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PNLE IV for Care of Clients with Physiologic and Psychosocial Alterations Part 2 (PM)
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Question 1
Herbert, a 45 year old construction engineer is brought to the hospital unconscious after falling from a 2-story building. When assessing the client, the nurse would be most concerned if the assessment revealed:
A
A depressed fontanel
B
Reactive pupils
C
An elevated temperature
D
Bleeding from ears
Question 1 Explanation:
The nurse needs to perform a thorough assessment that could indicate alterations in cerebral function, increased intracranial pressures, fractures and bleeding. Bleeding from the ears occurs only with basal skull fractures that can easily contribute to increased intracranial pressure and brain herniation.
Question 2
Katrina has an abnormal result on a Papanicolaou test. After admitting that she read her chart while the nurse was out of the room, Katrina asks what dysplasia means. Which definition should the nurse provide?
A
Presence of completely undifferentiated tumor cells that don't resemble cells of the tissues of their origin.
B
Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn't found.
C
Alteration in the size, shape, and organization of differentiated cells.
D
Increase in the number of normal cells in a normal arrangement in a tissue or an organ.
Question 2 Explanation:
Dysplasia refers to an alteration in the size, shape, and organization of differentiated cells. The presence of completely undifferentiated tumor cells that don't resemble cells of the tissues of their origin is called anaplasia. An increase in the number of normal cells in a normal arrangement in a tissue or an organ is called hyperplasia. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn't found is called metaplasia.
Question 3
If a client requires a pneumonectomy, what fills the area of the thoracic cavity?
A
The tissue from the other lung grows over to the other side
B
The space remains filled with air only
C
The surgeon fills the space with a gel
D
Serous fluids fills the space and consolidates the region
Question 3 Explanation:
Serous fluid fills the space and eventually consolidates, preventing extensive mediastinal shift of the heart and remaining lung. Air can’t be left in the space. There’s no gel that can be placed in the pleural space. The tissue from the other lung can’t cross the mediastinum, although a temporary mediastinal shift exits until the space is filled.
Question 4
Mickey, a 6-year-old child with a congenital heart disorder is admitted with congestive heart failure. Digoxin (lanoxin) 0.12 mg is ordered for the child. The bottle of Lanoxin contains .05 mg of Lanoxin in 1 ml of solution. What amount should the nurse administer to the child?
A
4.2 ml
B
3.5 ml
C
1.2 ml
D
2.4 ml
Question 4 Explanation:
.05 mg/ 1 ml = .12mg/ x ml, .05x = .12, x = 2.4 ml.
Question 5
Ricardo is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist's instructions. Why does the client require special positioning for this type of anesthesia?
A
To prevent cerebrospinal fluid (CSF) leakage
B
To prevent confusion
C
To prevent seizures
D
To prevent cardiac arrhythmias
Question 5 Explanation:
The client receiving a subarachnoid block requires special positioning to prevent CSF leakage and headache and to ensure proper anesthetic distribution. Proper positioning doesn't help prevent confusion, seizures, or cardiac arrhythmias.
Question 6
The nurse is aware that the following terms used to describe reduced cardiac output and perfusion impairment due to ineffective pumping of the heart is:
A
Distributive shock
B
Anaphylactic shock
C
Myocardial infarction (MI)
D
Cardiogenic shock
Question 6 Explanation:
Cardiogenic shock is shock related to ineffective pumping of the heart. Anaphylactic shock results from an allergic reaction. Distributive shock results from changes in the intravascular volume distribution and is usually associated with increased cardiac output. MI isn’t a shock state, though a severe MI can lead to shock.
Question 7
For a client with Graves' disease, which nursing intervention promotes comfort?
A
Restricting intake of oral fluids
B
Placing extra blankets on the client's bed
C
Limiting intake of high-carbohydrate foods
D
Maintaining room temperature in the low-normal range
Question 7 Explanation:
Graves' disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client's room temperature in the low-normal range. To replace fluids lost via diaphoresis, the nurse should encourage, not restrict, intake of oral fluids. Placing extra blankets on the bed of a client with heat intolerance would cause discomfort. To provide needed energy and calories, the nurse should encourage the client to eat high-carbohydrate foods.
Question 8
Nurse Ron begins to teach a male client how to perform colostomy irrigations. The nurse would evaluate that the instructions were understood when the client states, “I should:
A
Insert the irrigating catheter deeper into the stoma if cramping occurs during the procedure.”
B
Lie on my left side while instilling the irrigating solution.”
C
Keep the irrigating container less than 18 inches above the stoma.”
D
Instill a minimum of 1200 ml of irrigating solution to stimulate evacuation of the bowel.”
Question 8 Explanation:
This height permits the solution to flow slowly with little force so that excessive peristalsis is not immediately precipitated.
Question 9
Ricardo, was diagnosed with type I diabetes. The nurse is aware that acute hypoglycemia also can develop in the client who is diagnosed with:
A
Hypertension
B
Type 2 diabetes
C
Hyperthyroidism
D
Liver disease
Question 9 Explanation:
The client with liver disease has a decreased ability to metabolize carbohydrates because of a decreased ability to form glycogen (glycogenesis) and to form glucose from glycogen.
Question 10
A client with shortness of breath has decreased to absent breath sounds on the right side, from the apex to the base. Which of the following conditions would best explain this?
A
Spontaneous pneumothorax
B
Pneumonia
C
Chronic bronchitis
D
Acute asthma
Question 10 Explanation:
A spontaneous pneumothorax occurs when the client’s lung collapses, causing an acute decreased in the amount of functional lung used in oxygenation. The sudden collapse was the cause of his chest pain and shortness of breath. An asthma attack would show wheezing breath sounds, and bronchitis would have rhonchi. Pneumonia would have bronchial breath sounds over the area of consolidation.
Question 11
Randy has undergone kidney transplant, what assessment would prompt Nurse Katrina to suspect organ rejection?
A
Sudden weight loss
B
Hypertension
C
Shock
D
Polyuria
Question 11 Explanation:
Hypertension, along with fever, and tenderness over the grafted kidney, reflects acute rejection.
Question 12
Cleo is diagnosed with osteoporosis. Which electrolytes are involved in the development of this disorder?
A
Phosphorous and potassium
B
Calcium and phosphorous
C
Calcium and sodium
D
Potassium and sodium
Question 12 Explanation:
In osteoporosis, bones lose calcium and phosphate salts, becoming porous, brittle, and abnormally vulnerable to fracture. Sodium and potassium aren't involved in the development of osteoporosis.
Question 13
A male client arriving in the emergency department is receiving cardiopulmonary resuscitation from paramedics who are giving ventilations through an endotracheal (ET) tube that they placed in the client’s home. During a pause in compressions, the cardiac monitor shows narrow QRS complexes and a heart rate of beats/minute with a palpable pulse. Which of the following actions should the nurse take first?
A
Check endotracheal tube placement.
B
Obtain an arterial blood gas (ABG) sample.
C
Start an L.V. line and administer amiodarone (Cardarone), 300 mg L.V. over 10 minutes.
D
Administer atropine, 1 mg L.V.
Question 13 Explanation:
ET tube placement should be confirmed as soon as the client arrives in the emergency department. Once the airways is secured, oxygenation and ventilation should be confirmed using an end-tidal carbon dioxide monitor and pulse oximetry. Next, the nurse should make sure L.V. access is established. If the client experiences symptomatic bradycardia, atropine is administered as ordered 0.5 to 1 mg every 3 to 5 minutes to a total of 3 mg. Then the nurse should try to find the cause of the client’s arrest by obtaining an ABG sample. Amiodarone is indicated for ventricular tachycardia, ventricular fibrillation and atrial flutter – not symptomatic bradycardia.
Question 14
Patrick is in the oliguric phase of acute tubular necrosis and is experiencing fluid and electrolyte imbalances. The client is somewhat confused and complains of nausea and muscle weakness. As part of the prescribed therapy to correct this electrolyte imbalance, the nurse would expect to:
A
Restrict foods high in protein
B
Administer Kayexalate
C
Increase oral intake of cheese and milk.
D
Administer large amounts of normal saline via I.V.
Question 14 Explanation:
Kayexalate,a potassium exchange resin, permits sodium to be exchanged for potassium in the intestine, reducing the serum potassium level.
Question 15
When prioritizing care, which of the following clients should the nurse Olivia assess first?
A
A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome
B
A 50-year-old client 3 days postmyocardial infarction
C
A 50-year-old client with diverticulitis
D
A 17-year-old clients 24-hours postappendectomy
Question 15 Explanation:
Guillain-Barre syndrome is characterized by ascending paralysis and potential respiratory failure. The order of client assessment should follow client priorities, with disorder of airways, breathing, and then circulation. There’s no information to suggest the postmyocardial infarction client has an arrhythmia or other complication. There’s no evidence to suggest hemorrhage or perforation for the remaining clients as a priority of care.
Question 16
Nurse Ron is assessing a client admitted with second- and third-degree burns on the face, arms, and chest. Which finding indicates a potential problem?
A
Rectal temperature of 100.6° F (38° C).
B
White pulmonary secretions.
C
Urine output of 20 ml/hour.
D
Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg.
Question 16 Explanation:
A urine output of less than 40 ml/hour in a client with burns indicates a fluid volume deficit. This client's PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions also are normal. The client's rectal temperature isn't significantly elevated and probably results from the fluid volume deficit.
Question 17
Nurse Maria plans to administer dexamethasone cream to a female client who has dermatitis over the anterior chest. How should the nurse apply this topical agent?
A
In long, even, outward, and downward strokes in the direction of hair growth
B
With an upward motion, to increase blood supply to the affected area
C
With a circular motion, to enhance absorption.
D
In long, even, outward, and upward strokes in the direction opposite hair growth
Question 17 Explanation:
When applying a topical agent, the nurse should begin at the midline and use long, even, outward, and downward strokes in the direction of hair growth. This application pattern reduces the risk of follicle irritation and skin inflammation.
Question 18
Patrick is treated in the emergency department for a Colles' fracture sustained during a fall. What is a Colles' fracture?
A
Fracture of the olecranon
B
Fracture of the humerus
C
Fracture of the carpal scaphoid
D
Fracture of the distal radius
Question 18 Explanation:
Colles' fracture is a fracture of the distal radius, such as from a fall on an outstretched hand. It's most common in women. Colles' fracture doesn't refer to a fracture of the olecranon, humerus, or carpal scaphoid.
Question 19
Francis with leukemia has neutropenia. Which of the following functions must frequently assessed?
A
Blood pressure
B
Breath sounds
C
Heart sounds
D
Bowel sounds
Question 19 Explanation:
Pneumonia, both viral and fungal, is a common cause of death in clients with neutropenia, so frequent assessment of respiratory rate and breath sounds is required. Although assessing blood pressure, bowel sounds, and heart sounds is important, it won’t help detect pneumonia.
Question 20
A male client with a gunshot wound requires an emergency blood transfusion. His blood type is AB negative. Which blood type would be the safest for him to receive?
A
A Rh-negative
B
O Rh-positive
C
AB Rh-positive
D
A Rh-positive
Question 20 Explanation:
Human blood can sometimes contain an inherited D antigen. Persons with the D antigen have Rh-positive blood type; those lacking the antigen have Rh-negative blood. It’s important that a person with Rhnegative blood receives Rh-negative blood. If Rh-positive blood is administered to an Rh-negative person, the recipient develops anti-Rh agglutinins, and sub sequent transfusions with Rh-positive blood may cause serious reactions with clumping and hemolysis of red blood cells.
Question 21
Nurse Tristan is caring for a male client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat:
A
hypercalcemia.
B
hypokalemia.
C
hypernatremia.
D
hyperkalemia.
Question 21 Explanation:
Hyperkalemia is a common complication of acute renal failure. It's life-threatening if immediate action isn't taken to reverse it. The administration of glucose and regular insulin, with sodium bicarbonate if necessary, can temporarily prevent cardiac arrest by moving potassium into the cells and temporarily reducing serum potassium levels. Hypernatremia, hypokalemia, and hypercalcemia don't usually occur with acute renal failure and aren't treated with glucose, insulin, or sodium bicarbonate.
Question 22
Rico with diabetes mellitus must learn how to self-administer insulin. The physician has prescribed 10 U of U-100 regular insulin and 35 U of U-100 isophane insulin suspension (NPH) to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction?
A
"Rotate injection sites within the same anatomic region, not among different regions."
B
"Inject insulin into healthy tissue with large blood vessels and nerves."
C
"Administer insulin into areas of scar tissue or hypotrophy whenever possible."
D
"Administer insulin into sites above muscles that you plan to exercise heavily later that day."
Question 22 Explanation:
The nurse should instruct the client to rotate injection sites within the same anatomic region. Rotating sites among different regions may cause excessive day-to-day variations in the blood glucose level; also, insulin absorption differs from one region to the next. Insulin should be injected only into healthy tissue lacking large blood vessels, nerves, or scar tissue or other deviations. Injecting insulin into areas of hypertrophy may delay absorption. The client shouldn't inject insulin into areas of lipodystrophy (such as hypertrophy or atrophy); to prevent lipodystrophy, the client should rotate injection sites systematically. Exercise speeds drug absorption, so the client shouldn't inject insulin into sites above muscles that will be exercised heavily.
Question 23
Norma asks for information about osteoarthritis. Which of the following statements about osteoarthritis is correct?
A
Osteoarthritis is the most common form of arthritis
B
Osteoarthritis is a rare form of arthritis
C
Osteoarthritis afflicts people over 60
D
Osteoarthritis is rarely debilitating
Question 23 Explanation:
Osteoarthritis is the most common form of arthritis and can be extremely debilitating. It can afflict people of any age, although most are elderly.
Question 24
Situation: Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out cirrhosis of the liver:
When Mr. Gonzales regained consciousness, the physician orders 50 ml of Lactose p.o. every 2 hours. Mr. Gozales develops diarrhea. The nurse best action would be:
A
“Frequently, bowel movements are needed to reduce sodium level”.
B
“Maybe your reacting to the drug; I will withhold the next dose”.
C
“I’ll see if your physician is in the hospital”.
D
“I’ll lower the dosage as ordered so the drug causes only 2 to 4 stools a day”.
Question 24 Explanation:
Lactulose is given to a patients with hepatic encephalopathy to reduce absorption of ammonia in the intestines by binding with ammonia and promoting more frequent bowel movements. If the patient experience diarrhea, it indicates over dosage and the nurse must reduce the amount of medication given to the patient. The stool will be mashy or soft. Lactulose is also very sweet and may cause cramping and bloating.
Question 25
Which of the following laboratory test results would suggest to the nurse Len that a client has a corticotropin-secreting pituitary adenoma?
A
Low corticotropin and high cortisol levels
B
Low corticotropin and low cortisol levels
C
High corticotropin and high cortisol levels
D
High corticotropin and low cortisol levels
Question 25 Explanation:
A corticotropin-secreting pituitary tumor would cause high corticotropin and high cortisol levels. A high corticotropin level with a low cortisol level and a low corticotropin level with a low cortisol level would be associated with hypocortisolism. Low corticotropin and high cortisol levels would be seen if there was a primary defect in the adrenal glands.
Question 26
Marco falls off his bicycle and injuries his ankle. Which of the following actions shows the initial response to the injury in the extrinsic pathway?
A
Conversion of factor VIII to factor VIIIa
B
Release of tissue thromboplastin
C
Release of Calcium
D
Conversion of factors XII to factor XIIa
Question 26 Explanation:
Tissue thromboplastin is released when damaged tissue comes in contact with clotting factors. Calcium is released to assist the conversion of factors X to Xa. Conversion of factors XII to XIIa and VIII to VIII a are part of the intrinsic pathway.
Question 27
A female client arrives at the emergency department with chest and stomach pain and a report of black tarry stool for several months. Which of the following order should the nurse Oliver anticipate?
Cardiac monitor, oxygen, creatine kinase and lactate dehydrogenase levels
Question 27 Explanation:
An electrocardiogram evaluates the complaints of chest pain, laboratory tests determines anemia, and the stool test for occult blood determines blood in the stool. Cardiac monitoring, oxygen, and creatine kinase and lactate dehydrogenase levels are appropriate for a cardiac primary problem. A basic metabolic panel and alkaline phosphatase and aspartate aminotransferase levels assess liver function. Prothrombin time, partial thromboplastin time, fibrinogen and fibrin split products are measured to verify bleeding dyscrasias, An electroencephalogram evaluates brain electrical activity.
Question 28
A male client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, Nurse Oliver notes that the client's stoma appears dusky. How should the nurse interpret this finding?
A
This is a normal finding 1 day after surgery.
B
Blood supply to the stoma has been interrupted.
C
An intestinal obstruction has occurred.
D
The ostomy bag should be adjusted.
Question 28 Explanation:
An ileostomy stoma forms as the ileum is brought through the abdominal wall to the surface skin, creating an artificial opening for waste elimination. The stoma should appear cherry red, indicating adequate arterial perfusion. A dusky stoma suggests decreased perfusion, which may result from interruption of the stoma's blood supply and may lead to tissue damage or necrosis. A dusky stoma isn't a normal finding. Adjusting the ostomy bag wouldn't affect stoma color, which depends on blood supply to the area. An intestinal obstruction also wouldn't change stoma color.
Question 29
The nurse is ware that the most relevant knowledge about oxygen administration to a male client with COPD is
A
Blood gases are monitored using a pulse oximeter.
B
Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.
C
Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breath.
D
Oxygen is administered best using a non-rebreathing mask
Question 29 Explanation:
COPD causes a chronic CO2 retention that renders the medulla insensitive to the CO2 stimulation for breathing. The hypoxic state of the client then becomes the stimulus for breathing. Giving the client oxygen in low concentrations will maintain the client’s hypoxic drive.
Question 30
Matilda, with hyperthyroidism is to receive Lugol’s iodine solution before a subtotal thyroidectomy is performed. The nurse is aware that this medication is given to:
A
Block the formation of thyroxine by the thyroid gland.
B
Maintain the function of the parathyroid glands.
C
Decrease the total basal metabolic rate.
D
Decrease the size and vascularity of the thyroid gland.
Question 30 Explanation:
Lugol’s solution provides iodine, which aids in decreasing the vascularity of the thyroid gland, which limits the risk of hemorrhage when surgery is performed.
Question 31
After cardiac surgery, a client’s blood pressure measures 126/80 mm Hg. Nurse Katrina determines that mean arterial pressure (MAP) is which of the following?
A
90 mm Hg
B
95 mm Hg
C
46 mm Hg
D
80 mm Hg
Question 31 Explanation:
(Look for no. 36 of text mode to view the computation.)
Question 32
Tonny has undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are inserted, and one-bottle water-seal drainage is instituted in the operating room. In the postanesthesia care unit Tonny is placed in Fowler's position on either his right side or on his back. The nurse is aware that this position:
A
Increase venous return
B
Reduce incisional pain.
C
Equalize pressure in the pleural space.
D
Facilitate ventilation of the left lung.
Question 32 Explanation:
Since only a partial pneumonectomy is done, there is a need to promote expansion of this remaining Left lung by positioning the client on the opposite unoperated side.
Question 33
Nurse Sarah expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate?
A
Below-normal serum potassium level
B
Serum alkalosis
C
Elevated serum acetone level
D
Serum ketone bodies
Question 33 Explanation:
A client with HHNS has an overall body deficit of potassium resulting from diuresis, which occurs secondary to the hyperosmolar, hyperglycemic state caused by the relative insulin deficiency. An elevated serum acetone level and serum ketone bodies are characteristic of diabetic ketoacidosis. Metabolic acidosis, not serum alkalosis, may occur in HHNS.
Question 34
Maritess was recently diagnosed with a genitourinary problem and is being examined in the emergency department. When palpating the her kidneys, the nurse should keep which anatomical fact in mind?
A
The kidneys lie between the 10th and 12th thoracic vertebrae.
B
The kidneys are situated just above the adrenal glands.
C
The average kidney is approximately 5 cm (2") long and 2 to 3 cm (¾" to 1-1/8") wide.
D
The left kidney usually is slightly higher than the right one.
Question 34 Explanation:
The left kidney usually is slightly higher than the right one. An adrenal gland lies atop each kidney. The average kidney measures approximately 11 cm (4-3/8") long, 5 to 5.8 cm (2" to 2¼") wide, and 2.5 cm (1") thick. The kidneys are located retroperitoneally, in the posterior aspect of the abdomen, on either side of the vertebral column. They lie between the 12th thoracic and 3rd lumbar vertebrae.
Question 35
Situation: Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out cirrhosis of the liver:
Which laboratory test indicates liver cirrhosis?
A
Decreased serum acid phosphate level
B
Elevated white blood cell count
C
Decreased red blood cell count
D
Elevated serum aminotransferase
Question 35 Explanation:
Hepatic cell death causes release of liver enzymes alanine aminotransferase (ALT), aspartate aminotransferase (AST) and lactate dehydrogenase (LDH) into the circulation. Liver cirrhosis is a chronic and irreversible disease of the liver characterized by generalized inflammation and fibrosis of the liver tissues.
Question 36
After undergoing a cardiac catheterization, Tracy has a large puddle of blood under his buttocks. Which of the following steps should the nurse take first?
A
Obtain vital signs
B
Call for help.
C
Apply gloves and assess the groin site
D
Ask the client to “lift up”
Question 36 Explanation:
Observing standard precautions is the first priority when dealing with any blood fluid. Assessment of the groin site is the second priority. This establishes where the blood is coming from and determineshow much blood has been lost. The goal in this situation is to stop the bleeding. The nurse would call for help if it were warranted after the assessment of the situation. After determining the extent of the bleeding, vital signs assessment is important. The nurse should never move the client, in case a clot has formed. Moving can disturb the clot and cause rebleeding.
Question 37
A 67-year-old client develops acute shortness of breath and progressive hypoxia requiring right femur. The hypoxia was probably caused by which of the following conditions?
A
Atelectasis
B
Bronchitis
C
Fat embolism
D
Asthma attack
Question 37 Explanation:
Long bone fractures are correlated with fat emboli, whichcause shortness of breath and hypoxia. It’s unlikely the client has developed asthma or bronchitis without a previous history. He could develop atelectasis but it typically doesn’t produce progressive hypoxia.
Question 38
Situation: Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out cirrhosis of the liver:
The biopsy of Mr. Gonzales confirms the diagnosis of cirrhosis. Mr. Gonzales is at increased risk for excessive bleeding primarily because of:
A
Inadequate nutrition
B
Varix formation
C
Impaired clotting mechanism
D
Trauma of invasive procedure
Question 38 Explanation:
Cirrhosis of the liver results in decreased Vitamin K absorption and formation of clotting factors resulting in impaired clotting mechanism.
Question 39
Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin. Nurse Mariner should expect the dose's:
A
onset to be at 2 p.m. and its peak to be at 3 p.m.
B
onset to be at 2:15 p.m. and its peak to be at 3 p.m.
C
onset to be at 4 p.m. and its peak to be at 6 p.m.
D
onset to be at 2:30 p.m. and its peak to be at 4 p.m.
Question 39 Explanation:
Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be from 2:15 p.m. to 2:30 p.m. and the peak from 4 p.m. to 6 p.m.
Question 40
A 66-year-old client has been complaining of sleeping more, increased urination, anorexia, weakness, irritability, depression, and bone pain that interferes with her going outdoors. Based on these assessment findings, the nurse would suspect which of the following disorders?
A
Diabetes mellitus
B
Hypoparathyroidism
C
Hyperparathyroidism
D
Diabetes insipidus
Question 40 Explanation:
Hyperparathyroidism is most common in older women and is characterized by bone pain and weakness from excess parathyroid hormone (PTH). Clients also exhibit hypercaliuria-causing polyuria. While clients with diabetes mellitus and diabetes insipidus also have polyuria, they don't have bone pain and increased sleeping. Hypoparathyroidism is characterized by urinary frequency rather than polyuria.
Question 41
Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy.
During the administration of chemotherapy agents, Nurse Oliver observed that the IV site is red and swollen, when the IV is touched Stacy shouts in pain. The first nursing action to take is:
A
Flush the IV line with saline solution
B
Immediately discontinue the infusion
C
Apply an ice pack to the site, followed by warm compress.
D
Notify the physician
Question 41 Explanation:
Edema or swelling at the IV site is a sign that the needle has been dislodged and the IV solution is leaking into the tissues causing the edema. The patient feels pain as the nerves are irritated by pressure and the IV solution. The first action of the nurse would be to discontinue the infusion right away to prevent further edema and other complication.
Question 42
Jestoni with chronic renal failure (CRF) is admitted to the urology unit. The nurse is aware that the diagnostic test are consistent with CRF if the result is:
A
Increased pH with decreased hydrogen ions.
B
Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein (PSP) excretion 75%.
C
Increased serum levels of potassium, magnesium, and calcium.
The normal BUN level ranges 8 to 23 mg/dl; the normal serum creatinine level ranges from 0.7 to 1.5 mg/dl. The test results of the answer are abnormally elevated, reflecting CRF and the kidneys' decreased ability to remove nonprotein nitrogen waste from the blood. CRF causes decreased pH and increased hydrogen ions — not vice versa. CRF also increases serum levels of potassium, magnesium, and phosphorous, and decreases serum levels of calcium. A uric acid analysis of 3.5 mg/dl falls within the normal range of 2.7 to 7.7 mg/dl; PSP excretion of 75% also falls with the normal range of 60% to 75%.
Question 43
Which of the following treatment is a suitable surgical intervention for a client with unstable angina?
PTCA can alleviate the blockage and restore blood flow and oxygenation. An echocardiogram is a noninvasive diagnosis test. Nitroglycerin is an oral sublingual medication. Cardiac catheterization is a diagnostic tool – not a treatment.
Question 44
Nurse Sherry is teaching male client regarding his permanent artificial pacemaker. Which information given by the nurse shows her knowledge deficit about the artificial cardiac pacemaker?
A
May be allowed to use electrical appliances
B
take the pulse rate once a day, in the morning upon awakening
C
May engage in contact sports
D
Have regular follow up care
Question 44 Explanation:
The client should be advised by the nurse to avoid contact sports. This will prevent trauma to the area of the pacemaker generator.
Question 45
A male client is scheduled for a transsphenoidal hypophysectomy to remove a pituitary tumor. Preoperatively, the nurse should assess for potential complications by doing which of the following?
A
Performing capillary glucose testing every 4 hours
B
Testing for ketones in the urine
C
Checking temperature every 4 hours
D
Testing urine specific gravity
Question 45 Explanation:
The nurse should perform capillary glucose testing every 4 hours because excess cortisol may cause insulin resistance, placing the client at risk for hyperglycemia. Urine ketone testing isn't indicated because the client does secrete insulin and, therefore, isn't at risk for ketosis. Urine specific gravity isn't indicated because although fluid balance can be compromised, it usually isn't dangerously imbalanced. Temperature regulation may be affected by excess cortisol and isn't an accurate indicator of infection.
Question 46
A 62-year-old male client was in a motor vehicle accident as an unrestrained driver. He’s now in the emergency department complaining of difficulty of breathing and chest pain. On auscultation of his lung field, no breath sounds are present in the upper lobe. This client may have which of the following conditions?
A
Bronchitis
B
Tuberculosis (TB)
C
Pneumonia
D
Pneumothorax
Question 46 Explanation:
From the trauma the client experienced, it’s unlikely he has bronchitis, pneumonia, or TB; rhonchi with bronchitis, bronchial breath sounds with TB would be heard.
Question 47
Nurse Alexandra teaches a client about elastic stockings. Which of the following statements, if made by the client, indicates to the nurse that the teaching was successful?
A
“Every four hours I should remove the stockings for a half hour.”
B
“I should put on the stockings before getting out of bed in the morning.”
C
“I will wear the stockings until the physician tells me to remove them.”
D
“I should wear the stockings even when I am sleep.”
Question 47 Explanation:
Promote venous return by applying external pressure on veins.
Question 48
After a motor vehicle accident, Armand an 22-year-old client is admitted with a pneumothorax. The surgeon inserts a chest tube and attaches it to a chest drainage system. Bubbling soon appears in the water seal chamber. Which of the following is the most likely cause of the bubbling?
A
Inadequate suction
B
Air leak
C
Kinked chest tube
D
Adequate suction
Question 48 Explanation:
Bubbling in the water seal chamber of a chest drainage system stems from an air leak. In pneumothorax an air leak can occur as air is pulled from the pleural space. Bubbling doesn’t normally occur with either adequate or inadequate suction or any preexisting bubbling in the water seal chamber.
Question 49
Terence suffered form burn injury. Using the rule of nines, which has the largest percent of burns?
A
Right thigh and penis
B
Upper trunk
C
Right upper arm and penis
D
Face and neck
Question 49 Explanation:
The percentage designated for each burned part of the body using the rule of nines: Head and neck 9%; Right upper extremity 9%; Left upper extremity 9%; Anterior trunk 18%; Posterior trunk 18%; Right lower extremity 18%; Left lower extremity 18%; Perineum 1%.
Question 50
Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy.
Stacy has beginning stomatitis. To promote oral hygiene and comfort, the nurse in-charge should:
A
Apply viscous Lidocaine to oral ulcers as needed.
B
Rinse mouth with Hydrogen Peroxide.
C
Provide frequent mouthwash with normal saline.
D
Use lemon glycerine swabs every 2 hours.
Question 50 Explanation:
Stomatitis can cause pain and this can be relieved by applying topical anesthetics such as lidocaine before mouth care. When the patient is already comfortable, the nurse can proceed with providing the patient with oral rinses of saline solution mixed with equal part of water or hydrogen peroxide mixed water in 1:3 concentrations to promote oral hygiene. Every 2-4 hours.
Question 51
Aldo with a massive pulmonary embolism will have an arterial blood gas analysis performed to determine the extent of hypoxia. The acid-base disorder that may be present is?
A
Metabolic alkalosis
B
Respiratory acidosis
C
Respiratory alkalosis
D
Metabolic acidosis
Question 51 Explanation:
A client with massive pulmonary embolism will have a large region and blow off large amount of carbon dioxide, which crosses the unaffected alveolar-capillary membrane more readily than does oxygen and results in respiratory alkalosis.
Question 52
Nurse Rose is aware that the statement that best explains why furosemide (Lasix) is administered to treat hypertension is:
A
It inhibits the angiotensin-coverting enzymes
B
It inhibits reabsorption of sodium and water in the loop of Henle.
C
It dilates peripheral blood vessels.
D
It decreases sympathetic cardioacceleration.
Question 52 Explanation:
Furosemide is a loop diuretic that inhibits sodium and water reabsorption in the loop Henle, thereby causing a decrease in blood pressure. Vasodilators cause dilation of peripheral blood vessels, directly relaxing vascular smooth muscle and decreasing blood pressure. Adrenergic blockers decrease sympathetic cardioacceleration and decrease blood pressure. Angiotensin-converting enzyme inhibitors decrease blood pressure due to their action on angiotensin.
Question 53
Norma has started a new drug for hypertension. Thirty minutes after she takes the drug, she develops chest tightness and becomes short of breath and tachypneic. She has a decreased level of consciousness. These signs indicate which of the following conditions?
A
Respiratory failure
B
Rheumatoid arthritis
C
Pulmonary embolism
D
Asthma attack
Question 53 Explanation:
The client was reacting to the drug with respiratory signs of impending anaphylaxis, which could lead to eventually respiratory failure. Although the signs are also related to an asthma attack or a pulmonary embolism, consider the new drug first. Rheumatoid arthritis doesn’t manifest these signs.
Question 54
Cyrill with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty-six hours later, the client's urine output suddenly rises above 200 ml/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse's suspicion of diabetes insipidus?
In diabetes insipidus, excessive polyuria causes dilute urine, resulting in a below-normal urine osmolality level. At the same time, polyuria depletes the body of water, causing dehydration that leads to an above-normal serum osmolality level. For the same reasons, diabetes insipidus doesn't cause above-normal urine osmolality or below-normal serum osmolality levels.
Question 55
When evaluating an arterial blood gas from a male client with a subdural hematoma, the nurse notes the Paco2 is 30 mm Hg. Which of the following responses best describes the result?
A
Normal
B
Emergent; the client is poorly oxygenated
C
Significant; the client has alveolar hypoventilation
A normal Paco2 value is 35 to 45 mm Hg CO2 has vasodilating properties; therefore, lowering Paco2 through hyperventilation will lower ICP caused by dilated cerebral vessels. Oxygenation is evaluated through Pao2 and oxygen saturation. Alveolar hypoventilation would be reflected in an increased Paco2.
Question 56
The immediate objective of nursing care for an overweight, mildly hypertensive male client with ureteral colic and hematuria is to decrease:
A
Hypertension
B
Pain
C
Weight
D
Hematuria
Question 56 Explanation:
Sharp, severe pain (renal colic) radiating toward the genitalia and thigh is caused by uretheral distention and smooth muscle spasm; relief form pain is the priority.
Question 57
Macario had coronary artery bypass graft (CABG) surgery 3 days ago. Which of the following conditions is suspected by the nurse when a decrease in platelet count from 230,000 ul to 5,000 ul is noted?
A
Disseminated intravascular coagulation (DIC)
B
Idiopathic thrombocytopemic purpura (ITP)
C
Pancytopenia
D
Heparin-associated thrombosis and thrombocytopenia (HATT)
Question 57 Explanation:
HATT may occur after CABG surgery due to heparin use during surgery. Although DIC and ITP cause platelet aggregation and bleeding, neither is common in a client after revascularization surgery. Pancytopenia is a reduction in all blood cells.
Question 58
A female client is scheduled to receive a heart valve replacement with a porcine valve. Which of the following types of transplant is this?
A
Autologous
B
Allogeneic
C
Xenogeneic
D
Syngeneic
Question 58 Explanation:
An xenogeneic transplant is between is between human and another species. A syngeneic transplant is between identical twins, allogeneic transplant is between two humans, and autologous is a transplant from the same individual.
Question 59
Mario comes to the clinic complaining of fever, drenching night sweats, and unexplained weight loss over the past 3 months. Physical examination reveals a single enlarged supraclavicular lymph node. Which of the following is the most probable diagnosis?
A
Hodgkin’s disease
B
Leukemia
C
Sickle cell anemia
D
Influenza
Question 59 Explanation:
Hodgkin’s disease typically causes fever night sweats, weight loss, and lymph mode enlargement. Influenza doesn’t last for months. Clients with sickle cell anemia manifest signs and symptoms of chronic anemia with pallor of the mucous membrane, fatigue, and decreased tolerance for exercise; they don’t show fever, night sweats, weight loss or lymph node enlargement. Leukemia doesn’t cause lymph node enlargement.
Question 60
The term “blue bloater” refers to a male client which of the following conditions?
A
Chronic obstructive bronchitis
B
Emphysema
C
Asthma
D
Adult respiratory distress syndrome (ARDS)
Question 60 Explanation:
Clients with chronic obstructive bronchitis appear bloated; they have large barrel chest and peripheral edema, cyanotic nail beds, and at times, circumoral cyanosis. Clients with ARDS are acutely short of breath and frequently need intubation for mechanical ventilation and large amount of oxygen. Clients with asthma don’t exhibit characteristics of chronic disease, and clients with emphysema appear pink and cachectic.
Question 61
JP has been diagnosed with gout and wants to know why colchicine is used in the treatment of gout. Which of the following actions of colchicines explains why it’s effective for gout?
A
Decreases bone demineralization
B
Decreases inflammation
C
Replaces estrogen
D
Decreases infection
Question 61 Explanation:
Then action of colchicines is to decrease inflammation by reducing the migration of leukocytes to synovial fluid. Colchicine doesn’t replace estrogen, decrease infection, or decrease bone demineralization.
Question 62
Tracy is receiving combination chemotherapy for treatment of metastatic carcinoma. Nurse Ruby should monitor the client for the systemic side effect of:
A
Nystagmus
B
Leukopenia
C
Polycythemia
D
Ascites
Question 62 Explanation:
Leukopenia, a reduction in WBCs, is a systemic effect of chemotherapy as a result of myelosuppression.
Question 63
The term “pink puffer” refers to the female client with which of the following conditions?
A
Adult respiratory distress syndrome (ARDS)
B
Asthma
C
Emphysema
D
Chronic obstructive bronchitis
Question 63 Explanation:
Because of the large amount of energy it takes to breathe, clients with emphysema are usually cachectic. They’re pink and usually breathe through pursed lips, hence the term “puffer.” Clients with ARDS are usually acutely short of breath. Clients with asthma don’t have any particular characteristics, and clients with chronic obstructive bronchitis are bloated and cyanotic in appearance.
Question 64
The physician orders laboratory tests to confirm hyperthyroidism in a female client with classic signs and symptoms of this disorder. Which test result would confirm the diagnosis?
A
An increase in the TSH level after 30 minutes during the TSH stimulation test
B
A decreased TSH level
C
No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test
D
Below-normal levels of serum triiodothyronine (T3) and serum thyroxine (T4) as detected by radioimmunoassay
Question 64 Explanation:
In the TSH test, failure of the TSH level to rise after 30 minutes confirms hyperthyroidism. A decreased TSH level indicates a pituitary deficiency of this hormone. Below-normal levels of T3 and T4, as detected by radioimmunoassay, signal hypothyroidism. A below-normal T4 level also occurs in malnutrition and liver disease and may result from administration of phenytoin and certain other drugs.
Question 65
Nurse Lourdes is teaching a client recovering from addisonian crisis about the need to take fludrocortisone acetate and hydrocortisone at home. Which statement by the client indicates an understanding of the instructions?
A
"I'll take the entire dose at bedtime."
B
"I'll take all of my hydrocortisone in the morning, right after I wake up."
C
"I'll take my hydrocortisone in the late afternoon, before dinner."
D
"I'll take two-thirds of the dose when I wake up and one-third in the late afternoon."
Question 65 Explanation:
Hydrocortisone, a glucocorticoid, should be administered according to a schedule that closely reflects the body's own secretion of this hormone; therefore, two-thirds of the dose of hydrocortisone should be taken in the morning and one-third in the late afternoon. This dosage schedule reduces adverse effects.
Question 66
A male client has a reduced serum high-density lipoprotein (HDL) level and an elevated low-density lipoprotein (LDL) level. Which of the following dietary modifications is not appropriate for this client?
A
Cholesterol intake of less than 300 mg daily
B
Less than 30% of calories form fat
C
Less than 10% of calories from saturated fat
D
Fiber intake of 25 to 30 g daily
Question 66 Explanation:
A client with low serum HDL and high serum LDL levels should get less than 30% of daily calories from fat. The other modifications are appropriate for this client.
Question 67
Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy. Stacy is discharged from the hospital following her chemotherapy treatments. Which statement of Stacy’s mother indicated that she understands when she will contact the physician?
A
“My physician should be called if Stacy is irritable and unhappy”.
B
“Should Stacy have continued hair loss, I need to call the doctor”.
C
“I should contact the physician if Stacy has difficulty in sleeping”.
D
“I will call my doctor if Stacy has persistent vomiting and diarrhea”.
Question 67 Explanation:
Persistent (more than 24 hours) vomiting, anorexia, and diarrhea are signs of toxicity and the patient should stop the medication and notify the health care provider. The other manifestations are expected side effects of chemotherapy.
Question 68
Hemoptysis may be present in the client with a pulmonary embolism because of which of the following reasons?
A
Loss of lung tissue
B
Alveolar damage in the infracted area
C
Involvement of major blood vessels in the occluded area
D
Loss of lung parenchyma
Question 68 Explanation:
The infracted area produces alveolar damage that can lead to the production of bloody sputum, sometimes in massive amounts. Clot formation usually occurs in the legs. There’s a loss of lung parenchyma and subsequent scar tissue formation.
Question 69
Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy.
Stacy’s mother states to the nurse that it is hard to see Stacy with no hair. The best response for the nurse is:
A
“You should not worry about her hair, just be glad that she is alive”.
B
“Yes it is upsetting. But try to cover up your feelings when you are with her or else she may be upset”.
C
“Stacy looks very nice wearing a hat”.
D
“This is only temporary; Stacy will re-grow new hair in 3-6 months, but may be different in texture”.
Question 69 Explanation:
This is the appropriate response. The nurse should help the mother how to cope with her own feelings regarding the child’s disease so as not to affect the child negatively. When the hair grows back, it is still of the same color and texture.
Question 70
Timothy’s arterial blood gas (ABG) results are as follows; pH 7.16; Paco2 80 mm Hg; Pao2 46 mm Hg; HCO3- 24mEq/L; Sao2 81%. This ABG result represents which of the following conditions?
A
Respiratory alkalosis
B
Respiratory acidosis
C
Metabolic acidosis
D
Metabolic alkalosis
Question 70 Explanation:
Because Paco2 is high at 80 mm Hg and the metabolic measure, HCO3- is normal, the client has respiratory acidosis. The pH is less than 7.35, academic, which eliminates metabolic and respiratory alkalosis as possibilities. If the HCO3- was below 22 mEq/L the client would have metabolic acidosis.
Question 71
Jose is in danger of respiratory arrest following the administration of a narcotic analgesic. An arterial blood gas value is obtained. Nurse Oliver would expect the paco2 to be which of the following values?
A
30 mm Hg
B
40 mm Hg
C
15 mm Hg
D
80 mm Hg
Question 71 Explanation:
A client about to go into respiratory arrest will have inefficient ventilation and will be retaining carbon dioxide. The value expected would be around 80 mm Hg. All other values are lower than expected.
Question 72
Ruby is receiving thyroid replacement therapy develops the flu and forgets to take her thyroid replacement medicine. The nurse understands that skipping this medication will put the client at risk for developing which of the following lifethreatening complications?
A
Tibial myxedema
B
Thyroid storm
C
Myxedema coma
D
Exophthalmos
Question 72 Explanation:
Myxedema coma, severe hypothyroidism, is a life-threatening condition that may develop if thyroid replacement medication isn't taken. Exophthalmos, protrusion of the eyeballs, is seen with hyperthyroidism. Thyroid storm is life-threatening but is caused by severe hyperthyroidism. Tibial myxedema, peripheral mucinous edema involving the lower leg, is associated with hypothyroidism but isn't life-threatening.
Question 73
Jomari is diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which of the following statements indicates that the client understands her condition and how to control it?
A
"I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual."
B
"I will have to monitor my blood glucose level closely and notify the physician if it's constantly elevated."
C
"If I experience trembling, weakness, and headache, I should drink a glass of soda that contains sugar."
D
"If I begin to feel especially hungry and thirsty, I'll eat a snack high in carbohydrates."
Question 73 Explanation:
Inadequate fluid intake during hyperglycemic episodes often leads to HHNS. By recognizing the signs of hyperglycemia (polyuria, polydipsia, and polyphagia) and increasing fluid intake, the client may prevent HHNS. Drinking a glass of nondiet soda would be appropriate for hypoglycemia. A client whose diabetes is controlled with oral antidiabetic agents usually doesn't need to monitor blood glucose levels. A highcarbohydrate diet would exacerbate the client's condition, particularly if fluid intake is low.
Question 74
Norma, with recent colostomy expresses concern about the inability to control the passage of gas. Nurse Oliver should suggest that the client plan to:
A
Decrease fluid intake at meal times.
B
Avoid foods that in the past caused flatus.
C
Eliminate foods high in cellulose.
D
Adhere to a bland diet prior to social events.
Question 74 Explanation:
Foods that bothered a person preoperatively will continue to do so after a colostomy.
Question 75
Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, Nurse Celia should:
A
Turn him frequently.
B
Perform passive range-of-motion (ROM) exercises.
C
Reduce the client's fluid intake.
D
Encourage the client to use a footboard.
Question 75 Explanation:
The most important intervention to prevent pressure ulcers is frequent position changes, which relieve pressure on the skin and underlying tissues. If pressure isn't relieved, capillaries become occluded, reducing circulation and oxygenation of the tissues and resulting in cell death and ulcer formation. During passive ROM exercises, the nurse moves each joint through its range of movement, which improves joint mobility and circulation to the affected area but doesn't prevent pressure ulcers. Adequate hydration is necessary to maintain healthy skin and ensure tissue repair. A footboard prevents plantar flexion and footdrop by maintaining the foot in a dorsiflexed position.
Question 76
A male client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:
A
Palpate the abdomen.
B
Auscultate bowel sounds.
C
Change the client's position.
D
Insert a rectal tube.
Question 76 Explanation:
If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician. Palpation should be avoided postoperatively with abdominal distention. If peristalsis is absent, changing positions and inserting a rectal tube won't relieve the client's discomfort.
Question 77
During a routine checkup, Nurse Mariane assesses a male client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the most common AIDS-related cancer?
A
Kaposi's sarcoma
B
Leukemia
C
Multiple myeloma
D
Squamous cell carcinoma
Question 77 Explanation:
Kaposi's sarcoma is the most common cancer associated with AIDS. Squamous cell carcinoma, multiple myeloma, and leukemia may occur in anyone and aren't associated specifically with AIDS.
Question 78
The nurse is aware that the following symptoms is most commonly an early indication of stage 1 Hodgkin’s disease?
A
Splenomegaly
B
Pericarditis
C
Persistent hypothermia
D
Night sweat
Question 78 Explanation:
In stage 1, symptoms include a single enlarged lymph node (usually), unexplained fever, night sweats, malaise, and generalized pruritis. Although splenomegaly may be present in some clients, night sweats are generally more prevalent. Pericarditis isn’t associated with Hodgkin’s disease, nor is hypothermia. Moreover, splenomegaly and pericarditis aren’t symptoms. Persistent hypothermia is associated with Hodgkin’s but isn’t an early sign of the disease.
Question 79
Arnold, a 19-year-old client with a mild concussion is discharged from the emergency department. Before discharge, he complains of a headache. When offered acetaminophen, his mother tells the nurse the headache is severe and she would like her son to have something stronger. Which of the following responses by the nurse is appropriate?
A
“Your son had a mild concussion, acetaminophen is strong enough.”
B
Stronger medications may lead to vomiting, which increases the intracarnial pressure (ICP).”
C
“Narcotics are avoided after a head injury because they may hide a worsening condition.”
D
“Aspirin is avoided because of the danger of Reye’s syndrome in children or young adults.”
Question 79 Explanation:
Narcotics may mask changes in the level of consciousness that indicate increased ICP and shouldn’t acetaminophen is strong enough ignores the mother’s question and therefore isn’t appropriate. Aspirin is contraindicated in conditions that may have bleeding, such as trauma, and for children or young adults with viral illnesses due to the danger of Reye’s syndrome. Stronger medications may not necessarily lead to vomiting but will sedate the client, thereby masking changes in his level of consciousness.
Question 80
Mario has burn injury. After Forty48 hours, the physician orders for Mario 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
18 gtt/min
C
36 gtt/min
D
28 gtt/min
Question 80 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 81
Which of the following drugs would be ordered by the physician to improve the platelet count in a male client with idiopathic thrombocytopenic purpura (ITP)?
A
Vitamin K
B
Methotrezate
C
Corticosteroids
D
Acetylsalicylic acid (ASA)
Question 81 Explanation:
Corticosteroid therapy can decrease antibody production and phagocytosis of the antibody-coated platelets, retaining more functioning platelets. Methotrexate can cause thrombocytopenia. Vitamin K is used to treat an excessive anticoagulate state from warfarin overload, and ASA decreases platelet aggregation.
Question 82
Ms. X has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client?
A
The most common treatment is metronidazole (Flagyl), which should eradicate the problem within 7 to 10 days.
B
This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually.
C
The potential for transmission to her sexual partner will be eliminated if condoms are used every time they have sexual intercourse.
D
The human papillomavirus (HPV), which causes condylomata acuminata, can't be transmitted during oral sex.
Question 82 Explanation:
Women with condylomata acuminata are at risk for cancer of the cervix and vulva. Yearly Pap smears are very important for early detection. Because condylomata acuminata is a virus, there is no permanent cure. Because condylomata acuminata can occur on the vulva, a condom won't protect sexual partners. HPV can be transmitted to other parts of the body, such as the mouth, oropharynx, and larynx.
Question 83
Anthony suffers burns on the legs, which nursing intervention helps prevent contractures?
A
Hyperextending the client's palms
B
Applying knee splints
C
Elevating the foot of the bed
D
Performing shoulder range-of-motion exercises
Question 83 Explanation:
Applying knee splints prevents leg contractures by holding the joints in a position of function. Elevating the foot of the bed can't prevent contractures because this action doesn't hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs.
Question 84
A 37-year-old male client was admitted to the coronary care unit (CCU) 2 days ago with an acute myocardial infarction. Which of the following actions would breach the client confidentiality?
A
The CCU nurse notifies the on-call physician about a change in the client’s condition
B
The CCU nurse gives a verbal report to the nurse on the telemetry unit before transferring the client to that unit
C
At the client’s request, the CCU nurse updates the client’s wife on his condition
D
The emergency department nurse calls up the latest electrocardiogram results to check the client’s progress.
Question 84 Explanation:
The emergency department nurse is no longer directly involved with the client’s care and thus has no legal right to information about his present condition. Anyone directly involved in his care (such as the telemetry nurse and the on-call physician) has the right to information about his condition. Because the client requested that the nurse update his wife on his condition, doing so doesn’t breach confidentiality.
Question 85
Which of the following groups of symptoms indicates a ruptured abdominal aortic aneurysm?
A
Severe lower back pain, decreased blood pressure, decreased RBC count, increased WBC count.
B
Lower back pain, increased blood pressure, decreased re blood cell (RBC) count, increased white blood (WBC) count.
Severe lower back pain, decreased blood pressure, decreased RBC count, decreased RBC count, decreased WBC count.
Question 85 Explanation:
Severe lower back pain indicates an aneurysm rupture, secondary to pressure being applied within the abdominal cavity. When ruptured occurs, the pain is constant because it can’t be alleviated until the aneurysm is repaired. Blood pressure decreases due to the loss of blood. After the aneurysm ruptures, the vasculature is interrupted and blood volume is lost, so blood pressure wouldn’t increase. For the same reason, the RBC count is decreased – not increased. The WBC count increases as cell migrate to the site of injury.
Question 86
An 18-year-old male client admitted with heat stroke begins to show signs of disseminated intravascular coagulation (DIC). Which of the following laboratory findings is most consistent with DIC?
A
Low levels of fibrin degradation products
B
Low platelet count
C
Elevated fibrinogen levels
D
Reduced prothrombin time
Question 86 Explanation:
In DIC, platelets and clotting factors are consumed, resulting in microthrombi and excessive bleeding. As clots form, fibrinogen levels decrease and the prothrombin time increases. Fibrin degeneration products increase as fibrinolysis takes places.
Question 87
Nurse Nikki knows that laboratory results supports the diagnosis of systemic lupus erythematosus (SLE) is:
A
Leukocysis, elevated blood urea nitrogen (BUN) and creatinine levels
Laboratory findings for clients with SLE usually show pancytopenia, elevated ANA titer, and decreased serum complement levels. Clients may have elevated BUN and creatinine levels from nephritis, but the increase does not indicate SLE.
Question 88
Kristine is scheduled for a bronchoscopy. When teaching Kristine what to expect afterward, the nurse's highest priority of information would be:
A
Food and fluids will be withheld for at least 2 hours.
B
Only ice chips and cold liquids will be allowed initially.
C
Warm saline gargles will be done q 2h.
D
Coughing and deep-breathing exercises will be done q2h.
Question 88 Explanation:
Prior to bronchoscopy, the doctors sprays the back of the throat with anesthetic to minimize the gag reflex and thus facilitate the insertion of the bronchoscope. Giving the client food and drink after the procedure without checking on the return of the gag reflex can cause the client to aspirate. The gag reflex usually returns after two hours.
Question 89
Nurse Michelle calculates the IV flow rate for a postoperative client. The client receives 3,000 ml of Ringer’s lactate solution IV to run over 24 hours. The IV infusion set has a drop factor of 10 drops per milliliter. The nurse should regulate the client’s IV to deliver how many drops per minute?
A
18
B
21
C
35
D
40
Question 89 Explanation:
3000 x 10 divided by 24 x 60.
Question 90
The nurse is aware that one of the following classes of medications maximizes cardiac performance in clients with heart failure by increasing ventricular contractility?
A
Inotropic agents
B
Diuretics
C
Beta-adrenergic blockers
D
Calcium channel blocker
Question 90 Explanation:
Inotropic agents are administered to increase the force of the heart’s contractions, thereby increasing ventricular contractility and ultimately increasing cardiac output. Beta-adrenergic blockers and calcium channel blockers decrease the heart rate and ultimately decreased the workload of the heart. Diuretics are administered to decrease the overall vascular volume, also decreasing the workload of the heart.
Question 91
Situation: Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out cirrhosis of the liver:
Mr. Gonzales develops hepatic encephalopathy. Which clinical manifestation is most common with this condition?
A
Hypotension
B
Increased urine output
C
Altered level of consciousness
D
Decreased tendon reflex
Question 91 Explanation:
Changes in behavior and level of consciousness are the first sins of hepatic encephalopathy. Hepatic encephalopathy is caused by liver failure and develops when the liver is unable to convert protein metabolic product ammonia to urea. This results in accumulation of ammonia and other toxic in the blood that damages the cells.
Question 92
A client with hypertension ask the nurse which factors can cause blood pressure to drop to normal levels?
A
Kidneys’ excretion to sodium only.
B
Kidneys’ retention of sodium and water
C
Kidneys’ retention of sodium and excretion of water
D
Kidneys’ excretion of sodium and water
Question 92 Explanation:
The kidneys respond to rise in blood pressure by excreting sodium and excess water. This response ultimately affects sysmolic blood pressure by regulating blood volume. Sodium or water retention would only further increase blood pressure. Sodium and water travel together across the membrane in the kidneys; one can’t travel without the other.
Question 93
Nurse Patricia is aware that the average length of time from human immunodeficiency virus (HIV) infection to the development of acquired immunodeficiency syndrome (AIDS)?
A
More than 10 years
B
10 years
C
Less than 5 years
D
5 to 7 years
Question 93 Explanation:
Epidermiologic studies show the average time from initial contact with HIV to the development of AIDS is 10 years.
Question 94
A male client has jugular distention. On what position should the nurse place the head of the bed to obtain the most accurate reading of jugular vein distention?
A
Raised 30 degrees
B
Supine position
C
High Fowler’s
D
Raised 10 degrees
Question 94 Explanation:
Jugular venous pressure is measured with a centimeter ruler to obtain the vertical distance between the sternal angle and the point of highest pulsation with the head of the bed inclined between 15 to 30 degrees. Increased pressure can’t be seen when the client is supine or when the head of the bed is raised 10 degrees because the point that marks the pressure level is above the jaw (therefore, not visible). In high Fowler’s position, the veins would be barely discernible above the clavicle.
Question 95
Nurse Kate is aware that one of the following classes of medication protect the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation is:
A
Beta -adrenergic blockers
B
Narcotics
C
Nitrates
D
Calcium channel blocker
Question 95 Explanation:
Beta-adrenergic blockers work by blocking beta receptors in the myocardium, reducing the response to catecholamines and sympathetic nerve stimulation. They protect the myocardium, helping to reduce the risk of another infraction by decreasing myocardial oxygen demand. Calcium channel blockers reduce the workload of the heart by
decreasing the heart rate. Narcotics reduce myocardial oxygen demand, promote vasodilation, and decrease anxiety. Nitrates reduce myocardial oxygen consumption bt decreasing left ventricular end diastolic pressure (preload) and systemic vascular resistance (afterload).
Question 96
Wilfredo with a recent history of rectal bleeding is being prepared for a colonoscopy. How should the nurse Patricia position the client for this test initially?
A
Prone with the torso elevated
B
Bent over with hands touching the floor
C
Lying on the right side with legs straight
D
Lying on the left side with knees bent
Question 96 Explanation:
For a colonoscopy, the nurse initially should position the client on the left side with knees bent. Placing the client on the right side with legs straight, prone with the torso elevated, or bent over with hands touching the floor wouldn't allow proper visualization of the large intestine.
Question 97
The nurse knows that neurologic complications of multiple myeloma (MM) usually involve which of the following body system?
A
Brain
B
Muscle spasm
C
Myocardial irritability
D
Renal dysfunction
Question 97 Explanation:
Back pain or paresthesia in the lower extremities may indicate impending spinal cord compression from a spinal tumor. This should be recognized and treated promptly as progression of the tumor may result in paraplegia. The other options, which reflect parts of the nervous system, aren’t usually affected by MM.
Question 98
Instructions for a client with systemic lupus erythematosus (SLE) would include information about which of the following blood dyscrasias?
A
Von Willebrand’s disease
B
Dressler’s syndrome
C
Essential thrombocytopenia
D
Polycythemia
Question 98 Explanation:
Essential thrombocytopenia is linked to immunologic disorders, such as SLE and human immunodeficiency vitus. The disorder known as von Willebrand’s disease is a type of hemophilia and isn’t linked to SLE. Moderate to severe anemia is associated with SLE, not polycythermia. Dressler’s syndrome is pericarditis that occurs after a myocardial infarction and isn’t linked to SLE.
Question 99
Nurse Sugar is assessing a client with Cushing's syndrome. Which observation should the nurse report to the physician immediately?
A
Pitting edema of the legs
B
Frequent urination
C
Dry mucous membranes
D
An irregular apical pulse
Question 99 Explanation:
Because Cushing's syndrome causes aldosterone overproduction, which increases urinary potassium loss, the disorder may lead to hypokalemia. Therefore, the nurse should immediately report signs and symptoms of hypokalemia, such as an irregular apical pulse, to the physician. Edema is an expected finding because aldosterone overproduction causes sodium and fluid retention. Dry mucous membranes and frequent urination signal dehydration, which isn't associated with Cushing's syndrome.
Question 100
Johnny a firefighter was involved in extinguishing a house fire and is being treated to smoke inhalation. He develops severe hypoxia 48 hours after the incident, requiring intubation and mechanical ventilation. He most likely has developed which of the following conditions?
A
Pneumonia
B
Atelectasis
C
Bronchitis
D
Adult respiratory distress syndrome (ARDS)
Question 100 Explanation:
Severe hypoxia after smoke inhalation is typically related to ARDS. The other conditions listed aren’t typically associated with smoke inhalation and severe hypoxia.
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PNLE IV for Care of Clients with Physiologic and Psychosocial Alterations Part 2 (EM)
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Question 1
Jestoni with chronic renal failure (CRF) is admitted to the urology unit. The nurse is aware that the diagnostic test are consistent with CRF if the result is:
A
Increased serum levels of potassium, magnesium, and calcium.
Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein (PSP) excretion 75%.
Question 1 Explanation:
The normal BUN level ranges 8 to 23 mg/dl; the normal serum creatinine level ranges from 0.7 to 1.5 mg/dl. The test results of the answer are abnormally elevated, reflecting CRF and the kidneys' decreased ability to remove nonprotein nitrogen waste from the blood. CRF causes decreased pH and increased hydrogen ions — not vice versa. CRF also increases serum levels of potassium, magnesium, and phosphorous, and decreases serum levels of calcium. A uric acid analysis of 3.5 mg/dl falls within the normal range of 2.7 to 7.7 mg/dl; PSP excretion of 75% also falls with the normal range of 60% to 75%.
Question 2
Norma has started a new drug for hypertension. Thirty minutes after she takes the drug, she develops chest tightness and becomes short of breath and tachypneic. She has a decreased level of consciousness. These signs indicate which of the following conditions?
A
Asthma attack
B
Rheumatoid arthritis
C
Respiratory failure
D
Pulmonary embolism
Question 2 Explanation:
The client was reacting to the drug with respiratory signs of impending anaphylaxis, which could lead to eventually respiratory failure. Although the signs are also related to an asthma attack or a pulmonary embolism, consider the new drug first. Rheumatoid arthritis doesn’t manifest these signs.
Question 3
Aldo with a massive pulmonary embolism will have an arterial blood gas analysis performed to determine the extent of hypoxia. The acid-base disorder that may be present is?
A
Respiratory acidosis
B
Metabolic acidosis
C
Metabolic alkalosis
D
Respiratory alkalosis
Question 3 Explanation:
A client with massive pulmonary embolism will have a large region and blow off large amount of carbon dioxide, which crosses the unaffected alveolar-capillary membrane more readily than does oxygen and results in respiratory alkalosis.
Question 4
Situation: Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out cirrhosis of the liver:
Which laboratory test indicates liver cirrhosis?
A
Decreased red blood cell count
B
Decreased serum acid phosphate level
C
Elevated serum aminotransferase
D
Elevated white blood cell count
Question 4 Explanation:
Hepatic cell death causes release of liver enzymes alanine aminotransferase (ALT), aspartate aminotransferase (AST) and lactate dehydrogenase (LDH) into the circulation. Liver cirrhosis is a chronic and irreversible disease of the liver characterized by generalized inflammation and fibrosis of the liver tissues.
Question 5
Terence suffered form burn injury. Using the rule of nines, which has the largest percent of burns?
A
Face and neck
B
Right thigh and penis
C
Right upper arm and penis
D
Upper trunk
Question 5 Explanation:
The percentage designated for each burned part of the body using the rule of nines: Head and neck 9%; Right upper extremity 9%; Left upper extremity 9%; Anterior trunk 18%; Posterior trunk 18%; Right lower extremity 18%; Left lower extremity 18%; Perineum 1%.
Question 6
Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy.
During the administration of chemotherapy agents, Nurse Oliver observed that the IV site is red and swollen, when the IV is touched Stacy shouts in pain. The first nursing action to take is:
A
Notify the physician
B
Apply an ice pack to the site, followed by warm compress.
C
Flush the IV line with saline solution
D
Immediately discontinue the infusion
Question 6 Explanation:
Edema or swelling at the IV site is a sign that the needle has been dislodged and the IV solution is leaking into the tissues causing the edema. The patient feels pain as the nerves are irritated by pressure and the IV solution. The first action of the nurse would be to discontinue the infusion right away to prevent further edema and other complication.
Question 7
Situation: Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out cirrhosis of the liver:
The biopsy of Mr. Gonzales confirms the diagnosis of cirrhosis. Mr. Gonzales is at increased risk for excessive bleeding primarily because of:
A
Varix formation
B
Trauma of invasive procedure
C
Inadequate nutrition
D
Impaired clotting mechanism
Question 7 Explanation:
Cirrhosis of the liver results in decreased Vitamin K absorption and formation of clotting factors resulting in impaired clotting mechanism.
Question 8
A 62-year-old male client was in a motor vehicle accident as an unrestrained driver. He’s now in the emergency department complaining of difficulty of breathing and chest pain. On auscultation of his lung field, no breath sounds are present in the upper lobe. This client may have which of the following conditions?
A
Pneumonia
B
Bronchitis
C
Pneumothorax
D
Tuberculosis (TB)
Question 8 Explanation:
From the trauma the client experienced, it’s unlikely he has bronchitis, pneumonia, or TB; rhonchi with bronchitis, bronchial breath sounds with TB would be heard.
Question 9
Nurse Sherry is teaching male client regarding his permanent artificial pacemaker. Which information given by the nurse shows her knowledge deficit about the artificial cardiac pacemaker?
A
May be allowed to use electrical appliances
B
take the pulse rate once a day, in the morning upon awakening
C
Have regular follow up care
D
May engage in contact sports
Question 9 Explanation:
The client should be advised by the nurse to avoid contact sports. This will prevent trauma to the area of the pacemaker generator.
Question 10
Nurse Kate is aware that one of the following classes of medication protect the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation is:
A
Beta -adrenergic blockers
B
Calcium channel blocker
C
Nitrates
D
Narcotics
Question 10 Explanation:
Beta-adrenergic blockers work by blocking beta receptors in the myocardium, reducing the response to catecholamines and sympathetic nerve stimulation. They protect the myocardium, helping to reduce the risk of another infraction by decreasing myocardial oxygen demand. Calcium channel blockers reduce the workload of the heart by
decreasing the heart rate. Narcotics reduce myocardial oxygen demand, promote vasodilation, and decrease anxiety. Nitrates reduce myocardial oxygen consumption bt decreasing left ventricular end diastolic pressure (preload) and systemic vascular resistance (afterload).
Question 11
When prioritizing care, which of the following clients should the nurse Olivia assess first?
A
A 50-year-old client 3 days postmyocardial infarction
B
A 50-year-old client with diverticulitis
C
A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome
D
A 17-year-old clients 24-hours postappendectomy
Question 11 Explanation:
Guillain-Barre syndrome is characterized by ascending paralysis and potential respiratory failure. The order of client assessment should follow client priorities, with disorder of airways, breathing, and then circulation. There’s no information to suggest the postmyocardial infarction client has an arrhythmia or other complication. There’s no evidence to suggest hemorrhage or perforation for the remaining clients as a priority of care.
Question 12
A male client has a reduced serum high-density lipoprotein (HDL) level and an elevated low-density lipoprotein (LDL) level. Which of the following dietary modifications is not appropriate for this client?
A
Fiber intake of 25 to 30 g daily
B
Cholesterol intake of less than 300 mg daily
C
Less than 10% of calories from saturated fat
D
Less than 30% of calories form fat
Question 12 Explanation:
A client with low serum HDL and high serum LDL levels should get less than 30% of daily calories from fat. The other modifications are appropriate for this client.
Question 13
Cleo is diagnosed with osteoporosis. Which electrolytes are involved in the development of this disorder?
A
Potassium and sodium
B
Calcium and sodium
C
Phosphorous and potassium
D
Calcium and phosphorous
Question 13 Explanation:
In osteoporosis, bones lose calcium and phosphate salts, becoming porous, brittle, and abnormally vulnerable to fracture. Sodium and potassium aren't involved in the development of osteoporosis.
Question 14
Cyrill with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty-six hours later, the client's urine output suddenly rises above 200 ml/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse's suspicion of diabetes insipidus?
In diabetes insipidus, excessive polyuria causes dilute urine, resulting in a below-normal urine osmolality level. At the same time, polyuria depletes the body of water, causing dehydration that leads to an above-normal serum osmolality level. For the same reasons, diabetes insipidus doesn't cause above-normal urine osmolality or below-normal serum osmolality levels.
Question 15
Macario had coronary artery bypass graft (CABG) surgery 3 days ago. Which of the following conditions is suspected by the nurse when a decrease in platelet count from 230,000 ul to 5,000 ul is noted?
A
Heparin-associated thrombosis and thrombocytopenia (HATT)
B
Pancytopenia
C
Disseminated intravascular coagulation (DIC)
D
Idiopathic thrombocytopemic purpura (ITP)
Question 15 Explanation:
HATT may occur after CABG surgery due to heparin use during surgery. Although DIC and ITP cause platelet aggregation and bleeding, neither is common in a client after revascularization surgery. Pancytopenia is a reduction in all blood cells.
Question 16
A female client is scheduled to receive a heart valve replacement with a porcine valve. Which of the following types of transplant is this?
A
Allogeneic
B
Autologous
C
Xenogeneic
D
Syngeneic
Question 16 Explanation:
An xenogeneic transplant is between is between human and another species. A syngeneic transplant is between identical twins, allogeneic transplant is between two humans, and autologous is a transplant from the same individual.
Question 17
A male client is scheduled for a transsphenoidal hypophysectomy to remove a pituitary tumor. Preoperatively, the nurse should assess for potential complications by doing which of the following?
A
Testing for ketones in the urine
B
Performing capillary glucose testing every 4 hours
C
Checking temperature every 4 hours
D
Testing urine specific gravity
Question 17 Explanation:
The nurse should perform capillary glucose testing every 4 hours because excess cortisol may cause insulin resistance, placing the client at risk for hyperglycemia. Urine ketone testing isn't indicated because the client does secrete insulin and, therefore, isn't at risk for ketosis. Urine specific gravity isn't indicated because although fluid balance can be compromised, it usually isn't dangerously imbalanced. Temperature regulation may be affected by excess cortisol and isn't an accurate indicator of infection.
Question 18
Francis with leukemia has neutropenia. Which of the following functions must frequently assessed?
A
Heart sounds
B
Bowel sounds
C
Breath sounds
D
Blood pressure
Question 18 Explanation:
Pneumonia, both viral and fungal, is a common cause of death in clients with neutropenia, so frequent assessment of respiratory rate and breath sounds is required. Although assessing blood pressure, bowel sounds, and heart sounds is important, it won’t help detect pneumonia.
Question 19
The physician orders laboratory tests to confirm hyperthyroidism in a female client with classic signs and symptoms of this disorder. Which test result would confirm the diagnosis?
A
No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test
B
Below-normal levels of serum triiodothyronine (T3) and serum thyroxine (T4) as detected by radioimmunoassay
C
An increase in the TSH level after 30 minutes during the TSH stimulation test
D
A decreased TSH level
Question 19 Explanation:
In the TSH test, failure of the TSH level to rise after 30 minutes confirms hyperthyroidism. A decreased TSH level indicates a pituitary deficiency of this hormone. Below-normal levels of T3 and T4, as detected by radioimmunoassay, signal hypothyroidism. A below-normal T4 level also occurs in malnutrition and liver disease and may result from administration of phenytoin and certain other drugs.
Question 20
Situation: Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out cirrhosis of the liver:
Mr. Gonzales develops hepatic encephalopathy. Which clinical manifestation is most common with this condition?
A
Hypotension
B
Decreased tendon reflex
C
Increased urine output
D
Altered level of consciousness
Question 20 Explanation:
Changes in behavior and level of consciousness are the first sins of hepatic encephalopathy. Hepatic encephalopathy is caused by liver failure and develops when the liver is unable to convert protein metabolic product ammonia to urea. This results in accumulation of ammonia and other toxic in the blood that damages the cells.
Question 21
After cardiac surgery, a client’s blood pressure measures 126/80 mm Hg. Nurse Katrina determines that mean arterial pressure (MAP) is which of the following?
A
95 mm Hg
B
90 mm Hg
C
46 mm Hg
D
80 mm Hg
Question 21 Explanation:
(Look for no. 36 of text mode to view the computation.)
Question 22
Mario comes to the clinic complaining of fever, drenching night sweats, and unexplained weight loss over the past 3 months. Physical examination reveals a single enlarged supraclavicular lymph node. Which of the following is the most probable diagnosis?
A
Leukemia
B
Influenza
C
Sickle cell anemia
D
Hodgkin’s disease
Question 22 Explanation:
Hodgkin’s disease typically causes fever night sweats, weight loss, and lymph mode enlargement. Influenza doesn’t last for months. Clients with sickle cell anemia manifest signs and symptoms of chronic anemia with pallor of the mucous membrane, fatigue, and decreased tolerance for exercise; they don’t show fever, night sweats, weight loss or lymph node enlargement. Leukemia doesn’t cause lymph node enlargement.
Question 23
The nurse is aware that one of the following classes of medications maximizes cardiac performance in clients with heart failure by increasing ventricular contractility?
A
Beta-adrenergic blockers
B
Diuretics
C
Calcium channel blocker
D
Inotropic agents
Question 23 Explanation:
Inotropic agents are administered to increase the force of the heart’s contractions, thereby increasing ventricular contractility and ultimately increasing cardiac output. Beta-adrenergic blockers and calcium channel blockers decrease the heart rate and ultimately decreased the workload of the heart. Diuretics are administered to decrease the overall vascular volume, also decreasing the workload of the heart.
Question 24
Anthony suffers burns on the legs, which nursing intervention helps prevent contractures?
A
Elevating the foot of the bed
B
Performing shoulder range-of-motion exercises
C
Hyperextending the client's palms
D
Applying knee splints
Question 24 Explanation:
Applying knee splints prevents leg contractures by holding the joints in a position of function. Elevating the foot of the bed can't prevent contractures because this action doesn't hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs.
Question 25
Arnold, a 19-year-old client with a mild concussion is discharged from the emergency department. Before discharge, he complains of a headache. When offered acetaminophen, his mother tells the nurse the headache is severe and she would like her son to have something stronger. Which of the following responses by the nurse is appropriate?
A
“Aspirin is avoided because of the danger of Reye’s syndrome in children or young adults.”
B
“Your son had a mild concussion, acetaminophen is strong enough.”
C
“Narcotics are avoided after a head injury because they may hide a worsening condition.”
D
Stronger medications may lead to vomiting, which increases the intracarnial pressure (ICP).”
Question 25 Explanation:
Narcotics may mask changes in the level of consciousness that indicate increased ICP and shouldn’t acetaminophen is strong enough ignores the mother’s question and therefore isn’t appropriate. Aspirin is contraindicated in conditions that may have bleeding, such as trauma, and for children or young adults with viral illnesses due to the danger of Reye’s syndrome. Stronger medications may not necessarily lead to vomiting but will sedate the client, thereby masking changes in his level of consciousness.
Question 26
Ruby is receiving thyroid replacement therapy develops the flu and forgets to take her thyroid replacement medicine. The nurse understands that skipping this medication will put the client at risk for developing which of the following lifethreatening complications?
A
Tibial myxedema
B
Myxedema coma
C
Thyroid storm
D
Exophthalmos
Question 26 Explanation:
Myxedema coma, severe hypothyroidism, is a life-threatening condition that may develop if thyroid replacement medication isn't taken. Exophthalmos, protrusion of the eyeballs, is seen with hyperthyroidism. Thyroid storm is life-threatening but is caused by severe hyperthyroidism. Tibial myxedema, peripheral mucinous edema involving the lower leg, is associated with hypothyroidism but isn't life-threatening.
Question 27
Katrina has an abnormal result on a Papanicolaou test. After admitting that she read her chart while the nurse was out of the room, Katrina asks what dysplasia means. Which definition should the nurse provide?
A
Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn't found.
B
Increase in the number of normal cells in a normal arrangement in a tissue or an organ.
C
Alteration in the size, shape, and organization of differentiated cells.
D
Presence of completely undifferentiated tumor cells that don't resemble cells of the tissues of their origin.
Question 27 Explanation:
Dysplasia refers to an alteration in the size, shape, and organization of differentiated cells. The presence of completely undifferentiated tumor cells that don't resemble cells of the tissues of their origin is called anaplasia. An increase in the number of normal cells in a normal arrangement in a tissue or an organ is called hyperplasia. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn't found is called metaplasia.
Question 28
The nurse is aware that the following symptoms is most commonly an early indication of stage 1 Hodgkin’s disease?
A
Persistent hypothermia
B
Pericarditis
C
Night sweat
D
Splenomegaly
Question 28 Explanation:
In stage 1, symptoms include a single enlarged lymph node (usually), unexplained fever, night sweats, malaise, and generalized pruritis. Although splenomegaly may be present in some clients, night sweats are generally more prevalent. Pericarditis isn’t associated with Hodgkin’s disease, nor is hypothermia. Moreover, splenomegaly and pericarditis aren’t symptoms. Persistent hypothermia is associated with Hodgkin’s but isn’t an early sign of the disease.
Question 29
A 66-year-old client has been complaining of sleeping more, increased urination, anorexia, weakness, irritability, depression, and bone pain that interferes with her going outdoors. Based on these assessment findings, the nurse would suspect which of the following disorders?
A
Diabetes mellitus
B
Hypoparathyroidism
C
Diabetes insipidus
D
Hyperparathyroidism
Question 29 Explanation:
Hyperparathyroidism is most common in older women and is characterized by bone pain and weakness from excess parathyroid hormone (PTH). Clients also exhibit hypercaliuria-causing polyuria. While clients with diabetes mellitus and diabetes insipidus also have polyuria, they don't have bone pain and increased sleeping. Hypoparathyroidism is characterized by urinary frequency rather than polyuria.
Question 30
Mickey, a 6-year-old child with a congenital heart disorder is admitted with congestive heart failure. Digoxin (lanoxin) 0.12 mg is ordered for the child. The bottle of Lanoxin contains .05 mg of Lanoxin in 1 ml of solution. What amount should the nurse administer to the child?
A
2.4 ml
B
1.2 ml
C
4.2 ml
D
3.5 ml
Question 30 Explanation:
.05 mg/ 1 ml = .12mg/ x ml, .05x = .12, x = 2.4 ml.
Question 31
Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin. Nurse Mariner should expect the dose's:
A
onset to be at 2:30 p.m. and its peak to be at 4 p.m.
B
onset to be at 2 p.m. and its peak to be at 3 p.m.
C
onset to be at 4 p.m. and its peak to be at 6 p.m.
D
onset to be at 2:15 p.m. and its peak to be at 3 p.m.
Question 31 Explanation:
Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be from 2:15 p.m. to 2:30 p.m. and the peak from 4 p.m. to 6 p.m.
Question 32
Randy has undergone kidney transplant, what assessment would prompt Nurse Katrina to suspect organ rejection?
A
Shock
B
Polyuria
C
Sudden weight loss
D
Hypertension
Question 32 Explanation:
Hypertension, along with fever, and tenderness over the grafted kidney, reflects acute rejection.
Question 33
Nurse Sarah expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate?
A
Serum ketone bodies
B
Elevated serum acetone level
C
Serum alkalosis
D
Below-normal serum potassium level
Question 33 Explanation:
A client with HHNS has an overall body deficit of potassium resulting from diuresis, which occurs secondary to the hyperosmolar, hyperglycemic state caused by the relative insulin deficiency. An elevated serum acetone level and serum ketone bodies are characteristic of diabetic ketoacidosis. Metabolic acidosis, not serum alkalosis, may occur in HHNS.
Question 34
Nurse Patricia is aware that the average length of time from human immunodeficiency virus (HIV) infection to the development of acquired immunodeficiency syndrome (AIDS)?
A
5 to 7 years
B
Less than 5 years
C
More than 10 years
D
10 years
Question 34 Explanation:
Epidermiologic studies show the average time from initial contact with HIV to the development of AIDS is 10 years.
Question 35
Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy.
Stacy’s mother states to the nurse that it is hard to see Stacy with no hair. The best response for the nurse is:
A
“Yes it is upsetting. But try to cover up your feelings when you are with her or else she may be upset”.
B
“Stacy looks very nice wearing a hat”.
C
“This is only temporary; Stacy will re-grow new hair in 3-6 months, but may be different in texture”.
D
“You should not worry about her hair, just be glad that she is alive”.
Question 35 Explanation:
This is the appropriate response. The nurse should help the mother how to cope with her own feelings regarding the child’s disease so as not to affect the child negatively. When the hair grows back, it is still of the same color and texture.
Question 36
The nurse is ware that the most relevant knowledge about oxygen administration to a male client with COPD is
A
Oxygen is administered best using a non-rebreathing mask
B
Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.
C
Blood gases are monitored using a pulse oximeter.
D
Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breath.
Question 36 Explanation:
COPD causes a chronic CO2 retention that renders the medulla insensitive to the CO2 stimulation for breathing. The hypoxic state of the client then becomes the stimulus for breathing. Giving the client oxygen in low concentrations will maintain the client’s hypoxic drive.
Question 37
After a motor vehicle accident, Armand an 22-year-old client is admitted with a pneumothorax. The surgeon inserts a chest tube and attaches it to a chest drainage system. Bubbling soon appears in the water seal chamber. Which of the following is the most likely cause of the bubbling?
A
Air leak
B
Adequate suction
C
Kinked chest tube
D
Inadequate suction
Question 37 Explanation:
Bubbling in the water seal chamber of a chest drainage system stems from an air leak. In pneumothorax an air leak can occur as air is pulled from the pleural space. Bubbling doesn’t normally occur with either adequate or inadequate suction or any preexisting bubbling in the water seal chamber.
Question 38
Ricardo is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist's instructions. Why does the client require special positioning for this type of anesthesia?
A
To prevent confusion
B
To prevent cardiac arrhythmias
C
To prevent cerebrospinal fluid (CSF) leakage
D
To prevent seizures
Question 38 Explanation:
The client receiving a subarachnoid block requires special positioning to prevent CSF leakage and headache and to ensure proper anesthetic distribution. Proper positioning doesn't help prevent confusion, seizures, or cardiac arrhythmias.
Question 39
Nurse Ron is assessing a client admitted with second- and third-degree burns on the face, arms, and chest. Which finding indicates a potential problem?
A
Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg.
B
Rectal temperature of 100.6° F (38° C).
C
Urine output of 20 ml/hour.
D
White pulmonary secretions.
Question 39 Explanation:
A urine output of less than 40 ml/hour in a client with burns indicates a fluid volume deficit. This client's PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions also are normal. The client's rectal temperature isn't significantly elevated and probably results from the fluid volume deficit.
Question 40
Instructions for a client with systemic lupus erythematosus (SLE) would include information about which of the following blood dyscrasias?
A
Dressler’s syndrome
B
Essential thrombocytopenia
C
Polycythemia
D
Von Willebrand’s disease
Question 40 Explanation:
Essential thrombocytopenia is linked to immunologic disorders, such as SLE and human immunodeficiency vitus. The disorder known as von Willebrand’s disease is a type of hemophilia and isn’t linked to SLE. Moderate to severe anemia is associated with SLE, not polycythermia. Dressler’s syndrome is pericarditis that occurs after a myocardial infarction and isn’t linked to SLE.
Question 41
Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, Nurse Celia should:
A
Encourage the client to use a footboard.
B
Turn him frequently.
C
Perform passive range-of-motion (ROM) exercises.
D
Reduce the client's fluid intake.
Question 41 Explanation:
The most important intervention to prevent pressure ulcers is frequent position changes, which relieve pressure on the skin and underlying tissues. If pressure isn't relieved, capillaries become occluded, reducing circulation and oxygenation of the tissues and resulting in cell death and ulcer formation. During passive ROM exercises, the nurse moves each joint through its range of movement, which improves joint mobility and circulation to the affected area but doesn't prevent pressure ulcers. Adequate hydration is necessary to maintain healthy skin and ensure tissue repair. A footboard prevents plantar flexion and footdrop by maintaining the foot in a dorsiflexed position.
Question 42
Jose is in danger of respiratory arrest following the administration of a narcotic analgesic. An arterial blood gas value is obtained. Nurse Oliver would expect the paco2 to be which of the following values?
A
15 mm Hg
B
30 mm Hg
C
80 mm Hg
D
40 mm Hg
Question 42 Explanation:
A client about to go into respiratory arrest will have inefficient ventilation and will be retaining carbon dioxide. The value expected would be around 80 mm Hg. All other values are lower than expected.
Question 43
During a routine checkup, Nurse Mariane assesses a male client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the most common AIDS-related cancer?
A
Leukemia
B
Multiple myeloma
C
Squamous cell carcinoma
D
Kaposi's sarcoma
Question 43 Explanation:
Kaposi's sarcoma is the most common cancer associated with AIDS. Squamous cell carcinoma, multiple myeloma, and leukemia may occur in anyone and aren't associated specifically with AIDS.
Question 44
A client with shortness of breath has decreased to absent breath sounds on the right side, from the apex to the base. Which of the following conditions would best explain this?
A
Pneumonia
B
Chronic bronchitis
C
Spontaneous pneumothorax
D
Acute asthma
Question 44 Explanation:
A spontaneous pneumothorax occurs when the client’s lung collapses, causing an acute decreased in the amount of functional lung used in oxygenation. The sudden collapse was the cause of his chest pain and shortness of breath. An asthma attack would show wheezing breath sounds, and bronchitis would have rhonchi. Pneumonia would have bronchial breath sounds over the area of consolidation.
Question 45
A male client arriving in the emergency department is receiving cardiopulmonary resuscitation from paramedics who are giving ventilations through an endotracheal (ET) tube that they placed in the client’s home. During a pause in compressions, the cardiac monitor shows narrow QRS complexes and a heart rate of beats/minute with a palpable pulse. Which of the following actions should the nurse take first?
A
Administer atropine, 1 mg L.V.
B
Check endotracheal tube placement.
C
Start an L.V. line and administer amiodarone (Cardarone), 300 mg L.V. over 10 minutes.
D
Obtain an arterial blood gas (ABG) sample.
Question 45 Explanation:
ET tube placement should be confirmed as soon as the client arrives in the emergency department. Once the airways is secured, oxygenation and ventilation should be confirmed using an end-tidal carbon dioxide monitor and pulse oximetry. Next, the nurse should make sure L.V. access is established. If the client experiences symptomatic bradycardia, atropine is administered as ordered 0.5 to 1 mg every 3 to 5 minutes to a total of 3 mg. Then the nurse should try to find the cause of the client’s arrest by obtaining an ABG sample. Amiodarone is indicated for ventricular tachycardia, ventricular fibrillation and atrial flutter – not symptomatic bradycardia.
Question 46
Ms. X has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client?
A
The potential for transmission to her sexual partner will be eliminated if condoms are used every time they have sexual intercourse.
B
The most common treatment is metronidazole (Flagyl), which should eradicate the problem within 7 to 10 days.
C
The human papillomavirus (HPV), which causes condylomata acuminata, can't be transmitted during oral sex.
D
This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually.
Question 46 Explanation:
Women with condylomata acuminata are at risk for cancer of the cervix and vulva. Yearly Pap smears are very important for early detection. Because condylomata acuminata is a virus, there is no permanent cure. Because condylomata acuminata can occur on the vulva, a condom won't protect sexual partners. HPV can be transmitted to other parts of the body, such as the mouth, oropharynx, and larynx.
Question 47
Jomari is diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which of the following statements indicates that the client understands her condition and how to control it?
A
"If I begin to feel especially hungry and thirsty, I'll eat a snack high in carbohydrates."
B
"I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual."
C
"If I experience trembling, weakness, and headache, I should drink a glass of soda that contains sugar."
D
"I will have to monitor my blood glucose level closely and notify the physician if it's constantly elevated."
Question 47 Explanation:
Inadequate fluid intake during hyperglycemic episodes often leads to HHNS. By recognizing the signs of hyperglycemia (polyuria, polydipsia, and polyphagia) and increasing fluid intake, the client may prevent HHNS. Drinking a glass of nondiet soda would be appropriate for hypoglycemia. A client whose diabetes is controlled with oral antidiabetic agents usually doesn't need to monitor blood glucose levels. A highcarbohydrate diet would exacerbate the client's condition, particularly if fluid intake is low.
Question 48
The term “pink puffer” refers to the female client with which of the following conditions?
A
Emphysema
B
Adult respiratory distress syndrome (ARDS)
C
Asthma
D
Chronic obstructive bronchitis
Question 48 Explanation:
Because of the large amount of energy it takes to breathe, clients with emphysema are usually cachectic. They’re pink and usually breathe through pursed lips, hence the term “puffer.” Clients with ARDS are usually acutely short of breath. Clients with asthma don’t have any particular characteristics, and clients with chronic obstructive bronchitis are bloated and cyanotic in appearance.
Question 49
A male client with a gunshot wound requires an emergency blood transfusion. His blood type is AB negative. Which blood type would be the safest for him to receive?
A
A Rh-positive
B
AB Rh-positive
C
A Rh-negative
D
O Rh-positive
Question 49 Explanation:
Human blood can sometimes contain an inherited D antigen. Persons with the D antigen have Rh-positive blood type; those lacking the antigen have Rh-negative blood. It’s important that a person with Rhnegative blood receives Rh-negative blood. If Rh-positive blood is administered to an Rh-negative person, the recipient develops anti-Rh agglutinins, and sub sequent transfusions with Rh-positive blood may cause serious reactions with clumping and hemolysis of red blood cells.
Question 50
A female client arrives at the emergency department with chest and stomach pain and a report of black tarry stool for several months. Which of the following order should the nurse Oliver anticipate?
A
Cardiac monitor, oxygen, creatine kinase and lactate dehydrogenase levels
B
Prothrombin time, partial thromboplastin time, fibrinogen and fibrin split product values.
An electrocardiogram evaluates the complaints of chest pain, laboratory tests determines anemia, and the stool test for occult blood determines blood in the stool. Cardiac monitoring, oxygen, and creatine kinase and lactate dehydrogenase levels are appropriate for a cardiac primary problem. A basic metabolic panel and alkaline phosphatase and aspartate aminotransferase levels assess liver function. Prothrombin time, partial thromboplastin time, fibrinogen and fibrin split products are measured to verify bleeding dyscrasias, An electroencephalogram evaluates brain electrical activity.
Question 51
When evaluating an arterial blood gas from a male client with a subdural hematoma, the nurse notes the Paco2 is 30 mm Hg. Which of the following responses best describes the result?
Significant; the client has alveolar hypoventilation
Question 51 Explanation:
A normal Paco2 value is 35 to 45 mm Hg CO2 has vasodilating properties; therefore, lowering Paco2 through hyperventilation will lower ICP caused by dilated cerebral vessels. Oxygenation is evaluated through Pao2 and oxygen saturation. Alveolar hypoventilation would be reflected in an increased Paco2.
Question 52
Nurse Ron begins to teach a male client how to perform colostomy irrigations. The nurse would evaluate that the instructions were understood when the client states, “I should:
A
Instill a minimum of 1200 ml of irrigating solution to stimulate evacuation of the bowel.”
B
Lie on my left side while instilling the irrigating solution.”
C
Insert the irrigating catheter deeper into the stoma if cramping occurs during the procedure.”
D
Keep the irrigating container less than 18 inches above the stoma.”
Question 52 Explanation:
This height permits the solution to flow slowly with little force so that excessive peristalsis is not immediately precipitated.
Question 53
The immediate objective of nursing care for an overweight, mildly hypertensive male client with ureteral colic and hematuria is to decrease:
A
Weight
B
Pain
C
Hypertension
D
Hematuria
Question 53 Explanation:
Sharp, severe pain (renal colic) radiating toward the genitalia and thigh is caused by uretheral distention and smooth muscle spasm; relief form pain is the priority.
Question 54
Wilfredo with a recent history of rectal bleeding is being prepared for a colonoscopy. How should the nurse Patricia position the client for this test initially?
A
Bent over with hands touching the floor
B
Lying on the left side with knees bent
C
Prone with the torso elevated
D
Lying on the right side with legs straight
Question 54 Explanation:
For a colonoscopy, the nurse initially should position the client on the left side with knees bent. Placing the client on the right side with legs straight, prone with the torso elevated, or bent over with hands touching the floor wouldn't allow proper visualization of the large intestine.
Question 55
JP has been diagnosed with gout and wants to know why colchicine is used in the treatment of gout. Which of the following actions of colchicines explains why it’s effective for gout?
A
Decreases infection
B
Replaces estrogen
C
Decreases bone demineralization
D
Decreases inflammation
Question 55 Explanation:
Then action of colchicines is to decrease inflammation by reducing the migration of leukocytes to synovial fluid. Colchicine doesn’t replace estrogen, decrease infection, or decrease bone demineralization.
Question 56
A male client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, Nurse Oliver notes that the client's stoma appears dusky. How should the nurse interpret this finding?
A
The ostomy bag should be adjusted.
B
This is a normal finding 1 day after surgery.
C
An intestinal obstruction has occurred.
D
Blood supply to the stoma has been interrupted.
Question 56 Explanation:
An ileostomy stoma forms as the ileum is brought through the abdominal wall to the surface skin, creating an artificial opening for waste elimination. The stoma should appear cherry red, indicating adequate arterial perfusion. A dusky stoma suggests decreased perfusion, which may result from interruption of the stoma's blood supply and may lead to tissue damage or necrosis. A dusky stoma isn't a normal finding. Adjusting the ostomy bag wouldn't affect stoma color, which depends on blood supply to the area. An intestinal obstruction also wouldn't change stoma color.
Question 57
Herbert, a 45 year old construction engineer is brought to the hospital unconscious after falling from a 2-story building. When assessing the client, the nurse would be most concerned if the assessment revealed:
A
A depressed fontanel
B
An elevated temperature
C
Bleeding from ears
D
Reactive pupils
Question 57 Explanation:
The nurse needs to perform a thorough assessment that could indicate alterations in cerebral function, increased intracranial pressures, fractures and bleeding. Bleeding from the ears occurs only with basal skull fractures that can easily contribute to increased intracranial pressure and brain herniation.
Question 58
Kristine is scheduled for a bronchoscopy. When teaching Kristine what to expect afterward, the nurse's highest priority of information would be:
A
Only ice chips and cold liquids will be allowed initially.
B
Coughing and deep-breathing exercises will be done q2h.
C
Warm saline gargles will be done q 2h.
D
Food and fluids will be withheld for at least 2 hours.
Question 58 Explanation:
Prior to bronchoscopy, the doctors sprays the back of the throat with anesthetic to minimize the gag reflex and thus facilitate the insertion of the bronchoscope. Giving the client food and drink after the procedure without checking on the return of the gag reflex can cause the client to aspirate. The gag reflex usually returns after two hours.
Question 59
A client with hypertension ask the nurse which factors can cause blood pressure to drop to normal levels?
A
Kidneys’ excretion of sodium and water
B
Kidneys’ retention of sodium and water
C
Kidneys’ retention of sodium and excretion of water
D
Kidneys’ excretion to sodium only.
Question 59 Explanation:
The kidneys respond to rise in blood pressure by excreting sodium and excess water. This response ultimately affects sysmolic blood pressure by regulating blood volume. Sodium or water retention would only further increase blood pressure. Sodium and water travel together across the membrane in the kidneys; one can’t travel without the other.
Question 60
Which of the following groups of symptoms indicates a ruptured abdominal aortic aneurysm?
A
Lower back pain, increased blood pressure, decreased re blood cell (RBC) count, increased white blood (WBC) count.
Severe lower back pain, decreased blood pressure, decreased RBC count, increased WBC count.
D
Severe lower back pain, decreased blood pressure, decreased RBC count, decreased RBC count, decreased WBC count.
Question 60 Explanation:
Severe lower back pain indicates an aneurysm rupture, secondary to pressure being applied within the abdominal cavity. When ruptured occurs, the pain is constant because it can’t be alleviated until the aneurysm is repaired. Blood pressure decreases due to the loss of blood. After the aneurysm ruptures, the vasculature is interrupted and blood volume is lost, so blood pressure wouldn’t increase. For the same reason, the RBC count is decreased – not increased. The WBC count increases as cell migrate to the site of injury.
Question 61
Timothy’s arterial blood gas (ABG) results are as follows; pH 7.16; Paco2 80 mm Hg; Pao2 46 mm Hg; HCO3- 24mEq/L; Sao2 81%. This ABG result represents which of the following conditions?
A
Respiratory alkalosis
B
Metabolic acidosis
C
Metabolic alkalosis
D
Respiratory acidosis
Question 61 Explanation:
Because Paco2 is high at 80 mm Hg and the metabolic measure, HCO3- is normal, the client has respiratory acidosis. The pH is less than 7.35, academic, which eliminates metabolic and respiratory alkalosis as possibilities. If the HCO3- was below 22 mEq/L the client would have metabolic acidosis.
Question 62
Tracy is receiving combination chemotherapy for treatment of metastatic carcinoma. Nurse Ruby should monitor the client for the systemic side effect of:
A
Ascites
B
Polycythemia
C
Leukopenia
D
Nystagmus
Question 62 Explanation:
Leukopenia, a reduction in WBCs, is a systemic effect of chemotherapy as a result of myelosuppression.
Question 63
A male client has jugular distention. On what position should the nurse place the head of the bed to obtain the most accurate reading of jugular vein distention?
A
Raised 10 degrees
B
Raised 30 degrees
C
Supine position
D
High Fowler’s
Question 63 Explanation:
Jugular venous pressure is measured with a centimeter ruler to obtain the vertical distance between the sternal angle and the point of highest pulsation with the head of the bed inclined between 15 to 30 degrees. Increased pressure can’t be seen when the client is supine or when the head of the bed is raised 10 degrees because the point that marks the pressure level is above the jaw (therefore, not visible). In high Fowler’s position, the veins would be barely discernible above the clavicle.
Question 64
Patrick is in the oliguric phase of acute tubular necrosis and is experiencing fluid and electrolyte imbalances. The client is somewhat confused and complains of nausea and muscle weakness. As part of the prescribed therapy to correct this electrolyte imbalance, the nurse would expect to:
A
Administer Kayexalate
B
Administer large amounts of normal saline via I.V.
C
Increase oral intake of cheese and milk.
D
Restrict foods high in protein
Question 64 Explanation:
Kayexalate,a potassium exchange resin, permits sodium to be exchanged for potassium in the intestine, reducing the serum potassium level.
Question 65
Norma, with recent colostomy expresses concern about the inability to control the passage of gas. Nurse Oliver should suggest that the client plan to:
A
Adhere to a bland diet prior to social events.
B
Decrease fluid intake at meal times.
C
Avoid foods that in the past caused flatus.
D
Eliminate foods high in cellulose.
Question 65 Explanation:
Foods that bothered a person preoperatively will continue to do so after a colostomy.
Question 66
The term “blue bloater” refers to a male client which of the following conditions?
A
Emphysema
B
Chronic obstructive bronchitis
C
Asthma
D
Adult respiratory distress syndrome (ARDS)
Question 66 Explanation:
Clients with chronic obstructive bronchitis appear bloated; they have large barrel chest and peripheral edema, cyanotic nail beds, and at times, circumoral cyanosis. Clients with ARDS are acutely short of breath and frequently need intubation for mechanical ventilation and large amount of oxygen. Clients with asthma don’t exhibit characteristics of chronic disease, and clients with emphysema appear pink and cachectic.
Question 67
A 37-year-old male client was admitted to the coronary care unit (CCU) 2 days ago with an acute myocardial infarction. Which of the following actions would breach the client confidentiality?
A
The emergency department nurse calls up the latest electrocardiogram results to check the client’s progress.
B
The CCU nurse notifies the on-call physician about a change in the client’s condition
C
At the client’s request, the CCU nurse updates the client’s wife on his condition
D
The CCU nurse gives a verbal report to the nurse on the telemetry unit before transferring the client to that unit
Question 67 Explanation:
The emergency department nurse is no longer directly involved with the client’s care and thus has no legal right to information about his present condition. Anyone directly involved in his care (such as the telemetry nurse and the on-call physician) has the right to information about his condition. Because the client requested that the nurse update his wife on his condition, doing so doesn’t breach confidentiality.
Question 68
Tonny has undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are inserted, and one-bottle water-seal drainage is instituted in the operating room. In the postanesthesia care unit Tonny is placed in Fowler's position on either his right side or on his back. The nurse is aware that this position:
A
Reduce incisional pain.
B
Increase venous return
C
Equalize pressure in the pleural space.
D
Facilitate ventilation of the left lung.
Question 68 Explanation:
Since only a partial pneumonectomy is done, there is a need to promote expansion of this remaining Left lung by positioning the client on the opposite unoperated side.
Question 69
After undergoing a cardiac catheterization, Tracy has a large puddle of blood under his buttocks. Which of the following steps should the nurse take first?
A
Call for help.
B
Apply gloves and assess the groin site
C
Obtain vital signs
D
Ask the client to “lift up”
Question 69 Explanation:
Observing standard precautions is the first priority when dealing with any blood fluid. Assessment of the groin site is the second priority. This establishes where the blood is coming from and determineshow much blood has been lost. The goal in this situation is to stop the bleeding. The nurse would call for help if it were warranted after the assessment of the situation. After determining the extent of the bleeding, vital signs assessment is important. The nurse should never move the client, in case a clot has formed. Moving can disturb the clot and cause rebleeding.
Question 70
Nurse Rose is aware that the statement that best explains why furosemide (Lasix) is administered to treat hypertension is:
A
It decreases sympathetic cardioacceleration.
B
It dilates peripheral blood vessels.
C
It inhibits reabsorption of sodium and water in the loop of Henle.
D
It inhibits the angiotensin-coverting enzymes
Question 70 Explanation:
Furosemide is a loop diuretic that inhibits sodium and water reabsorption in the loop Henle, thereby causing a decrease in blood pressure. Vasodilators cause dilation of peripheral blood vessels, directly relaxing vascular smooth muscle and decreasing blood pressure. Adrenergic blockers decrease sympathetic cardioacceleration and decrease blood pressure. Angiotensin-converting enzyme inhibitors decrease blood pressure due to their action on angiotensin.
Question 71
A male client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:
A
Auscultate bowel sounds.
B
Change the client's position.
C
Insert a rectal tube.
D
Palpate the abdomen.
Question 71 Explanation:
If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician. Palpation should be avoided postoperatively with abdominal distention. If peristalsis is absent, changing positions and inserting a rectal tube won't relieve the client's discomfort.
Question 72
A 67-year-old client develops acute shortness of breath and progressive hypoxia requiring right femur. The hypoxia was probably caused by which of the following conditions?
A
Atelectasis
B
Fat embolism
C
Bronchitis
D
Asthma attack
Question 72 Explanation:
Long bone fractures are correlated with fat emboli, whichcause shortness of breath and hypoxia. It’s unlikely the client has developed asthma or bronchitis without a previous history. He could develop atelectasis but it typically doesn’t produce progressive hypoxia.
Question 73
For a client with Graves' disease, which nursing intervention promotes comfort?
A
Limiting intake of high-carbohydrate foods
B
Maintaining room temperature in the low-normal range
C
Placing extra blankets on the client's bed
D
Restricting intake of oral fluids
Question 73 Explanation:
Graves' disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client's room temperature in the low-normal range. To replace fluids lost via diaphoresis, the nurse should encourage, not restrict, intake of oral fluids. Placing extra blankets on the bed of a client with heat intolerance would cause discomfort. To provide needed energy and calories, the nurse should encourage the client to eat high-carbohydrate foods.
Question 74
Which of the following laboratory test results would suggest to the nurse Len that a client has a corticotropin-secreting pituitary adenoma?
A
High corticotropin and low cortisol levels
B
Low corticotropin and low cortisol levels
C
Low corticotropin and high cortisol levels
D
High corticotropin and high cortisol levels
Question 74 Explanation:
A corticotropin-secreting pituitary tumor would cause high corticotropin and high cortisol levels. A high corticotropin level with a low cortisol level and a low corticotropin level with a low cortisol level would be associated with hypocortisolism. Low corticotropin and high cortisol levels would be seen if there was a primary defect in the adrenal glands.
Question 75
If a client requires a pneumonectomy, what fills the area of the thoracic cavity?
A
Serous fluids fills the space and consolidates the region
B
The space remains filled with air only
C
The tissue from the other lung grows over to the other side
D
The surgeon fills the space with a gel
Question 75 Explanation:
Serous fluid fills the space and eventually consolidates, preventing extensive mediastinal shift of the heart and remaining lung. Air can’t be left in the space. There’s no gel that can be placed in the pleural space. The tissue from the other lung can’t cross the mediastinum, although a temporary mediastinal shift exits until the space is filled.
Question 76
Johnny a firefighter was involved in extinguishing a house fire and is being treated to smoke inhalation. He develops severe hypoxia 48 hours after the incident, requiring intubation and mechanical ventilation. He most likely has developed which of the following conditions?
A
Bronchitis
B
Atelectasis
C
Pneumonia
D
Adult respiratory distress syndrome (ARDS)
Question 76 Explanation:
Severe hypoxia after smoke inhalation is typically related to ARDS. The other conditions listed aren’t typically associated with smoke inhalation and severe hypoxia.
Question 77
Norma asks for information about osteoarthritis. Which of the following statements about osteoarthritis is correct?
A
Osteoarthritis afflicts people over 60
B
Osteoarthritis is rarely debilitating
C
Osteoarthritis is the most common form of arthritis
D
Osteoarthritis is a rare form of arthritis
Question 77 Explanation:
Osteoarthritis is the most common form of arthritis and can be extremely debilitating. It can afflict people of any age, although most are elderly.
Question 78
Which of the following treatment is a suitable surgical intervention for a client with unstable angina?
PTCA can alleviate the blockage and restore blood flow and oxygenation. An echocardiogram is a noninvasive diagnosis test. Nitroglycerin is an oral sublingual medication. Cardiac catheterization is a diagnostic tool – not a treatment.
Question 79
The nurse is aware that the following terms used to describe reduced cardiac output and perfusion impairment due to ineffective pumping of the heart is:
A
Distributive shock
B
Myocardial infarction (MI)
C
Cardiogenic shock
D
Anaphylactic shock
Question 79 Explanation:
Cardiogenic shock is shock related to ineffective pumping of the heart. Anaphylactic shock results from an allergic reaction. Distributive shock results from changes in the intravascular volume distribution and is usually associated with increased cardiac output. MI isn’t a shock state, though a severe MI can lead to shock.
Question 80
Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy.
Stacy has beginning stomatitis. To promote oral hygiene and comfort, the nurse in-charge should:
A
Rinse mouth with Hydrogen Peroxide.
B
Apply viscous Lidocaine to oral ulcers as needed.
C
Provide frequent mouthwash with normal saline.
D
Use lemon glycerine swabs every 2 hours.
Question 80 Explanation:
Stomatitis can cause pain and this can be relieved by applying topical anesthetics such as lidocaine before mouth care. When the patient is already comfortable, the nurse can proceed with providing the patient with oral rinses of saline solution mixed with equal part of water or hydrogen peroxide mixed water in 1:3 concentrations to promote oral hygiene. Every 2-4 hours.
Question 81
Mario has burn injury. After Forty48 hours, the physician orders for Mario 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
36 gtt/min
B
32 gtt/min
C
28 gtt/min
D
18 gtt/min
Question 81 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 82
Nurse Alexandra teaches a client about elastic stockings. Which of the following statements, if made by the client, indicates to the nurse that the teaching was successful?
A
“I should put on the stockings before getting out of bed in the morning.”
B
“I should wear the stockings even when I am sleep.”
C
“I will wear the stockings until the physician tells me to remove them.”
D
“Every four hours I should remove the stockings for a half hour.”
Question 82 Explanation:
Promote venous return by applying external pressure on veins.
Question 83
Situation: Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out cirrhosis of the liver:
When Mr. Gonzales regained consciousness, the physician orders 50 ml of Lactose p.o. every 2 hours. Mr. Gozales develops diarrhea. The nurse best action would be:
A
“Frequently, bowel movements are needed to reduce sodium level”.
B
“I’ll see if your physician is in the hospital”.
C
“I’ll lower the dosage as ordered so the drug causes only 2 to 4 stools a day”.
D
“Maybe your reacting to the drug; I will withhold the next dose”.
Question 83 Explanation:
Lactulose is given to a patients with hepatic encephalopathy to reduce absorption of ammonia in the intestines by binding with ammonia and promoting more frequent bowel movements. If the patient experience diarrhea, it indicates over dosage and the nurse must reduce the amount of medication given to the patient. The stool will be mashy or soft. Lactulose is also very sweet and may cause cramping and bloating.
Question 84
An 18-year-old male client admitted with heat stroke begins to show signs of disseminated intravascular coagulation (DIC). Which of the following laboratory findings is most consistent with DIC?
A
Elevated fibrinogen levels
B
Low platelet count
C
Low levels of fibrin degradation products
D
Reduced prothrombin time
Question 84 Explanation:
In DIC, platelets and clotting factors are consumed, resulting in microthrombi and excessive bleeding. As clots form, fibrinogen levels decrease and the prothrombin time increases. Fibrin degeneration products increase as fibrinolysis takes places.
Question 85
Nurse Maria plans to administer dexamethasone cream to a female client who has dermatitis over the anterior chest. How should the nurse apply this topical agent?
A
In long, even, outward, and downward strokes in the direction of hair growth
B
In long, even, outward, and upward strokes in the direction opposite hair growth
C
With a circular motion, to enhance absorption.
D
With an upward motion, to increase blood supply to the affected area
Question 85 Explanation:
When applying a topical agent, the nurse should begin at the midline and use long, even, outward, and downward strokes in the direction of hair growth. This application pattern reduces the risk of follicle irritation and skin inflammation.
Question 86
Nurse Tristan is caring for a male client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat:
A
hypercalcemia.
B
hypokalemia.
C
hypernatremia.
D
hyperkalemia.
Question 86 Explanation:
Hyperkalemia is a common complication of acute renal failure. It's life-threatening if immediate action isn't taken to reverse it. The administration of glucose and regular insulin, with sodium bicarbonate if necessary, can temporarily prevent cardiac arrest by moving potassium into the cells and temporarily reducing serum potassium levels. Hypernatremia, hypokalemia, and hypercalcemia don't usually occur with acute renal failure and aren't treated with glucose, insulin, or sodium bicarbonate.
Question 87
Hemoptysis may be present in the client with a pulmonary embolism because of which of the following reasons?
A
Loss of lung parenchyma
B
Loss of lung tissue
C
Alveolar damage in the infracted area
D
Involvement of major blood vessels in the occluded area
Question 87 Explanation:
The infracted area produces alveolar damage that can lead to the production of bloody sputum, sometimes in massive amounts. Clot formation usually occurs in the legs. There’s a loss of lung parenchyma and subsequent scar tissue formation.
Question 88
Which of the following drugs would be ordered by the physician to improve the platelet count in a male client with idiopathic thrombocytopenic purpura (ITP)?
A
Corticosteroids
B
Vitamin K
C
Acetylsalicylic acid (ASA)
D
Methotrezate
Question 88 Explanation:
Corticosteroid therapy can decrease antibody production and phagocytosis of the antibody-coated platelets, retaining more functioning platelets. Methotrexate can cause thrombocytopenia. Vitamin K is used to treat an excessive anticoagulate state from warfarin overload, and ASA decreases platelet aggregation.
Question 89
Nurse Michelle calculates the IV flow rate for a postoperative client. The client receives 3,000 ml of Ringer’s lactate solution IV to run over 24 hours. The IV infusion set has a drop factor of 10 drops per milliliter. The nurse should regulate the client’s IV to deliver how many drops per minute?
A
21
B
35
C
40
D
18
Question 89 Explanation:
3000 x 10 divided by 24 x 60.
Question 90
Patrick is treated in the emergency department for a Colles' fracture sustained during a fall. What is a Colles' fracture?
A
Fracture of the carpal scaphoid
B
Fracture of the olecranon
C
Fracture of the distal radius
D
Fracture of the humerus
Question 90 Explanation:
Colles' fracture is a fracture of the distal radius, such as from a fall on an outstretched hand. It's most common in women. Colles' fracture doesn't refer to a fracture of the olecranon, humerus, or carpal scaphoid.
Question 91
Ricardo, was diagnosed with type I diabetes. The nurse is aware that acute hypoglycemia also can develop in the client who is diagnosed with:
A
Liver disease
B
Hypertension
C
Hyperthyroidism
D
Type 2 diabetes
Question 91 Explanation:
The client with liver disease has a decreased ability to metabolize carbohydrates because of a decreased ability to form glycogen (glycogenesis) and to form glucose from glycogen.
Question 92
Maritess was recently diagnosed with a genitourinary problem and is being examined in the emergency department. When palpating the her kidneys, the nurse should keep which anatomical fact in mind?
A
The kidneys lie between the 10th and 12th thoracic vertebrae.
B
The left kidney usually is slightly higher than the right one.
C
The kidneys are situated just above the adrenal glands.
D
The average kidney is approximately 5 cm (2") long and 2 to 3 cm (¾" to 1-1/8") wide.
Question 92 Explanation:
The left kidney usually is slightly higher than the right one. An adrenal gland lies atop each kidney. The average kidney measures approximately 11 cm (4-3/8") long, 5 to 5.8 cm (2" to 2¼") wide, and 2.5 cm (1") thick. The kidneys are located retroperitoneally, in the posterior aspect of the abdomen, on either side of the vertebral column. They lie between the 12th thoracic and 3rd lumbar vertebrae.
Question 93
Nurse Nikki knows that laboratory results supports the diagnosis of systemic lupus erythematosus (SLE) is:
Leukocysis, elevated blood urea nitrogen (BUN) and creatinine levels
Question 93 Explanation:
Laboratory findings for clients with SLE usually show pancytopenia, elevated ANA titer, and decreased serum complement levels. Clients may have elevated BUN and creatinine levels from nephritis, but the increase does not indicate SLE.
Question 94
Matilda, with hyperthyroidism is to receive Lugol’s iodine solution before a subtotal thyroidectomy is performed. The nurse is aware that this medication is given to:
A
Maintain the function of the parathyroid glands.
B
Decrease the total basal metabolic rate.
C
Decrease the size and vascularity of the thyroid gland.
D
Block the formation of thyroxine by the thyroid gland.
Question 94 Explanation:
Lugol’s solution provides iodine, which aids in decreasing the vascularity of the thyroid gland, which limits the risk of hemorrhage when surgery is performed.
Question 95
Nurse Lourdes is teaching a client recovering from addisonian crisis about the need to take fludrocortisone acetate and hydrocortisone at home. Which statement by the client indicates an understanding of the instructions?
A
"I'll take two-thirds of the dose when I wake up and one-third in the late afternoon."
B
"I'll take my hydrocortisone in the late afternoon, before dinner."
C
"I'll take the entire dose at bedtime."
D
"I'll take all of my hydrocortisone in the morning, right after I wake up."
Question 95 Explanation:
Hydrocortisone, a glucocorticoid, should be administered according to a schedule that closely reflects the body's own secretion of this hormone; therefore, two-thirds of the dose of hydrocortisone should be taken in the morning and one-third in the late afternoon. This dosage schedule reduces adverse effects.
Question 96
Marco falls off his bicycle and injuries his ankle. Which of the following actions shows the initial response to the injury in the extrinsic pathway?
A
Conversion of factors XII to factor XIIa
B
Release of tissue thromboplastin
C
Conversion of factor VIII to factor VIIIa
D
Release of Calcium
Question 96 Explanation:
Tissue thromboplastin is released when damaged tissue comes in contact with clotting factors. Calcium is released to assist the conversion of factors X to Xa. Conversion of factors XII to XIIa and VIII to VIII a are part of the intrinsic pathway.
Question 97
The nurse knows that neurologic complications of multiple myeloma (MM) usually involve which of the following body system?
A
Myocardial irritability
B
Brain
C
Muscle spasm
D
Renal dysfunction
Question 97 Explanation:
Back pain or paresthesia in the lower extremities may indicate impending spinal cord compression from a spinal tumor. This should be recognized and treated promptly as progression of the tumor may result in paraplegia. The other options, which reflect parts of the nervous system, aren’t usually affected by MM.
Question 98
Rico with diabetes mellitus must learn how to self-administer insulin. The physician has prescribed 10 U of U-100 regular insulin and 35 U of U-100 isophane insulin suspension (NPH) to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction?
A
"Administer insulin into sites above muscles that you plan to exercise heavily later that day."
B
"Rotate injection sites within the same anatomic region, not among different regions."
C
"Administer insulin into areas of scar tissue or hypotrophy whenever possible."
D
"Inject insulin into healthy tissue with large blood vessels and nerves."
Question 98 Explanation:
The nurse should instruct the client to rotate injection sites within the same anatomic region. Rotating sites among different regions may cause excessive day-to-day variations in the blood glucose level; also, insulin absorption differs from one region to the next. Insulin should be injected only into healthy tissue lacking large blood vessels, nerves, or scar tissue or other deviations. Injecting insulin into areas of hypertrophy may delay absorption. The client shouldn't inject insulin into areas of lipodystrophy (such as hypertrophy or atrophy); to prevent lipodystrophy, the client should rotate injection sites systematically. Exercise speeds drug absorption, so the client shouldn't inject insulin into sites above muscles that will be exercised heavily.
Question 99
Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy. Stacy is discharged from the hospital following her chemotherapy treatments. Which statement of Stacy’s mother indicated that she understands when she will contact the physician?
A
“Should Stacy have continued hair loss, I need to call the doctor”.
B
“I should contact the physician if Stacy has difficulty in sleeping”.
C
“My physician should be called if Stacy is irritable and unhappy”.
D
“I will call my doctor if Stacy has persistent vomiting and diarrhea”.
Question 99 Explanation:
Persistent (more than 24 hours) vomiting, anorexia, and diarrhea are signs of toxicity and the patient should stop the medication and notify the health care provider. The other manifestations are expected side effects of chemotherapy.
Question 100
Nurse Sugar is assessing a client with Cushing's syndrome. Which observation should the nurse report to the physician immediately?
A
An irregular apical pulse
B
Dry mucous membranes
C
Frequent urination
D
Pitting edema of the legs
Question 100 Explanation:
Because Cushing's syndrome causes aldosterone overproduction, which increases urinary potassium loss, the disorder may lead to hypokalemia. Therefore, the nurse should immediately report signs and symptoms of hypokalemia, such as an irregular apical pulse, to the physician. Edema is an expected finding because aldosterone overproduction causes sodium and fluid retention. Dry mucous membranes and frequent urination signal dehydration, which isn't associated with Cushing's syndrome.
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1. Randy has undergone kidney transplant, what assessment would prompt Nurse Katrina to suspect organ rejection?
Sudden weight loss
Polyuria
Hypertension
Shock
2. The immediate objective of nursing care for an overweight, mildly hypertensive male client with ureteral colic and hematuria is to decrease:
Pain
Weight
Hematuria
Hypertension
3. Matilda, with hyperthyroidism is to receive Lugol’s iodine solution before a subtotal thyroidectomy is performed. The nurse is aware that this medication is given to:
Decrease the total basal metabolic rate.
Maintain the function of the parathyroid glands.
Block the formation of thyroxine by the thyroid gland.
Decrease the size and vascularity of the thyroid gland.
4. Ricardo, was diagnosed with type I diabetes. The nurse is aware that acute hypoglycemia also can develop in the client who is diagnosed with:
Liver disease
Hypertension
Type 2 diabetes
Hyperthyroidism
5. Tracy is receiving combination chemotherapy for treatment of metastatic carcinoma. Nurse Ruby should monitor the client for the systemic side effect of:
Ascites
Nystagmus
Leukopenia
Polycythemia
6. Norma, with recent colostomy expresses concern about the inability to control the passage of gas. Nurse Oliver should suggest that the client plan to:
Eliminate foods high in cellulose.
Decrease fluid intake at meal times.
Avoid foods that in the past caused flatus.
Adhere to a bland diet prior to social events.
7. Nurse Ron begins to teach a male client how to perform colostomy irrigations. The nurse would evaluate that the instructions were understood when the client states, “I should:
Lie on my left side while instilling the irrigating solution.”
Keep the irrigating container less than 18 inches above the stoma.”
Instill a minimum of 1200 ml of irrigating solution to stimulate evacuation of the bowel.”
Insert the irrigating catheter deeper into the stoma if cramping occurs during the procedure.”
8. Patrick is in the oliguric phase of acute tubular necrosis and is experiencing fluid and electrolyte imbalances. The client is somewhat confused and complains of nausea and muscle weakness. As part of the prescribed therapy to correct this electrolyte imbalance, the nurse would expect to:
Administer Kayexalate
Restrict foods high in protein
Increase oral intake of cheese and milk.
Administer large amounts of normal saline via I.V.
9. Mario has burn injury. After Forty48 hours, the physician orders for Mario 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
10.Terence suffered form burn injury. Using the rule of nines, which has the largest percent of burns?
Face and neck
Right upper arm and penis
Right thigh and penis
Upper trunk
11. Herbert, a 45 year old construction engineer is brought to the hospital unconscious after falling from a 2-story building. When assessing the client, the nurse would be most concerned if the assessment revealed:
Reactive pupils
A depressed fontanel
Bleeding from ears
An elevated temperature
12. Nurse Sherry is teaching male client regarding his permanent artificial pacemaker. Which information given by the nurse shows her knowledge deficit about the artificial cardiac pacemaker?
take the pulse rate once a day, in the morning upon awakening
May be allowed to use electrical appliances
Have regular follow up care
May engage in contact sports
13.The nurse is ware that the most relevant knowledge about oxygen administration to a male client with COPD is
Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.
Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breath.
Oxygen is administered best using a non-rebreathing mask
Blood gases are monitored using a pulse oximeter.
14.Tonny has undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are inserted, and one-bottle water-seal drainage is instituted in the operating room. In the postanesthesia care unit Tonny is placed in Fowler’s position on either his right side or on his back. The nurse is aware that this position:
Reduce incisional pain.
Facilitate ventilation of the left lung.
Equalize pressure in the pleural space.
Increase venous return
15.Kristine is scheduled for a bronchoscopy. When teaching Kristine what to expect afterward, the nurse’s highest priority of information would be:
Food and fluids will be withheld for at least 2 hours.
Warm saline gargles will be done q 2h.
Coughing and deep-breathing exercises will be done q2h.
Only ice chips and cold liquids will be allowed initially.
16.Nurse Tristan is caring for a male client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat:
hypernatremia.
hypokalemia.
hyperkalemia.
hypercalcemia.
17.Ms. X has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client?
This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually.
The most common treatment is metronidazole (Flagyl), which should eradicate the problem within 7 to 10 days.
The potential for transmission to her sexual partner will be eliminated if condoms are used every time they have sexual intercourse.
The human papillomavirus (HPV), which causes condylomata acuminata, can’t be transmitted during oral sex.
18.Maritess was recently diagnosed with a genitourinary problem and is being examined in the emergency department. When palpating the her kidneys, the nurse should keep which anatomical fact in mind?
The left kidney usually is slightly higher than the right one.
The kidneys are situated just above the adrenal glands.
The average kidney is approximately 5 cm (2″) long and 2 to 3 cm (¾” to 1-1/8″) wide.
The kidneys lie between the 10th and 12th thoracic vertebrae.
19.Jestoni with chronic renal failure (CRF) is admitted to the urology unit. The nurse is aware that the diagnostic test are consistent with CRF if the result is:
Increased pH with decreased hydrogen ions.
Increased serum levels of potassium, magnesium, and calcium.
Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein (PSP) excretion 75%.
20. Katrina has an abnormal result on a Papanicolaou test. After admitting that she read her chart while the nurse was out of the room, Katrina asks what dysplasia means. Which definition should the nurse provide?
Presence of completely undifferentiated tumor cells that don’t resemble cells of the tissues of their origin.
Increase in the number of normal cells in a normal arrangement in a tissue or an organ.
Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn’t found.
Alteration in the size, shape, and organization of differentiated cells.
21. During a routine checkup, Nurse Mariane assesses a male client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the most common AIDS-related cancer?
Squamous cell carcinoma
Multiple myeloma
Leukemia
Kaposi’s sarcoma
22.Ricardo is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist’s instructions. Why does the client require special positioning for this type of anesthesia?
To prevent confusion
To prevent seizures
To prevent cerebrospinal fluid (CSF) leakage
To prevent cardiac arrhythmias
23.A male client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:
Auscultate bowel sounds.
Palpate the abdomen.
Change the client’s position.
Insert a rectal tube.
24.Wilfredo with a recent history of rectal bleeding is being prepared for a colonoscopy. How should the nurse Patricia position the client for this test initially?
Lying on the right side with legs straight
Lying on the left side with knees bent
Prone with the torso elevated
Bent over with hands touching the floor
25.A male client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, Nurse Oliver notes that the client’s stoma appears dusky. How should the nurse interpret this finding?
Blood supply to the stoma has been interrupted.
This is a normal finding 1 day after surgery.
The ostomy bag should be adjusted.
An intestinal obstruction has occurred.
26.Anthony suffers burns on the legs, which nursing intervention helps prevent contractures?
Applying knee splints
Elevating the foot of the bed
Hyperextending the client’s palms
Performing shoulder range-of-motion exercises
27.Nurse Ron is assessing a client admitted with second- and third-degree burns on the face, arms, and chest. Which finding indicates a potential problem?
Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg.
Urine output of 20 ml/hour.
White pulmonary secretions.
Rectal temperature of 100.6° F (38° C).
28. Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, Nurse Celia should:
Turn him frequently.
Perform passive range-of-motion (ROM) exercises.
Reduce the client’s fluid intake.
Encourage the client to use a footboard.
29.Nurse Maria plans to administer dexamethasone cream to a female client who has dermatitis over the anterior chest. How should the nurse apply this topical agent?
With a circular motion, to enhance absorption.
With an upward motion, to increase blood supply to the affected area
In long, even, outward, and downward strokes in the direction of hair growth
In long, even, outward, and upward strokes in the direction opposite hair growth
30.Nurse Kate is aware that one of the following classes of medication protect the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation is:
Beta -adrenergic blockers
Calcium channel blocker
Narcotics
Nitrates
31.A male client has jugular distention. On what position should the nurse place the head of the bed to obtain the most accurate reading of jugular vein distention?
High Fowler’s
Raised 10 degrees
Raised 30 degrees
Supine position
32.The nurse is aware that one of the following classes of medications maximizes cardiac performance in clients with heart failure by increasing ventricular contractility?
Beta-adrenergic blockers
Calcium channel blocker
Diuretics
Inotropic agents
33.A male client has a reduced serum high-density lipoprotein (HDL) level and an elevated low-density lipoprotein (LDL) level. Which of the following dietary modifications is not appropriate for this client?
Fiber intake of 25 to 30 g daily
Less than 30% of calories form fat
Cholesterol intake of less than 300 mg daily
Less than 10% of calories from saturated fat
34. A 37-year-old male client was admitted to the coronary care unit (CCU) 2 days ago with an acute myocardial infarction. Which of the following actions would breach the client confidentiality?
The CCU nurse gives a verbal report to the nurse on the telemetry unit before transferring the client to that unit
The CCU nurse notifies the on-call physician about a change in the client’s condition
The emergency department nurse calls up the latest electrocardiogram results to check the client’s progress.
At the client’s request, the CCU nurse updates the client’s wife on his condition
35. A male client arriving in the emergency department is receiving cardiopulmonary resuscitation from paramedics who are giving ventilations through an endotracheal (ET) tube that they placed in the client’s home. During a pause in compressions, the cardiac monitor shows narrow QRS complexes and a heart rate of beats/minute with a palpable pulse. Which of the following actions
should the nurse take first?
Start an L.V. line and administer amiodarone (Cardarone), 300 mg L.V. over 10 minutes.
Check endotracheal tube placement.
Obtain an arterial blood gas (ABG) sample.
Administer atropine, 1 mg L.V.
36. After cardiac surgery, a client’s blood pressure measures 126/80 mm Hg. Nurse Katrina determines that mean arterial pressure (MAP) is which of the following?
46 mm Hg
80 mm Hg
95 mm Hg
90 mm Hg
37. A female client arrives at the emergency department with chest and stomach pain and a report of black tarry stool for several months. Which of the following order should the nurse Oliver anticipate?
Cardiac monitor, oxygen, creatine kinase and lactate dehydrogenase levels
Prothrombin time, partial thromboplastin time, fibrinogen and fibrin split product values.
38. Macario had coronary artery bypass graft (CABG) surgery 3 days ago. Which of the following conditions is suspected by the nurse when a decrease in platelet count from 230,000 ul to 5,000 ul is noted?
Pancytopenia
Idiopathic thrombocytopemic purpura (ITP)
Disseminated intravascular coagulation (DIC)
Heparin-associated thrombosis and thrombocytopenia (HATT)
39. Which of the following drugs would be ordered by the physician to improve the platelet count in a male client with idiopathic thrombocytopenic purpura (ITP)?
Acetylsalicylic acid (ASA)
Corticosteroids
Methotrezate
Vitamin K
40. A female client is scheduled to receive a heart valve replacement with a porcine valve. Which of the following types of transplant is this?
Allogeneic
Autologous
Syngeneic
Xenogeneic
41. Marco falls off his bicycle and injuries his ankle. Which of the following actions shows the initial response to the injury in the extrinsic pathway?
Release of Calcium
Release of tissue thromboplastin
Conversion of factors XII to factor XIIa
Conversion of factor VIII to factor VIIIa
42. Instructions for a client with systemic lupus erythematosus (SLE) would include information about which of the following blood dyscrasias?
Dressler’s syndrome
Polycythemia
Essential thrombocytopenia
Von Willebrand’s disease
43. The nurse is aware that the following symptoms is most commonly an early indication of stage 1 Hodgkin’s disease?
Pericarditis
Night sweat
Splenomegaly
Persistent hypothermia
44. Francis with leukemia has neutropenia. Which of the following functions must frequently assessed?
Blood pressure
Bowel sounds
Heart sounds
Breath sounds
45. The nurse knows that neurologic complications of multiple myeloma (MM) usually involve which of the following body system?
Brain
Muscle spasm
Renal dysfunction
Myocardial irritability
46. Nurse Patricia is aware that the average length of time from human immunodeficiency virus (HIV) infection to the development of acquired immunodeficiency syndrome (AIDS)?
Less than 5 years
5 to 7 years
10 years
More than 10 years
47. An 18-year-old male client admitted with heat stroke begins to show signs of disseminated intravascular coagulation (DIC). Which of the following laboratory findings is most consistent with DIC?
Low platelet count
Elevated fibrinogen levels
Low levels of fibrin degradation products
Reduced prothrombin time
48. Mario comes to the clinic complaining of fever, drenching night sweats, and unexplained weight loss over the past 3 months. Physical examination reveals a single enlarged supraclavicular lymph node. Which of the following is the most probable diagnosis?
Influenza
Sickle cell anemia
Leukemia
Hodgkin’s disease
49. A male client with a gunshot wound requires an emergency blood transfusion. His blood type is AB negative. Which blood type would be the safest for him to receive?
AB Rh-positive
A Rh-positive
A Rh-negative
O Rh-positive
Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy.
50. Stacy is discharged from the hospital following her chemotherapy treatments. Which statement of Stacy’s mother indicated that she understands when she will contact the physician?
“I should contact the physician if Stacy has difficulty in sleeping”.
“I will call my doctor if Stacy has persistent vomiting and diarrhea”.
“My physician should be called if Stacy is irritable and unhappy”.
“Should Stacy have continued hair loss, I need to call the doctor”.
51. Stacy’s mother states to the nurse that it is hard to see Stacy with no hair. The best response for the nurse is:
“Stacy looks very nice wearing a hat”.
“You should not worry about her hair, just be glad that she is alive”.
“Yes it is upsetting. But try to cover up your feelings when you are with her or else she may be upset”.
“This is only temporary; Stacy will re-grow new hair in 3-6 months, but may be different in texture”.
52. Stacy has beginning stomatitis. To promote oral hygiene and comfort, the nurse in-charge should:
Provide frequent mouthwash with normal saline.
Apply viscous Lidocaine to oral ulcers as needed.
Use lemon glycerine swabs every 2 hours.
Rinse mouth with Hydrogen Peroxide.
53. During the administration of chemotherapy agents, Nurse Oliver observed that the IV site is red and swollen, when the IV is touched Stacy shouts in pain. The first nursing action to take is:
Notify the physician
Flush the IV line with saline solution
Immediately discontinue the infusion
Apply an ice pack to the site, followed by warm compress.
54. The term “blue bloater” refers to a male client which of the following conditions?
Adult respiratory distress syndrome (ARDS)
Asthma
Chronic obstructive bronchitis
Emphysema
55. The term “pink puffer” refers to the female client with which of the following conditions?
Adult respiratory distress syndrome (ARDS)
Asthma
Chronic obstructive bronchitis
Emphysema
56. Jose is in danger of respiratory arrest following the administration of a narcotic analgesic. An arterial blood gas value is obtained. Nurse Oliver would expect the paco2 to be which of the following values?
15 mm Hg
30 mm Hg
40 mm Hg
80 mm Hg
57. Timothy’s arterial blood gas (ABG) results are as follows; pH 7.16; Paco2 80 mm Hg; Pao2 46 mm Hg; HCO3- 24mEq/L; Sao2 81%. This ABG result represents which of the following conditions?
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respirator y alkalosis
58. Norma has started a new drug for hypertension. Thirty minutes after she takes the drug, she develops chest tightness and becomes short of breath and tachypneic. She has a decreased level of consciousness. These signs indicate which of the following conditions?
Asthma attack
Pulmonary embolism
Respiratory failure
Rheumatoid arthritis
Situation: Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out cirrhosis of the liver:
59. Which laboratory test indicates liver cirrhosis?
Decreased red blood cell count
Decreased serum acid phosphate level
Elevated white blood cell count
Elevated serum aminotransferase
60.The biopsy of Mr. Gonzales confirms the diagnosis of cirrhosis. Mr. Gonzales is at increased risk for excessive bleeding primarily because of:
Impaired clotting mechanism
Varix formation
Inadequate nutrition
Trauma of invasive procedure
61. Mr. Gonzales develops hepatic encephalopathy. Which clinical manifestation is most common with this condition?
Increased urine output
Altered level of consciousness
Decreased tendon reflex
Hypotension
62. When Mr. Gonzales regained consciousness, the physician orders 50 ml of Lactose p.o. every 2 hours. Mr. Gozales develops diarrhea. The nurse best action would be:
“I’ll see if your physician is in the hospital”.
“Maybe your reacting to the drug; I will withhold the next dose”.
“I’ll lower the dosage as ordered so the drug causes only 2 to 4 stools a day”.
“Frequently, bowel movements are needed to reduce sodium level”.
63. Which of the following groups of symptoms indicates a ruptured abdominal aortic aneurysm?
Lower back pain, increased blood pressure, decreased re blood cell (RBC) count, increased white blood (WBC) count.
Severe lower back pain, decreased blood pressure, decreased RBC count, increased WBC count.
Severe lower back pain, decreased blood pressure, decreased RBC count, decreased RBC count, decreased WBC count.
64. After undergoing a cardiac catheterization, Tracy has a large puddle of blood under his buttocks. Which of the following steps should the nurse take first?
Call for help.
Obtain vital signs
Ask the client to “lift up”
Apply gloves and assess the groin site
65. Which of the following treatment is a suitable surgical intervention for a client with unstable angina?
66. The nurse is aware that the following terms used to describe reduced cardiac output and perfusion impairment due to ineffective pumping of the heart is:
Anaphylactic shock
Cardiogenic shock
Distributive shock
Myocardial infarction (MI)
67. A client with hypertension ask the nurse which factors can cause blood pressure to drop to normal levels?
Kidneys’ excretion to sodium only.
Kidneys’ retention of sodium and water
Kidneys’ excretion of sodium and water
Kidneys’ retention of sodium and excretion of water
68. Nurse Rose is aware that the statement that best explains why furosemide (Lasix) is administered to treat hypertension is:
It dilates peripheral blood vessels.
It decreases sympathetic cardioacceleration.
It inhibits the angiotensin-coverting enzymes
It inhibits reabsorption of sodium and water in the loop of Henle.
69. Nurse Nikki knows that laboratory results supports the diagnosis of systemic lupus erythematosus (SLE) is:
Leukocysis, elevated blood urea nitrogen (BUN) and creatinine levels
70. Arnold, a 19-year-old client with a mild concussion is discharged from the emergency department. Before discharge, he complains of a headache. When offered acetaminophen, his mother tells the nurse the headache is severe and she would like her son to have something stronger. Which of the following responses by the nurse is appropriate?
“Your son had a mild concussion, acetaminophen is strong enough.”
“Aspirin is avoided because of the danger of Reye’s syndrome in children or young adults.”
“Narcotics are avoided after a head injury because they may hide a worsening condition.”
Stronger medications may lead to vomiting, which increases the intracarnial pressure (ICP).”
71. When evaluating an arterial blood gas from a male client with a subdural hematoma, the nurse notes the Paco2 is 30 mm Hg. Which of the following responses best describes the result?
Significant; the client has alveolar hypoventilation
72. When prioritizing care, which of the following clients should the nurse Olivia assess first?
A 17-year-old clients 24-hours postappendectomy
A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome
A 50-year-old client 3 days postmyocardial infarction
A 50-year-old client with diverticulitis
73. JP has been diagnosed with gout and wants to know why colchicine is used in the treatment of gout. Which of the following actions of colchicines explains why it’s effective for gout?
Replaces estrogen
Decreases infection
Decreases inflammation
Decreases bone demineralization
74. Norma asks for information about osteoarthritis. Which of the following statements about osteoarthritis is correct?
Osteoarthritis is rarely debilitating
Osteoarthritis is a rare form of arthritis
Osteoarthritis is the most common form of arthritis
Osteoarthritis afflicts people over 60
75. Ruby is receiving thyroid replacement therapy develops the flu and forgets to take her thyroid replacement medicine. The nurse understands that skipping this medication will put the client at risk for developing which of the following lifethreatening complications?
Exophthalmos
Thyroid storm
Myxedema coma
Tibial myxedema
76. Nurse Sugar is assessing a client with Cushing’s syndrome. Which observation should the nurse report to the physician immediately?
Pitting edema of the legs
An irregular apical pulse
Dry mucous membranes
Frequent urination
77. Cyrill with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty-six hours later, the client’s urine output suddenly rises above 200 ml/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse’s suspicion of diabetes insipidus?
78. Jomari is diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which of the following statements indicates that the client understands her condition and how to control it?
“I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual.”
“If I experience trembling, weakness, and headache, I should drink a glass of soda that contains sugar.”
“I will have to monitor my blood glucose level closely and notify the physician if it’s constantly elevated.”
“If I begin to feel especially hungry and thirsty, I’ll eat a snack high in carbohydrates.”
79. A 66-year-old client has been complaining of sleeping more, increased urination, anorexia, weakness, irritability, depression, and bone pain that interferes with her going outdoors. Based on these assessment findings, the nurse would suspect which of the following disorders?
Diabetes mellitus
Diabetes insipidus
Hypoparathyroidism
Hyperparathyroidism
80. Nurse Lourdes is teaching a client recovering from addisonian crisis about the need to take fludrocortisone acetate and hydrocortisone at home. Which statement by the client indicates an understanding of the instructions?
“I’ll take my hydrocortisone in the late afternoon, before dinner.”
“I’ll take all of my hydrocortisone in the morning, right after I wake up.”
“I’ll take two-thirds of the dose when I wake up and one-third in the late afternoon.”
“I’ll take the entire dose at bedtime.”
81. Which of the following laboratory test results would suggest to the nurse Len that a client has a corticotropin-secreting pituitary adenoma?
High corticotropin and low cortisol levels
Low corticotropin and high cortisol levels
High corticotropin and high cortisol levels
Low corticotropin and low cortisol levels
82. A male client is scheduled for a transsphenoidal hypophysectomy to remove a pituitary tumor. Preoperatively, the nurse should assess for potential complications by doing which of the following?
Testing for ketones in the urine
Testing urine specific gravity
Checking temperature every 4 hours
Performing capillary glucose testing every 4 hours
83. Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin. Nurse Mariner should expect the dose’s:
onset to be at 2 p.m. and its peak to be at 3 p.m.
onset to be at 2:15 p.m. and its peak to be at 3 p.m.
onset to be at 2:30 p.m. and its peak to be at 4 p.m.
onset to be at 4 p.m. and its peak to be at 6 p.m.
84. The physician orders laboratory tests to confirm hyperthyroidism in a female client with classic signs and symptoms of this disorder. Which test result would confirm the diagnosis?
No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test
A decreased TSH level
An increase in the TSH level after 30 minutes during the TSH stimulation test
Below-normal levels of serum triiodothyronine (T3) and serum thyroxine (T4) as detected by radioimmunoassay
85. Rico with diabetes mellitus must learn how to self-administer insulin. The physician has prescribed 10 U of U-100 regular insulin and 35 U of U-100 isophane insulin suspension (NPH) to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction?
“Inject insulin into healthy tissue with large blood vessels and nerves.”
“Rotate injection sites within the same anatomic region, not among different regions.”
“Administer insulin into areas of scar tissue or hypotrophy whenever possible.”
“Administer insulin into sites above muscles that you plan to exercise heavily later that day.”
86. Nurse Sarah expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate?
Elevated serum acetone level
Serum ketone bodies
Serum alkalosis
Below-normal serum potassium level
87. For a client with Graves’ disease, which nursing intervention promotes comfort?
Restricting intake of oral fluids
Placing extra blankets on the client’s bed
Limiting intake of high-carbohydrate foods
Maintaining room temperature in the low-normal range
88. Patrick is treated in the emergency department for a Colles’ fracture sustained during a fall. What is a Colles’ fracture?
Fracture of the distal radius
Fracture of the olecranon
Fracture of the humerus
Fracture of the carpal scaphoid
89. Cleo is diagnosed with osteoporosis. Which electrolytes are involved in the development of this disorder?
Calcium and sodium
Calcium and phosphorous
Phosphorous and potassium
Potassium and sodium
90. Johnny a firefighter was involved in extinguishing a house fire and is being treated to smoke inhalation. He develops severe hypoxia 48 hours after the incident, requiring intubation and mechanical ventilation. He most likely has developed which of the following conditions?
Adult respiratory distress syndrome (ARDS)
Atelectasis
Bronchitis
Pneumonia
91. A 67-year-old client develops acute shortness of breath and progressive hypoxia requiring right femur. The hypoxia was probably caused by which of the following conditions?
Asthma attack
Atelectasis
Bronchitis
Fat embolism
92. A client with shortness of breath has decreased to absent breath sounds on the right side, from the apex to the base. Which of the following conditions would best explain this?
Acute asthma
Chronic bronchitis
Pneumonia
Spontaneous pneumothorax
93. A 62-year-old male client was in a motor vehicle accident as an unrestrained driver. He’s now in the emergency department complaining of difficulty of breathing and chest pain. On auscultation of his lung field, no breath sounds are present in the upper lobe. This client may have which of the following conditions?
Bronchitis
Pneumonia
Pneumothorax
Tuberculosis (TB)
94. If a client requires a pneumonectomy, what fills the area of the thoracic cavity?
The space remains filled with air only
The surgeon fills the space with a gel
Serous fluids fills the space and consolidates the region
The tissue from the other lung grows over to the other side
95. Hemoptysis may be present in the client with a pulmonary embolism because of which of the following reasons?
Alveolar damage in the infracted area
Involvement of major blood vessels in the occluded area
Loss of lung parenchyma
Loss of lung tissue
96. Aldo with a massive pulmonary embolism will have an arterial blood gas analysis performed to determine the extent of hypoxia. The acid-base disorder that may be present is?
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
97. After a motor vehicle accident, Armand an 22-year-old client is admitted with a pneumothorax. The surgeon inserts a chest tube and attaches it to a chest drainage system. Bubbling soon appears in the water seal chamber. Which of the following is the most likely cause of the bubbling?
Air leak
Adequate suction
Inadequate suction
Kinked chest tube
98. Nurse Michelle calculates the IV flow rate for a postoperative client. The client receives 3,000 ml of Ringer’s lactate solution IV to run over 24 hours. The IV infusion set has a drop factor of 10 drops per milliliter. The nurse should regulate the client’s IV to deliver how many drops per minute?
18
21
35
40
99. Mickey, a 6-year-old child with a congenital heart disorder is admitted with congestive heart failure. Digoxin (lanoxin) 0.12 mg is ordered for the child. The bottle of Lanoxin contains .05 mg of Lanoxin in 1 ml of solution. What amount should the nurse administer to the child?
1.2 ml
2.4 ml
3.5 ml
4.2 ml
100. Nurse Alexandra teaches a client about elastic stockings. Which of the following statements, if made by the client, indicates to the nurse that the teaching was successful?
“I will wear the stockings until the physician tells me to remove them.”
“I should wear the stockings even when I am sleep.”
“Every four hours I should remove the stockings for a half hour.”
“I should put on the stockings before getting out of bed in the morning.”
Answers and Rationales
Answer: (C) Hypertension. Hypertension, along with fever, and tenderness over the grafted kidney, reflects acute rejection.
Answer: (A) Pain. Sharp, severe pain (renal colic) radiating toward the genitalia and thigh is caused by uretheral distention and smooth muscle spasm; relief form pain is the priority.
Answer: (D) Decrease the size and vascularity of the thyroid gland. Lugol’s solution provides iodine, which aids in decreasing the vascularity of the thyroid gland, which limits the risk of hemorrhage when surgery is performed.
Answer: (A) Liver Disease. The client with liver disease has a decreased ability to metabolize carbohydrates because of a decreased ability to form glycogen (glycogenesis) and to form glucose from glycogen.
Answer: (C) Leukopenia. Leukopenia, a reduction in WBCs, is a systemic effect of chemotherapy as a result of myelosuppression.
Answer: (C) Avoid foods that in the past caused flatus. Foods that bothered a person preoperatively will continue to do so after a colostomy.
Answer: (B) Keep the irrigating container less than 18 inches above the stoma.” This height permits the solution to flow slowly with little force so that excessive peristalsis is not immediately precipitated.
Answer: (A) Administer Kayexalate. Kayexalate,a potassium exchange resin, permits sodium to be exchanged for potassium in the intestine, reducing the serum potassium level.
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: (D) Upper trunk. The percentage designated for each burned part of the body using the rule of nines: Head and neck 9%; Right upper extremity 9%; Left upper extremity 9%; Anterior trunk 18%; Posterior trunk 18%; Right lower extremity 18%; Left lower extremity 18%; Perineum 1%.
Answer: (C) Bleeding from ears. The nurse needs to perform a thorough assessment that could indicate alterations in cerebral function, increased intracranial pressures, fractures and bleeding. Bleeding from the ears occurs only with basal skull fractures that can easily contribute to increased intracranial pressure and brain herniation.
Answer: (D) may engage in contact sports. The client should be advised by the nurse to avoid contact sports. This will prevent trauma to the area of the pacemaker generator.
Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing. COPD causes a chronic CO2 retention that renders the medulla insensitive to the CO2 stimulation for breathing. The hypoxic state of the client then becomes the stimulus for breathing. Giving the client oxygen in low concentrations will maintain the client’s hypoxic drive.
Answer: (B) Facilitate ventilation of the left lung. Since only a partial pneumonectomy is done, there is a need to promote expansion of this remaining Left lung by positioning the client on the opposite unoperated side.
Answer: (A) Food and fluids will be withheld for at least 2 hours. Prior to bronchoscopy, the doctors sprays the back of the throat with anesthetic to minimize the gag reflex and thus facilitate the insertion of the bronchoscope. Giving the client food and drink after the procedure without checking on the return of the gag reflex can cause the client to aspirate. The gag reflex usually returns after two hours.
Answer: (C) hyperkalemia. Hyperkalemia is a common complication of acute renal failure. It’s life-threatening if immediate action isn’t taken to reverse it. The administration of glucose and regular insulin, with sodium bicarbonate if necessary, can temporarily prevent cardiac arrest by moving potassium into the cells and temporarily reducing serum potassium levels. Hypernatremia, hypokalemia, and hypercalcemia don’t usually occur with acute renal failure and aren’t treated with glucose, insulin, or sodium bicarbonate.
Answer: (A) This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually. Women with condylomata acuminata are at risk for cancer of the cervix and vulva. Yearly Pap smears are very important for early detection. Because condylomata acuminata is a virus, there is no permanent cure. Because condylomata acuminata can occur on the vulva, a condom won’t protect sexual partners. HPV can be transmitted to other parts of the body, such as the mouth, oropharynx, and larynx.
Answer: (A) The left kidney usually is slightly higher than the right one. The left kidney usually is slightly higher than the right one. An adrenal gland lies atop each kidney. The average kidney measures approximately 11 cm (4-3/8″) long, 5 to 5.8 cm (2″ to 2¼”) wide, and 2.5 cm (1″) thick. The kidneys are located retroperitoneally, in the posterior aspect of the abdomen, on either side of the vertebral column. They lie between the 12th thoracic and 3rd lumbar vertebrae.
Answer: (C) Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/dl. The normal BUN level ranges 8 to 23 mg/dl; the normal serum creatinine level ranges from 0.7 to 1.5 mg/dl. The test results in option C are abnormally elevated, reflecting CRF and the kidneys’ decreased ability to remove nonprotein nitrogen waste from the blood. CRF causes decreased pH and increased hydrogen ions — not vice versa. CRF also increases serum levels of potassium, magnesium, and phosphorous, and decreases serum levels of calcium. A uric acid analysis of 3.5 mg/dl falls within the normal range of 2.7 to 7.7 mg/dl; PSP excretion of 75% also falls with the normal range of 60% to 75%.
Answer: (D) Alteration in the size, shape, and organization of differentiated cells. Dysplasia refers to an alteration in the size, shape, and organization of differentiated cells. The presence of completely undifferentiated tumor cells that don’t resemble cells of the tissues of their origin is called anaplasia. An increase in the number of normal cells in a normal arrangement in a tissue or an organ is called hyperplasia. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn’t found is called metaplasia.
Answer: (D) Kaposi’s sarcoma. Kaposi’s sarcoma is the most common cancer associated with AIDS. Squamous cell carcinoma, multiple myeloma, and leukemia may occur in anyone and aren’t associated specifically with AIDS.
Answer: (C) To prevent cerebrospinal fluid (CSF) leakage. The client receiving a subarachnoid block requires special positioning to prevent CSF leakage and headache and to ensure proper anesthetic distribution. Proper positioning doesn’t help prevent confusion, seizures, or cardiac arrhythmias.
Answer: (A) Auscultate bowel sounds. If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician. Palpation should be avoided postoperatively with abdominal distention. If peristalsis is absent, changing positions and inserting a rectal tube won’t relieve the client’s discomfort.
Answer: (B) Lying on the left side with knees bent. For a colonoscopy, the nurse initially should position the client on the left side with knees bent. Placing the client on the right side with legs straight, prone with the torso elevated, or bent over with hands touching the floor wouldn’t allow proper visualization of the large intestine.
Answer: (A) Blood supply to the stoma has been interrupted. An ileostomy stoma forms as the ileum is brought through the abdominal wall to the surface skin, creating an artificial opening for waste elimination. The stoma should appear cherry red, indicating adequate arterial perfusion. A dusky stoma suggests decreased perfusion, which may result from interruption of the stoma’s blood supply and may lead to tissue damage or necrosis. A dusky stoma isn’t a normal finding. Adjusting the ostomy bag wouldn’t affect stoma color, which depends on blood supply to the area. An intestinal obstruction also wouldn’t change stoma color.
Answer: (A) Applying knee splints. Applying knee splints prevents leg contractures by holding the joints in a position of function. Elevating the foot of the bed can’t prevent contractures because this action doesn’t hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs.
Answer: (B) Urine output of 20 ml/hour. A urine output of less than 40 ml/hour in a client with burns indicates a fluid volume deficit. This client’s PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions also are normal. The client’s rectal temperature isn’t significantly elevated and probably results from the fluid volume deficit.
Answer: (A) Turn him frequently. The most important intervention to prevent pressure ulcers is frequent position changes, which relieve pressure on the skin and underlying tissues. If pressure isn’t relieved, capillaries become occluded, reducing circulation and oxygenation of the tissues and resulting in cell death and ulcer formation. During passive ROM exercises, the nurse moves each joint through its range of movement, which improves joint mobility and circulation to the affected area but doesn’t prevent pressure ulcers. Adequate hydration is necessary to maintain healthy skin and ensure tissue repair. A footboard prevents plantar flexion and footdrop by maintaining the foot in a dorsiflexed position.
Answer: (C) In long, even, outward, and downward strokes in the direction of hair growth. When applying a topical agent, the nurse should begin at the midline and use long, even, outward, and downward strokes in the direction of hair growth. This application pattern reduces the risk of follicle irritation and skin inflammation.
Answer: (A) Beta -adrenergic blockers. Beta-adrenergic blockers work by blocking beta receptors in the myocardium, reducing the response to catecholamines and sympathetic nerve stimulation. They protect the myocardium, helping to reduce the risk of another infraction by decreasing myocardial oxygen demand. Calcium channel blockers reduce the workload of the heart by decreasing the heart rate. Narcotics reduce myocardial oxygen demand, promote vasodilation, and decrease anxiety. Nitrates reduce myocardial oxygen consumption bt decreasing left ventricular end diastolic pressure (preload) and systemic vascular resistance (afterload).
Answer: (C) Raised 30 degrees. Jugular venous pressure is measured with a centimeter ruler to obtain the vertical distance between the sternal angle and the point of highest pulsation with the head of the bed inclined between 15 to 30 degrees. Increased pressure can’t be seen when the client is supine or when the head of the bed is raised 10 degrees because the point that marks the pressure level is above the jaw (therefore, not visible). In high Fowler’s position, the veins would be barely discernible above the clavicle.
Answer: (D) Inotropic agents. Inotropic agents are administered to increase the force of the heart’s contractions, thereby increasing ventricular contractility and ultimately increasing cardiac output. Beta-adrenergic blockers and calcium channel blockers decrease the heart rate and ultimately decreased the workload of the heart. Diuretics are administered to decrease the overall vascular volume, also decreasing the workload of the heart.
Answer: (B) Less than 30% of calories form fat. A client with low serum HDL and high serum LDL levels should get less than 30% of daily calories from fat. The other modifications are appropriate for this client.
Answer: (C) The emergency department nurse calls up the latest electrocardiogram results to check the client’s progress. The emergency department nurse is no longer directly involved with the client’s care and thus has no legal right to information about his present condition. Anyone directly involved in his care (such as the telemetry nurse and the on-call physician) has the right to information about his condition. Because the client requested that the nurse update his wife on his condition, doing so doesn’t breach confidentiality.
Answer: (B) Check endotracheal tube placement. ET tube placement should be confirmed as soon as the client arrives in the emergency department. Once the airways is secured, oxygenation and ventilation should be confirmed using an end-tidal carbon dioxide monitor and pulse oximetry. Next, the nurse should make sure L.V. access is established. If the client experiences symptomatic bradycardia, atropine is administered as ordered 0.5 to 1 mg every 3 to 5 minutes to a total of 3 mg. Then the nurse should try to find the cause of the client’s arrest by obtaining an ABG sample. Amiodarone is indicated for ventricular tachycardia, ventricular fibrillation and atrial flutter – not symptomatic bradycardia.
Answer: (C) 95 mm Hg. Use the following formula to calculate MAP
MAP = systolic + 2 (diastolic) /3
MAP=[126 mm Hg + 2 (80 mm Hg) ]/3
MAP=286 mm HG/ 3
MAP=95 mm Hg
Answer: (C) Electrocardiogram, complete blood count, testing for occult blood, comprehensive serum metabolic panel. An electrocardiogram evaluates the complaints of chest pain, laboratory tests determines anemia, and the stool test for occult blood determines blood in the stool. Cardiac monitoring, oxygen, and creatine kinase and lactate dehydrogenase levels are appropriate for a cardiac primary problem. A basic metabolic panel and alkaline phosphatase and aspartate aminotransferase levels assess liver function. Prothrombin time, partial thromboplastin time, fibrinogen and fibrin split products are measured to verify bleeding dyscrasias, An electroencephalogram evaluates brain electrical activity.
Answer: (D) Heparin-associated thrombosis and thrombocytopenia (HATT). HATT may occur after CABG surgery due to heparin use during surgery. Although DIC and ITP cause platelet aggregation and bleeding, neither is common in a client after revascularization surgery. Pancytopenia is a reduction in all blood cells.
Answer: (B) Corticosteroids. Corticosteroid therapy can decrease antibody production and phagocytosis of the antibody-coated platelets, retaining more functioning platelets. Methotrexate can cause thrombocytopenia. Vitamin K is used to treat an excessive anticoagulate state from warfarin overload, and ASA decreases platelet aggregation.
Answer: (D) Xenogeneic. An xenogeneic transplant is between is between human and another species. A syngeneic transplant is between identical twins, allogeneic transplant is between two humans, and autologous is a transplant from the same individual.
Answer: (B). Tissue thromboplastin is released when damaged tissue comes in contact with clotting factors. Calcium is released to assist the conversion of factors X to Xa. Conversion of factors XII to XIIa and VIII to VIII a are part of the intrinsic pathway.
Answer: (C) Essential thrombocytopenia. Essential thrombocytopenia is linked to immunologic disorders, such as SLE and human immunodeficiency vitus. The disorder known as von Willebrand’s disease is a type of hemophilia and isn’t linked to SLE. Moderate to severe anemia is associated with SLE, not polycythermia. Dressler’s syndrome is pericarditis that occurs after a myocardial infarction and isn’t linked to SLE.
Answer: (B) Night sweat. In stage 1, symptoms include a single enlarged lymph node (usually), unexplained fever, night sweats, malaise, and generalized pruritis. Although splenomegaly may be present in some clients, night sweats are generally more prevalent. Pericarditis isn’t associated with Hodgkin’s disease, nor is hypothermia. Moreover, splenomegaly and pericarditis aren’t symptoms. Persistent hypothermia is associated with Hodgkin’s but isn’t an early sign of the disease.
Answer: (D) Breath sounds. Pneumonia, both viral and fungal, is a common cause of death in clients with neutropenia, so frequent assessment of respiratory rate and breath sounds is required. Although assessing blood pressure, bowel sounds, and heart sounds is important, it won’t help detect pneumonia.
Answer: (B) Muscle spasm. Back pain or paresthesia in the lower extremities may indicate impending spinal cord compression from a spinal tumor. This should be recognized and treated promptly as progression of the tumor may result in paraplegia. The other options, which reflect parts of the nervous system, aren’t usually affected by MM.
Answer: (C)10 years. Epidermiologic studies show the average time from initial contact with HIV to the development of AIDS is 10 years.
Answer: (A) Low platelet count. In DIC, platelets and clotting factors are consumed, resulting in microthrombi and excessive bleeding. As clots form, fibrinogen levels decrease and the prothrombin time increases. Fibrin degeneration products increase as fibrinolysis takes places.
Answer: (D) Hodgkin’s disease. Hodgkin’s disease typically causes fever night sweats, weight loss, and lymph mode enlargement. Influenza doesn’t last for months. Clients with sickle cell anemia manifest signs and symptoms of chronic anemia with pallor of the mucous membrane, fatigue, and decreased tolerance for exercise; they don’t show fever, night sweats, weight loss or lymph node enlargement. Leukemia doesn’t cause lymph node enlargement.
Answer: (C) A Rh-negative. Human blood can sometimes contain an inherited D antigen. Persons with the D antigen have Rh-positive blood type; those lacking the antigen have Rh-negative blood. It’s important that a person with Rhnegative blood receives Rh-negative blood. If Rh-positive blood is administered to an Rh-negative person, the recipient develops anti-Rh agglutinins, and sub sequent transfusions with Rh-positive blood may cause serious reactions with clumping and hemolysis of red blood cells.
Answer: (B) “I will call my doctor if Stacy has persistent vomiting and diarrhea”. Persistent (more than 24 hours) vomiting, anorexia, and diarrhea are signs of toxicity and the patient should stop the medication and notify the health care provider. The other manifestations are expected side effects of chemotherapy.
Answer: (D) “This is only temporary; Stacy will re-grow new hair in 3-6 months, but may be different in texture”. This is the appropriate response. The nurse should help the mother how to cope with her own feelings regarding the child’s disease so as not to affect the child negatively. When the hair grows back, it is still of the same color and texture.
Answer: (B) Apply viscous Lidocaine to oral ulcers as needed. Stomatitis can cause pain and this can be relieved by applying topical anesthetics such as lidocaine before mouth care. When the patient is already comfortable, the nurse can proceed with providing the patient with oral rinses of saline solution mixed with equal part of water or hydrogen peroxide mixed water in 1:3 concentrations to promote oral hygiene. Every 2-4 hours.
Answer: (C) Immediately discontinue the infusion. Edema or swelling at the IV site is a sign that the needle has been dislodged and the IV solution is leaking into the tissues causing the edema. The patient feels pain as the nerves are irritated by pressure and the IV solution. The first action of the nurse would be to discontinue the infusion right away to prevent further edema and other complication.
Answer: (C) Chronic obstructive bronchitis. Clients with chronic obstructive bronchitis appear bloated; they have large barrel chest and peripheral edema, cyanotic nail beds, and at times, circumoral cyanosis. Clients with ARDS are acutely short of breath and frequently need intubation for mechanical ventilation and large amount of oxygen. Clients with asthma don’t exhibit characteristics of chronic disease, and clients with emphysema appear pink and cachectic.
Answer: (D) Emphysema. Because of the large amount of energy it takes to breathe, clients with emphysema are usually cachectic. They’re pink and usually breathe through pursed lips, hence the term “puffer.” Clients with ARDS are usually acutely short of breath. Clients with asthma don’t have any particular characteristics, and clients with chronic obstructive bronchitis are bloated and cyanotic in appearance.
Answer: D 80 mm Hg. A client about to go into respiratory arrest will have inefficient ventilation and will be retaining carbon dioxide. The value expected would be around 80 mm Hg. All other values are lower than expected.
Answer: (C) Respiratory acidosis. Because Paco2 is high at 80 mm Hg and the metabolic measure, HCO3- is normal, the client has respiratory acidosis. The pH is less than 7.35, academic, which eliminates metabolic and respiratory alkalosis as possibilities. If the HCO3- was below 22 mEq/L the client would have metabolic acidosis.
Answer: (C) Respiratory failure. The client was reacting to the drug with respiratory signs of impending anaphylaxis, which could lead to eventually respiratory failure. Although the signs are also related to an asthma attack or a pulmonary embolism, consider the new drug first. Rheumatoid arthritis doesn’t manifest these signs.
Answer: (D) Elevated serum aminotransferase. Hepatic cell death causes release of liver enzymes alanine aminotransferase (ALT), aspartate aminotransferase (AST) and lactate dehydrogenase (LDH) into the circulation. Liver cirrhosis is a chronic and irreversible disease of the liver characterized by generalized inflammation and fibrosis of the liver tissues.
Answer: (A) Impaired clotting mechanism. Cirrhosis of the liver results in decreased Vitamin K absorption and formation of clotting factors resulting in impaired clotting mechanism.
Answer: (B) Altered level of consciousness. Changes in behavior and level of consciousness are the first sins of hepatic encephalopathy. Hepatic encephalopathy is caused by liver failure and develops when the liver is unable to convert protein metabolic product ammonia to urea. This results in accumulation of ammonia and other toxic in the blood that damages the cells.
Answer: (C) “I’ll lower the dosage as ordered so the drug causes only 2 to 4 stools a day”. Lactulose is given to a patients with hepatic encephalopathy to reduce absorption of ammonia in the intestines by binding with ammonia and promoting more frequent bowel movements. If the patient experience diarrhea, it indicates over dosage and the nurse must reduce the amount of medication given to the patient. The stool will be mashy or soft. Lactulose is also very sweet and may cause cramping and bloating.
Answer: (B) Severe lower back pain, decreased blood pressure, decreased RBC count, increased WBC count.Severe lower back pain indicates an aneurysm rupture, secondary to pressure being applied within the abdominal cavity. When ruptured occurs, the pain is constant because it can’t be alleviated until the aneurysm is repaired. Blood pressure decreases due to the loss of blood. After the aneurysm ruptures, the vasculature is interrupted and blood volume is lost, so blood pressure wouldn’t increase. For the same reason, the RBC count is decreased – not increased. The WBC count increases as cell migrate to the site of injury.
Answer: (D) Apply gloves and assess the groin site. Observing standard precautions is the first priority when dealing with any blood fluid. Assessment of the groin site is the second priority. This establishes where the blood is coming from and determineshow much blood has been lost. The goal in this situation is to stop the bleeding. The nurse would call for help if it were warranted after the assessment of the situation. After determining the extent of the bleeding, vital signs assessment is important. The nurse should never move the client, in case a clot has formed. Moving can disturb the clot and cause rebleeding.
Answer: (D) Percutaneous transluminal coronary angioplasty (PTCA). PTCA can alleviate the blockage and restore blood flow and oxygenation. An echocardiogram is a noninvasive diagnosis test. Nitroglycerin is an oral sublingual medication. Cardiac catheterization is a diagnostic tool – not a treatment.
Answer: (B) Cardiogenic shock. Cardiogenic shock is shock related to ineffective pumping of the heart. Anaphylactic shock results from an allergic reaction. Distributive shock results from changes in the intravascular volume distribution and is usually associated with increased cardiac output. MI isn’t a shock state, though a severe MI can lead to shock.
Answer: (C) Kidneys’ excretion of sodium and water. The kidneys respond to rise in blood pressure by excreting sodium and excess water. This response ultimately affects sysmolic blood pressure by regulating blood volume. Sodium or water retention would only further increase blood pressure. Sodium and water travel together across the membrane in the kidneys; one can’t travel without the other.
Answer: (D) It inhibits reabsorption of sodium and water in the loop of Henle. Furosemide is a loop diuretic that inhibits sodium and water reabsorption in the loop Henle, thereby causing a decrease in blood pressure. Vasodilators cause dilation of peripheral blood vessels, directly relaxing vascular smooth muscle and decreasing blood pressure. Adrenergic blockers decrease sympathetic cardioacceleration and decrease blood pressure. Angiotensin-converting enzyme inhibitors decrease blood pressure due to their action on angiotensin.
Answer: (C) Pancytopenia, elevated antinuclear antibody (ANA) titer. Laboratory findings for clients with SLE usually show pancytopenia, elevated ANA titer, and decreased serum complement levels. Clients may have elevated BUN and creatinine levels from nephritis, but the increase does not indicate SLE.
Answer: (C) Narcotics are avoided after a head injury because they may hide a worsening condition. Narcotics may mask changes in the level of consciousness that indicate increased ICP and shouldn’t acetaminophen is strong enough ignores the mother’s question and therefore isn’t appropriate. Aspirin is contraindicated in conditions that may have bleeding, such as trauma, and for children or young adults with viral illnesses due to the danger of Reye’s syndrome. Stronger medications may not necessarily lead to vomiting but will sedate the client, thereby masking changes in his level of consciousness.
Answer: (A) Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). A normal Paco2 value is 35 to 45 mm Hg CO2 has vasodilating properties; therefore, lowering Paco2 through hyperventilation will lower ICP caused by dilated cerebral vessels. Oxygenation is evaluated through Pao2 and oxygen saturation. Alveolar hypoventilation would be reflected in an increased Paco2.
Answer: (B) A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome . Guillain-Barre syndrome is characterized by ascending paralysis and potential respiratory failure. The order of client assessment should follow client priorities, with disorder of airways, breathing, and then circulation. There’s no information to suggest the postmyocardial infarction client has an arrhythmia or other complication. There’s no evidence to suggest hemorrhage or perforation for the remaining clients as a priority of care.
Answer: (C) Decreases inflammation. Then action of colchicines is to decrease inflammation by reducing the migration of leukocytes to synovial fluid. Colchicine doesn’t replace estrogen, decrease infection, or decrease bone demineralization.
Answer: (C) Osteoarthritis is the most common form of arthritis. Osteoarthritis is the most common form of arthritis and can be extremely debilitating. It can afflict people of any age, although most are elderly.
Answer: (C) Myxedema coma. Myxedema coma, severe hypothyroidism, is a life-threatening condition that may develop if thyroid replacement medication isn’t taken. Exophthalmos, protrusion of the eyeballs, is seen with hyperthyroidism. Thyroid storm is life-threatening but is caused by severe hyperthyroidism. Tibial myxedema, peripheral mucinous edema involving the lower leg, is associated with hypothyroidism but isn’t life-threatening.
Answer: (B) An irregular apical pulse. Because Cushing’s syndrome causes aldosterone overproduction, which increases urinary potassium loss, the disorder may lead to hypokalemia. Therefore, the nurse should immediately report signs and symptoms of hypokalemia, such as an irregular apical pulse, to the physician. Edema is an expected finding because aldosterone overproduction causes sodium and fluid retention. Dry mucous membranes and frequent urination signal dehydration, which isn’t associated with Cushing’s syndrome.
Answer: (D) Below-normal urine osmolality level, above-normal serum osmolality level. In diabetes insipidus, excessive polyuria causes dilute urine, resulting in a below-normal urine osmolality level. At the same time, polyuria depletes the body of water, causing dehydration that leads to an above-normal serum osmolality level. For the same reasons, diabetes insipidus doesn’t cause above-normal urine osmolality or below-normal serum osmolality levels.
Answer: (A) “I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual.” Inadequate fluid intake during hyperglycemic episodes often leads to HHNS. By recognizing the signs of hyperglycemia (polyuria, polydipsia, and polyphagia) and increasing fluid intake, the client may prevent HHNS. Drinking a glass of nondiet soda would be appropriate for hypoglycemia. A client whose diabetes is controlled with oral antidiabetic agents usually doesn’t need to monitor blood glucose levels. A highcarbohydrate diet would exacerbate the client’s condition, particularly if fluid intake is low.
Answer: (D) Hyperparathyroidism. Hyperparathyroidism is most common in older women and is characterized by bone pain and weakness from excess parathyroid hormone (PTH). Clients also exhibit hypercaliuria-causing polyuria. While clients with diabetes mellitus and diabetes insipidus also have polyuria, they don’t have bone pain and increased sleeping. Hypoparathyroidism is characterized by urinary frequency rather than polyuria.
Answer: (C) “I’ll take two-thirds of the dose when I wake up and one-third in the late afternoon.” Hydrocortisone, a glucocorticoid, should be administered according to a schedule that closely reflects the body’s own secretion of this hormone; therefore, two-thirds of the dose of hydrocortisone should be taken in the morning and one-third in the late afternoon. This dosage schedule reduces adverse effects.
Answer: (C) High corticotropin and high cortisol levels. A corticotropin-secreting pituitary tumor would cause high corticotropin and high cortisol levels. A high corticotropin level with a low cortisol level and a low corticotropin level with a low cortisol level would be associated with hypocortisolism. Low corticotropin and high cortisol levels would be seen if there was a primary defect in the adrenal glands.
Answer: (D) Performing capillary glucose testing every 4 hours. The nurse should perform capillary glucose testing every 4 hours because excess cortisol may cause insulin resistance, placing the client at risk for hyperglycemia. Urine ketone testing isn’t indicated because the client does secrete insulin and, therefore, isn’t at risk for ketosis. Urine specific gravity isn’t indicated because although fluid balance can be compromised, it usually isn’t dangerously imbalanced. Temperature regulation may be affected by excess cortisol and isn’t an accurate indicator of infection.
Answer: (C) onset to be at 2:30 p.m. and its peak to be at 4 p.m.. Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be from 2:15 p.m. to 2:30 p.m. and the peak from 4 p.m. to 6 p.m.
Answer: (A) No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test. In the TSH test, failure of the TSH level to rise after 30 minutes confirms hyperthyroidism. A decreased TSH level indicates a pituitary deficiency of this hormone. Below-normal levels of T3 and T4, as detected by radioimmunoassay, signal hypothyroidism. A below-normal T4 level also occurs in malnutrition and liver disease and may result from administration of phenytoin and certain other drugs.
Answer: (B) “Rotate injection sites within the same anatomic region, not among different regions.” The nurse should instruct the client to rotate injection sites within the same anatomic region. Rotating sites among different regions may cause excessive day-to-day variations in the blood glucose level; also, insulin absorption differs from one region to the next. Insulin should be injected only into healthy tissue lacking large blood vessels, nerves, or scar tissue or other deviations. Injecting insulin into areas of hypertrophy may delay absorption. The client shouldn’t inject insulin into areas of lipodystrophy (such as hypertrophy or atrophy); to prevent lipodystrophy, the client should rotate injection sites systematically. Exercise speeds drug absorption, so the client shouldn’t inject insulin into sites above muscles that will be exercised heavily.
Answer: (D) Below-normal serum potassium level. A client with HHNS has an overall body deficit of potassium resulting from diuresis, which occurs secondary to the hyperosmolar, hyperglycemic state caused by the relative insulin deficiency. An elevated serum acetone level and serum ketone bodies are characteristic of diabetic ketoacidosis. Metabolic acidosis, not serum alkalosis, may occur in HHNS.
Answer: (D) Maintaining room temperature in the low-normal range. Graves’ disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client’s room temperature in the low-normal range. To replace fluids lost via diaphoresis, the nurse should encourage, not restrict, intake of oral fluids. Placing extra blankets on the bed of a client with heat intolerance would cause discomfort. To provide needed energy and calories, the nurse should encourage the client to eat high-carbohydrate foods.
Answer: (A) Fracture of the distal radius. Colles’ fracture is a fracture of the distal radius, such as from a fall on an outstretched hand. It’s most common in women. Colles’ fracture doesn’t refer to a fracture of the olecranon, humerus, or carpal scaphoid.
Answer: (B) Calcium and phosphorous. In osteoporosis, bones lose calcium and phosphate salts, becoming porous, brittle, and abnormally vulnerable to fracture. Sodium and potassium aren’t involved in the development of osteoporosis.
Answer: (A) Adult respiratory distress syndrome (ARDS). Severe hypoxia after smoke inhalation is typically related to ARDS. The other conditions listed aren’t typically associated with smoke inhalation and severe hypoxia.
Answer: (D) Fat embolism. Long bone fractures are correlated with fat emboli, whichcause shortness of breath and hypoxia. It’s unlikely the client has developed asthma or bronchitis without a previous history. He could develop atelectasis but it typically doesn’t produce progressive hypoxia.
Answer: (D) Spontaneous pneumothorax. A spontaneous pneumothorax occurs when the client’s lung collapses, causing an acute decreased in the amount of functional lung used in oxygenation. The sudden collapse was the cause of his chest pain and shortness of breath. An asthma attack would show wheezing breath sounds, and bronchitis would have rhonchi. Pneumonia would have bronchial breath sounds over the area of consolidation.
Answer: (C) Pneumothorax. From the trauma the client experienced, it’s unlikely he has bronchitis, pneumonia, or TB; rhonchi with bronchitis, bronchial breath sounds with TB would be heard.
Answer: (C) Serous fluids fills the space and consolidates the region. Serous fluid fills the space and eventually consolidates, preventing extensive mediastinal shift of the heart and remaining lung. Air can’t be left in the space. There’s no gel that can be placed in the pleural space. The tissue from the other lung can’t cross the mediastinum, although a temporary mediastinal shift exits until the space is filled.
Answer: (A) Alveolar damage in the infracted area. The infracted area produces alveolar damage that can lead to the production of bloody sputum, sometimes in massive amounts. Clot formation usually occurs in the legs. There’s a loss of lung parenchyma and subsequent scar tissue formation.
Answer: (D) Respiratory alkalosis. A client with massive pulmonary embolism will have a large region and blow off large amount of carbon dioxide, which crosses the unaffected alveolar-capillary membrane more readily than does oxygen and results in respiratory alkalosis.
Answer: (A) Air leak. Bubbling in the water seal chamber of a chest drainage system stems from an air leak. In pneumothorax an air leak can occur as air is pulled from the pleural space. Bubbling doesn’t normally occur with either adequate or inadequate suction or any preexisting bubbling in the water seal chamber.
Answer: (B) 21. 3000 x 10 divided by 24 x 60.
Answer: (B) 2.4 ml. .05 mg/ 1 ml = .12mg/ x ml, .05x = .12, x = 2.4 ml.
Answer: (D) “I should put on the stockings before getting out of bed in the morning. Promote venous return by applying external pressure on veins.