Exam 2010 multichoice

Question 1

1. The nurse assesses a surgical patient the morning of the first postoperative day. Signs of a local inflammatory response that the nurse expects to find include
   A. redness and heat of the incision
   B. leukocytosis with elevated monocytes
   C. pain and purulent drainage of the incision.
   D. fever and increased pulse and respiration rate

Answer 1

A. redness and heat of the incision

Question 2

2. A paraplegic patient is admitted to the hospital for intensive management of an open, infected pressure ulcer on the left buttock at the prominence of the ischial tuberosity. The initial assessment of the patient’s pressure ulcer indicates that it is 5cm long by 2.5cm wide and is 1.5 cm deep. The base of the wound is yellow and involves subcutaneous tissue. The nurse classifies the pressure ulcer as
   a. Stage I
   b. Stage II
   c. Stage III
   d. Stage IV

Answer 2

c. Stage III

Question 3

3. Initial evidence that would indicate to the nurse that a patient is experiencing a systemic anaphylaxis to an injected allergen is the development of
   A. dyspnea
   B. dilation of the pupils
   c. itching and edema at the injection site
   d. a wheal-and-flare reaction at the injection site.

Answer 3

d. a wheal-and-flare reaction at the injection site.

Question 4

4. A patient with a severe allergic reaction is treated with epinephrine. The nurse recognises that the rationale for the use of ephinephrine is that epinephrine opposes the effects of
   a. Histamine
   b. Lymphokines
   c. Interleukin-2
   d. Lysosomal enzymes

Answer 4

a. Histamine

Question 5

5. It is especially important for the nurse to determine the patient’s current use of medications during the preoperative assessment because
   a. These medications may alter the patient’s perceptions about surgery.
   b. Anaesthetics alter renal and hepatic function, causing toxicity by other drugs
   c. Other medications may cause interactions with anaesthetics, altering the potency and effect of the drugs
   d. Routine medications are usually withheld the day of surgery, requiring dosage and schedule adjustments.

Answer 5

c. Other medications may cause interactions with anaesthetics, altering the potency and effect of the drugs

Question 6

6. Ten minutes after a patient has received his preoperative medication by IM injection, he asks to get up to go to the bathroom to urinate. The most appropriate action by the nurse is to
   a. Offer him a urinal and position him in bed to promote voiding.
   b. Assist him to the bathroom and stay with him to protect him from falling
   c. Tell him to try to hold the urine because he will be catheterised at the beginning of the surgical procedure
   d. Allow him to go to the bathroom because the onset of the effect of the medication takes more than 10 minutes.

Answer 6

a. Offer him a urinal and position him in bed to promote voiding.

Question 7

7. When a patient is transferred from the Post Anaesthetic Care Unit (PACU) to the clinical surgical unit, the first action by the nurse on the surgical unit should be to
   a. Assess the patient’s pain
   b. Take the patient’s vital signs
   c. Check the rate of the IV infusion
   d. Check the physician’s postoperative orders

Answer 7

b. Take the patient’s vital signs

Question 8

8. Postoperatively a patient is receiving low molecular weight heparin (LMWH). When administering this drug, the nurse
   a. Explains that the drug will help prevent clot formation in the legs
   b. Administers the dose with meals to prevent GI irritation and bleeding
   c. Checks the results of the partial thromboplastin time before administration
   d. Informs the patient that blood will be drawn every 6 hours to monitor the prothrombin time.

Answer 8

a. Explains that the drug will help prevent clot formation in the legs

Question 9

9. The patient is hospitalised with vomiting of “coffee ground” emesis of unknown cause. The patient is very anxious about the source of the bleeding and asks the nurse whether it is possible to find the cause. The nurse’s response is based on the knowledge that the diagnostic test which can most accurately identify the source of the bleeding is
   a. An endoscopy
   b. An angiogrqaphy
   c. A gastric analysis
   d. Barium contrast studies

Answer 9

a. An endoscopy

Question 10

10. A dark-skinned person has been admitted to the hospital in severe respiratory distress. To assess for cyanosis in the patient, the nurse knows that
    a. Cyanosis in patients with dark skin can be seen only in the sclera
    b. It is not possible to assess abnormal colour changes in patients with dark skin
    c. Cyanosis can be seen in the lips and mucous membranes of patients with dark skin
    d. Cyanosis will blanch out with direct pressure to the soles of the feet in dark-skinned patients

Answer 10

c. Cyanosis can be seen in the lips and mucous membranes of patients with dark skin

Question 11

11. The best example of nursing documentation of a normal assessment of the skin is
    a. “Skin warm and dry; turgor good; nails flat and pink; old surgical scars noted on abdomen.”
    b. “History of allergic rashes; skin very fair with numerous freckles, warm and intact; no lesions noted”
    c. “Skin brown, slightly moist, and warm; turgor immediate return; no lesions noted. States no problems with skin.”
    d. “No history of skin problems; skin intact, pink, temperature consistent over body; no lesions except numerous brown moles.”

Answer 11

d. “No history of skin problems; skin intact, pink, temperature consistent over body; no lesions except numerous brown moles.”

Question 12

12. During application of a wet dressing to the skin of a patient with impetigo, it is most important for the nurse to
    a. Use cool solutions to debride the lesions
    b. Use clean gloves to prevent the spread of infection to others
    c. Use sterile gloves and dressings to prevent infection of the lesions
    d. Apply a prescribed topical antibiotic ointment before the application of the dressings

Answer 12

b. Use clean gloves to prevent the spread of infection to others

Question 13

13. A patient is scheduled for an outpatient ultrasound of the gallbladder. The nurse instructs the patient that the evening before the test it will be necessary for her to
    A. eat a high-fat evening meal
    B. drink a liquid barium contrast medium
    C. use enemas until the return is clear of stool
    D. take nothing by mouth for 8 hours before the test.

Answer 13

D. take nothing by mouth for 8 hours before the test.

Question 14

14. Following diagnostic testing, a patient with recurring heartburn and indigestion is diagnosed with a hiatial hernia. The nurse explains to the patient that this condition involves
    a. Extension of the esophagus through the diaphragm
    b. Displacement of the duodenum through the stomach to the esophagus
    c. Twisting of the stomach around the esophagus, occluding the esophagus
    d. Protrusion of the stomach into the esophagus thorugh an opening in the diaphragm

Answer 14

d. Protrusion of the stomach into the esophagus thorugh an opening in the diaphragm

Question 15

15. A patient with upper gastrointestinal bleeding is diagnosed with a duodenal ulcer following an endoscopy, with a histology of a mucosal specimen is positive for Helicobacter pylori. When the nurse administers antibiotic therapy for the H.pylori, the patient asks if ulcers are caused by an infection. The best response the nurse includes in the information that
    a. H.pylori is strongly associated with gastric ulcers but it is rarely present in those with duodenal ulcers.
    b. Although H.pylori is believed to be a cause of gastritis, its role in the development of ulcers is not known.
    c. Because most of the population is infected with H.pylori, it is believed that other factors are responsible for ulcer development
    d. Infection with this bacteria in combination with other factors is believed to be a major cause of breakdown of the gastric mucosal barrier

Answer 15

d. Infection with this bacteria in combination with other factors is believed to be a major cause of breakdown of the gastric mucosal barrier

Question 16

16. A 78-year-old patient is transferred to the hospital from a nursing home upon developing abdominal pain and watery, incontinent diarrhoea following a course of antibiotic therapy for pneumonia. Stool cultures reveal the presence of Clostridium difficile. In planing care for the patient, the nurse recognises that a priority nursing goal is to
    a. Maintain normal nutritional intake
    b. Prevent transmission of the microorganism to others
    c. Promote relief of abdominal pain with comfort measures
    d. Control the diarrhoea with administration of antidiarrheal drugs

Answer 16

d. Control the diarrhoea with administration of antidiarrheal drugs

Question 17

17. While obtaining a nursing history from a patient with inflammatory bowel disease, the nurse recognises that the patient most likely has ulcerative colitis rather than Crohn’s disease when the patient reports experiencing
    a. Weight loss
    b. Bloody diarrhoea
    c. Abdominal pain and cramping
    d. The onset of the disease at age 20

Answer 17

c. Abdominal pain and cramping

Question 18

18. An 81-year old patient has a large bowel obstruction that occurred as a result of a fecal impaction. During nursing assessment of the patient, a finding by the nurse that is consistent with a large bowel obstruction includes
    a. Metabolic alkalosis
    b. Referred pain to the back
    c. Rapid onset of copious vomiting
    d. Greatly increased abdominal distention

Answer 18

d. Greatly increased abdominal distention

Question 19

19. During the initial postoperative assessment of a patient’s stoma formed with a transverse colostomy, the nurse finds it to be red with moderate edema and a small amount of bleeding. The most appropriate interpretation of this finding by the nurse is that there is
    a. A viable stoma with high vascularity
    b. Obstruction of the stoma with venous congestion
    c. Inadequate blood supply to the stoma, caused by edema
    d. An abnormal stomal condition that should be reported to the surgeon

Answer 19

a. A viable stoma with high vascularity

Question 20

20. A patient has a newly formed ileostomy for treatment of ulcerative colitis. In teaching the patient about the care of her ileostomy, the nurse informs the patient that she should
    a. Restrict fluid intake to prevent constant liquid drainage from the stoma.
    b. Change the pouch every day to prevent leakage of contents onto the skin
    c. Maintain as normal a diet as possible, avoiding foods that cause gas or diarrhoea
    d. Irrigate the ileostomy daily or every other day to avoid having to wear a drainage appliance

Answer 20

c. Maintain as normal a diet as possible, avoiding foods that cause gas or diarrhoea

Question 21

21. When the nurse applies a painful stimuli to an unconscious patient, the patient responds by stiffly extending and abducting the arms and hyperpronating the wrists. The nurse interprets this finding as
    a. Decorticate posturing indicating an interruption of voluntary motor tracts.
    b. Decerebrate posturing indicating an interruption of voluntary motor tracts.
    c. Decorticate posturing indicating a distruption of motor fibers in the midbrain and brainstem
    d. Decerebrate posturing indicating indicating a distruption of motor fibers in the midbrain and brainstem

Answer 21

d. Decerebrate posturing indicating indicating a distruption of motor fibers in the midbrain and brainstem

Question 22

22. When assessing a patient with a neurologic disorder using the Glasgow Coma Scale, the nurse is obtaining information related to the
    a. Level of consciousness
    b. Presence of cerebral edema.
    c. Presence of corneal and pupillary reflexes.
    d. Integrated functions of the cerebral cortex.

Answer 22

a. Level of consciousness

Question 23

23. A 68 year old man has had several transient ischemic attacks (TIA’s) with temporary hemiparesis and dysarthria that have lasted up to an hour. The nurse encourages the patient to seek immediate medical assistance for any symptoms that last longer than an hour, explaining that permanent disability from a stoke may be reduce if therapy is initiated within 3 hours with use of
    a. Intravenous heparin
    b. Transluminal angioplasty
    c. A surgical endarterectomy
    d. Tissue plasminogen activator (TPA)

Answer 23

d. Tissue plasminogen activator (TPA)

Question 24

24. When taking a patient history during assessment of the musculoskeletal system, the nurse identifies an increase risk for the patient who reports a family history of
    a. Osteoporosis
    b. Osteomalacia
    c. Osteomyelitis
    d. Bony tuberculosis

Answer 24

a. Osteoporosis

Question 25

25. A patient is admitted to the emergency department, with possible fractures of the bones of the left lower extremity. Prior to initiating treatment for the patient, it is most important for the nurse to
    a. Spint the lower leg
    b. Elevate the injured leg
    c. Check neurovascular status distal to the injury
    d. Assess the patient’s tetanus immunisation status

Answer 25

c. Check neurovascular status distal to the injury