is assigned to care to a client who undergone thyroidectomy. What nursing intervention is important during the immediate postoperative period following a thyroidectomy?
A
Medicate for restlessness and anxiety
B
Assess extremities for weakness and flaccidity
C
Position the client in high Fowler’s
D
Support the head and neck during position changes
Question 41 Explanation:
Stress on the suture line should be avoided. Prevent flexion or hyperextension of the neck, and provide a small pillow under the head and neck. Neck muscles have been affected during a thyroidectomy, support essential for comfort and incisional support.
Question 42
What effective precautions should the nurse use to control the transmission of methicillin-resistant Staphylococcus aureus (MRSA)?
A
Use gloves and handwashing before and after client contact
B
Do nasal cultures on healthcare providers
C
Use mask and gown during care of the MRSA client
D
Place the client on total isolation
Question 42 Explanation:
Contact isolation has been advised by the Centers for Disease Control and Prevention (CDC) to control transmission of MRSA, which includes gloves and handwashing.
Question 43
A client with AIDS is admitted in the hospital. He is receiving intravenous therapy. While the nurse is assessing the IV site, the client becomes confused and restless and the intravenous catheter becomes disconnected and minimal amount of the client’s blood spills onto the floor. Which action will the nurse take to remove the blood spill?
A
Allow the blood to dry before cleaning to decrease the possibility of cross-contamination
B
Immediately mop the floor with boiling water
C
Promptly clean with a 1:10 solution of household bleach and water
D
Promptly clean up the blood spill with full-strength antimicrobial cleaning solution
Question 43 Explanation:
A 1:10 solution of household bleach and water is recommended by the Centers for Disease Control and Prevention to kill the human immunodeficiency virus (HIV).
Question 44
A client is scheduled to have an inguinal herniorraphy in the outpatient surgical department. The nurse is providing health teaching about post surgical care to the client. Which of the following statement if made by the client would reflect the need for more teaching?
A
“I will not be able to do any heavy lifting for 3-6 weeks after surgery”
B
“I should call the physician if I have a cough or cold before surgery”
C
“I will be able to drive soon after surgery”
D
“I should support my incision if I have to cough or turn”
Question 44 Explanation:
The client should not drive for 2 weeks after surgery to avoid stress on the incision. This reflects a need for additional teaching.
Question 45
Mrs. Moore, 62-year-old, with diabetes is in the emergency department. She stepped on a sharp sea shells while walking barefoot along the beach. Mrs. Moore did not notice that the object pierced the skin until later that evening. What problem does the client most probably have?
A
Macroangiopathy
B
Peripheral neuropathy
C
Nephropathy
D
Carpal tunnel syndrome
Question 45 Explanation:
Peripheral neuropathy refers to nerve damage of the hands and feet. The client did not notice that the object pierced the skin.
Question 46
A 18-year-old male client had sustained a head injury from a motorbike accident. It is uncertain whether the client may have minimal but permanent disability. The family is concerned regarding the client’s difficulty accepting the possibility of long term effects. Which nursing diagnosis is best for this situation?
A
Injury, potential for sensory-perceptual alterations
B
Nutrition, less than body requirements
C
Anticipatory grieving, due to the loss of independence
D
Impaired mobility, related to muscle weakness
Question 46 Explanation:
Stem of the question supports this choice by stating that the client has difficulty accepting the potential disability.
Question 47
Mr. Whitman is a stroke client and is having difficulty in swallowing. Which is the best nursing intervention is most likely to assist the client?
A
Asking the patient to speak slowly
B
Increasing fiber in the diet
C
Increasing fluid intake
D
Placing food in the unaffected side of the mouth
Question 47 Explanation:
Placing food in the unaffected side of the mouth assists in the swallowing process because the client has sensation on that side and will have more control over the swallowing process.
Question 48
Ms Jones is brought to the emergency room and is complaining of muscle spasms, numbness, tremors and weakness in the arms and legs. The client was diagnosed with multiple sclerosis. The nurse assigned to Ms. Jones is aware that she has to prevent fatigue to the client to alleviate the discomfort. Which of the following teaching is necessary to prevent fatigue?
A
Install safety devices in the home
B
Avoid extremes in temperature
C
Attend support group meetings
D
Avoid physical exercise
Question 48 Explanation:
Extremes in heat and cold will exacerbate symptoms. Heat delays transmission of impulses and increases fatigue.
Question 49
Mr. Park is 32-year-old, a badminton player and has a type 1 diabetes mellitus. After the game, the client complains of becoming diaphoretic and light-headedness. The client asks the nurse how to avoid this reaction. The nurse will recommend to:
A
Take insulin just before starting the badminton match
B
Eat a carbohydrate snack before and during the badminton match
C
Allow plenty of time after the insulin injection and before beginning the match
D
Drink plenty of fluids before, during, and after bed time
Question 49 Explanation:
Exercise enhances glucose uptake, and the client is at risk for an insulin reaction. Snacks with carbohydrates will help.
Question 50
The nurse in the nursing care unit is assigned to care to a client who is Immunocompromised. The client tells the nurse that his chest is painful and the blisters are itchy. What would be the nursing intervention to this client?
A
Give a prn pain medication
B
Clarify if the client is on a new medication
C
Call the physician
D
Use gown and gloves while assessing the lesions
Question 50 Explanation:
The client may have herpes zoster (shingles), a viral infection. The nurse should use standard precautions in assessing the lesions. Immunocompromised clients are at risk for infection.
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PNLE III Nursing Practice (EM)
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Question 1
A client is scheduled to have an inguinal herniorraphy in the outpatient surgical department. The nurse is providing health teaching about post surgical care to the client. Which of the following statement if made by the client would reflect the need for more teaching?
A
“I will not be able to do any heavy lifting for 3-6 weeks after surgery”
B
“I should support my incision if I have to cough or turn”
C
“I will be able to drive soon after surgery”
D
“I should call the physician if I have a cough or cold before surgery”
Question 1 Explanation:
The client should not drive for 2 weeks after surgery to avoid stress on the incision. This reflects a need for additional teaching.
Question 2
Following nephrectomy, the nurse closely monitors the urinary output of the client. Which assessment finding is an early indicator of fluid retention in the postoperative period?
A
Increased specific gravity of urine
B
Periorbital edema
C
A urinary output of 50mL/hr
D
Daily weight gain of 2 lb or more
Question 2 Explanation:
Daily weights are taken following nephrectomy. Daily increases of 2 lb or more are indicative of fluid retention and should be reported to the physician. Intake and output records may also reflect this imbalance.
Question 3
John is diagnosed with Addison’s disease and admitted in the hospital. What would be the appropriate nursing care for John?
A
Reducing physical and emotional stress
B
Restricting fluids to 1500ml/day
C
Administering insulin-replacement therapy
D
Providing a low-sodium diet
Question 3 Explanation:
Because the client’s ability is to react to stress is decreased, maintaining a quiet environment becomes A nursing priority. Dehydration is a common problem in Addison’s disease, so close observation of the client’s hydration level is crucial. To promote optimal hydration and sodium intake, fluid intake is increased, particularly fluid containing electrolytes, such as broths, carbonated beverages, and juices.
Question 4
Mr. Stewart is in sickle cell crisis and complaining pain in the joints and difficulty of breathing. On the assessment of the nurse, his temperature is 38.1 ºC. The physician ordered Morphine sulfate via patient-controlled analgesia (PCA), and oxygen at 4L/min. A priority nursing diagnosis to Mr. Stewart is risk for infection. A nursing intervention to assist in preventing infection is:
A
Using standard precautions and medical asepsis
B
Enforcing a “no visitors” rule
C
Monitoring a vital signs every 2 hour
D
Using moist heat on painful joints
Question 4 Explanation:
Vigilant implementation of standard precautions and medical asepsis is an effective means of preventing infection
Question 5
Mr. Bean, a 70-year-old client is admitted in the hospital for almost one month. The nurse understands that prolonged immobilization could lead to decubitus ulcers. Which of the following would be the least appropriate nursing intervention in the prevention of decubitus?
A
Frequent assessment of the skin
B
Encouraging a high-protein diet
C
Giving backrubs with alcohol
D
Use of a bed cradle
Question 5 Explanation:
Alcohol is extremely drying and contributes to skin break down. An emollient lotion should be used.
Question 6
What would be the recommended diet the nurse will implement to a client with burns of the head, face, neck and anterior chest?
A
Monitor intake to prevent weight gain
B
Serve a high-protein, high-carbohydrate diet
C
Serve a high-fat diet, high-fiber diet
D
Encourage full liquid diet
Question 6 Explanation:
A positive nitrogen balance is important for meeting metabolic needs, tissue repair, and resistance to infection. Caloric goals may be as high as 5000 calories per day.
Question 7
The nurse on the night shift is making rounds in the nursing care unit. The nurse is about to enter to the client’s room when a ventilator alarm sounds, what is the first action the nurse should do?
A
Suction the client right away
B
Look at the client
C
Assess the lung sounds
D
Turn and position the client
Question 7 Explanation:
A quick look at the client can help identify the type and cause of the ventilator alarm. Disconnection of the tube from the ventilator, bronchospasm, and anxiety are some of the obvious reasons that could trigger an alarm.
Question 8
A client is placed on digoxin, high potassium foods are recommended in the diet of the client. Which of the following foods will the nurse give to the client?
A
Cottage cheese, cooked broccoli, and roast beef
B
Fish, green beans and cherry pie
C
Whole grain cereal, orange juice, and apricots
D
Turkey, green bean, and Italian bread
Question 8 Explanation:
These foods are high in potassium
Question 9
Before surgery, the physician ordered pentobarbital sodium (Nembutal) for the client to sleep. The night before the scheduled surgery, the nurse gave the pre-medication. One hour later the client is still unable to sleep. The nurse review the client’s chart and note the physician’s prescription with an order to repeat. What should the nurse do next?
A
Give the second dose of pentobarbital sodium
B
Explore the client’s feelings about surgery
C
Prepare a glass of warm milk
D
Rub the client’s back until relaxed
Question 9 Explanation:
Given the data, presurgical anxiety is suspected. The client needs an opportunity to talk about concerns related to surgery before further actions (which may mask the anxiety).
Question 10
A male client visits the clinic for check-up. The client tells the nurse that there is a yellow discharge from his penis. He also experiences a burning sensation when urinating. The nurse is suspecting of gonorrhea. What teaching is necessary for this client?
A
Sex partner needs to be evaluated
B
Use a condom for sexual activity
C
Sex partner of 3 months ago must be treated
D
Women with gonorrhea are symptomatic
Question 10 Explanation:
If infected, the sex partner must be evaluated and treated
Question 11
A client is admitted and has been diagnosed with bacterial (meningococcal) meningitis. The infection control registered nurse visits the staff nurse caring to the client. What statement made by the nurse reflects an understanding of the management of this client?
A
speech pattern may be altered
B
Expect abnormal general muscle contractions
C
Perform skin culture on the macular popular rash
D
Respiratory isolation is necessary for 24 hours after antibiotics are started
Question 11 Explanation:
After a minimum of 24 hours of IV antibiotics, the client is no longer considered communicable. Evaluation of the nurse’s knowledge is needed for safe care and continuity of care.
Question 12
The physician ordered a low-sodium diet to the client. Which of the following food will the nurse avoid to give to the client?
A
Black coffee.
B
Orange juice.
C
Ginger ale.
D
Whole milk.
Question 12 Explanation:
Whole milk should be avoided to include in the client’s diet because it has 120 mg of sodium in 8 0z of milk.
Question 13
A client is diagnosed with detached retina and scheduled for surgery. Preoperative teaching of the nurse to the client includes:
A
Semi-fowler’s position will be used to reduce pressure in the eye.
B
No eye pain is expected postoperatively
C
Return of normal vision is expected following surgery
D
Eye patches may be used postoperatively
Question 13 Explanation:
Use of eye patches may be continued postoperatively, depending on surgeon preference. This is done to achieve >90% success rate of the surgery.
Question 14
The nurse in the morning shift is making rounds in the ward. The nurse enters the client’s room and found the client in discomfort condition. The client complains of stiffness in the joints. To reduce the early morning stiffness of the joints of the client, the nurse can encourage the client to:
A
Take to aspirins before arising, and wait 15 minutes before attempting locomotion
B
Put joints through passive ROM before trying to move them actively
C
Sleep with a hot pad
D
Take a hot tub bath or shower in the morning
Question 14 Explanation:
A hot tub bath or shower in the morning helps many patients limber up and reduces the symptoms of early morning stiffness. Cold and ice packs are used to a lesser degree, though some clients state that cold decreases localized pain, particularly during acute attacks.
Question 15
A client with acute bronchitis is admitted in the hospital. The nurse assigned to the client is making a plan of care regarding expectoration of thick sputum. Which nursing action is most effective?
A
Place the client in a lateral position every 2 hour
B
Offer fluids at regular intervals
C
Use humified oxygen
D
Splint the patient’s chest with pillows when coughing
Question 15 Explanation:
Fluids liquefy secretions and therefore make it easier to expectorate
Question 16
Mr. Whitman is a stroke client and is having difficulty in swallowing. Which is the best nursing intervention is most likely to assist the client?
A
Increasing fiber in the diet
B
Asking the patient to speak slowly
C
Increasing fluid intake
D
Placing food in the unaffected side of the mouth
Question 16 Explanation:
Placing food in the unaffected side of the mouth assists in the swallowing process because the client has sensation on that side and will have more control over the swallowing process.
Question 17
The nurse is assigned to care to a client who undergone thyroidectomy. What nursing intervention is important during the immediate postoperative period following a thyroidectomy?
A
Assess extremities for weakness and flaccidity
B
Support the head and neck during position changes
C
Medicate for restlessness and anxiety
D
Position the client in high Fowler’s
Question 17 Explanation:
Stress on the suture line should be avoided. Prevent flexion or hyperextension of the neck, and provide a small pillow under the head and neck. Neck muscles have been affected during a thyroidectomy, support essential for comfort and incisional support.
Question 18
The postoperative gastrectomy client is scheduled for discharge. The client asks the nurse, “When I will be allowed to eat three meals a day like the rest of my family?”. The appropriate nursing response is:
A
“You will probably have to eat six meals a day for the rest of your life.”
B
“Eating six meals a day can be a bother, can’t it?”
C
“ It varies from client to client, but generally in 6-12 months most clients can return to their previous meal patterns”
D
“Some clients can tolerate three meals a day by the time they leave the hospital. Maybe it will be a little longer for you.”
Question 18 Explanation:
In response to the question of the client, the nurse needs to provide brief, accurate information. Some clients who have had gastrectomies are able to tolerate three meals a day before discharge from the hospital. However, for the majority of clients, it takes 6-12 months before their surgically reduced stomach has stretched enough to accommodate a larger meal.
Question 19
A nurse is completing an assessment to a client with cirrhosis. Which of the following nursing assessment is important to notify the physician?
A
Expanding ecchymosis
B
Slurred speech
C
Hematocrit of 37% and hemoglobin of 12g/dl
D
Ascites and serum albumin of 3.2 g/dl
Question 19 Explanation:
Clients with cirrhosis have already coagulation due to thrombocytopenia and vitamin K deficiency. This could be a sign of bleeding
Question 20
A 18-year-old male client had sustained a head injury from a motorbike accident. It is uncertain whether the client may have minimal but permanent disability. The family is concerned regarding the client’s difficulty accepting the possibility of long term effects. Which nursing diagnosis is best for this situation?
A
Impaired mobility, related to muscle weakness
B
Anticipatory grieving, due to the loss of independence
C
Injury, potential for sensory-perceptual alterations
D
Nutrition, less than body requirements
Question 20 Explanation:
Stem of the question supports this choice by stating that the client has difficulty accepting the potential disability.
Question 21
The nurse is going to insert a Miller-Abbott tube to the client. Before insertion of the tube, the balloon is tested for patency and capacity and then deflated. Which of the following nursing measure will ease the insertion to the tube?
A
Warming the tube before insertion
B
Administering a sedative to reduce anxiety
C
Chilling the tube before insertion
D
Positioning the client in Semi-Fowler’s position
Question 21 Explanation:
Chilling the tube before insertion assists in relieving some of the nasal discomfort. Water-soluble lubricants along with viscous lidocaine (Xylocaine) may also be used. It is usually only lightly lubricated before insertion
Question 22
Mrs. Maupin is a professor in a prestigious university for 30 years. After lecture, she experience blurring of vision and tiredness. Mrs. Maupin is brought to the emergency department. On assessment, the nurse notes that the blood pressure of the client is 139/90. Mrs. Maupin has been diagnosed with essential hypertension and placed on medication to control her BP. Which potential nursing diagnosis will be a priority for discharge teaching?
A
Noncompliance
B
Sleep Pattern disturbance
C
Fluid volume excess
D
Impaired physical mobility
Question 22 Explanation:
Noncompliance is a major problem in the management of chronic disease. In hypertension, the client often does not feel ill and thus does not see a need to follow a treatment regimen.
Question 23
After a right lower lobectomy on a 55-year-old client, which action should the nurse initiate when the client is transferred from the post anesthesia care unit?
A
Encourage coughing and deep breathing every 2 hours
B
Immediately administer the narcotic as ordered
C
Keep client on right side supported by pillows
D
Notify the family to report the client’s condition
Question 23 Explanation:
Coughing and deep breathing are essential for re-expansion of the lung
Question 24
A client with multiple fractures of both lower extremities is admitted for 3 days ago and is on skeletal traction. The client is complaining of having difficulty in bowel movement. Which of the following would be the most appropriate nursing intervention?
A
Perform range-of-motion exercise to all extremities
B
Ensure maximum fluid intake (3000ml/day)
C
Put the client on the bedpan every 2 hours
D
Administer an enema
Question 24 Explanation:
The best early intervention would be to increase fluid intake, because constipation is common when activity is decreased or usual routines have been interrupted.
Question 25
The nurse encourages the client to wear compression stockings. What is the rationale behind in using compression stockings?
Compression stockings decreases workload on the heart
C
Compression stockings divert blood to major vessels
D
Compression stockings promote venous return
Question 25 Explanation:
Compression stockings promote venous return and prevent peripheral pooling.
Question 26
The physician has given instruction to the nurse that the client can be ambulated on crutches, with no weight bearing on the affected limb. The nurse is aware that the appropriate crutch gait for the nurse to teach the client would be:
A
Four-point gait
B
Three-point gait
C
Two-point gait
D
Tripod gait
Question 26 Explanation:
The three-point gait is appropriate when weight bearing is not allowed on the affected limb. The swing-to and swing-through crutch gaits may also be used when only one leg can be used for weight bearing
Question 27
The nurse is providing a discharge instruction about the prevention of urinary stasis to a client with frequent bladder infection. Which of the following will the nurse include in the instruction?
A
Drink 3-4 quarts of fluid every day
B
Empty the bladder every 2-4 hours while awake
C
Teach Kegel exercises to control bladder flow
D
Encourage the use of coffee, tea, and colas for their diuretic effect
Question 27 Explanation:
Avoiding stasis of urine by emptying the bladder every 2-4 hours will prevent overdistention of the bladder and future urinary tract infections.
Question 28
Mr. Park is 32-year-old, a badminton player and has a type 1 diabetes mellitus. After the game, the client complains of becoming diaphoretic and light-headedness. The client asks the nurse how to avoid this reaction. The nurse will recommend to:
A
Take insulin just before starting the badminton match
B
Drink plenty of fluids before, during, and after bed time
C
Allow plenty of time after the insulin injection and before beginning the match
D
Eat a carbohydrate snack before and during the badminton match
Question 28 Explanation:
Exercise enhances glucose uptake, and the client is at risk for an insulin reaction. Snacks with carbohydrates will help.
Question 29
A client with a diagnosis of gastric ulcer is complaining of syncope and vertigo. What would be the initial nursing intervention by the nurse?
A
Keep the patient on bed rest
B
Give a stat dose of Sucralfate (Carafate)
C
Keep the client on bed rest
D
Monitor the client’s vital signs
Question 29 Explanation:
The priority is to maintain client’s safety. With syncope and vertigo, the client is at high risk for falling.
Question 30
A client is diagnosed with peptic ulcer. The nurse caring for the client expects the physician to order which diet?
A
Frequent feedings of clear liquids
B
Small feedings of bland food
C
A regular diet given frequently in small amounts
D
NPO
Question 30 Explanation:
Bland feedings should be given in small amounts on a frequent basis to neutralize the hydrochloric acid and to prevent overload
Question 31
A client with AIDS is admitted in the hospital. He is receiving intravenous therapy. While the nurse is assessing the IV site, the client becomes confused and restless and the intravenous catheter becomes disconnected and minimal amount of the client’s blood spills onto the floor. Which action will the nurse take to remove the blood spill?
A
Immediately mop the floor with boiling water
B
Promptly clean with a 1:10 solution of household bleach and water
C
Allow the blood to dry before cleaning to decrease the possibility of cross-contamination
D
Promptly clean up the blood spill with full-strength antimicrobial cleaning solution
Question 31 Explanation:
A 1:10 solution of household bleach and water is recommended by the Centers for Disease Control and Prevention to kill the human immunodeficiency virus (HIV).
Question 32
The physician prescribed digoxin 0.125 mg PO qd to a client and instructed the nurse that the client is on high-potassium diet. High potassium foods are recommended in the diet of a client taking digitalis preparations because a low serum potassium has which of the following effects?
A
Puts the client at risk for digitalis toxicity
B
Promotes calcium retention
C
Promotes sodium excretion
D
Potentiates the action of digoxin
Question 32 Explanation:
Potassium influences the excitability of nerves and muscles. When potassium is low and the client is on digoxin, the risk of digoxin toxicity is increased.
Question 33
Ms Jones is brought to the emergency room and is complaining of muscle spasms, numbness, tremors and weakness in the arms and legs. The client was diagnosed with multiple sclerosis. The nurse assigned to Ms. Jones is aware that she has to prevent fatigue to the client to alleviate the discomfort. Which of the following teaching is necessary to prevent fatigue?
A
Attend support group meetings
B
Install safety devices in the home
C
Avoid extremes in temperature
D
Avoid physical exercise
Question 33 Explanation:
Extremes in heat and cold will exacerbate symptoms. Heat delays transmission of impulses and increases fatigue.
Question 34
The nurse is going to assess the bowel sound of the client. For accurate assessment of the bowel sound, the nurse should listen for at least:
A
2 minutes
B
60 seconds
C
5 minutes
D
30 seconds
Question 34 Explanation:
Physical assessment guidelines recommend listening for atleast 2 minutes in each quadrant (and up to 5 minutes, not at least 5 minutes).
Question 35
A client is rushed to the emergency room due to serious vehicle accident. The nurse is suspecting of head injury. Which of the following assessment findings would the nurse report to the physician?
A
CVP of 5mmHa
B
Insomnia
C
Glasgow Coma Scale score of 13
D
Polyuria and dilute urinary output
Question 35 Explanation:
These are symptoms of diabetes insipidus. The patient can become hypovolemic and vasopressin may reverse the Polyuria.
Question 36
A 70-year-old client is brought to the emergency department with a caregiver. The client has manifestations of anorexia, wasting of muscles and multiple bruises. What nursing interventions would the nurse implement?
A
Complete a gastrointestinal and neurological assessment
B
Check the lab data for serum albumin, hematocrit and hemoglobin
C
Complete a police report on elder abuse
D
Talk to the client about the caregiver and support system
Question 36 Explanation:
Assessment and more data collection are needed. The client may have gastrointestinal or neurological problems that account for the symptoms. The anorexia could result from medications, poor dentition, or indigestion, the bruises may be attributed to ataxia, frequent falls, vertigo, or medication.
Question 37
Mrs. Moore, 62-year-old, with diabetes is in the emergency department. She stepped on a sharp sea shells while walking barefoot along the beach. Mrs. Moore did not notice that the object pierced the skin until later that evening. What problem does the client most probably have?
A
Carpal tunnel syndrome
B
Macroangiopathy
C
Peripheral neuropathy
D
Nephropathy
Question 37 Explanation:
Peripheral neuropathy refers to nerve damage of the hands and feet. The client did not notice that the object pierced the skin.
Question 38
A client with gangrenous foot has undergone a below-knee amputation. The nurse in the nursing care unit knows that the priority nursing intervention in the immediate post operative care of this client is:
A
Position the client prone periodically
B
Elevate the stump on a pillow for the first 24 hours
C
Encourage use of trapeze
D
Apply a cone-shaped dressing
Question 38 Explanation:
The elevation of the stump on a pillow for the first 24 hours decreases edema and increases venous return.
Question 39
The nurse is caring for a client who is transferred from the operating room for pneumonectomy. The nurse knows that immediately following pneumonectomy; the client should be in what position?
A
Supine on the unaffected side
B
Semi-Fowler’s on the unaffected side
C
Semi-Fowler’s on the affected side
D
Low-Fowler’s on the back
Question 39 Explanation:
This position allows maximum expansion, ventilation, and perfusion of the remaining lung.
Question 40
The client is transferred to the nursing care unit from the operating room after a transurethral resection of the prostate. The client is complaining of pain in the abdomen area. The nurse suspects of bladder spasms, which of the following is the best nursing action to minimize the pain felt by the client?
A
Repositioning catheter to relieve pressure
B
Giving prescribed narcotics every 4 hour
C
Advising the client not to urinate around catheter
D
Intermittent catheter irrigation with saline
Question 40 Explanation:
The client needs to be told before surgery that the catheter causes the urge to void. Attempts to void around the catheter cause the bladder muscles to contract and result in painful spasms.
Question 41
The client with acute pancreatitis and fluid volume deficit is transferred from the ward to the ICU. Which of the following will alert the nurse?
A
Decreased pain in the fetal position
B
Urine output of 35mL/hr
C
CVP of 12 mmHg
D
Cardiac output of 5L/min
Question 41 Explanation:
C = the normal CVP is 0-8 mmHg. This value reflects hypervolemia. The right ventricular function of this client reflects fluid volume overload, and the physician should be notified.
Question 42
A nurse is providing a discharge instruction to the client about the self-catheterization at home. Which of the following instructions would the nurse include?
A
Replace the catheter with a new one every 24 hour
B
Wash the catheter with soap and water after each use
C
Perform the Valsalva maneuver to promote insertion
D
Lubricate the catheter with Vaseline
Question 42 Explanation:
The catheter should be washed with soap and water after withdrawal and placed in a clean container. It can be reused until it is too hard or too soft for insertion. Self-care, prevention of complications, and cost-effectiveness are important in home management.
Question 43
Mr. Smith is scheduled for an above-the-knee amputation. After the surgery he was transferred to the nursing care unit. The nurse assigned to him knows that 72 hours after the procedure the client should be positioned properly to prevent contractures. Which of the following is the best position to the client?
A
Side-lying, alternating left and right sides
B
Sitting in a reclining chair twice a day
C
Lying on abdomen several times daily
D
Supine with stump elevated at least 30 degrees
Question 43 Explanation:
At about 48-72 hours, the client must be turned onto the abdomen to prevent flexion contractures.
Question 44
A male client with cirrhosis is complaining of belly pain, itchiness and his breasts are getting larger and also the abdomen. The client is so upset because of the discomfort and asks the nurse why his breast and abdomen are getting larger. Which of the following is the appropriate nursing response?
A
“It’s part of the swelling your body is experiencing”
B
“How much of a difference have you noticed”
C
“Your liver is not destroying estrogen hormones that all men produce”
D
“It’s probably because you have been less physically active”
Question 44 Explanation:
This allows the client to elaborate his concern and provides the nurse a baseline of assessment
Question 45
The nurse is planning of care to a client with peptic ulcer disease. To avoid the worsening condition of the client, the nurse should carefully plan the diet of the client. Which of the following will be included in the diet regime of the client?
A
Eliminating intake of alcohol and coffee
B
Eating small, frequent meals and a bedtime snack
C
Eating mainly bland food and milk or dairy products
D
Reducing intake of high-fiber foods
Question 45 Explanation:
These substances stimulate the production of hydrochloric acid, which is detrimental in peptic ulcer disease.
Question 46
What effective precautions should the nurse use to control the transmission of methicillin-resistant Staphylococcus aureus (MRSA)?
A
Place the client on total isolation
B
Do nasal cultures on healthcare providers
C
Use gloves and handwashing before and after client contact
D
Use mask and gown during care of the MRSA client
Question 46 Explanation:
Contact isolation has been advised by the Centers for Disease Control and Prevention (CDC) to control transmission of MRSA, which includes gloves and handwashing.
Question 47
Following a needle biopsy of the kidney, which assessment is an indication that the client is bleeding?
A
Throbbing headache
B
Slow, irregular pulse
C
Dull, abdominal discomfort
D
Urinary frequency
Question 47 Explanation:
An accumulation of blood from the kidney into the abdomen would manifest itself with these symptoms
Question 48
The nurse is going to replace the Pleur-O-Vac attached to the client with a small, persistent left upper lobe pneumothorax with a Heimlich Flutter Valve. Which of the following is the best rationale for this?
A
Prevent kinking of the tube
B
Promote air and pleural drainage
C
Eliminate the need for a water-seal drainage
D
Eliminate the need for a dressing
Question 48 Explanation:
The Heimlich flutter valve has a one-way valve that allows air and fluid to drain. Underwater seal drainage is not necessary. This can be connected to a drainage bag for the patient’s mobility. The absence of a long drainage tubing and the presence of a one-way valve promote effective therapy
Question 49
The nurse in the nursing care unit is assigned to care to a client who is Immunocompromised. The client tells the nurse that his chest is painful and the blisters are itchy. What would be the nursing intervention to this client?
A
Clarify if the client is on a new medication
B
Give a prn pain medication
C
Use gown and gloves while assessing the lesions
D
Call the physician
Question 49 Explanation:
The client may have herpes zoster (shingles), a viral infection. The nurse should use standard precautions in assessing the lesions. Immunocompromised clients are at risk for infection.
Question 50
A client with AIDS is scheduled for discharge. The client tells the nurse that one of his hobbies at home is gardening. What will be the discharge instruction of the nurse to the client knowing that the client is prone to toxoplasmosis?
A
Wear a mask when travelling to foreign countries
B
Avoid contact with cats and birds
C
Wash all vegetables before cooking
D
Wear gloves when gardening
Question 50 Explanation:
Toxoplasmosis is an opportunistic infection and a parasite of birds and mammals. The oocysts remain infectious in moist soil for about 1 year.
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Text Mode – Text version of the exam
The scope of this Nursing Test III is parallel to the NP3 NLE Coverage:
Medical Surgical Nursing
1. The nurse is going to replace the Pleur-O-Vac attached to the client with a small, persistent left upper lobe pneumothorax with a Heimlich Flutter Valve. Which of the following is the best rationale for this?
Promote air and pleural drainage
Prevent kinking of the tube
Eliminate the need for a dressing
Eliminate the need for a water-seal drainage
2. The client with acute pancreatitis and fluid volume deficit is transferred from the ward to the ICU. Which of the following will alert the nurse?
Decreased pain in the fetal position
Urine output of 35mL/hr
CVP of 12 mmHg
Cardiac output of 5L/min
3. The nurse in the morning shift is making rounds in the ward. The nurse enters the client’s room and found the client in discomfort condition. The client complains of stiffness in the joints. To reduce the early morning stiffness of the joints of the client,the nurse can encourage the client to:
Sleep with a hot pad
Take to aspirins before arising, and wait 15 minutes before attempting locomotion
Take a hot tub bath or shower in the morning
Put joints through passive ROM before trying to move them actively
4. The nurse is planning of care to a client with peptic ulcer disease. To avoid the worsening condition of the client, the nurse should carefully plan the diet of the client. Which of the following will be included in the diet regime of the client?
Eating mainly bland food and milk or dairy products
Reducing intake of high-fiber foods
Eating small, frequent meals and a bedtime snack
Eliminating intake of alcohol and coffee
5. The physician has given instruction to the nurse that the client can be ambulated on crutches, with no weight bearing on the affected limb. The nurse is aware that the appropriate crutch gait for the nurse to teach the client would be:
Tripod gait
Two-point gait
Four-point gait
Three-point gait
6. The client is transferred to the nursing care unit from the operating room after a transurethral resection of the prostate. The client is complaining of pain in the abdomen area. The nurse suspects of bladder spasms, which of the following is the best nursing action to minimize the pain felt by the client?
Advising the client not to urinate around catheter
Intermittent catheter irrigation with saline
Giving prescribed narcotics every 4 hour
Repositioning catheter to relieve pressure
7. A client is diagnosed with peptic ulcer. The nurse caring for the client expects the physician to order which diet?
NPO
Small feedings of bland food
A regular diet given frequently in small amounts
Frequent feedings of clear liquids
8. The nurse is going to insert a Miller-Abbott tube to the client. Before insertion of the tube, the balloon is tested for patency and capacity and then deflated. Which of the following nursing measure will ease the insertion to the tube?
Positioning the client in Semi-Fowler’s position
Administering a sedative to reduce anxiety
Chilling the tube before insertion
Warming the tube before insertion
9. The physician ordered a low-sodium diet to the client. Which of the following food will the nurse avoid to give to the client?
Orange juice.
Whole milk.
Ginger ale.
Black coffee.
10. Mr. Bean, a 70-year-old client is admitted in the hospital for almost one month. The nurse understands that prolonged immobilization could lead to decubitus ulcers. Which of the following would be the least appropriate nursing intervention in the prevention of decubitus?
Giving backrubs with alcohol
Use of a bed cradle
Frequent assessment of the skin
Encouraging a high-protein diet
11. The physician prescribed digoxin 0.125 mg PO qd to a client and instructed the nurse that the client is on high-potassium diet. High potassium foods are recommended in the diet of a client taking digitalis preparations because a low serum potassium has which of the following effects?
Potentiates the action of digoxin
Promotes calcium retention
Promotes sodium excretion
Puts the client at risk for digitalis toxicity
12. The nurse is caring for a client who is transferred from the operating room for pneumonectomy. The nurse knows that immediately following pneumonectomy; the client should be in what position?
Supine on the unaffected side
Low-Fowler’s on the back
Semi-Fowler’s on the affected side
Semi-Fowler’s on the unaffected side
13. A client is placed on digoxin, high potassium foods are recommended in the diet of the client. Which of the following foods willthe nurse give to the client?
Whole grain cereal, orange juice, and apricots
Turkey, green bean, and Italian bread
Cottage cheese, cooked broccoli, and roast beef
Fish, green beans and cherry pie
14. The nurse is assigned to care to a client who undergone thyroidectomy. What nursing intervention is important during the immediate postoperative period following a thyroidectomy?
Assess extremities for weakness and flaccidity
Support the head and neck during position changes
Position the client in high Fowler’s
Medicate for restlessness and anxiety
15. What would be the recommended diet the nurse will implement to a client with burns of the head, face, neck and anterior chest?
Serve a high-protein, high-carbohydrate diet
Encourage full liquid diet
Serve a high-fat diet, high-fiber diet
Monitor intake to prevent weight gain
16. A client with multiple fractures of both lower extremities is admitted for 3 days ago and is on skeletal traction. The client is complaining of having difficulty in bowel movement. Which of the following would be the most appropriate nursing intervention?
Administer an enema
Perform range-of-motion exercise to all extremities
Ensure maximum fluid intake (3000ml/day)
Put the client on the bedpan every 2 hours
17. John is diagnosed with Addison’s disease and admitted in the hospital. What would be the appropriate nursing care for John?
Reducing physical and emotional stress
Providing a low-sodium diet
Restricting fluids to 1500ml/day
Administering insulin-replacement therapy
18. Mr. Smith is scheduled for an above-the-knee amputation. After the surgery he was transferred to the nursing care unit. The nurse assigned to him knows that 72 hours after the procedure the client should be positioned properly to prevent contractures. Which of the following is the best position to the client?
Side-lying, alternating left and right sides
Sitting in a reclining chair twice a day
Lying on abdomen several times daily
Supine with stump elevated at least 30 degrees
19. A client is scheduled to have an inguinal herniorraphy in the outpatient surgical department. The nurse is providing health teaching about post surgical care to the client. Which of the following statement if made by the client would reflect the need for more teaching?
“I should call the physician if I have a cough or cold before surgery”
“I will be able to drive soon after surgery”
“I will not be able to do any heavy lifting for 3-6 weeks after surgery”
“I should support my incision if I have to cough or turn”
20. Ms Jones is brought to the emergency room and is complaining of muscle spasms, numbness, tremors and weakness in the arms and legs. The client was diagnosed with multiple sclerosis. The nurse assigned to Ms. Jones is aware that she has to prevent fatigue to the client to alleviate the discomfort. Which of the following teaching is necessary to prevent fatigue?
Avoid extremes in temperature
Install safety devices in the home
Attend support group meetings
Avoid physical exercise
21. Mr. Stewart is in sickle cell crisis and complaining pain in the joints and difficulty of breathing. On the assessment of the nurse, his temperature is 38.1 ºC. The physician ordered Morphine sulfate via patient-controlled analgesia (PCA), and oxygen at 4L/min. A priority nursing diagnosis to Mr. Stewart is risk for infection. A nursing intervention to assist in preventing infection is:
Using standard precautions and medical asepsis
Enforcing a “no visitors” rule
Using moist heat on painful joints
Monitoring a vital signs every 2 hour
22. Mrs. Maupin is a professor in a prestigious university for 30 years. After lecture, she experience blurring of vision and tiredness. Mrs. Maupin is brought to the emergency department. On assessment, the nurse notes that the blood pressure of the client is 139/90. Mrs. Maupin has been diagnosed with essential hypertension and placed on medication to control her BP. Which potential nursing diagnosis will be a priority for discharge teaching?
Sleep Pattern disturbance
Impaired physical mobility
Noncompliance
Fluid volume excess
23. Following a needle biopsy of the kidney, which assessment is an indication that the client is bleeding?
Slow, irregular pulse
Dull, abdominal discomfort
Urinary frequency
Throbbing headache
24. A client with acute bronchitis is admitted in the hospital. The nurse assigned to the client is making a plan of care regarding expectoration of thick sputum. Which nursing action is most effective?
Place the client in a lateral position every 2 hour
Splint the patient’s chest with pillows when coughing
Use humified oxygen
Offer fluids at regular intervals
25. The nurse is going to assess the bowel sound of the client. For accurate assessment of the bowel sound, the nurse should listen for at least:
5 minutes
60 seconds
30 seconds
2 minutes
26. The nurse encourages the client to wear compression stockings. What is the rationale behind in using compression stockings?
Compression stockings promote venous return
Compression stockings divert blood to major vessels
Compression stockings decreases workload on the heart
27. Mr. Whitman is a stroke client and is having difficulty in swallowing. Which is the best nursing intervention is most likely to assist the client?
Placing food in the unaffected side of the mouth
Increasing fiber in the diet
Asking the patient to speak slowly
Increasing fluid intake
28. Following nephrectomy, the nurse closely monitors the urinary output of the client. Which assessment finding is an early indicator of fluid retention in the postoperative period?
Periorbital edema
Increased specific gravity of urine
A urinary output of 50mL/hr
Daily weight gain of 2 lb or more
29. A nurse is completing an assessment to a client with cirrhosis. Which of the following nursing assessment is important to notify the physician?
Expanding ecchymosis
Ascites and serum albumin of 3.2 g/dl
Slurred speech
Hematocrit of 37% and hemoglobin of 12g/dl
30. Mr. Park is 32-year-old, a badminton player and has a type 1 diabetes mellitus. After the game, the client complains of becoming diaphoretic and light-headedness. The client asks the nurse how to avoid this reaction. The nurse will recommend to:
Allow plenty of time after the insulin injection and before beginning the match
Eat a carbohydrate snack before and during the badminton match
Drink plenty of fluids before, during, and after bed time
Take insulin just before starting the badminton match
31. A client is rushed to the emergency room due to serious vehicle accident. The nurse is suspecting of head injury. Which of the following assessment findings would the nurse report to the physician?
CVP of 5mmHa
Glasgow Coma Scale score of 13
Polyuria and dilute urinary output
Insomnia
32. Mrs. Moore, 62-year-old, with diabetes is in the emergency department. She stepped on a sharp sea shells while walking barefoot along the beach. Mrs. Moore did not notice that the object pierced the skin until later that evening. What problem does the client most probably have?
Nephropathy
Macroangiopathy
Carpal tunnel syndrome
Peripheral neuropathy
33. A client with gangrenous foot has undergone a below-knee amputation. The nurse in the nursing care unit knows that the priority nursing intervention in the immediate post operative care of this client is:
Elevate the stump on a pillow for the first 24 hours
Encourage use of trapeze
Position the client prone periodically
Apply a cone-shaped dressing
34. A client with a diagnosis of gastric ulcer is complaining of syncope and vertigo. What would be the initial nursing intervention by the nurse?
Monitor the client’s vital signs
Keep the client on bed rest
Keep the patient on bed rest
Give a stat dose of Sucralfate (Carafate)
35. After a right lower lobectomy on a 55-year-old client, which action should the nurse initiate when the client is transferred from the post anesthesia care unit?
Notify the family to report the client’s condition
Immediately administer the narcotic as ordered
Keep client on right side supported by pillows
Encourage coughing and deep breathing every 2 hours
36. The nurse is providing a discharge instruction about the prevention of urinary stasis to a client with frequent bladder infection. Which of the following will the nurse include in the instruction?
Drink 3-4 quarts of fluid every day
Empty the bladder every 2-4 hours while awake
Encourage the use of coffee, tea, and colas for their diuretic effect
Teach Kegel exercises to control bladder flow
37. A male client visits the clinic for check-up. The client tells the nurse that there is a yellow discharge from his penis. He also experiences a burning sensation when urinating. The nurse is suspecting of gonorrhea. What teaching is necessary for this client?
Sex partner of 3 months ago must be treated
Women with gonorrhea are symptomatic
Use a condom for sexual activity
Sex partner needs to be evaluated
38. A client with AIDS is admitted in the hospital. He is receiving intravenous therapy. While the nurse is assessing the IV site, the client becomes confused and restless and the intravenous catheter becomes disconnected and minimal amount of the client’s blood spills onto the floor. Which action will the nurse take to remove the blood spill?
Promptly clean with a 1:10 solution of household bleach and water
Promptly clean up the blood spill with full-strength antimicrobial cleaning solution
Immediately mop the floor with boiling water
Allow the blood to dry before cleaning to decrease the possibility of cross-contamination
39. Before surgery, the physician ordered pentobarbital sodium (Nembutal) for the client to sleep. The night before the scheduled surgery, the nurse gave the pre-medication. One hour later the client is still unable to sleep. The nurse review the client’s chart and note the physician’s prescription with an order to repeat. What should the nurse do next?
Rub the client’s back until relaxed
Prepare a glass of warm milk
Give the second dose of pentobarbital sodium
Explore the client’s feelings about surgery
40. The nurse on the night shift is making rounds in the nursing care unit. The nurse is about to enter to the client’s room when a ventilator alarm sounds, what is the first action the nurse should do?
Assess the lung sounds
Suction the client right away
Look at the client
Turn and position the client
41. What effective precautions should the nurse use to control the transmission of methicillin-resistant Staphylococcus aureus (MRSA)?
Use gloves and handwashing before and after client contact
Do nasal cultures on healthcare providers
Place the client on total isolation
Use mask and gown during care of the MRSA client
42. The postoperative gastrectomy client is scheduled for discharge. The client asks the nurse, “When I will be allowed to eat three meals a day like the rest of my family?”. The appropriate nursing response is:
“You will probably have to eat six meals a day for the rest of your life.”
“Eating six meals a day can be a bother, can’t it?”
“Some clients can tolerate three meals a day by the time they leave the hospital. Maybe it will be a little longer for you.”
“ It varies from client to client, but generally in 6-12 months most clients can return to their previous meal patterns”
43. A male client with cirrhosis is complaining of belly pain, itchiness and his breasts are getting larger and also the abdomen. The client is so upset because of the discomfort and asks the nurse why his breast and abdomen are getting larger. Which of the following is the appropriate nursing response?
“How much of a difference have you noticed”
“It’s part of the swelling your body is experiencing”
“It’s probably because you have been less physically active”
“Your liver is not destroying estrogen hormones that all men produce”
44. A client is diagnosed with detached retina and scheduled for surgery. Preoperative teaching of the nurse to the client includes:
No eye pain is expected postoperatively
Semi-fowler’s position will be used to reduce pressure in the eye.
Eye patches may be used postoperatively
Return of normal vision is expected following surgery
45. A 70-year-old client is brought to the emergency department with a caregiver. The client has manifestations of anorexia, wasting of muscles and multiple bruises. What nursing interventions would the nurse implement?
Talk to the client about the caregiver and support system
Complete a gastrointestinal and neurological assessment
Check the lab data for serum albumin, hematocrit and hemoglobin
Complete a police report on elder abuse
46. A nurse is providing a discharge instruction to the client about the self-catheterization at home. Which of the following instructions would the nurse include?
Wash the catheter with soap and water after each use
Lubricate the catheter with Vaseline
Perform the Valsalva maneuver to promote insertion
Replace the catheter with a new one every 24 hour
47. The nurse in the nursing care unit is assigned to care to a client who is Immunocompromised. The client tells the nurse that his chest is painful and the blisters are itchy. What would be the nursing intervention to this client?
Call the physician
Give a prn pain medication
Clarify if the client is on a new medication
Use gown and gloves while assessing the lesions
48. A client is admitted and has been diagnosed with bacterial (meningococcal) meningitis. The infection control registered nurse visits the staff nurse caring to the client. What statement made by the nurse reflects an understanding of the management of this client?
speech pattern may be altered
Respiratory isolation is necessary for 24 hours after antibiotics are started
Perform skin culture on the macular popular rash
Expect abnormal general muscle contractions
49. A 18-year-old male client had sustained a head injury from a motorbike accident. It is uncertain whether the client may have minimal but permanent disability. The family is concerned regarding the client’s difficulty accepting the possibility of long term effects. Which nursing diagnosis is best for this situation?
Nutrition, less than body requirements
Injury, potential for sensory-perceptual alterations
Impaired mobility, related to muscle weakness
Anticipatory grieving, due to the loss of independence
50. A client with AIDS is scheduled for discharge. The client tells the nurse that one of his hobbies at home is gardening. What will be the discharge instruction of the nurse to the client knowing that the client is prone to toxoplasmosis?
Wash all vegetables before cooking
Wear gloves when gardening
Wear a mask when travelling to foreign countries
Avoid contact with cats and birds
Answers and Rationales
D. The Heimlich flutter valve has a one-way valve that allows air and fluid to drain. Underwater seal drainage is not necessary. This can be connected to a drainage bag for the patient’s mobility. The absence of a long drainage tubing and the presence of a one-way valve promote effective therapy
C. C = the normal CVP is 0-8 mmHg. This value reflects hypervolemia. The right ventricular function of this client reflects fluid volume overload, and the physician should be notified.
C. A hot tub bath or shower in the morning helps many patients limber up and reduces the symptoms of early morning stiffness. Cold and ice packs are used to a lesser degree, though some clients state that cold decreases localized pain, particularly during acute attacks.
D. These substances stimulate the production of hydrochloric acid, which is detrimental in peptic ulcer disease.
D. The three-point gait is appropriate when weight bearing is not allowed on the affected limb. The swing-to and swing-through crutch gaits may also be used when only one leg can be used for weight bearing
A. The client needs to be told before surgery that the catheter causes the urge to void. Attempts to void around the catheter cause the bladder muscles to contract and result in painful spasms.
B. Bland feedings should be given in small amounts on a frequent basis to neutralize the hydrochloric acid and to prevent overload
C. Chilling the tube before insertion assists in relieving some of the nasal discomfort. Water-soluble lubricants along with viscous lidocaine (Xylocaine) may also be used. It is usually only lightly lubricated before insertion
B. Whole milk should be avoided to include in the client’s diet because it has 120 mg of sodium in 8 0z of milk.
A. Alcohol is extremely drying and contributes to skin break down. An emollient lotion should be used.
D. Potassium influences the excitability of nerves and muscles. When potassium is low and the client is on digoxin, the risk of digoxin toxicity is increased.
C. This position allows maximum expansion, ventilation, and perfusion of the remaining lung.
A. These foods are high in potassium
B. Stress on the suture line should be avoided. Prevent flexion or hyperextension of the neck, and provide a small pillow under thehead and neck. Neck muscles have been affected during a thyroidectomy, support essential for comfort and incisional support.
A. A positive nitrogen balance is important for meeting metabolic needs, tissue repair, and resistance to infection. Caloric goals may be as high as 5000 calories per day.
C. The best early intervention would be to increase fluid intake, because constipation is common when activity is decreased or usual routines have been interrupted.
A. Because the client’s ability is to react to stress is decreased, maintaining a quiet environment becomes A nursing priority. Dehydration is a common problem in Addison’s disease, so close observation of the client’s hydration level is crucial. To promote optimal hydration and sodium intake, fluid intake is increased, particularly fluid containing electrolytes, such as broths, carbonated beverages, and juices.
C. At about 48-72 hours, the client must be turned onto the abdomen to prevent flexion contractures.
B. The client should not drive for 2 weeks after surgery to avoid stress on the incision. This reflects a need for additional teaching.
A. Extremes in heat and cold will exacerbate symptoms. Heat delays transmission of impulses and increases fatigue.
A. Vigilant implementation of standard precautions and medical asepsis is an effective means of preventing infection
C. Noncompliance is a major problem in the management of chronic disease. In hypertension, the client often does not feel ill and thus does not see a need to follow a treatment regimen.
B. An accumulation of blood from the kidney into the abdomen would manifest itself with these symptoms
D. Fluids liquefy secretions and therefore make it easier to expectorate
D. Physical assessment guidelines recommend listening for atleast 2 minutes in each quadrant (and up to 5 minutes, not at least 5 minutes).
A. Compression stockings promote venous return and prevent peripheral pooling.
A. Placing food in the unaffected side of the mouth assists in the swallowing process because the client has sensation on that side and will have more control over the swallowing process.
D. Daily weights are taken following nephrectomy. Daily increases of 2 lb or more are indicative of fluid retention and should be reported to the physician. Intake and output records may also reflect this imbalance.
A. Clients with cirrhosis have already coagulation due to thrombocytopenia and vitamin K deficiency. This could be a sign of bleeding
B. Exercise enhances glucose uptake, and the client is at risk for an insulin reaction. Snacks with carbohydrates will help.
C. These are symptoms of diabetes insipidus. The patient can become hypovolemic and vasopressin may reverse the Polyuria.
D. Peripheral neuropathy refers to nerve damage of the hands and feet. The client did not notice that the object pierced the skin.
A. The elevation of the stump on a pillow for the first 24 hours decreases edema and increases venous return.
B. The priority is to maintain client’s safety. With syncope and vertigo, the client is at high risk for falling.
D. Coughing and deep breathing are essential for re-expansion of the lung
B. Avoiding stasis of urine by emptying the bladder every 2-4 hours will prevent overdistention of the bladder and future urinary tract infections.
D. If infected, the sex partner must be evaluated and treated
A. A 1:10 solution of household bleach and water is recommended by the Centers for Disease Control and Prevention to kill the human immunodeficiency virus (HIV).
D. Given the data, presurgical anxiety is suspected. The client needs an opportunity to talk about concerns related to surgery before further actions (which may mask the anxiety).
C. A quick look at the client can help identify the type and cause of the ventilator alarm. Disconnection of the tube from the ventilator, bronchospasm, and anxiety are some of the obvious reasons that could trigger an alarm.
A. Contact isolation has been advised by the Centers for Disease Control and Prevention (CDC) to control transmission of MRSA, which includes gloves and handwashing.
D. In response to the question of the client, the nurse needs to provide brief, accurate information. Some clients who have had gastrectomies are able to tolerate three meals a day before discharge from the hospital. However, for the majority of clients, it takes 6-12 months before their surgically reduced stomach has stretched enough to accommodate a larger meal.
A. This allows the client to elaborate his concern and provides the nurse a baseline of assessment
C. Use of eye patches may be continued postoperatively, depending on surgeon preference. This is done to achieve >90% success rate of the surgery.
B. Assessment and more data collection are needed. The client may have gastrointestinal or neurological problems that account for the symptoms. The anorexia could result from medications, poor dentition, or indigestion, the bruises may be attributed to ataxia, frequent falls, vertigo, or medication.
A. The catheter should be washed with soap and water after withdrawal and placed in a clean container. It can be reused until it is too hard or too soft for insertion. Self-care, prevention of complications, and cost-effectiveness are important in home management.
D. The client may have herpes zoster (shingles), a viral infection. The nurse should use standard precautions in assessing the lesions. Immunocompromised clients are at risk for infection.
B. After a minimum of 24 hours of IV antibiotics, the client is no longer considered communicable. Evaluation of the nurse’s knowledge is needed for safe care and continuity of care.
D. Stem of the question supports this choice by stating that the client has difficulty accepting the potential disability.
B. Toxoplasmosis is an opportunistic infection and a parasite of birds and mammals. The oocysts remain infectious in moist soil for about 1 year.