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Question 1

2. The Monro-Kellie hypothesis explains the compensatory relationship among the structures in the skull that play a role with intracranial pressure. Which of the following are NOT compensatory mechanisms performed by the body to decrease intracranial pressure naturally? Select all that apply:
   I. Shifting cerebrospinal fluid to other areas of the brain and spinal cord
   II. Vasodilation of cerebral vessels
   III. Decreasing cerebrospinal fluid production
   IV. Leaking proteins into the brain barrier

A. land Il
B. land IV
C. ll and IV
D. Ill and IV

Answer 1

C. ll and IV

Question 1

1. Select the main structures below that play a role with altering intracranial pressure:

I. Brain
II. Neurons
III. Cerebrospinal Fluid
IV. Blood
V. Periosteum
VI. Dura mater

A. I, II, III
B. I, III, IV
C. III, IV, VI
D. All mentioned

Answer 1

B. I, III, IV

Inside the skull are three structures that can alter intracranial pressure. They are the brain, cerebrospinal fluid (CSF), and blood.

Question 2

patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing? Select all that apply;
I. Coughing
II. Sneezing
III. Talking
IV. Valsalva maneuver
V. Vomiting
VI. Keeping the head of the bed between 30- 35 degrees

A. I, II, IV, V
B. IlI IV. V
C. I, IV. V. VI
D. II IV. V. VI

Answer 2

A. I, II, IV, V

Question 3

A patient is experiencing hyperventilation and has a PaCO2 level of 52 The patient has an ICP of 20 mmHg As the nurse you know that the PaCO2 level will?
A. cause vasoconstriction and decrease the ICP
B. promote diuresis and decrease the ICP
C. cause vasodilation and increase the ICP
D. cause vasodilation and decrease the ICP

Answer 3

C. cause vasodilation and increase the ICP

Question 4

You’re providing education to a group of nursing students about ICP. You explain that when cerebral perfusion pressure falls too low the brain is not properly perfused and brain tissue dies. A student asks, “What is a normal cerebral perfusion pressure level? Your response is:
A. 5-15 mmHq
B. 60-100 mmHg
C. 30-45 mmHg
D. 160 mmHg

Answer 4

B. 60-100 mmHg

Question 5

Which patient below is at MOST risk for increased intracranial pressure?
A patient who is experiencing severe hypotension.
B. A patient who is admitted with a traumatic brain injury.
C. A patient who recently experienced a myocardial infarction
D. A patient post op from eye surgery

Answer 5

B. A patient who is admitted with a traumatic brain injury.

Question 6

A patient with increased ICP has the following vital signs: blood pressure 99/60. HR 65, Temperature 101.6 ‘F, respirations 14, oxygen saturation of 95%. IP reading is 21 mmHg Based on these findings you would?
A. Administered PR dose of a vasoressol
B. Administer 2 L Of oxvgen
C. Remove extra blankets and give the patient a cool patch
D. Perform suctioning

Answer 6

C. Remove extra blankets and give the patient a cool patch

Question 7

patient has a ventriculostomy. Which finding would you immediately report to the doctor?
A. Temperature 98 4 ‘F
B. CPP 70 mmHg
C. ICP 24 mmHg
D. PaC02 35

Answer 7

C. ICP 24 mmHg

Question 7

External ventricular drains monitor IP and are inserted where?
A. Subarachnoid space
B. Lateral Ventricle
C. Epidural space
D. Right Ventricle

Answer 7

B. Lateral Ventricle

Question 8

Which of the following is contraindicated in a patient with increased ICP?
A. Lumbar puncture
B. Midline position of the head
C. Hyperosmotis-diuretics.
D. Barbiturate medications

Answer 8

A. Lumbar puncture

Question 9

You’re collecting vital signs on a patient with ICP. The patient has a Glascoma scale rating 4. How will you assess the patient’s temperature?
A. Rectal
B. Oral
C. Axillary
D. Auricle

Answer 9

A. Rectal

Question 10

A patient who experienced a cerebral hemorrhage is at risk for developing increased Which sign and symptom below is the EARLIEST indicator the patient is having this complication?
A. Bradycardia
B. Decerebrate posturing
C. Restlessness
D. Unequal pupil size

Answer 10

C. Restlessness

Question 11

Select all the signs and symptoms that occur with increased ICP
I. Decorticate posturing
II. Tachycardia
III. Decrease in pulse pressure
IV. Cheyne-stokes
V. Hemiplegia
VI. Decerebrate posturing

A. I, II, III, IV
B. I, IV. V. VI
C. III, IV, V, VI
D. All mentioned

Answer 11

B. I, IV. V. VI

Question 12

You’re maintaining an external ventricular drain The ICP readings should be?
A. 5 to 15 mmHg
B. 20 to 35 mmHg
C. 60 to 100 mmHg
D. 5 to 25 mmHg

Answer 12

A. 5 to 15 mmHg

Question 13

Which patient below with ICP is experiencing Cushing’s Triad? A patient with the following:
A. BP 150/112, HR 110, RR 8
B. BP 90/60. HR 80. RR 22
C. BP 200/60, HR 50, RR 8
D. BP 80/40, HR 49, RR 12

Answer 13

C. BP 200/60, HR 50, RR 8

Question 14

16. The patient has a blood pressure of 130/88 and ICP reading of 12. What is the patient’s cerebral pension pressure, and now do you interpret this as the nurse?
    A. 90 mmHg, normal
    B. 62 mmHg, abnormal
    C. 36 mmHg, abnormal
    D. 56 mmHa, normal

Answer 14

A. 90 mmHg, normal

CPP = MAP - ICP

Question 15

Per question 16, the patient’s blood pressure is 130/88. What is the patient’s mean arterial pressure (MAP)?
A. 42
B. 74
C. 102
D. 88

Answer 15

C. 102

MAP = 2* DBP + SBP / 3

Question 16

During the assessment of a patient with increased ICP, you note that the patient’s arms are extended straight out and toes pointed downward. You will document this as:
A. Decorticate posturing
B. Decerebrate posturing
C. Flaccid posturing
D. Catatonia

Answer 16

B. Decerebrate posturing

Question 17

While positioning a patient in bed with increased ICP, it important to avoid?
A. Midline positioning of the head
B. Placing the HOB at 30-35 degrees
C. Preventing flexion of the neck
D. Flexion of the hips

Answer 17

D. Flexion of the hips

Question 18

During the eye assessment of a patient with increased ICP, you need to assess tha oculocephalic reflex. If the patient has brain stem damage what response will you find?
A. The eyes will move in the same direction as the head is moved side to side
B. The eyes will move in the opposite direction as the head is moved side to side
C. The eves will roll back as the head is moved side to side.
D. The eyes will be in a fixed midline position as the head is moved side to side.

Answer 18

D. The eyes will be in a fixed midline position as the head is moved side to side.

positive response occurs when the eyes rotate to the opposite side to the direction of head rotation, thus indicating that the brainstem (CN3,6,8) is intact.

Question 19

All the following causes of Spinal Cord Injuries are non-traumatic in nature, which is not included?
A. Rheumatoid Arthritis and Ankylosing
B. Spondylitis
C. Vascular problems
D. Electric shock

Answer 19

D. Electric shock

Question 20

Mr. Yoshihiro Sato, an Olympic swimmer, suffered from a diving accident and had respiratory arrest before being transferred to the hospital. The nurse seeing the scene opens the patient’s airway to provide rescue breathing using which maneuver?
A. Head tilt
B. Jaw thrust
C. Chin lift
D. Logroll technique

Answer 20

B. Jaw thrust

Question 21

Injuries involving the spinal cord in the thoracic level will lead to a paralysis confined to the lower limbs, a condition known as
A.Aletradlecia
B.Hemiplegia
C.Quadriplegia
D.Paraplegia

Answer 21

D.Paraplegia

Question 22

Mr. Blake is confirmed to be having a spinal cord injury at the sacral level (S3). The nurse includes in the plan of care of Mr. Blake, which interventions?
A Insertion of a foley catheter B.Monitoring the patient while being hooked to a mechanical ventilator
C. Exercises to prevent atrophy of the paralyzed upper and lower extremities
D.Coping strategies for sensory and motor deficits on the left/right half of the body.
E All the above

Answer 22

A Insertion of a foley catheter

Question 23

Which of the ff. is given to a patient with spinal cord injury, primarily to address hypotension?
A. Calcium channel blocker
B. Dextran
C. Methylprednisolone Sodium Succinate
D.Mannitol

Answer 23

B. Dextran

Dextran is a medication used in managing and treating various clinical conditions, including during hemorrhage, shock, surgical procedures, radiological imaging, antithrombotic administration, and ophthalmic relief of xerophthalmia.

Question 24

A nurse is reviewing the health care record of a client with a new diagnosis of rheumatoid arthritis (RA). The nurse understands that which of the following is an early clinical manifestation of RA?
A. Complaints of fatigue
B. Increased energy level
C. Increased appetite
D. Weight gain

Answer 24

A. Complaints of fatigue

Question 25

A nurse is caring for a client with a diagnosis of gout. Which of the following laboratory values would the nurse expect to note in the client
A Calcium level of 9.0 mg/dL
B. Uric acid level of 8.6 mg/dL
C. Potassium level of 4.1 mg/dL
D. Phosphorus level 3.1 mg/dL

Answer 25

B. Uric acid level of 8.6 mg/dL

Normal values range between 3.5 to 7.2 milligrams per deciliter (mg/dL).

Question 26

A nurse is caring for a client with osteoarthritis. The nurse performs an assessment, knowing that which of the following is a clinical manifestation associated with the disorder?
A. Morning stiffness
B. A decreased sedimentation rate
C. Joint pain that diminishes after rest
D. Elevated antinuclear antibody levels

Answer 26

C. Joint pain that diminishes after rest

Question 27

The client has had surgery to repair a fractured hip. The nurse obtains which of the following most important items from the unit storage area to use when repositioning the client from side to side in bed?
A. Abductor splint
B. Adductor splint
C. Bed pillow
D. Overhead trapeze

Answer 27

A. Abductor splint

Question 28

The nurse has developed a plan of care for a client who is in traction and documents a nursing diagnosis of self-care deficit. The nurse evaluates the plan of care and determines which of the following observations indicates a successful outcome?
A. The client allows the nurse the nurse to complete the care daily
B. The client allows the family to assist in the care
C. The client refuses care
D. The client assists in self-care as much as possible

Answer 28

D. The client assists in self-care as much as possible

Question 29

A home care nurse is visiting a client who is in a body cast. The nurse is performing an assessment and Is assessing the psychosocial adjustment of the client to the cast. The nurse would most appropriately assess the
A. Type of transportation available for follow-up care
B. Ability to perform activities of daily living
C. Need for sensory stimulation
D. Amount of home care support available

Answer 29

C. Need for sensory stimulation

Question 30

A community health nurse is providing an educational session for community members regarding dietary measures that will assist in reducing the risk of osteoporosis. The nurse instructs the community members to increase dietary intake of which food known to be helpful in minimizing this risk?
A. Yogurt
B. Turkey
C. Spaghetti
D. Shellfish

Answer 30

A. Yogurt

Question 31

A nurse is teaching a client with a right arm cast how to prevent stiff or frozen shoulder. The nurse should instruct the client to:
A Keep a sling on the arm always
B. Lift the shoulder of the casted arm over the head-periodically throughout the day
C. Avoid range-of-mation exercises
D. Wear the sling at nighttime

Answer 31

B. Lift the shoulder of the casted arm over the head-periodically throughout the day

Question 32

A nurse is performing neurovascular assessment on a client with a cast on the left lower leg. The nurse notes the presence of edema in the foot below the cast. The nurse would interpret that this finding indicates:
A. Impaired arterial circulation
B. The presence of an infection
C. Impaired venous return
D. Arterial insufficiency

Answer 32

C. Impaired venous return

Question 33

A client is complaining of knee pain. The knee is swollen, reddened and warm to touch. The nurse interprets that the client’s signs and symptoms are not compatible with:
A. Inflammation
B. Degenerative disease
C. Infection
D. Recent injury

Answer 33

B. Degenerative disease

Question 34

A nurse witnesses a client sustain a fall and suspects that the right leg may be broken. The nurse takes which priority action?
A. Take a set of vital signs
B. Call the radiology department
C. Reassure the client that everything will be
D. Immobilize the right leg before moving the client.

Answer 34

D. Immobilize the right leg before moving the client.

Question 35

A nurse in the hospital emergency department is caring for a client with a fractured arm and is preparing the client for a reduction of the fracture that will be done in the casting room. Which of the following is unnecessary?
A. Explanation of the procedure to the client
B. Administration of an analgesIc
C. Anesthesia consent
D. Consent for the procedure

Answer 35

C. Anesthesia consent

Question 36

A nurse has suggested specific leg exercises for a client immobilized in right skeletal lower leg traction. The nurse determines that the client needs further instruction of the nurse observes the client:
A. Pulling up using the trapeze
B. Flexing and extending the feet
C. Performing active range of motion to the right ankle and knee
D. Doing quadriceps-setting and gluteal setting exercises

Answer 36

C. Performing active range of motion to the right ankle and knee

Question 37

A client has a slight weakness in the right leg. Based on this assessment finding, the nurse determines that the client would benefit most from the use of
A. walker
B. A wooden crutch
C. A Lofstrand crutch
D. A straight leg cranes

Answer 37

D. A straight leg cranes

Question 38

A client who has experienced a brain attack (stroke) has partial hemiplegia of the left leg. The straight leg cane formerly used by the client is not quite sufficient now. The nurse interprets that the client could benefit from the somewhat greater support and stability provided by a
A. Quad cane
B. Wooden crutch
C. Loistrand crutch
D. Wheelchair

Answer 38

A. Quad cane

Question 39

A client who is learning to use a cane is afraid that they will slip with ambulation, causing a fall. The nurse provides the client with the greatest reassurance by stating that.
A. Canes prevent falls; they do not cause ther
B. The cane has a flared tip with concentric rings to give stability
C. The physical therapist will determine if the cane is inadequate
D. The cane would help to break a fall, even if you do slip

Answer 39

B. The cane has a flared tip with concentric rings to give stability

Question 40

A nurse in the hospital emergency department is assessing a client with an open leg fracture. The nurse inquires about the date of the client’s last
A. Physical examination
B. Chest radiograph
C. Tetanus vaccine
D. Tuberculin test

Answer 40

C. Tetanus vaccine

Question 41

A client has just been admitted to the hospital with a fractured femur and pelvic fractures. The nurse plans to carefully monitor the client for which of the following signs and symptoms?
A. Tachycardia, hypotension
B. Bradycardia, hypertension
C. Fever, bradycardia
D. Fever, hypertension

Answer 41

A. Tachycardia, hypotension

Question 42

A client is complaining of pain underneath a cast in a bony prominence. The nurse interprets that this client may need:
A. To have the cast replaced with an air splint
B. To have extra padding put over this area of the cast
C. To have the cast bivalve
D. To have a window cut in the cast

Answer 42

D. To have a window cut in the cast

Question 43

A test for the presence of rheumatoid factor is performed in a client with a diagnosis of rheumatoid arthritis. The nurse understands that this test assesses for the presence of:
A. Unusual antibodies of the IgG and IgM type
B. Antigens of IgA
C. Inflammation
D. Infection in the body

Answer 43

A. Unusual antibodies of the IgG and IgM type

Question 44

You are initiating a nursing care plan for a patient with osteoporosis. These nursing interventions apply to the nursing diagnosis Risk for Falls. Which intervention should you delegate to the nursing assistant?
A. Identify environmental factors that increase risk for falls.
B. Monitor gait, balance, and fatigue level with ambulation.
C. Collaborate with physical therapy to provide patient with walker
D. Assist the patient with ambulation to bathroom and in halls.

Answer 44

D. Assist the patient with ambulation to bathroom and in halls.

Question 45

You are preparing to teach a newly diagnosed patient with osteoporosis about strategies to prevent falls. Which of these points will you be sure to include? (Choose all that apply.)
A. Wear a hip protector when
ambulating.-
B. Remove throw rugs and other obstacles at home-
C. Exercise will help build your strength-
D. You should expect a few bumps and bruises when you go home
E. When you are tired, you should rest.-

Answer 45

A. Wear a hip protector when
ambulating.-
B. Remove throw rugs and other obstacles at home-
C. Exercise will help build your strength-
E. When you are tired, you should rest.-

Question 46

You discover these assessment findings when admitting a patient with Paget’s disease. Which finding indicates that the physician should be notified?
A. The patient has bowing of both legs and the knees are asymmetricasymmetric
B. The base of the patient’s skull is Invaginated (platypasia).
C. The patient is only 5 feet tall and weighs 120 pounds.
D. D. The patient’s skull is soft, thick, and larger than normal

Answer 46

B. The base of the patient’s skull is Invaginated (platypasia).

Question 47

As charge nurse you observe the LPN/LVN providing these interventions for the patient with Paget’s disease. Which action requires that you intervene?
A. Administers 600 mg of ibuprofen to the patient
B. Encourages the patient to perform PT recommended exercises
C. Applies ice and gentle massage to the patient’s lower extremities
D. Reminds the patient to drink milk and eat cottage cheese

Answer 47

C. Applies ice and gentle massage to the patient’s lower extremities

Paget’s disease of bone is a chronic (long-lasting) disorder that causes bones to grow larger and become weaker than normal. The disease usually affects just one or a few bones. The bones most commonly affected by Paget’s disease include: Pelvis. Skull.

Question 48

As charge nurse you are making assignments for the day shift. Which patient would you assign to the nurse who has been pulled from the post-anesthesia care unit (PACU) for the day?
A. A 35-year-old patient with osteomyelitis who needs teaching prior to hyperbaric oxygen therapy
B. A 62-year-old patient with osteomalacia who is being discharged to a long-term care facility
C. A 68-year-Old patient with osteoporosis and a new orthotic device whose knowledge of use of this device must be assessed.
D. A 72-year-old patient with Paget’s disease who has just returned from surgery for total knee replacement

Answer 48

D. A 72-year-old patient with Paget’s disease who has just returned from surgery for total knee replacement

Question 49

A patient is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The patient develops a sudden, sharp pain in the midepigastric region along with a rigid, boardlike abdomen. These clinical manitestations most likely indicate which of the following?
A. An intestinal obstruction has developed.
B. The ulcer has perforated.
C. Additional ulcers have developed
D. The esophagus has become inflamed

Answer 49

B. The ulcer has perforated.

Question 50

The patient asks the nurse what causes a Peptic Ulcer to develop. The nurse responds that recent research indicates that many peptic ulcers are the result of which of the following?
A. Helicobacter pylori infection
B. Diets high in fat
C. Work-related stress.
D. A genetic defect in the gastric mucosa.

Answer 50

A. Helicobacter pylori infection

Question 51

The nurse is preparing to teach a patient with a Peptic Ulcer about the diet that should be followed by discharge. The nurse should explain that the diet will most likely consist of the following.
A. Any foods that are tolerated.
B. Large amounts of milk.
C. Bland foods.
D. High-protein foods.

Answer 51

A. Any foods that are tolerated.

Question 52

A patient is to take one daily dose of ranitidine (Zantac) at home to treat her peptic ulcer. The nurse knows that the patient understands proper drug administration of ranitidine when she says that she will take the drug at which of the following times?
A. When pain occurs.
B. Before meals.
C. With meals.
D. At Bedtime

Answer 52

D. At Bedtime

Question 53

Which of the following would be an expected outcome for a patient with Peptic Ulcer disease?
A. The patient will explain the rationale for eliminating alcohol from the diet.
B. The patient will verbalize the importance of monitoring hemoglobin and hematocrit every 3 months.
C. The patient will demonstrate appropriate use of analgesics to control pain.
D. The patient will eliminate contact sports from his or her lifestyle

Answer 53

A. The patient will explain the rationale for eliminating alcohol from the diet.

Question 54

A patient with suspected gastric cancer undergoes an endoscopy of the stomach. Which of the following assessments made after the procedure would indicate the development of a potential complication?
A. The patient complains of a sore throat.
B. The patient demonstrates a lack of appetite
C. The patient displays signs of sedation.
D. The patient experiences a sudden increase in temperature

Answer 54

D. The patient experiences a sudden increase in temperature

Sign of infection

Question 55

After a subtotal Gastrectomy, the nurse should anticipate that NGT drainage will be what color for about 12 to 24 hours after surgery?
A. Bright red.
B. Cloudy white.
C. Dark brown.
D. Bile green.

Answer 55

C. Dark brown.

Question 56

The nurse understands that the best position for the patient who has undergone a Gastrectomy is:
A. Supine.
B. Prone.
C. Low Fowlers
D. Right or left Sim’s.

Answer 56

C. Low Fowlers

Question 57

To reduce the risk of dumping syndrome, the nurse should teach the patient which of the following interventions?
A. Decrease the carbohydrate content of meals.
B. Avoid milk and other dairy products.
C. Drink liquids with meals, avoiding caffeine
D. Sit upright for 30 minutes after meals.

Answer 57

A. Decrease the carbohydrate content of meals.

Carbohydrates ate restricted, but protein, including meat and dairy products, is recommended because it is digested more slowly. Lying down for 30 minutes after a meal is encouraged to slow movement of the food bolus. Fluids are restricted to reduce the bulk of food. There is no need to avoid caffeine.

Question 58

Which of the following symptoms would be indicative of the Dumping Syndrome?
A. Diaphoresis.
B. Vomiting.
C. Hunger
D. Heartburn.

Answer 58

A. Diaphoresis.

Question 59

After surgery for gastric cancer, a patient is scheduled to undergo radiation therapy. It will be most important for the nurse to include information about which of the following in the patient’s teaching plan?
A. Nutritional intake
B. Exercise and activity levels.
C. Management of alopecia.
D. Access to community resources.

Answer 59

A. Nutritional intake

Question 60

Situation: A patient who has been diagnosed with Gastroesophageal reflux disease (GERD) complains of heartburn.

To decrease the heartburn, the nurse should instruct the patient to eliminate which of the following items from the diet?
A. Hot chocolate.
B. Air-popped popcorn.
C. Raw vegetables
D. Lean beef

Answer 60

A. Hot chocolate.

Question 61

The patient with GERD complains of a chronic cough. The nurse understands that in a patient with GERD this symptom may be indicative of which of the following conditions.
A. Aspiration of gastric contents.
B. Development of laryngeal cancer.
C. Esophageal scar tissue formation.
D. Irritation of the esophagus.

Answer 61

A. Aspiration of gastric contents.

Question 62

The patient attends two sessions with the dietician to learn about diet modifications to minimize Gastroesophageal Reflux. The teaching would be considered successful if the patient says that she will decrease her intake of which of the following foods?
A. Fats
B. High-sodium foods
C. Carbohydrates.
D. High-calcium foods.

Answer 62

A. Fats

Question 63

Which position would be ideal for the patient in the early postoperative period after a Hemorrhoidectomy?
A. Supine.
B. Side-lying.
C. Trendelenburg
D. High-Fowler’s.

Answer 63

B. Side-lying.

lubot

Question 64

When the patient’s common bile duct is obstructed, the nurse should evaluate the patient for signs of which of the following complications?
A. Circulatory overload
B. Urinary tract infection.
C. Prolonged bleeding time.
D. Respiratory distress

Answer 64

idk A guro

Question 65

How much bile would the nurse expect the T- tube to drain during the first 24 hours after a Choledocholithotomy?
A. 300 to 500 mL.
B. 550 to 700 mL.
C. 50 to 100 mL.
D. 150 to 250 mL

Answer 65

A. 300 to 500 mL.

The T-tube should drain approximately 300 to 500 mL in the first 24 hours and after 3 to 4 days the amount should decrease to less than 200 mL in 24 hours.

Question 66

After a Cholecystectomy it is recommended that the patient follow a low-fat diet at home. Which of the following foods would be most appropriate to include in a low-fat diet?
A. Roast beef.
B. Cheese omelet
C. Peanut butter
D. Ham salad sandwich

Answer 66

A. Roast beef.

Question 67

Which of the following discharge instructions would be appropriate for a patient who has had a laparoscopic Cholecystectomy?
A. Change the dressing daily until the incision nedis
B. Avoid showering for 48 hours after surgery.
C. Use acetaminophen (Tylenol) to control any fever
D. Return to work within 1 week.

Answer 67

A. Change the dressing daily until the incision nedis
( Leave dressings in place until you see the surgeon at the postoperative visit. Sa quizlet)

Question 68

Celso is admitted to the hospital with acute pancreatitis. The nurse taking a history should question the client about which of these risks for developing pancreatitis?
A. inflammatory bowel disease
B. alcoholism
C. diabetes mellitus
D. high-fiber diet

Answer 68

B. alcoholism

Question 69

Which of the following factors should be the focus of nursing management in a client with Acute Pancreatitis?
A. Fluid and electrolyte balance.-
B. Management of hypoglycemia
C. Pain control.
D.Dietary management.

Answer 69

A. Fluid and electrolyte balance.-

Question 70

In alcohol-related pancreatitis, which of the following interventions is the best way to reduce the exacerbation of pain?
A. Eating a low-fat diet.
B. Abstaining from alcohol.
C. Lying supine.
D. Taking aspirin.

Answer 70

B. Abstaining from alcohol.

Question 71

Which of the following findings would strongly indicate the possibility of Cirrhosis?
A. Pruritus
B. Peripheral edema.
C. Hepatomegaly.
D. Dry skin.

Answer 71

C. Hepatomegaly.

Question 72

The nurse is aware that the symptoms of Portal Hypertension in clients with liver cirrhosis are chiefly the result of.
A. Infection of the liver parenchyma
B. Fatty degeneration of Kupffer cell
C. Obstruction of the portal circulation
D. Obstruction of the cystic and hepatic ducts

Answer 72

C. Obstruction of the portal circulation

Question 73

Which goal for the patient’s care should take priority during the first day of hospitalization for an exacerbation of Ulcerative Colitis?
A. Maintaining adequate nutrition.
B. Managing diarrhea.
C. Promoting self-care and independence.
D. Promoting rest and comfort.

Answer 73

B. Managing diarrhea.

Question 74

Situation: Pedro consulted a urologist because of his chronic renal problem. The physician advised him to undergo peritoneal dialysis.

Which of the following assessments would be most appropriate for the nurse to make while the dialysis solution is dwelling within the patient’s abdomen?
A. Check capillary refill time
B. Assess for urticaria.
C. Monitor electrolyte status
D. Observe respiratory status.

Answer 74

D. Observe respiratory status.

Question 75

The dialysis solution is warmed before use in peritoneal dialysis primarily to:
A. force potassium back into the cells
B. promote abdominal muscle relaxation.
C. add extra warmth to the body
D. encourage the removal of serum urea

Answer 75

D. encourage the removal of serum urea

Question 76

During dialysis, the nurse observes that the flow of dialysate stops before all the solution has drained out. The nurse should:
A. Reposition the peritoneal catheter
B. Have the patient sit in a chair.
C. Have the patient walk.
D. Turn the patient from side to side.

Answer 76

D. Turn the patient from side to side.

Question 77

Which of the following nursing interventions should be included in the patient’s care plan during dialysis therapy?
A. Keep the patient NPO.
B. Monitor patient’s blood pressure.
C. Limit the patient’s visitors.
D. Pad the side rails of the bed.

Answer 77

B. Monitor patient’s blood pressure.

Question 78

What is the most potentially dangerous complication of peritoneal dialysis?
A. Muscle cramps.
B. Abdominal pain.
C. Gastrointestinal bleeding.
D. Peritonitis

Answer 78

D. Peritonitis

Question 79

After completion of peritoneal dialysis, the nurse would expect the patient to exhibit which of the following characteristics?
A. Weight loss.
B. Hypertension.
C. Hematuria.
D. Increased urine output.

Answer 79

A. Weight loss.

Question 80

Situation: Cecil a 38-year married woman, seeks consultation for painful urination, urgency in voiding and fever for 3 days.

Which of the following symptoms would most likely indicate Pyelonephritis?
A. Costovertebral angle (CVA)
tenderness
B Nausea and vomiting
C. Ascites
D. Polyuria.

Answer 80

A. Costovertebral angle (CVA)
tenderness

Question 81

The nurse is aware that one of the following laboratory values will support a diagnosis of Pyelonephritis.
A. Myoglobinuria
B. Pyuria
C. Ketonuria
D. Low white blood cell (WBC) count

Answer 81

B. Pyuria

Question 82

The patient with acute Pyelonephritis wants to know the possibility of developing chronic Pyelonephritis. The nurse’s response is based on knowledge that which of the following disorders most commonly leads to chronic Pyelonephritis?
A. Acute renal failure
B. Recurrent UTI
C. Acute pyelonephritis.
D. Glomerulonephritis.

Answer 82

B. Recurrent UTI

Question 83

Situation: Gina 24-year-old, patient who is newlywed comes to an ambulatory clinic in moderate distress with a diagnosis of acute cystitis,

Which of the following symptoms would the nurse most likely expect the patient to report during the assessment?
A. Hematuria
B. Frequency and burning on
urination
C. Flank pain and nausea
D. Fever and chills

Answer 83

B. Frequency and burning on
urination

Question 84

The patient asks the nurse, “How did I get this urinary tract infection?” The nurse should explain that in most instances, cystitis is caused
A. Congenital strictures in the urethra.
B. An infection elsewhere in the body
C. Urine stasis in the urinary bladder
D. An ascending infection from the urethra.

Answer 84

D. An ascending infection from the urethra.

Question 85

The patient is afraid to discuss her diagnosis of Cystitis with her husband. Which would be the nurse’s best approach?
A. Spend time with the patient addressing her concerns and then stay with her while she talks with her husband.
B. Talk first with the husband alone and then with both of them together to share the husband’s reactions.
C. Insist that the patient talk with her husband because good communication is necessary for a successful marriage
D. Arrange a meeting with the patient, her husband the doctor and the nurse

Answer 85

A. Spend time with the patient addressing her concerns and then stay with her while she talks with her husband.

Question 86

The nurse teaches a patient some method to relieve her discomfort until the antibiotic takes effect. Which of the following responses by the patient would indicate that she understands the Nurse’s instructions?
A. “I will place ice packs on my perineum.”
B. I will drink a cup of warm tea every hour
C. *I will take hot tub baths.”
D. I will void every 5 to 6 hours.

Answer 86

C. *I will take hot tub baths.”

Hot tub baths promote relaxation and help relieve urgency, discomfort, and spasm. Applying heat to the perineum is more helpful than cold because heat reduces inflammation.

Question 87

Which of the following statements by the patient would indicate that she is at high risk for recurrence of Cystitis?
A. “I drink a lot of water during the day
B. “I take a tub bath every evening
C. “I wipe from front to back after voiding.
D. “I can usually go 8 to 10 hours without needing to empty my bladder.

Answer 87

D. “I can usually go 8 to 10 hours without needing to empty my bladder.

Question 88

A client who has been treated for chronic renal failure (CRF) is ready for discharge. The nurse should reinforce which dietary instruction?
A. “Be sure to eat meat at every meal”
B. “Monitor your fruit intake, and eat plenty of bananas.
C. “Increase your carbohydrate intake
D. “Drink plenty of fluids, and use a salt substitute.”

Answer 88

C. “Increase your carbohydrate intake

Question 89

A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is most appropriate for this client?
A. Altered urinary elimination
B. Toileting self-care deficit
C. Risk for infection
D. Activity intolerance

Answer 89

C. Risk for infection

Question 90

The client underwent a transurethral resection of the prostate gland 24 hours ago and is on continuous bladder irrigation. Which of the following nursing interventions is appropriate?
A. Tell the client to try to urinate around the catheter to remove blood clots
B. Restrict fluids to prevent the client’s bladder from becoming distended.
C. Prepare to remove the catheter.
D. Use aseptic technique when irrigating the catheter

Answer 90

D. Use aseptic technique when irrigating the catheter

Question 91

The nurse is inserting a urinary catheter into a client who is extremely anxious about the procedure. The nurse can facilitate the insertion by asking the client to:
A. initiate a stream of urine
B. breathe deeply
C. Turn to the side
D. hold the labia or shaft of penis.

Answer 91

B. breathe deeply

Question 92

94. Which steps should the nurse follow to insert a straight urinary catheter?
    A. Create a sterile field, drape client, clean meatus, and insert catheter only 6
    B. Put on gloves, prepare equipment, create a sterile field, expose urinary meatus, and insert catheter 6”
    C. Prepare client and equipment, Create à sterile field, put on gloves, clean urinary meatus, and insert catheter until urine flows.
    D. Prepare client and equipment, sterile field test catheter balloon clean meals, and insert catheter until unne flows

Answer 92

C. Prepare client and equipment, Create à sterile field, put on gloves, clean urinary meatus, and insert catheter until urine flows.

Question 93

Which of the following is an appropriate nursing diagnosis for a client with renal calculi?
A. Ineffective tissue perfusion
B. Functional urinary incontinence
C.Risk for infection
D. Decreased cardiac output

Answer 93

C.Risk for infection

Question 94

Which clinical manifestation would lead the nurse to suspect that a client Is experiencing hypermagnesemia?
A. Muscle pain and acute rhabdomyolysis
B. Hot, flushed skin and diaphoresis
C. Soft-tissue calcification and hyperreflexia
D. Increased respiratory rate and depth

Answer 94

B. Hot, flushed skin and diaphoresis

Question 95

Joshua is receiving furosemide and Digoxin, which laboratory data would be the most important to assess in planning the care for the client?
A. Sodium level
B. Magnesium level
C. Potassium level
D. Calcium level

Answer 95

C. Potassium level

Question 96

Mr. Salcedo has the following arterial blood gas (ABG) values: pH of 7.34, partial pressure of arterial oxygen of 80 mm Hg, partial pressure of arterial carbon dioxide of 49 mm Hg, and a bicarbonate level of 24 mEq/L. Based on these results, which intervention should the nurse implement?
A. Instructing the client to breathe slowly into a paper bag
B. Administering low-flow oxygen
C. Encouraging the client to cough and deep breathe
D. Nothing, because these ABG values are within normal limits.

Answer 96

C. Encouraging the client to cough and deep breathe

Question 97

A client is diagnosed with metabolic acidosis, which would the nurse expect the health care provider to order?
A. Potassium
B. Sodium bicarbonate
C. Serum sodium level
D. Bronchodilator

Answer 97

B. Sodium bicarbonate

Question 98

Lee Angela’s lab test just revealed that her chloride level is 96 mEq/L. As a nurse, you would interpret this serum chloride level as:
A. high
B. low
C. within normal range
D. high normal

Answer 98

C. within normal range

A typical normal range is 96 to 106 milliequivalents per liter (mEq/L) or 96 to 106 millimoles per liter (millimol/L). Normal value ranges may vary slightly among different laboratories.