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PNLE IV Nursing Practice (PM)
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Question 1
An older adult client with acute pain is admitted in the hospital. The nurse understands that in managing acute pain of the client during the first 24 hours, the nurse should ensure that:
A
An order for meperidine (Demerol) is secured for pain relief.
B
Pain medication is ordered via the intramuscular route.
C
Ordered PRN analgesics are administered on a scheduled basis.
D
Patient controlled analgesia is avoided in this population.
Question 1 Explanation:
Around-the-clock administration of analgesics is recommended for acute pain in the older adult population; this help to maintain a therapeutic blood level of pain medication.
Question 2
The nurse is reviewing the laboratory result of the client. The client’s serum potassium level is 5.8 mEq/L. Which of the following is the initial nursing action?
A
Call the cardiac arrest team to alert them
B
Take the client’s vital signs and notify the physician
Following an amputation of a lower limb to a male client, the nurse provides an instruction on how to prevent a hip flexion contracture. The nurse should instruct the client to:.
A
Perform quadriceps muscle setting exercises twice a day.
B
Sit in a chair for 30 minutes three times a day.
C
Lie on the abdomen 30 minutes every four hours.
D
Turn from side to side every 2 hours.
Question 3 Explanation:
The hips are in extension when the client is prone; this keeps the hips from flexing.
Question 4
The physician scheduled the client with rheumatoid arthritis for the injection of hydrocortisone into the knee joint. The client asks the nurse why there is a need for this injection. The nurse explains that the most important reason for doing this is to:
A
Lubricate the joint.
B
Provide physiotherapy.
C
Prevent ankylosis of the joint.
D
Reduce inflammation.
Question 4 Explanation:
Steroids have an anti-inflammatory effect that can reduce arthritic pannus formation.
Question 5
The physician advised the client with Hemiparesis to use a cane. The client asks the nurse why cane will be needed. The nurse explains to the client that cane is advised specifically to:
A
Prevent further injury to weakened muscles.
B
Relieve pressure on weight-bearing joints.
C
Aid in controlling involuntary muscle movements.
D
Maintain balance and improve stability.
Question 5 Explanation:
Hemiparesis creates instability. Using a cane provides a wider base of support and, therefore greater stability.
Question 6
The nurse is assigned to care for a client with diarrhea. Excessive fluid loss is expected. The nurse is aware that fluid deficit can most accurately be assessed by:
A
An altered general appearance
B
The presence of dry skin
C
A decrease in blood pressure
D
A change in body weight
Question 6 Explanation:
Dehydration is most readily and accurately measured by serial assessment of body weight; 1 L of fluid weighs 2.2 pounds.
Question 7
A 75-year-old male client tells the nurse that his wife has osteoporosis and asks what chances he had of getting also osteoporosis like his wife. Which of the following is the correct response of the nurse?
A
“Exercise is a good way to prevent this problem.”
B
“This is only a problem for women.”
C
“You might think about having a bone density test,”
D
“You are not at risk because of your small frame.”
Question 7 Explanation:
Osteoporosis is not restricted to women; it is a potential major health problem of all older adults; estimates indicate that half of all women have at least one osteoporitic fracture and the risk in men is estimated between 13% and 25%; a bone mineral density measurement assesses the mass of bone per unit volume or how tightly the bone is packed.
Question 8
A client is receiving diltiazem (Cardizem). What should the nurse include in a teaching plan aimed at reducing the side effects of this medication?
A
Change positions slowly.
B
Avoid dairy products in diet.
C
Take the drug with an antacid.
D
Lie down after meals.
Question 8 Explanation:
Changing positions slowly will help prevent the side effect of orthostatic hypotension.
Question 9
The nurse is assigned to care for a 57-year-old female client who had a cataract surgery an hour ago. The nurse should:
A
Encourage eye exercises to strengthen the ocular musculature.
B
Advise the client to refrain from vigorous brushing of teeth and hair.
C
Teach the client coughing and deep-breathing techniques.
D
Instruct the client to avoid driving for 2 weeks.
Question 9 Explanation:
Activities such as rigorous brushing of hair and teeth cause increased intraocular pressure and may lead to hemorrhage in the anterior chamber.
Question 10
The nurse is reviewing the laboratory results of the client. In reviewing the results of the RBC count, the nurse understands that the higher the red blood cell count, the :
A
Higher the blood pH.
B
Lower the hematocrit.
C
Less it contributes to immunity.
D
Greater the blood viscosity.
Question 10 Explanation:
Viscosity, a measure of a fluid’s internal resistance to flow, is increased as the number of red cells suspended in plasma.
Question 11
Which of the following client has a high risk for developing hyperkalemia?
A
Crohn’s disease
B
Cushing’s syndrome
C
End-Stage renal disease
D
Chronic heart failure
Question 11 Explanation:
The kidneys normally eliminate potassium from the body; hyperkalemia may necessitate dialysis.
Question 12
A client is receiving simvastatin (Zocor). The nurse is aware that this medication is effective when there is decrease in:
A
Chest pain
B
The triglycerides
C
The INR
D
Blood pressure
Question 12 Explanation:
Therapeutic effects of simvastatin include decreased serum triglyceries, LDL and cholesterol.
Question 13
The nurse is reviewing the client’s chart about the ordered medication. The nurse must observe for signs of hyperkalemia when administering:
A
Spironolactone (Aldactone)
B
Hydrochlorothiazide (HydroDIURIL)
C
Furosemide (Lasix)
D
Metolazone (Zaroxolyn)
Question 13 Explanation:
Aldactone is a potassium-sparing diuretic; hyperkalemia is an adverse effect.
Question 14
The nurse is planning to teach the client about a spontaneous pneumothorax. The nurse would base the teaching on the understanding that:
A
There is greater negative pressure within the chest cavity.
B
The other lung will collapse if not treated immediately.
C
The heart and great vessels shift to the affected side.
D
Inspired air will move from the lung into the pleural space.
Question 14 Explanation:
As a person with a tear in the lung inhales, air moves through that opening into the intrapleural and causes partial or complete collapse of the lungs.
Question 15
During an assessment, the nurse recognizes that the client has an increased risk for developing cancer of the tongue. Which of the following health history will be a concern?
A
Heavy consumption of alcohol.
B
Nail biting.
C
Poor dental habits.
D
Frequent gum chewing.
Question 15 Explanation:
Heavy alcohol ingestion predisposes an individual to the development of oral cancer.
Question 16
An 18-year-old college student is brought to the emergency department due to serious motor vehicle accident. Right above-knee-amputation is done. Upon awakening from surgery the client tells the nurse, “What happened to me? I cannot remember anything?” Which of the following would be the appropriate initial nursing response?
A
“An amputation of your right leg was necessary because of an accident.”
B
“You were in a car accident this morning.”
C
“You sound concerned; You’ll probably remember more as you wake up.”
D
“Tell me what you think happened.”
Question 16 Explanation:
This is truthful and provides basic information that may prompt recollection of what happened; it is a starting point.
Question 17
The client is transferred from the operating room to recovery room after an open-heart surgery. The nurse assigned is taking the vital signs of the client. The nurse notified the physician when the temperature of the client rises to 38.8 ºC or 102 ºF because elevated temperatures:
A
Are related to diaphoresis and possible chilling.
B
May be a forerunner of hemorrhage.
C
May indicate cerebral edema.
D
Increase the cardiac output.
Question 17 Explanation:
The temperature of 102 ºF (38.8ºC) or greater lead to an increased metabolism and cardiac workload.
Question 18
A client with Addison’s disease is scheduled for discharge. Before the discharge, the physician prescribes hydrocortisone and fludrocortisone. The nurse expects the hydrocortisone to:
A
Increase amounts of angiotensin II to raise the client’s blood pressure.
B
Prevent hypoglycemia and permit the client to respond to stress.
C
Decrease cardiac dysrhythmias and dyspnea.
D
Control excessive loss of potassium salts.
Question 18 Explanation:
Hydrocortisone is a glucocorticoid that has anti-inflammatory action and aids in metabolism of carbohydrate, fat, and protein, causing elevation of blood glucose. Thus it enables the body to adapt to stress.
Question 19
A 55-year-old client is admitted with chest pain that radiates to the neck, jaw and shoulders that occurs at rest, with high body temperature, weak with generalized sweating and with decreased blood pressure. A myocardial infarction is diagnosed. The nurse knows that the most accurate explanation for one of these presenting adaptations is:
A
Catecholamines released at the site of the infarction causes intermittent localized pain.
B
Parasympathetic reflexes from the infarcted myocardium causes diaphoresis.
C
Constriction of central and peripheral blood vessels causes a decrease in blood pressure.
D
Inflammation in the myocardium causes a rise in the systemic body temperature.
Question 19 Explanation:
Temperature may increase within the first 24 hours and persist as long as a week.
Question 20
A client with Addison’s disease has a blood pressure of 65/60. The nurse understands that decreased blood pressure of the client with Addison’s disease involves a disturbance in the production of:
A
Estrogen
B
Androgens
C
Mineralocorticoids
D
Glucocorticoids
Question 20 Explanation:
Mineralocorticoids such as aldosterone cause the kidneys to retain sodium ions. With sodium, water is also retained, elevating blood pressure. Absence of this hormone thus causes hypotension.
Question 21
A client with a partial occlusion of the left common carotid artery is scheduled for discharge. The client is still receiving Coumadin. The nurse provided a discharge instruction to the client regarding adverse effects of Coumadin. The nurse should tell the client to consult with the physician if:
A
Swelling of the ankles increases.
B
Increased transient Ischemic attacks occur.
C
Blood appears in the urine.
D
The ability to concentrate diminishes.
Question 21 Explanation:
Warfarin derivatives cause an increase in the prothrombin time and INR, leading to an increased risk for bleeding. Any abnormal or excessive bleeding must be reported, because it may indicate toxic levels of the drug.
Question 22
The nurse can determine the effectiveness of carbamazepine (Tegretol) in the management of trigeminal neuralgia by monitoring the client’s:
A
Pain relief
B
Cardiac output
C
Seizure activity
D
Liver function
Question 22 Explanation:
Carbamazepine ( Tegretol) is administered to control pain by reducing the transmission of nerve impulses in clients with trigeminal neuralgia.
Question 23
A client is scheduled for bariatric surgery. Preoperative teaching is done. Which of the following statement would alert the nurse that further teaching to the client is necessary?
A
“I need to eat more high-protein foods.”
B
“I will be limiting my intake to 600 to 800 calories a day once I start eating again.”
C
“I will be going to be out of bed and sitting in a chair the first day after surgery.”.
D
“I’m going to have a figure like a model in about a year.”
Question 23 Explanation:
Clients need to be prepared emotionally for the body image changes that occur after bariatric surgery. Clients generally experience excessive abdominal skin folds after weight stabilizes, which may require a panniculectomy. Body image disturbance often occurs in response to incorrectly estimating one’s size; it is not uncommon for the client to still feel fat no matter how much weight is lost.
Question 24
After radiation therapy for cancer of the prostate, the client experienced irritation in the bladder. Which of the following sign of bladder irritability is correct?
A
Dribbling
B
Hematuria
C
Dysuria
D
Polyuria
Question 24 Explanation:
Dysuria, nocturia, and urgency are all signs an irritable bladder after radiation therapy.
Question 25
The client is to receive an IV piggyback medication. When preparing the medication the nurse should be aware that it is very important to:
A
Rotate the bag after adding the medication
B
Change the needle just before adding the medication
C
Use exactly 100mL of fluid to mix the medication
D
Use strict sterile technique
Question 25 Explanation:
Because IV solutions enter the body’s internal environment, all solutions and medications utilizing this route must be sterile to prevent the introduction of microbes.
Question 26
The client who had transverse colostomy asks the nurse about the possible effect of the surgery on future sexual relationship. What would be the best nursing response?
A
The surgery will temporarily decrease the client’s sexual impulses.
B
The client will be able to resume normal sexual relationships.
C
Sexual relationships must be curtailed for several weeks.
D
The partner should be told about the surgery before any sexual activity.
Question 26 Explanation:
Surgery on the bowel has no direct anatomic or physiologic effect on sexual performance. However, the nurse should encourage verbalization.
Question 27
A client with AIDS develops bacterial pneumonia is admitted in the emergency department. The client’s arterial blood gases is drawn and the result is PaO2 80mmHg. then arterial blood gases are drawn again and the level is reduced from 80 mmHg to 65 mmHg. The nurse should;
A
Decrease the tension of oxygen in the plasma.
B
Notify the physician.
C
Increase the oxygen flow rate.
D
Have arterial blood gases performed again to check for accuracy.
Question 27 Explanation:
This decrease in PaO2 indicates respiratory failure; it warrants immediate medical evaluation.
Question 28
Potassium chloride, 20 mEq, is ordered and to be added in the IV solution of a client in a diabetic ketoacidosis. The primary reason for administering this drug is:
A
Treatment of hyperpnea
B
Prevention of flaccid paralysis
C
Replacement of excessive losses
D
Treatment of cardiac dysrhythmias
Question 28 Explanation:
Once treatment with insulin for diabetic ketoacidosis is begun, potassium ions reenter the cell, causing hypokalemia; therefore potassium, along with the replacement fluid, is generally supplied.
Question 29
A client with diabetes insipidus is taking Desmopressin acetate (DDAVP). To determine if the drug is effective, the nurse should monitor the client’s:
A
Pulse rate
B
Intake and output
C
Serum glucose
D
Arterial blood pH
Question 29 Explanation:
DDAVP replaces the ADH, facilitating reabsorption of water and consequent return of normal urine output and thirst.
Question 30
A client is diagnosed with a brain tumor in the occipital lobe. Which of the following will the client most likely experience?
A
Hemiparesis.
B
Visual hallucinations.
C
Personality changes.
D
Receptive aphasia.
Question 30 Explanation:
The occipital lobe is involve with visual interpretation.
Question 31
The physician reduced the client’s Dexamethasone (Decadron) dosage gradually and to continue a lower maintenance dosage. The client asks the nurse about the change of dosage. The nurse explains to the client that the purpose of gradual dosage reduction is to allow:
A
Building of glycogen and protein stores in liver and muscle
B
Production of antibodies by the immune system
C
Return of cortisone production by the adrenal glands.
D
Time to observe for return of increases intracranial pressure
Question 31 Explanation:
Any hormone normally produced by the body must be withdrawn slowly to allow the appropriate organ to adjust and resume production.
Question 32
The client in the orthopedic unit asks the nurse the reason behind why compact bone is stronger than cancellous bone. Which of the following is the correct response of the nurse?
A
Compact bone is stronger than cancellous bone because of its greater size.
B
Compact bone is stronger than cancellous bone because of its greater weight.
C
Compact bone is stronger than cancellous bone because of its greater density.
D
Compact bone is stronger than cancellous bone because of its greater volume.
Question 32 Explanation:
The greater the density of compact bone makes it stronger than the cancellous bone. Compact bone forms from cancellous bone by the addition of concentric rings of bones substances to the marrow spaces of cancellous bone. The large marrow spaces are reduced to haversian canals.
Question 33
A female client is brought to the emergency unit. The client is complaining of abdominal cramps. On assessment, client is experiencing anorexia and weight is reduced. The physician’s diagnosis is colitis. Which of the following symptoms of fluid and electrolyte imbalance should the nurse report immediately?
A
Skin rash, diarrhea, and diplopia
B
Nausea, vomiting, and leg and stomach cramps.
C
Extreme muscle weakness and tachycardia
D
Development of tetaniy with muscles spasms
Question 33 Explanation:
Potassium, the major intracellular cation, functions with sodium and calcium to regulate neuromuscular activity and contraction of muscle fibers, particularly the heart muscle. In hypokalemia these symptoms develop.
Question 34
Levodopa is ordered for a client with Parkinson’s disease. Before starting the medication, the nurse should know that:
A
Levodopa may cause the side effects of orthostatic hypotension.
B
Levodopa is inadequately absorbed if given with meals.
C
Levodopa must be monitored by weekly laboratory tests.
D
Levodopa causes an initial euphoria followed by depression.
Question 34 Explanation:
Levodopa is the metabolic precursor of dopamine. It reduces sympathetic outflow by limiting vasoconstriction, which may result in orthostatic hypotension.
Question 35
Before discharge, the nurse scheduled the client who had a colostomy for colorectal cancer for discharge instruction about resuming activities. The nurse should plan to help the client understands that:
A
With counseling and medical guidance, a near normal lifestyle, including complete sexual function is possible.
B
Activities of daily living should be resumed as quickly as possible to avoid depression and further dependency.
C
After surgery, changes in activities must be made to accommodate for the physiologic changes caused by the operation.
D
Most sports activities, except for swimming, can be resumed based on the client’s overall physical condition.
Question 35 Explanation:
There are few physical restraints on activity postoperatively, but the client may have emotional problems resulting from the body image changes.
Question 36
The nurse is reviewing the laboratory result of the client. An arterial blood gas report indicates the client’s pH is 7.20, PCO2 35 mmHg and HCO3 is 19 mEq/L. The results are consistent with:
A
Metabolic acidosis
B
Metabolic alkalosis
C
Respiratory acidosis
D
Respiratory alkalosis
Question 36 Explanation:
A low pH and bicarbonate level are consistent with metabolic acidosis.
Question 37
Following spinal injury, the nurse should encourage the client to drink fluids to avoid:
A
Dehydration.
B
Fluid and electrolyte imbalance.
C
Skin breakdown.
D
Urinary tract infection.
Question 37 Explanation:
Clients in the early stage of spinal cord damage experience an atonic bladder, which is characterized by the absence of muscle tone, an enlarged capacity, no feeling of discomfort with distention, and overflow with a large residual. This leads to urinary stasis and infection. High fluid intake limits urinary stasis and infection by diluting the urine and increasing urinary output.
Question 38
Which of the following is the most important electrolyte of intracellular fluid?
A
Calcium
B
Sodium
C
Potassium
D
Chloride
Question 38 Explanation:
The concentration of potassium is greater inside the cell and is important in establishing a membrane potential, a critical factor in the cell’s ability to function.
Question 39
A client with recurrent urinary tract infections is to be discharged. The client will be taking nitrofurantoin (Macrobid) 50 mg po every evening at home. The nurse provides discharge instructions to the client. Which of the following instructions will be correct?
A
Increase fluid intake.
B
Strain urine for crystals and stones
C
Maintain the exact time schedule for drug taking.
D
Stop the drug if the urinary output increases
Question 39 Explanation:
To prevent crystal formation, the client should have sufficient intake to produce 1000 to 1500 mL of urine daily while taking this drug.
Question 40
Administration of potassium iodide solution is ordered to the client who will undergo a subtotal thyroidectomy. The nurse understands that this medication is given to:
A
Decrease the total basal metabolic rate.
B
Ablate the cells of the thyroid gland that produce T4.
C
Maintain function of the parathyroid gland.
D
Decrease the size and vascularity of the thyroid.
Question 40 Explanation:
Potassium iodide, which aids in decreasing the vascularity of the thyroid gland, decreases the risk for hemorrhage.
Question 41
The physician prescribed Albuterol (Proventil) to the client with severe asthma. After the administration of the medication the nurse should monitor the client for:
A
Visual disturbance
B
Palpitation
C
Decreased pulse rate
D
Lethargy
Question 41 Explanation:
Albuterol’s sympathomimetic effect causes cardiac stimulation that may cause tachycardia and palpitation.
Question 42
The nurse is conducting a discharge teaching regarding the prevention of further problems to a client who undergone surgery for carpal tunnel syndrome of the right hand. Which of the following instruction will the nurse includes?
A
Avoid carrying heavy things using the right hand.
B
Avoid typing in a long period of time.
C
Do manual stretching exercise during breaks.
D
Learn to type using your left hand only.
Question 42 Explanation:
Manual stretching exercises will assist in keeping the muscles and tendons supple and pliable, reducing the traumatic consequences of repetitive activity.
Question 43
The client with an acute myocardial infarction is hospitalized for almost one week. The client experiences nausea and loss of appetite. The nurse caring for the client recognizes that these symptoms may indicate the:
A
Adverse effects of spironolactone (Aldactone)
B
Adverse effects of digoxin (Lanoxin)
C
Therapeutic effects of furosemide (Lasix)
D
Therapeutic effects of propranolol (Indiral)
Question 43 Explanation:
Toxic levels of Lanoxin stimulate the medullary chemoreceptor trigger zone, resulting in nausea and subsequent anorexia.
Question 44
In making a diagnosis of myasthenia gravis Edrophonium HCI (Tensilon) is used. The nurse knows that this drug will cause a temporary increase in:
A
Muscle strength
B
Consciousness
C
Symptoms
D
Blood pressure
Question 44 Explanation:
Tensilon, an anticholinesterase drug, causes temporary relief of symptoms of myasthenia gravis in client who have the disease and is therefore an effective diagnostic aid.
Question 45
A nurse is caring to an older adult with presbycusis. In formulating nursing care plan for this client, the nurse should expect that hearing loss of the client that is caused by aging to have:
A
Tears in the tympanic membrane.
B
Copious, moist cerumen.
C
Difficulty hearing women’s voices.
D
Overgrowth of the epithelial auditory lining.
Question 45 Explanation:
Generally, female voices have a higher pitch than male voices; older adults with presbycusis (hearing loss caused by the aging process) have more difficulty hearing higher-pitched sounds.
Question 46
A 38-year-old client with severe hypertension is hospitalized. The physician prescribed a Captopril (Capoten) and Alprazolam (Xanax) for treatment. The client tells the nurse that there is something wrong with the medication and nursing care. The nurse recognizes this behavior is probably a manifestation of the client’s:
A
Reaction to hypertensive medications.
B
Fear of the health problem.
C
Denial of illness.
D
Response to cerebral anoxia.
Question 46 Explanation:
Clients adapting to illness frequently feel afraid and helpless and strike out at health team members as a way of maintaining control or denying their fear.
Question 47
The physician prescribes Ibuprofen (Motrin) and hydroxychloroquine sulfate (Plaquenil) for a 58-year-old male client with arthritis. The nurse provides information about toxicity of the hydroxychloroquine. The nurse can determine if the information is clearly understood if the client states:
A
“I will contact the physician immediately if I develop feelings of irritability.”
B
“I will contact the physician immediately if I develop blurred vision.”
C
“I will contact the physician immediately if I develop urinary retention.”
D
“I will contact the physician immediately if I develop swallowing difficulty.”
Question 47 Explanation:
Visual disturbance are a sign of toxicity because retinopathy can occur with this drug.
Question 48
A client is taking nitroglycerine tablets, the nurse should teach the client the importance of:
A
Increasing the number of tablets if dizziness or hypertension occurs.
B
Discontinuing the medication if a headache develops.
C
Making certain the medication is stored in a dark container.
D
Limiting the number of tablets to 4 per day.
Question 48 Explanation:
Nitroglycerine is sensitive to light and moisture ad must be stored in a dark, airtight container.
Question 49
A client with cancer of the lung is receiving chemotherapy. The physician orders antibiotic therapy for the client. The nurse understands that chemotherapy destroys rapidly growing leukocytes in the:
A
Blood
B
Liver
C
Bone marrow
D
Lymph nodes
Question 49 Explanation:
Prolonged chemotherapy may slow the production of leukocytes in bone marrow, thus suppressing the activity of the immune system. Antibiotics may be required to help counter infections that the body can no longer handle easily.
Question 50
A female client is admitted because of recurrent urinary tract infections. The client asks the nurse why she is prone to this disease. The nurse states that the client is most susceptible because of:
A
Poor hygienic practices.
B
Continuity of the mucous membrane.
C
The length of the urethra.
D
Inadequate fluid intake.
Question 50 Explanation:
The length of the urethra is shorter in females than in males; therefore microorganisms have a shorter distance to travel to reach the bladder. The proximity of the meatus to the anus in females also increases this incidence.
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PNLE IV Nursing Practice (EM)
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Question 1
Following spinal injury, the nurse should encourage the client to drink fluids to avoid:
A
Urinary tract infection.
B
Dehydration.
C
Skin breakdown.
D
Fluid and electrolyte imbalance.
Question 1 Explanation:
Clients in the early stage of spinal cord damage experience an atonic bladder, which is characterized by the absence of muscle tone, an enlarged capacity, no feeling of discomfort with distention, and overflow with a large residual. This leads to urinary stasis and infection. High fluid intake limits urinary stasis and infection by diluting the urine and increasing urinary output.
Question 2
A female client is brought to the emergency unit. The client is complaining of abdominal cramps. On assessment, client is experiencing anorexia and weight is reduced. The physician’s diagnosis is colitis. Which of the following symptoms of fluid and electrolyte imbalance should the nurse report immediately?
A
Extreme muscle weakness and tachycardia
B
Development of tetaniy with muscles spasms
C
Nausea, vomiting, and leg and stomach cramps.
D
Skin rash, diarrhea, and diplopia
Question 2 Explanation:
Potassium, the major intracellular cation, functions with sodium and calcium to regulate neuromuscular activity and contraction of muscle fibers, particularly the heart muscle. In hypokalemia these symptoms develop.
Question 3
A 55-year-old client is admitted with chest pain that radiates to the neck, jaw and shoulders that occurs at rest, with high body temperature, weak with generalized sweating and with decreased blood pressure. A myocardial infarction is diagnosed. The nurse knows that the most accurate explanation for one of these presenting adaptations is:
A
Constriction of central and peripheral blood vessels causes a decrease in blood pressure.
B
Inflammation in the myocardium causes a rise in the systemic body temperature.
C
Catecholamines released at the site of the infarction causes intermittent localized pain.
D
Parasympathetic reflexes from the infarcted myocardium causes diaphoresis.
Question 3 Explanation:
Temperature may increase within the first 24 hours and persist as long as a week.
Question 4
The client with an acute myocardial infarction is hospitalized for almost one week. The client experiences nausea and loss of appetite. The nurse caring for the client recognizes that these symptoms may indicate the:
A
Therapeutic effects of furosemide (Lasix)
B
Adverse effects of digoxin (Lanoxin)
C
Adverse effects of spironolactone (Aldactone)
D
Therapeutic effects of propranolol (Indiral)
Question 4 Explanation:
Toxic levels of Lanoxin stimulate the medullary chemoreceptor trigger zone, resulting in nausea and subsequent anorexia.
Question 5
A client with a partial occlusion of the left common carotid artery is scheduled for discharge. The client is still receiving Coumadin. The nurse provided a discharge instruction to the client regarding adverse effects of Coumadin. The nurse should tell the client to consult with the physician if:
A
Blood appears in the urine.
B
The ability to concentrate diminishes.
C
Swelling of the ankles increases.
D
Increased transient Ischemic attacks occur.
Question 5 Explanation:
Warfarin derivatives cause an increase in the prothrombin time and INR, leading to an increased risk for bleeding. Any abnormal or excessive bleeding must be reported, because it may indicate toxic levels of the drug.
Question 6
A client with cancer of the lung is receiving chemotherapy. The physician orders antibiotic therapy for the client. The nurse understands that chemotherapy destroys rapidly growing leukocytes in the:
A
Liver
B
Bone marrow
C
Lymph nodes
D
Blood
Question 6 Explanation:
Prolonged chemotherapy may slow the production of leukocytes in bone marrow, thus suppressing the activity of the immune system. Antibiotics may be required to help counter infections that the body can no longer handle easily.
Question 7
The client is transferred from the operating room to recovery room after an open-heart surgery. The nurse assigned is taking the vital signs of the client. The nurse notified the physician when the temperature of the client rises to 38.8 ºC or 102 ºF because elevated temperatures:
A
May be a forerunner of hemorrhage.
B
Increase the cardiac output.
C
May indicate cerebral edema.
D
Are related to diaphoresis and possible chilling.
Question 7 Explanation:
The temperature of 102 ºF (38.8ºC) or greater lead to an increased metabolism and cardiac workload.
Question 8
The nurse is planning to teach the client about a spontaneous pneumothorax. The nurse would base the teaching on the understanding that:
A
The other lung will collapse if not treated immediately.
B
Inspired air will move from the lung into the pleural space.
C
There is greater negative pressure within the chest cavity.
D
The heart and great vessels shift to the affected side.
Question 8 Explanation:
As a person with a tear in the lung inhales, air moves through that opening into the intrapleural and causes partial or complete collapse of the lungs.
Question 9
The client who had transverse colostomy asks the nurse about the possible effect of the surgery on future sexual relationship. What would be the best nursing response?
A
The client will be able to resume normal sexual relationships.
B
The surgery will temporarily decrease the client’s sexual impulses.
C
The partner should be told about the surgery before any sexual activity.
D
Sexual relationships must be curtailed for several weeks.
Question 9 Explanation:
Surgery on the bowel has no direct anatomic or physiologic effect on sexual performance. However, the nurse should encourage verbalization.
Question 10
The nurse is reviewing the laboratory result of the client. An arterial blood gas report indicates the client’s pH is 7.20, PCO2 35 mmHg and HCO3 is 19 mEq/L. The results are consistent with:
A
Respiratory alkalosis
B
Metabolic acidosis
C
Respiratory acidosis
D
Metabolic alkalosis
Question 10 Explanation:
A low pH and bicarbonate level are consistent with metabolic acidosis.
Question 11
A client is scheduled for bariatric surgery. Preoperative teaching is done. Which of the following statement would alert the nurse that further teaching to the client is necessary?
A
“I will be limiting my intake to 600 to 800 calories a day once I start eating again.”
B
“I need to eat more high-protein foods.”
C
“I will be going to be out of bed and sitting in a chair the first day after surgery.”.
D
“I’m going to have a figure like a model in about a year.”
Question 11 Explanation:
Clients need to be prepared emotionally for the body image changes that occur after bariatric surgery. Clients generally experience excessive abdominal skin folds after weight stabilizes, which may require a panniculectomy. Body image disturbance often occurs in response to incorrectly estimating one’s size; it is not uncommon for the client to still feel fat no matter how much weight is lost.
Question 12
A female client is admitted because of recurrent urinary tract infections. The client asks the nurse why she is prone to this disease. The nurse states that the client is most susceptible because of:
A
Continuity of the mucous membrane.
B
The length of the urethra.
C
Inadequate fluid intake.
D
Poor hygienic practices.
Question 12 Explanation:
The length of the urethra is shorter in females than in males; therefore microorganisms have a shorter distance to travel to reach the bladder. The proximity of the meatus to the anus in females also increases this incidence.
Question 13
During an assessment, the nurse recognizes that the client has an increased risk for developing cancer of the tongue. Which of the following health history will be a concern?
A
Nail biting.
B
Poor dental habits.
C
Heavy consumption of alcohol.
D
Frequent gum chewing.
Question 13 Explanation:
Heavy alcohol ingestion predisposes an individual to the development of oral cancer.
Question 14
Administration of potassium iodide solution is ordered to the client who will undergo a subtotal thyroidectomy. The nurse understands that this medication is given to:
A
Decrease the size and vascularity of the thyroid.
B
Maintain function of the parathyroid gland.
C
Decrease the total basal metabolic rate.
D
Ablate the cells of the thyroid gland that produce T4.
Question 14 Explanation:
Potassium iodide, which aids in decreasing the vascularity of the thyroid gland, decreases the risk for hemorrhage.
Question 15
A 75-year-old male client tells the nurse that his wife has osteoporosis and asks what chances he had of getting also osteoporosis like his wife. Which of the following is the correct response of the nurse?
A
“Exercise is a good way to prevent this problem.”
B
“This is only a problem for women.”
C
“You might think about having a bone density test,”
D
“You are not at risk because of your small frame.”
Question 15 Explanation:
Osteoporosis is not restricted to women; it is a potential major health problem of all older adults; estimates indicate that half of all women have at least one osteoporitic fracture and the risk in men is estimated between 13% and 25%; a bone mineral density measurement assesses the mass of bone per unit volume or how tightly the bone is packed.
Question 16
Levodopa is ordered for a client with Parkinson’s disease. Before starting the medication, the nurse should know that:
A
Levodopa causes an initial euphoria followed by depression.
B
Levodopa must be monitored by weekly laboratory tests.
C
Levodopa is inadequately absorbed if given with meals.
D
Levodopa may cause the side effects of orthostatic hypotension.
Question 16 Explanation:
Levodopa is the metabolic precursor of dopamine. It reduces sympathetic outflow by limiting vasoconstriction, which may result in orthostatic hypotension.
Question 17
A nurse is caring to an older adult with presbycusis. In formulating nursing care plan for this client, the nurse should expect that hearing loss of the client that is caused by aging to have:
A
Overgrowth of the epithelial auditory lining.
B
Tears in the tympanic membrane.
C
Copious, moist cerumen.
D
Difficulty hearing women’s voices.
Question 17 Explanation:
Generally, female voices have a higher pitch than male voices; older adults with presbycusis (hearing loss caused by the aging process) have more difficulty hearing higher-pitched sounds.
Question 18
A client with diabetes insipidus is taking Desmopressin acetate (DDAVP). To determine if the drug is effective, the nurse should monitor the client’s:
A
Intake and output
B
Pulse rate
C
Serum glucose
D
Arterial blood pH
Question 18 Explanation:
DDAVP replaces the ADH, facilitating reabsorption of water and consequent return of normal urine output and thirst.
Question 19
The nurse can determine the effectiveness of carbamazepine (Tegretol) in the management of trigeminal neuralgia by monitoring the client’s:
A
Seizure activity
B
Pain relief
C
Cardiac output
D
Liver function
Question 19 Explanation:
Carbamazepine ( Tegretol) is administered to control pain by reducing the transmission of nerve impulses in clients with trigeminal neuralgia.
Question 20
The physician reduced the client’s Dexamethasone (Decadron) dosage gradually and to continue a lower maintenance dosage. The client asks the nurse about the change of dosage. The nurse explains to the client that the purpose of gradual dosage reduction is to allow:
A
Building of glycogen and protein stores in liver and muscle
B
Return of cortisone production by the adrenal glands.
C
Time to observe for return of increases intracranial pressure
D
Production of antibodies by the immune system
Question 20 Explanation:
Any hormone normally produced by the body must be withdrawn slowly to allow the appropriate organ to adjust and resume production.
Question 21
A client with recurrent urinary tract infections is to be discharged. The client will be taking nitrofurantoin (Macrobid) 50 mg po every evening at home. The nurse provides discharge instructions to the client. Which of the following instructions will be correct?
A
Stop the drug if the urinary output increases
B
Strain urine for crystals and stones
C
Increase fluid intake.
D
Maintain the exact time schedule for drug taking.
Question 21 Explanation:
To prevent crystal formation, the client should have sufficient intake to produce 1000 to 1500 mL of urine daily while taking this drug.
Question 22
The nurse is assigned to care for a client with diarrhea. Excessive fluid loss is expected. The nurse is aware that fluid deficit can most accurately be assessed by:
A
A change in body weight
B
An altered general appearance
C
The presence of dry skin
D
A decrease in blood pressure
Question 22 Explanation:
Dehydration is most readily and accurately measured by serial assessment of body weight; 1 L of fluid weighs 2.2 pounds.
Question 23
After radiation therapy for cancer of the prostate, the client experienced irritation in the bladder. Which of the following sign of bladder irritability is correct?
A
Dysuria
B
Hematuria
C
Dribbling
D
Polyuria
Question 23 Explanation:
Dysuria, nocturia, and urgency are all signs an irritable bladder after radiation therapy.
Question 24
The client in the orthopedic unit asks the nurse the reason behind why compact bone is stronger than cancellous bone. Which of the following is the correct response of the nurse?
A
Compact bone is stronger than cancellous bone because of its greater volume.
B
Compact bone is stronger than cancellous bone because of its greater weight.
C
Compact bone is stronger than cancellous bone because of its greater density.
D
Compact bone is stronger than cancellous bone because of its greater size.
Question 24 Explanation:
The greater the density of compact bone makes it stronger than the cancellous bone. Compact bone forms from cancellous bone by the addition of concentric rings of bones substances to the marrow spaces of cancellous bone. The large marrow spaces are reduced to haversian canals.
Question 25
The client is to receive an IV piggyback medication. When preparing the medication the nurse should be aware that it is very important to:
A
Use exactly 100mL of fluid to mix the medication
B
Change the needle just before adding the medication
C
Rotate the bag after adding the medication
D
Use strict sterile technique
Question 25 Explanation:
Because IV solutions enter the body’s internal environment, all solutions and medications utilizing this route must be sterile to prevent the introduction of microbes.
Question 26
A client with Addison’s disease has a blood pressure of 65/60. The nurse understands that decreased blood pressure of the client with Addison’s disease involves a disturbance in the production of:
A
Mineralocorticoids
B
Glucocorticoids
C
Estrogen
D
Androgens
Question 26 Explanation:
Mineralocorticoids such as aldosterone cause the kidneys to retain sodium ions. With sodium, water is also retained, elevating blood pressure. Absence of this hormone thus causes hypotension.
Question 27
Which of the following client has a high risk for developing hyperkalemia?
A
End-Stage renal disease
B
Chronic heart failure
C
Crohn’s disease
D
Cushing’s syndrome
Question 27 Explanation:
The kidneys normally eliminate potassium from the body; hyperkalemia may necessitate dialysis.
Question 28
An 18-year-old college student is brought to the emergency department due to serious motor vehicle accident. Right above-knee-amputation is done. Upon awakening from surgery the client tells the nurse, “What happened to me? I cannot remember anything?” Which of the following would be the appropriate initial nursing response?
A
“You sound concerned; You’ll probably remember more as you wake up.”
B
“An amputation of your right leg was necessary because of an accident.”
C
“Tell me what you think happened.”
D
“You were in a car accident this morning.”
Question 28 Explanation:
This is truthful and provides basic information that may prompt recollection of what happened; it is a starting point.
Question 29
Before discharge, the nurse scheduled the client who had a colostomy for colorectal cancer for discharge instruction about resuming activities. The nurse should plan to help the client understands that:
A
Most sports activities, except for swimming, can be resumed based on the client’s overall physical condition.
B
Activities of daily living should be resumed as quickly as possible to avoid depression and further dependency.
C
After surgery, changes in activities must be made to accommodate for the physiologic changes caused by the operation.
D
With counseling and medical guidance, a near normal lifestyle, including complete sexual function is possible.
Question 29 Explanation:
There are few physical restraints on activity postoperatively, but the client may have emotional problems resulting from the body image changes.
Question 30
The nurse is reviewing the client’s chart about the ordered medication. The nurse must observe for signs of hyperkalemia when administering:
A
Furosemide (Lasix)
B
Metolazone (Zaroxolyn)
C
Spironolactone (Aldactone)
D
Hydrochlorothiazide (HydroDIURIL)
Question 30 Explanation:
Aldactone is a potassium-sparing diuretic; hyperkalemia is an adverse effect.
Question 31
An older adult client with acute pain is admitted in the hospital. The nurse understands that in managing acute pain of the client during the first 24 hours, the nurse should ensure that:
A
Pain medication is ordered via the intramuscular route.
B
Patient controlled analgesia is avoided in this population.
C
Ordered PRN analgesics are administered on a scheduled basis.
D
An order for meperidine (Demerol) is secured for pain relief.
Question 31 Explanation:
Around-the-clock administration of analgesics is recommended for acute pain in the older adult population; this help to maintain a therapeutic blood level of pain medication.
Question 32
The nurse is conducting a discharge teaching regarding the prevention of further problems to a client who undergone surgery for carpal tunnel syndrome of the right hand. Which of the following instruction will the nurse includes?
A
Learn to type using your left hand only.
B
Avoid carrying heavy things using the right hand.
C
Do manual stretching exercise during breaks.
D
Avoid typing in a long period of time.
Question 32 Explanation:
Manual stretching exercises will assist in keeping the muscles and tendons supple and pliable, reducing the traumatic consequences of repetitive activity.
Question 33
Potassium chloride, 20 mEq, is ordered and to be added in the IV solution of a client in a diabetic ketoacidosis. The primary reason for administering this drug is:
A
Treatment of hyperpnea
B
Treatment of cardiac dysrhythmias
C
Replacement of excessive losses
D
Prevention of flaccid paralysis
Question 33 Explanation:
Once treatment with insulin for diabetic ketoacidosis is begun, potassium ions reenter the cell, causing hypokalemia; therefore potassium, along with the replacement fluid, is generally supplied.
Question 34
A client is taking nitroglycerine tablets, the nurse should teach the client the importance of:
A
Discontinuing the medication if a headache develops.
B
Limiting the number of tablets to 4 per day.
C
Increasing the number of tablets if dizziness or hypertension occurs.
D
Making certain the medication is stored in a dark container.
Question 34 Explanation:
Nitroglycerine is sensitive to light and moisture ad must be stored in a dark, airtight container.
Question 35
The nurse is reviewing the laboratory result of the client. The client’s serum potassium level is 5.8 mEq/L. Which of the following is the initial nursing action?
A
Call the cardiac arrest team to alert them
B
Call the laboratory and repeat the test
C
Obtain an ECG strip and have lidocaine available
D
Take the client’s vital signs and notify the physician
The nurse is reviewing the laboratory results of the client. In reviewing the results of the RBC count, the nurse understands that the higher the red blood cell count, the :
A
Less it contributes to immunity.
B
Lower the hematocrit.
C
Higher the blood pH.
D
Greater the blood viscosity.
Question 36 Explanation:
Viscosity, a measure of a fluid’s internal resistance to flow, is increased as the number of red cells suspended in plasma.
Question 37
A client is receiving diltiazem (Cardizem). What should the nurse include in a teaching plan aimed at reducing the side effects of this medication?
A
Avoid dairy products in diet.
B
Take the drug with an antacid.
C
Change positions slowly.
D
Lie down after meals.
Question 37 Explanation:
Changing positions slowly will help prevent the side effect of orthostatic hypotension.
Question 38
The nurse is assigned to care for a 57-year-old female client who had a cataract surgery an hour ago. The nurse should:
A
Teach the client coughing and deep-breathing techniques.
B
Advise the client to refrain from vigorous brushing of teeth and hair.
C
Encourage eye exercises to strengthen the ocular musculature.
D
Instruct the client to avoid driving for 2 weeks.
Question 38 Explanation:
Activities such as rigorous brushing of hair and teeth cause increased intraocular pressure and may lead to hemorrhage in the anterior chamber.
Question 39
A client is receiving simvastatin (Zocor). The nurse is aware that this medication is effective when there is decrease in:
A
Chest pain
B
The triglycerides
C
Blood pressure
D
The INR
Question 39 Explanation:
Therapeutic effects of simvastatin include decreased serum triglyceries, LDL and cholesterol.
Question 40
A client is diagnosed with a brain tumor in the occipital lobe. Which of the following will the client most likely experience?
A
Visual hallucinations.
B
Hemiparesis.
C
Receptive aphasia.
D
Personality changes.
Question 40 Explanation:
The occipital lobe is involve with visual interpretation.
Question 41
The physician prescribes Ibuprofen (Motrin) and hydroxychloroquine sulfate (Plaquenil) for a 58-year-old male client with arthritis. The nurse provides information about toxicity of the hydroxychloroquine. The nurse can determine if the information is clearly understood if the client states:
A
“I will contact the physician immediately if I develop blurred vision.”
B
“I will contact the physician immediately if I develop urinary retention.”
C
“I will contact the physician immediately if I develop swallowing difficulty.”
D
“I will contact the physician immediately if I develop feelings of irritability.”
Question 41 Explanation:
Visual disturbance are a sign of toxicity because retinopathy can occur with this drug.
Question 42
In making a diagnosis of myasthenia gravis Edrophonium HCI (Tensilon) is used. The nurse knows that this drug will cause a temporary increase in:
A
Symptoms
B
Blood pressure
C
Muscle strength
D
Consciousness
Question 42 Explanation:
Tensilon, an anticholinesterase drug, causes temporary relief of symptoms of myasthenia gravis in client who have the disease and is therefore an effective diagnostic aid.
Question 43
Following an amputation of a lower limb to a male client, the nurse provides an instruction on how to prevent a hip flexion contracture. The nurse should instruct the client to:.
A
Turn from side to side every 2 hours.
B
Perform quadriceps muscle setting exercises twice a day.
C
Lie on the abdomen 30 minutes every four hours.
D
Sit in a chair for 30 minutes three times a day.
Question 43 Explanation:
The hips are in extension when the client is prone; this keeps the hips from flexing.
Question 44
A 38-year-old client with severe hypertension is hospitalized. The physician prescribed a Captopril (Capoten) and Alprazolam (Xanax) for treatment. The client tells the nurse that there is something wrong with the medication and nursing care. The nurse recognizes this behavior is probably a manifestation of the client’s:
A
Reaction to hypertensive medications.
B
Denial of illness.
C
Fear of the health problem.
D
Response to cerebral anoxia.
Question 44 Explanation:
Clients adapting to illness frequently feel afraid and helpless and strike out at health team members as a way of maintaining control or denying their fear.
Question 45
The physician scheduled the client with rheumatoid arthritis for the injection of hydrocortisone into the knee joint. The client asks the nurse why there is a need for this injection. The nurse explains that the most important reason for doing this is to:
A
Provide physiotherapy.
B
Reduce inflammation.
C
Prevent ankylosis of the joint.
D
Lubricate the joint.
Question 45 Explanation:
Steroids have an anti-inflammatory effect that can reduce arthritic pannus formation.
Question 46
The physician prescribed Albuterol (Proventil) to the client with severe asthma. After the administration of the medication the nurse should monitor the client for:
A
Lethargy
B
Visual disturbance
C
Decreased pulse rate
D
Palpitation
Question 46 Explanation:
Albuterol’s sympathomimetic effect causes cardiac stimulation that may cause tachycardia and palpitation.
Question 47
The physician advised the client with Hemiparesis to use a cane. The client asks the nurse why cane will be needed. The nurse explains to the client that cane is advised specifically to:
A
Relieve pressure on weight-bearing joints.
B
Prevent further injury to weakened muscles.
C
Maintain balance and improve stability.
D
Aid in controlling involuntary muscle movements.
Question 47 Explanation:
Hemiparesis creates instability. Using a cane provides a wider base of support and, therefore greater stability.
Question 48
A client with AIDS develops bacterial pneumonia is admitted in the emergency department. The client’s arterial blood gases is drawn and the result is PaO2 80mmHg. then arterial blood gases are drawn again and the level is reduced from 80 mmHg to 65 mmHg. The nurse should;
A
Have arterial blood gases performed again to check for accuracy.
B
Notify the physician.
C
Increase the oxygen flow rate.
D
Decrease the tension of oxygen in the plasma.
Question 48 Explanation:
This decrease in PaO2 indicates respiratory failure; it warrants immediate medical evaluation.
Question 49
Which of the following is the most important electrolyte of intracellular fluid?
A
Sodium
B
Calcium
C
Potassium
D
Chloride
Question 49 Explanation:
The concentration of potassium is greater inside the cell and is important in establishing a membrane potential, a critical factor in the cell’s ability to function.
Question 50
A client with Addison’s disease is scheduled for discharge. Before the discharge, the physician prescribes hydrocortisone and fludrocortisone. The nurse expects the hydrocortisone to:
A
Control excessive loss of potassium salts.
B
Decrease cardiac dysrhythmias and dyspnea.
C
Increase amounts of angiotensin II to raise the client’s blood pressure.
D
Prevent hypoglycemia and permit the client to respond to stress.
Question 50 Explanation:
Hydrocortisone is a glucocorticoid that has anti-inflammatory action and aids in metabolism of carbohydrate, fat, and protein, causing elevation of blood glucose. Thus it enables the body to adapt to stress.
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The scope of this Nursing Test IV is parallel to the NP4 NLE Coverage:
Medical Surgical Nursing
1. Following spinal injury, the nurse should encourage the client to drink fluids to avoid:
Urinary tract infection.
Fluid and electrolyte imbalance.
Dehydration.
Skin breakdown.
2. The client is transferred from the operating room to recovery room after an open-heart surgery. The nurse assigned is taking the vital signs of the client. The nurse notified the physician when the temperature of the client rises to 38.8 ºC or 102 ºF because elevated temperatures:
May be a forerunner of hemorrhage.
Are related to diaphoresis and possible chilling.
May indicate cerebral edema.
Increase the cardiac output.
3. After radiation therapy for cancer of the prostate, the client experienced irritation in the bladder. Which of the following sign of bladder irritability is correct?
Hematuria
Dysuria
Polyuria
Dribbling
4. A client is diagnosed with a brain tumor in the occipital lobe. Which of the following will the client most likely experience?
Visual hallucinations.
Receptive aphasia.
Hemiparesis.
Personality changes.
5. A client with Addison’s disease has a blood pressure of 65/60. The nurse understands that decreased blood pressure of the client with Addison’s disease involves a disturbance in the production of:
Androgens
Glucocorticoids
Mineralocorticoids
Estrogen
6. The nurse is planning to teach the client about a spontaneous pneumothorax. The nurse would base the teaching on the understanding that:
Inspired air will move from the lung into the pleural space.
There is greater negative pressure within the chest cavity.
The heart and great vessels shift to the affected side.
The other lung will collapse if not treated immediately.
7. During an assessment, the nurse recognizes that the client has an increased risk for developing cancer of the tongue. Which of the following health history will be a concern?
Heavy consumption of alcohol.
Frequent gum chewing.
Nail biting.
Poor dental habits.
8. The client in the orthopedic unit asks the nurse the reason behind why compact bone is stronger than cancellous bone. Which of the following is the correct response of the nurse?
Compact bone is stronger than cancellous bone because of its greater size.
Compact bone is stronger than cancellous bone because of its greater weight.
Compact bone is stronger than cancellous bone because of its greater volume.
Compact bone is stronger than cancellous bone because of its greater density.
9. The nurse is reviewing the laboratory results of the client. In reviewing the results of the RBC count, the nurse understands that the higher the red blood cell count, the :
Greater the blood viscosity.
Higher the blood pH.
Less it contributes to immunity.
Lower the hematocrit.
10. The physician advised the client with Hemiparesis to use a cane. The client asks the nurse why cane will be needed. The nurse explains to the client that cane is advised specifically to:
Aid in controlling involuntary muscle movements.
Relieve pressure on weight-bearing joints.
Maintain balance and improve stability.
Prevent further injury to weakened muscles.
11. The nurse is conducting a discharge teaching regarding the prevention of further problems to a client who undergone surgery for carpal tunnel syndrome of the right hand. Which of the following instruction will the nurse includes?
Learn to type using your left hand only.
Avoid typing in a long period of time.
Avoid carrying heavy things using the right hand.
Do manual stretching exercise during breaks.
12. A female client is admitted because of recurrent urinary tract infections. The client asks the nurse why she is prone to this disease. The nurse states that the client is most susceptible because of:
Continuity of the mucous membrane.
Inadequate fluid intake.
The length of the urethra.
Poor hygienic practices.
13. A 55-year-old client is admitted with chest pain that radiates to the neck, jaw and shoulders that occurs at rest, with high body temperature, weak with generalized sweating and with decreased blood pressure. A myocardial infarction is diagnosed. The nurse knows that the most accurate explanation for one of these presenting adaptations is:
Catecholamines released at the site of the infarction causes intermittent localized pain.
Parasympathetic reflexes from the infarcted myocardium causes diaphoresis.
Constriction of central and peripheral blood vessels causes a decrease in blood pressure.
Inflammation in the myocardium causes a rise in the systemic body temperature.
14. Following an amputation of a lower limb to a male client, the nurse provides an instruction on how to prevent a hip flexion contracture. The nurse should instruct the client to:.
Perform quadriceps muscle setting exercises twice a day.
Sit in a chair for 30 minutes three times a day.
Lie on the abdomen 30 minutes every four hours.
Turn from side to side every 2 hours.
15. The physician scheduled the client with rheumatoid arthritis for the injection of hydrocortisone into the knee joint. The client asks the nurse why there is a need for this injection. The nurse explains that the most important reason for doing this is to:
Lubricate the joint.
Prevent ankylosis of the joint.
Reduce inflammation.
Provide physiotherapy.
16. The nurse is assigned to care for a 57-year-old female client who had a cataract surgery an hour ago. The nurse should:
Advise the client to refrain from vigorous brushing of teeth and hair.
Instruct the client to avoid driving for 2 weeks.
Encourage eye exercises to strengthen the ocular musculature.
Teach the client coughing and deep-breathing techniques.
17. A client with AIDS develops bacterial pneumonia is admitted in the emergency department. The client’s arterial blood gases is drawn and the result is PaO2 80mmHg. then arterial blood gases are drawn again and the level is reduced from 80 mmHg to 65 mmHg. The nurse should;
Have arterial blood gases performed again to check for accuracy.
Increase the oxygen flow rate.
Notify the physician.
Decrease the tension of oxygen in the plasma.
18. An 18-year-old college student is brought to the emergency department due to serious motor vehicle accident. Right above-knee-amputation is done. Upon awakening from surgery the client tells the nurse, “What happened to me? I cannot remember anything?” Which of the following would be the appropriate initial nursing response?
“You sound concerned; You’ll probably remember more as you wake up.”
“Tell me what you think happened.”
“You were in a car accident this morning.”
“An amputation of your right leg was necessary because of an accident.”
19. A 38-year-old client with severe hypertension is hospitalized. The physician prescribed a Captopril (Capoten) and Alprazolam (Xanax) for treatment. The client tells the nurse that there is something wrong with the medication and nursing care. The nurse recognizes this behavior is probably a manifestation of the client’s:
Reaction to hypertensive medications.
Denial of illness.
Response to cerebral anoxia.
Fear of the health problem.
20. Before discharge, the nurse scheduled the client who had a colostomy for colorectal cancer for discharge instruction about resuming activities. The nurse should plan to help the client understands that:
After surgery, changes in activities must be made to accommodate for the physiologic changes caused by the operation.
Most sports activities, except for swimming, can be resumed based on the client’s overall physical condition.
With counseling and medical guidance, a near normal lifestyle, including complete sexual function is possible.
Activities of daily living should be resumed as quickly as possible to avoid depression and further dependency.
21. A client is scheduled for bariatric surgery. Preoperative teaching is done. Which of the following statement would alert the nurse that further teaching to the client is necessary?
“I will be limiting my intake to 600 to 800 calories a day once I start eating again.”
“I’m going to have a figure like a model in about a year.”
“I need to eat more high-protein foods.”
“I will be going to be out of bed and sitting in a chair the first day after surgery.”.
22. The client who had transverse colostomy asks the nurse about the possible effect of the surgery on future sexual relationship. What would be the best nursing response?
The surgery will temporarily decrease the client’s sexual impulses.
Sexual relationships must be curtailed for several weeks.
The partner should be told about the surgery before any sexual activity.
The client will be able to resume normal sexual relationships.
23. A 75-year-old male client tells the nurse that his wife has osteoporosis and asks what chances he had of getting also osteoporosis like his wife. Which of the following is the correct response of the nurse?
“This is only a problem for women.”
“You are not at risk because of your small frame.”
“You might think about having a bone density test,”
“Exercise is a good way to prevent this problem.”
24. An older adult client with acute pain is admitted in the hospital. The nurse understands that in managing acute pain of the client during the first 24 hours, the nurse should ensure that:
Ordered PRN analgesics are administered on a scheduled basis.
Patient controlled analgesia is avoided in this population.
Pain medication is ordered via the intramuscular route.
An order for meperidine (Demerol) is secured for pain relief.
25. A nurse is caring to an older adult with presbycusis. In formulating nursing care plan for this client, the nurse should expect that hearing loss of the client that is caused by aging to have:
Overgrowth of the epithelial auditory lining.
Copious, moist cerumen.
Difficulty hearing women’s voices.
Tears in the tympanic membrane.
26. The nurse is reviewing the client’s chart about the ordered medication. The nurse must observe for signs of hyperkalemia when administering:
Furosemide (Lasix)
Hydrochlorothiazide (HydroDIURIL)
Metolazone (Zaroxolyn)
Spironolactone (Aldactone)
27. The physician prescribed Albuterol (Proventil) to the client with severe asthma. After the administration of the medication the nurse should monitor the client for:
Palpitation
Visual disturbance
Decreased pulse rate
Lethargy
28. A client is receiving diltiazem (Cardizem). What should the nurse include in a teaching plan aimed at reducing the side effects of this medication?
Take the drug with an antacid.
Lie down after meals.
Avoid dairy products in diet.
Change positions slowly.
29. A client is receiving simvastatin (Zocor). The nurse is aware that this medication is effective when there is decrease in:
The triglycerides
The INR
Chest pain
Blood pressure
30. A client is taking nitroglycerine tablets, the nurse should teach the client the importance of:
Increasing the number of tablets if dizziness or hypertension occurs.
Limiting the number of tablets to 4 per day.
Making certain the medication is stored in a dark container.
Discontinuing the medication if a headache develops.
31. The physician prescribes Ibuprofen (Motrin) and hydroxychloroquine sulfate (Plaquenil) for a 58-year-old male client with arthritis. The nurse provides information about toxicity of the hydroxychloroquine. The nurse can determine if the information is clearly understood if the client states:
“I will contact the physician immediately if I develop blurred vision.”
“I will contact the physician immediately if I develop urinary retention.”
“I will contact the physician immediately if I develop swallowing difficulty.”
“I will contact the physician immediately if I develop feelings of irritability.”
32. The client with an acute myocardial infarction is hospitalized for almost one week. The client experiences nausea and loss of appetite. The nurse caring for the client recognizes that these symptoms may indicate the:
Adverse effects of spironolactone (Aldactone)
Adverse effects of digoxin (Lanoxin)
Therapeutic effects of propranolol (Indiral)
Therapeutic effects of furosemide (Lasix)
33. A client with a partial occlusion of the left common carotid artery is scheduled for discharge. The client is still receiving Coumadin. The nurse provided a discharge instruction to the client regarding adverse effects of Coumadin. The nurse should tell the client to consult with the physician if:
Swelling of the ankles increases.
Blood appears in the urine.
Increased transient Ischemic attacks occur.
The ability to concentrate diminishes.
34. Levodopa is ordered for a client with Parkinson’s disease. Before starting the medication, the nurse should know that:
Levodopa is inadequately absorbed if given with meals.
Levodopa may cause the side effects of orthostatic hypotension.
Levodopa must be monitored by weekly laboratory tests.
Levodopa causes an initial euphoria followed by depression.
35. In making a diagnosis of myasthenia gravis Edrophonium HCI (Tensilon) is used. The nurse knows that this drug will cause a temporary increase in:
Muscle strength
Symptoms
Blood pressure
Consciousness
36. The nurse can determine the effectiveness of carbamazepine (Tegretol) in the management of trigeminal neuralgia by monitoring the client’s:
Seizure activity
Liver function
Cardiac output
Pain relief
37. Administration of potassium iodide solution is ordered to the client who will undergo a subtotal thyroidectomy. The nurse understands that this medication is given to:
Ablate the cells of the thyroid gland that produce T4.
Decrease the total basal metabolic rate.
Decrease the size and vascularity of the thyroid.
Maintain function of the parathyroid gland.
38. A client with Addison’s disease is scheduled for discharge. Before the discharge, the physician prescribes hydrocortisone and fludrocortisone. The nurse expects the hydrocortisone to:
Increase amounts of angiotensin II to raise the client’s blood pressure.
Control excessive loss of potassium salts.
Prevent hypoglycemia and permit the client to respond to stress.
Decrease cardiac dysrhythmias and dyspnea.
39. A client with diabetes insipidus is taking Desmopressin acetate (DDAVP). To determine if the drug is effective, the nurse should monitor the client’s:
Arterial blood pH
Pulse rate
Serum glucose
Intake and output
40. A client with recurrent urinary tract infections is to be discharged. The client will be taking nitrofurantoin (Macrobid) 50 mg po every evening at home. The nurse provides discharge instructions to the client. Which of the following instructions will be correct?
Strain urine for crystals and stones
Increase fluid intake.
Stop the drug if the urinary output increases
Maintain the exact time schedule for drug taking.
41. A client with cancer of the lung is receiving chemotherapy. The physician orders antibiotic therapy for the client. The nurse understands that chemotherapy destroys rapidly growing leukocytes in the:
Bone marrow
Liver
Lymph nodes
Blood
42. The physician reduced the client’s Dexamethasone (Decadron) dosage gradually and to continue a lower maintenance dosage. The client asks the nurse about the change of dosage. The nurse explains to the client that the purpose of gradual dosage reduction is to allow:
Return of cortisone production by the adrenal glands.
Production of antibodies by the immune system
Building of glycogen and protein stores in liver and muscle
Time to observe for return of increases intracranial pressure
43. The nurse is assigned to care for a client with diarrhea. Excessive fluid loss is expected. The nurse is aware that fluid deficit can most accurately be assessed by:
The presence of dry skin
A change in body weight
An altered general appearance
A decrease in blood pressure
44. Which of the following is the most important electrolyte of intracellular fluid?
Potassium
Sodium
Chloride
Calcium
45. Which of the following client has a high risk for developing hyperkalemia?
Crohn’s disease
End-Stage renal disease
Cushing’s syndrome
Chronic heart failure
46. The nurse is reviewing the laboratory result of the client. The client’s serum potassium level is 5.8 mEq/L. Which of the following is the initial nursing action?
Call the cardiac arrest team to alert them
Call the laboratory and repeat the test
Take the client’s vital signs and notify the physician
Obtain an ECG strip and have lidocaine available
47. Potassium chloride, 20 mEq, is ordered and to be added in the IV solution of a client in a diabetic ketoacidosis. The primary reason for administering this drug is:
Replacement of excessive losses
Treatment of hyperpnea
Prevention of flaccid paralysis
Treatment of cardiac dysrhythmias
48. A female client is brought to the emergency unit. The client is complaining of abdominal cramps. On assessment, client is experiencing anorexia and weight is reduced. The physician’s diagnosis is colitis. Which of the following symptoms of fluid and electrolyte imbalance should the nurse report immediately?
Skin rash, diarrhea, and diplopia
Development of tetaniy with muscles spasms
Extreme muscle weakness and tachycardia
Nausea, vomiting, and leg and stomach cramps.
49. The client is to receive an IV piggyback medication. When preparing the medication the nurse should be aware that it is very important to:
Use strict sterile technique
Use exactly 100mL of fluid to mix the medication
Change the needle just before adding the medication
Rotate the bag after adding the medication
50. The nurse is reviewing the laboratory result of the client. An arterial blood gas report indicates the client’s pH is 7.20, PCO2 35 mmHg and HCO3 is 19 mEq/L. The results are consistent with:
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
Answers and Rationales
A. Clients in the early stage of spinal cord damage experience an atonic bladder, which is characterized by the absence of muscle tone, an enlarged capacity, no feeling of discomfort with distention, and overflow with a large residual. This leads to urinary stasis and infection. High fluid intake limits urinary stasis and infection by diluting the urine and increasing urinary output.
D. The temperature of 102 ºF (38.8ºC) or greater lead to an increased metabolism and cardiac workload.
B. Dysuria, nocturia, and urgency are all signs an irritable bladder after radiation therapy.
A. The occipital lobe is involve with visual interpretation.
C. Mineralocorticoids such as aldosterone cause the kidneys to retain sodium ions. With sodium, water is also retained, elevating blood pressure. Absence of this hormone thus causes hypotension.
B. As a person with a tear in the lung inhales, air moves through that opening into the intrapleural and causes partial or complete collapse of the lungs.
A. Heavy alcohol ingestion predisposes an individual to the development of oral cancer.
D. The greater the density of compact bone makes it stronger than the cancellous bone. Compact bone forms from cancellous bone by the addition of concentric rings of bones substances to the marrow spaces of cancellous bone. The large marrow spaces are reduced to haversian canals.
A. Viscosity, a measure of a fluid’s internal resistance to flow, is increased as the number of red cells suspended in plasma.
C. Hemiparesis creates instability. Using a cane provides a wider base of support and, therefore greater stability.
D. Manual stretching exercises will assist in keeping the muscles and tendons supple and pliable, reducing the traumatic consequences of repetitive activity.
C. The length of the urethra is shorter in females than in males; therefore microorganisms have a shorter distance to travel to reach the bladder. The proximity of the meatus to the anus in females also increases this incidence.
D. Temperature may increase within the first 24 hours and persist as long as a week.
C. The hips are in extension when the client is prone; this keeps the hips from flexing.
C. Steroids have an anti-inflammatory effect that can reduce arthritic pannus formation.
A. Activities such as rigorous brushing of hair and teeth cause increased intraocular pressure and may lead to hemorrhage in the anterior chamber.
C. This decrease in PaO2 indicates respiratory failure; it warrants immediate medical evaluation.
C. This is truthful and provides basic information that may prompt recollection of what happened; it is a starting point.
D. Clients adapting to illness frequently feel afraid and helpless and strike out at health team members as a way of maintaining control or denying their fear.
C. There are few physical restraints on activity postoperatively, but the client may have emotional problems resulting from the body image changes.
B. Clients need to be prepared emotionally for the body image changes that occur after bariatric surgery. Clients generally experience excessive abdominal skin folds after weight stabilizes, which may require a panniculectomy. Body image disturbance often occurs in response to incorrectly estimating one’s size; it is not uncommon for the client to still feel fat no matter how much weight is lost.
D. Surgery on the bowel has no direct anatomic or physiologic effect on sexual performance. However, the nurse should encourage verbalization.
C. Osteoporosis is not restricted to women; it is a potential major health problem of all older adults; estimates indicate that half of all women have at least one osteoporitic fracture and the risk in men is estimated between 13% and 25%; a bone mineral density measurement assesses the mass of bone per unit volume or how tightly the bone is packed.
A. Around-the-clock administration of analgesics is recommended for acute pain in the older adult population; this help to maintain a therapeutic blood level of pain medication.
C. Generally, female voices have a higher pitch than male voices; older adults with presbycusis (hearing loss caused by the aging process) have more difficulty hearing higher-pitched sounds.
D. Aldactone is a potassium-sparing diuretic; hyperkalemia is an adverse effect.
A. Albuterol’s sympathomimetic effect causes cardiac stimulation that may cause tachycardia and palpitation.
D. Changing positions slowly will help prevent the side effect of orthostatic hypotension.
A. Therapeutic effects of simvastatin include decreased serum triglyceries, LDL and cholesterol.
C. Nitroglycerine is sensitive to light and moisture ad must be stored in a dark, airtight container.
A. Visual disturbance are a sign of toxicity because retinopathy can occur with this drug.
B. Toxic levels of Lanoxin stimulate the medullary chemoreceptor trigger zone, resulting in nausea and subsequent anorexia.
B. Warfarin derivatives cause an increase in the prothrombin time and INR, leading to an increased risk for bleeding. Any abnormal or excessive bleeding must be reported, because it may indicate toxic levels of the drug.
B. Levodopa is the metabolic precursor of dopamine. It reduces sympathetic outflow by limiting vasoconstriction, which may result in orthostatic hypotension.
A. Tensilon, an anticholinesterase drug, causes temporary relief of symptoms of myasthenia gravis in client who have the disease and is therefore an effective diagnostic aid.
D. Carbamazepine ( Tegretol) is administered to control pain by reducing the transmission of nerve impulses in clients with trigeminal neuralgia.
C. Potassium iodide, which aids in decreasing the vascularity of the thyroid gland, decreases the risk for hemorrhage.
C. Hydrocortisone is a glucocorticoid that has anti-inflammatory action and aids in metabolism of carbohydrate, fat, and protein, causing elevation of blood glucose. Thus it enables the body to adapt to stress.
D. DDAVP replaces the ADH, facilitating reabsorption of water and consequent return of normal urine output and thirst.
B. To prevent crystal formation, the client should have sufficient intake to produce 1000 to 1500 mL of urine daily while taking this drug.
A. Prolonged chemotherapy may slow the production of leukocytes in bone marrow, thus suppressing the activity of the immune system. Antibiotics may be required to help counter infections that the body can no longer handle easily.
A. Any hormone normally produced by the body must be withdrawn slowly to allow the appropriate organ to adjust and resume production.
B. Dehydration is most readily and accurately measured by serial assessment of body weight; 1 L of fluid weighs 2.2 pounds.
A. The concentration of potassium is greater inside the cell and is important in establishing a membrane potential, a critical factor in the cell’s ability to function.
B. The kidneys normally eliminate potassium from the body; hyperkalemia may necessitate dialysis.
A. Once treatment with insulin for diabetic ketoacidosis is begun, potassium ions reenter the cell, causing hypokalemia; therefore potassium, along with the replacement fluid, is generally supplied.
C. Potassium, the major intracellular cation, functions with sodium and calcium to regulate neuromuscular activity and contraction of muscle fibers, particularly the heart muscle. In hypokalemia these symptoms develop.
A. Because IV solutions enter the body’s internal environment, all solutions and medications utilizing this route must be sterile to prevent the introduction of microbes.
A. A low pH and bicarbonate level are consistent with metabolic acidosis.