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PNLE IV Nursing Practice (PM)
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Question 1
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
Maintain balance and improve stability.
B
Relieve pressure on weight-bearing joints.
C
Prevent further injury to weakened muscles.
D
Aid in controlling involuntary muscle movements.
Question 1 Explanation:
Hemiparesis creates instability. Using a cane provides a wider base of support and, therefore greater stability.
Question 2
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 strict sterile technique
B
Use exactly 100mL of fluid to mix the medication
C
Change the needle just before adding the medication
D
Rotate the bag after adding the medication
Question 2 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 3
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
Liver function
D
Seizure activity
Question 3 Explanation:
Carbamazepine ( Tegretol) is administered to control pain by reducing the transmission of nerve impulses in clients with trigeminal neuralgia.
Question 4
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
Androgens
B
Estrogen
C
Mineralocorticoids
D
Glucocorticoids
Question 4 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 5
Following spinal injury, the nurse should encourage the client to drink fluids to avoid:
A
Urinary tract infection.
B
Fluid and electrolyte imbalance.
C
Skin breakdown.
D
Dehydration.
Question 5 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 6
Levodopa is ordered for a client with Parkinson’s disease. Before starting the medication, the nurse should know that:
A
Levodopa must be monitored by weekly laboratory tests.
B
Levodopa may cause the side effects of orthostatic hypotension.
C
Levodopa causes an initial euphoria followed by depression.
D
Levodopa is inadequately absorbed if given with meals.
Question 6 Explanation:
Levodopa is the metabolic precursor of dopamine. It reduces sympathetic outflow by limiting vasoconstriction, which may result in orthostatic hypotension.
Question 7
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
Lethargy
D
Decreased pulse rate
Question 7 Explanation:
Albuterol’s sympathomimetic effect causes cardiac stimulation that may cause tachycardia and palpitation.
Question 8
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
“Tell me what you think happened.”
C
“You were in a car accident this morning.”
D
“You sound concerned; You’ll probably remember more as you wake up.”
Question 8 Explanation:
This is truthful and provides basic information that may prompt recollection of what happened; it is a starting point.
Question 9
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
Inflammation in the myocardium causes a rise in the systemic body temperature.
B
Constriction of central and peripheral blood vessels causes a decrease in blood pressure.
C
Catecholamines released at the site of the infarction causes intermittent localized pain.
D
Parasympathetic reflexes from the infarcted myocardium causes diaphoresis.
Question 9 Explanation:
Temperature may increase within the first 24 hours and persist as long as a week.
Question 10
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
Frequent gum chewing.
B
Heavy consumption of alcohol.
C
Nail biting.
D
Poor dental habits.
Question 10 Explanation:
Heavy alcohol ingestion predisposes an individual to the development of oral cancer.
Question 11
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 alkalosis
C
Metabolic acidosis
D
Respiratory acidosis
Question 11 Explanation:
A low pH and bicarbonate level are consistent with metabolic acidosis.
Question 12
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
With counseling and medical guidance, a near normal lifestyle, including complete sexual function is possible.
C
After surgery, changes in activities must be made to accommodate for the physiologic changes caused by the operation.
D
Activities of daily living should be resumed as quickly as possible to avoid depression and further dependency.
Question 12 Explanation:
There are few physical restraints on activity postoperatively, but the client may have emotional problems resulting from the body image changes.
Question 13
A client is receiving simvastatin (Zocor). The nurse is aware that this medication is effective when there is decrease in:
A
The triglycerides
B
Chest pain
C
The INR
D
Blood pressure
Question 13 Explanation:
Therapeutic effects of simvastatin include decreased serum triglyceries, LDL and cholesterol.
Question 14
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
Increase the cardiac output.
B
May indicate cerebral edema.
C
May be a forerunner of hemorrhage.
D
Are related to diaphoresis and possible chilling.
Question 14 Explanation:
The temperature of 102 ºF (38.8ºC) or greater lead to an increased metabolism and cardiac workload.
Question 15
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
Dribbling
C
Polyuria
D
Hematuria
Question 15 Explanation:
Dysuria, nocturia, and urgency are all signs an irritable bladder after radiation therapy.
Question 16
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 16 Explanation:
The hips are in extension when the client is prone; this keeps the hips from flexing.
Question 17
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
Prevention of flaccid paralysis
B
Treatment of hyperpnea
C
Replacement of excessive losses
D
Treatment of cardiac dysrhythmias
Question 17 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 18
Which of the following client has a high risk for developing hyperkalemia?
A
Chronic heart failure
B
Crohn’s disease
C
Cushing’s syndrome
D
End-Stage renal disease
Question 18 Explanation:
The kidneys normally eliminate potassium from the body; hyperkalemia may necessitate dialysis.
Question 19
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 going to be out of bed and sitting in a chair the first day after surgery.”.
C
“I will be limiting my intake to 600 to 800 calories a day once I start eating again.”
D
“I’m going to have a figure like a model in about a year.”
Question 19 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 20
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
An order for meperidine (Demerol) is secured for pain relief.
C
Patient controlled analgesia is avoided in this population.
D
Ordered PRN analgesics are administered on a scheduled basis.
Question 20 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 21
The nurse is reviewing the client’s chart about the ordered medication. The nurse must observe for signs of hyperkalemia when administering:
A
Hydrochlorothiazide (HydroDIURIL)
B
Metolazone (Zaroxolyn)
C
Furosemide (Lasix)
D
Spironolactone (Aldactone)
Question 21 Explanation:
Aldactone is a potassium-sparing diuretic; hyperkalemia is an adverse effect.
Question 22
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
Do manual stretching exercise during breaks.
B
Avoid typing in a long period of time.
C
Learn to type using your left hand only.
D
Avoid carrying heavy things using the right hand.
Question 22 Explanation:
Manual stretching exercises will assist in keeping the muscles and tendons supple and pliable, reducing the traumatic consequences of repetitive activity.
Question 23
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
Bone marrow
B
Blood
C
Liver
D
Lymph nodes
Question 23 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 24
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
A change in body weight
C
The presence of dry skin
D
A decrease in blood pressure
Question 24 Explanation:
Dehydration is most readily and accurately measured by serial assessment of body weight; 1 L of fluid weighs 2.2 pounds.
Question 25
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
Serum glucose
B
Arterial blood pH
C
Intake and output
D
Pulse rate
Question 25 Explanation:
DDAVP replaces the ADH, facilitating reabsorption of water and consequent return of normal urine output and thirst.
Question 26
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
Inspired air will move from the lung into the pleural space.
C
The heart and great vessels shift to the affected side.
D
The other lung will collapse if not treated immediately.
Question 26 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 27
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
Take the drug with an antacid.
C
Lie down after meals.
D
Avoid dairy products in diet.
Question 27 Explanation:
Changing positions slowly will help prevent the side effect of orthostatic hypotension.
Question 28
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
Therapeutic effects of furosemide (Lasix)
C
Adverse effects of digoxin (Lanoxin)
D
Therapeutic effects of propranolol (Indiral)
Question 28 Explanation:
Toxic levels of Lanoxin stimulate the medullary chemoreceptor trigger zone, resulting in nausea and subsequent anorexia.
Question 29
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
Increased transient Ischemic attacks occur.
B
The ability to concentrate diminishes.
C
Blood appears in the urine.
D
Swelling of the ankles increases.
Question 29 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 30
A client is diagnosed with a brain tumor in the occipital lobe. Which of the following will the client most likely experience?
A
Receptive aphasia.
B
Hemiparesis.
C
Visual hallucinations.
D
Personality changes.
Question 30 Explanation:
The occipital lobe is involve with visual interpretation.
Question 31
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
Greater the blood viscosity.
C
Less it contributes to immunity.
D
Lower the hematocrit.
Question 31 Explanation:
Viscosity, a measure of a fluid’s internal resistance to flow, is increased as the number of red cells suspended in plasma.
Question 32
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 32 Explanation:
Potassium iodide, which aids in decreasing the vascularity of the thyroid gland, decreases the risk for hemorrhage.
Question 33
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
“You are not at risk because of your small frame.”
B
“This is only a problem for women.”
C
“You might think about having a bone density test,”
D
“Exercise is a good way to prevent this problem.”
Question 33 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 34
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
Increase the oxygen flow rate.
B
Decrease the tension of oxygen in the plasma.
C
Have arterial blood gases performed again to check for accuracy.
D
Notify the physician.
Question 34 Explanation:
This decrease in PaO2 indicates respiratory failure; it warrants immediate medical evaluation.
Question 35
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 density.
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 size.
D
Compact bone is stronger than cancellous bone because of its greater volume.
Question 35 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 36
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
Teach the client coughing and deep-breathing techniques.
C
Instruct the client to avoid driving for 2 weeks.
D
Advise the client to refrain from vigorous brushing of teeth and hair.
Question 36 Explanation:
Activities such as rigorous brushing of hair and teeth cause increased intraocular pressure and may lead to hemorrhage in the anterior chamber.
Question 37
A client is taking nitroglycerine tablets, the nurse should teach the client the importance of:
A
Making certain the medication is stored in a dark container.
B
Increasing the number of tablets if dizziness or hypertension occurs.
C
Limiting the number of tablets to 4 per day.
D
Discontinuing the medication if a headache develops.
Question 37 Explanation:
Nitroglycerine is sensitive to light and moisture ad must be stored in a dark, airtight container.
Question 38
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
Time to observe for return of increases intracranial pressure
B
Return of cortisone production by the adrenal glands.
C
Building of glycogen and protein stores in liver and muscle
D
Production of antibodies by the immune system
Question 38 Explanation:
Any hormone normally produced by the body must be withdrawn slowly to allow the appropriate organ to adjust and resume production.
Question 39
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 feelings of irritability.”
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 39 Explanation:
Visual disturbance are a sign of toxicity because retinopathy can occur with this drug.
Question 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?
A
Strain urine for crystals and stones
B
Increase fluid intake.
C
Maintain the exact time schedule for drug taking.
D
Stop the drug if the urinary output increases
Question 40 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 41
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
Prevent hypoglycemia and permit the client to respond to stress.
C
Increase amounts of angiotensin II to raise the client’s blood pressure.
D
Decrease cardiac dysrhythmias and dyspnea.
Question 41 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 42
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
Take the client’s vital signs and notify the physician
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
Consciousness
B
Muscle strength
C
Symptoms
D
Blood pressure
Question 43 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 44
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
The length of the urethra.
C
Continuity of the mucous membrane.
D
Inadequate fluid intake.
Question 44 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 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
Overgrowth of the epithelial auditory lining.
B
Copious, moist cerumen.
C
Difficulty hearing women’s voices.
D
Tears in the tympanic membrane.
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
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 46 Explanation:
Steroids have an anti-inflammatory effect that can reduce arthritic pannus formation.
Question 47
Which of the following is the most important electrolyte of intracellular fluid?
A
Calcium
B
Chloride
C
Sodium
D
Potassium
Question 47 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 48
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 partner should be told about the surgery before any sexual activity.
C
The surgery will temporarily decrease the client’s sexual impulses.
D
Sexual relationships must be curtailed for several weeks.
Question 48 Explanation:
Surgery on the bowel has no direct anatomic or physiologic effect on sexual performance. However, the nurse should encourage verbalization.
Question 49
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
Denial of illness.
B
Reaction to hypertensive medications.
C
Fear of the health problem.
D
Response to cerebral anoxia.
Question 49 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 50
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
Nausea, vomiting, and leg and stomach cramps.
B
Extreme muscle weakness and tachycardia
C
Development of tetaniy with muscles spasms
D
Skin rash, diarrhea, and diplopia
Question 50 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.
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PNLE IV Nursing Practice (EM)
Choose the letter of the correct answer. You got 50 minutes to finish the exam .Good luck!
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Congratulations - you have completed PNLE IV Nursing Practice (EM).
You scored %%SCORE%% out of %%TOTAL%%.
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Your answers are highlighted below.
Question 1
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
Blood pressure
D
Symptoms
Question 1 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 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
Nausea, vomiting, and leg and stomach cramps.
B
Skin rash, diarrhea, and diplopia
C
Development of tetaniy with muscles spasms
D
Extreme muscle weakness and tachycardia
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
Inflammation in the myocardium causes a rise in the systemic body temperature.
B
Constriction of central and peripheral blood vessels causes a decrease in blood pressure.
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
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
Notify the physician.
B
Have arterial blood gases performed again to check for accuracy.
C
Decrease the tension of oxygen in the plasma.
D
Increase the oxygen flow rate.
Question 4 Explanation:
This decrease in PaO2 indicates respiratory failure; it warrants immediate medical evaluation.
Question 5
Following spinal injury, the nurse should encourage the client to drink fluids to avoid:
A
Skin breakdown.
B
Fluid and electrolyte imbalance.
C
Dehydration.
D
Urinary tract infection.
Question 5 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 6
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
Aid in controlling involuntary muscle movements.
B
Relieve pressure on weight-bearing joints.
C
Maintain balance and improve stability.
D
Prevent further injury to weakened muscles.
Question 6 Explanation:
Hemiparesis creates instability. Using a cane provides a wider base of support and, therefore greater stability.
Question 7
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
After surgery, changes in activities must be made to accommodate for the physiologic changes caused by the operation.
C
Most sports activities, except for swimming, can be resumed based on the client’s overall physical condition.
D
Activities of daily living should be resumed as quickly as possible to avoid depression and further dependency.
Question 7 Explanation:
There are few physical restraints on activity postoperatively, but the client may have emotional problems resulting from the body image changes.
Question 8
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 typing in a long period of time.
B
Avoid carrying heavy things using the right hand.
C
Learn to type using your left hand only.
D
Do manual stretching exercise during breaks.
Question 8 Explanation:
Manual stretching exercises will assist in keeping the muscles and tendons supple and pliable, reducing the traumatic consequences of repetitive activity.
Question 9
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 9 Explanation:
Changing positions slowly will help prevent the side effect of orthostatic hypotension.
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
Lower the hematocrit.
B
Less it contributes to immunity.
C
Greater the blood viscosity.
D
Higher the blood pH.
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
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
Decrease cardiac dysrhythmias and dyspnea.
B
Control excessive loss of potassium salts.
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 11 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 12
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
A change in body weight
C
A decrease in blood pressure
D
The presence of dry skin
Question 12 Explanation:
Dehydration is most readily and accurately measured by serial assessment of body weight; 1 L of fluid weighs 2.2 pounds.
Question 13
A client is diagnosed with a brain tumor in the occipital lobe. Which of the following will the client most likely experience?
A
Receptive aphasia.
B
Personality changes.
C
Hemiparesis.
D
Visual hallucinations.
Question 13 Explanation:
The occipital lobe is involve with visual interpretation.
Question 14
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 weight.
B
Compact bone is stronger than cancellous bone because of its greater size.
C
Compact bone is stronger than cancellous bone because of its greater volume.
D
Compact bone is stronger than cancellous bone because of its greater density.
Question 14 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 15
A client is receiving simvastatin (Zocor). The nurse is aware that this medication is effective when there is decrease in:
A
The INR
B
Chest pain
C
Blood pressure
D
The triglycerides
Question 15 Explanation:
Therapeutic effects of simvastatin include decreased serum triglyceries, LDL and cholesterol.
Question 16
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
Inadequate fluid intake.
C
Poor hygienic practices.
D
The length of the urethra.
Question 16 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 17
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
Frequent gum chewing.
B
Heavy consumption of alcohol.
C
Poor dental habits.
D
Nail biting.
Question 17 Explanation:
Heavy alcohol ingestion predisposes an individual to the development of oral cancer.
Question 18
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
Maintain the exact time schedule for drug taking.
C
Strain urine for crystals and stones
D
Stop the drug if the urinary output increases
Question 18 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 19
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 partner should be told about the surgery before any sexual activity.
B
The client will be able to resume normal sexual relationships.
C
The surgery will temporarily decrease the client’s sexual impulses.
D
Sexual relationships must be curtailed for several weeks.
Question 19 Explanation:
Surgery on the bowel has no direct anatomic or physiologic effect on sexual performance. However, the nurse should encourage verbalization.
Question 20
Levodopa is ordered for a client with Parkinson’s disease. Before starting the medication, the nurse should know that:
A
Levodopa must be monitored by weekly laboratory tests.
B
Levodopa is inadequately absorbed if given with meals.
C
Levodopa may cause the side effects of orthostatic hypotension.
D
Levodopa causes an initial euphoria followed by depression.
Question 20 Explanation:
Levodopa is the metabolic precursor of dopamine. It reduces sympathetic outflow by limiting vasoconstriction, which may result in orthostatic hypotension.
Question 21
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
Arterial blood pH
D
Serum glucose
Question 21 Explanation:
DDAVP replaces the ADH, facilitating reabsorption of water and consequent return of normal urine output and thirst.
Question 22
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 alkalosis
C
Metabolic acidosis
D
Respiratory acidosis
Question 22 Explanation:
A low pH and bicarbonate level are consistent with metabolic acidosis.
Question 23
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
Increase the cardiac output.
B
May be a forerunner of hemorrhage.
C
Are related to diaphoresis and possible chilling.
D
May indicate cerebral edema.
Question 23 Explanation:
The temperature of 102 ºF (38.8ºC) or greater lead to an increased metabolism and cardiac workload.
Question 24
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 were in a car accident this morning.”
B
“You sound concerned; You’ll probably remember more as you wake up.”
C
“An amputation of your right leg was necessary because of an accident.”
D
“Tell me what you think happened.”
Question 24 Explanation:
This is truthful and provides basic information that may prompt recollection of what happened; it is a starting point.
Question 25
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
Prevent ankylosis of the joint.
B
Reduce inflammation.
C
Provide physiotherapy.
D
Lubricate the joint.
Question 25 Explanation:
Steroids have an anti-inflammatory effect that can reduce arthritic pannus formation.
Question 26
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 26 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 27
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
Lie on the abdomen 30 minutes every four hours.
B
Sit in a chair for 30 minutes three times a day.
C
Turn from side to side every 2 hours.
D
Perform quadriceps muscle setting exercises twice a day.
Question 27 Explanation:
The hips are in extension when the client is prone; this keeps the hips from flexing.
Question 28
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 propranolol (Indiral)
B
Therapeutic effects of furosemide (Lasix)
C
Adverse effects of digoxin (Lanoxin)
D
Adverse effects of spironolactone (Aldactone)
Question 28 Explanation:
Toxic levels of Lanoxin stimulate the medullary chemoreceptor trigger zone, resulting in nausea and subsequent anorexia.
Question 29
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
Bone marrow
B
Liver
C
Blood
D
Lymph nodes
Question 29 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 30
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
Increased transient Ischemic attacks occur.
B
The ability to concentrate diminishes.
C
Blood appears in the urine.
D
Swelling of the ankles increases.
Question 30 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 31
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
Hydrochlorothiazide (HydroDIURIL)
D
Spironolactone (Aldactone)
Question 31 Explanation:
Aldactone is a potassium-sparing diuretic; hyperkalemia is an adverse effect.
Question 32
A client is taking nitroglycerine tablets, the nurse should teach the client the importance of:
A
Limiting the number of tablets to 4 per day.
B
Discontinuing the medication if a headache develops.
C
Making certain the medication is stored in a dark container.
D
Increasing the number of tablets if dizziness or hypertension occurs.
Question 32 Explanation:
Nitroglycerine is sensitive to light and moisture ad must be stored in a dark, airtight container.
Question 33
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
Hematuria
B
Dribbling
C
Polyuria
D
Dysuria
Question 33 Explanation:
Dysuria, nocturia, and urgency are all signs an irritable bladder after radiation therapy.
Question 34
Which of the following client has a high risk for developing hyperkalemia?
A
Cushing’s syndrome
B
End-Stage renal disease
C
Crohn’s disease
D
Chronic heart failure
Question 34 Explanation:
The kidneys normally eliminate potassium from the body; hyperkalemia may necessitate dialysis.
Question 35
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 35 Explanation:
Activities such as rigorous brushing of hair and teeth cause increased intraocular pressure and may lead to hemorrhage in the anterior chamber.
Question 36
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 swallowing difficulty.”
B
“I will contact the physician immediately if I develop feelings of irritability.”
C
“I will contact the physician immediately if I develop urinary retention.”
D
“I will contact the physician immediately if I develop blurred vision.”
Question 36 Explanation:
Visual disturbance are a sign of toxicity because retinopathy can occur with this drug.
Question 37
The nurse is planning to teach the client about a spontaneous pneumothorax. The nurse would base the teaching on the understanding that:
A
The heart and great vessels shift to the affected side.
B
Inspired air will move from the lung into the pleural space.
C
The other lung will collapse if not treated immediately.
D
There is greater negative pressure within the chest cavity.
Question 37 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 38
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
Replacement of excessive losses
B
Prevention of flaccid paralysis
C
Treatment of hyperpnea
D
Treatment of cardiac dysrhythmias
Question 38 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 39
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
Ablate the cells of the thyroid gland that produce T4.
C
Maintain function of the parathyroid gland.
D
Decrease the total basal metabolic rate.
Question 39 Explanation:
Potassium iodide, which aids in decreasing the vascularity of the thyroid gland, decreases the risk for hemorrhage.
Question 40
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
Decreased pulse rate
B
Lethargy
C
Visual disturbance
D
Palpitation
Question 40 Explanation:
Albuterol’s sympathomimetic effect causes cardiac stimulation that may cause tachycardia and palpitation.
Question 41
Which of the following is the most important electrolyte of intracellular fluid?
A
Calcium
B
Sodium
C
Potassium
D
Chloride
Question 41 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 42
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
Copious, moist cerumen.
B
Tears in the tympanic membrane.
C
Difficulty hearing women’s voices.
D
Overgrowth of the epithelial auditory lining.
Question 42 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 43
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
Glucocorticoids
D
Mineralocorticoids
Question 43 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 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
Denial of illness.
B
Reaction to hypertensive medications.
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
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
“You might think about having a bone density test,”
B
“You are not at risk because of your small frame.”
C
“Exercise is a good way to prevent this problem.”
D
“This is only a problem for women.”
Question 45 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 46
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
Use exactly 100mL of fluid to mix the medication
C
Change the needle just before adding the medication
D
Use strict sterile technique
Question 46 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 47
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 going to be out of bed and sitting in a chair the first day after surgery.”.
C
“I’m going to have a figure like a model in about a year.”
D
“I will be limiting my intake to 600 to 800 calories a day once I start eating again.”
Question 47 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 48
The nurse can determine the effectiveness of carbamazepine (Tegretol) in the management of trigeminal neuralgia by monitoring the client’s:
A
Pain relief
B
Liver function
C
Cardiac output
D
Seizure activity
Question 48 Explanation:
Carbamazepine ( Tegretol) is administered to control pain by reducing the transmission of nerve impulses in clients with trigeminal neuralgia.
Question 49
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 laboratory and repeat the test
B
Take the client’s vital signs and notify the physician
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
Time to observe for return of increases intracranial pressure
C
Return of cortisone production by the adrenal glands.
D
Production of antibodies by the immune system
Question 50 Explanation:
Any hormone normally produced by the body must be withdrawn slowly to allow the appropriate organ to adjust and resume production.
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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.