FINAL EXAM PRACTICE QUESTIONS

Question 1

A client has emergency surgery for a ruptured appendix. While in the postanesthesia care unit, the client manifests signs and symptoms of shock. The nurse should:
1/ Prepare for a blood transfusion
2/ Notify the surgeon immediately
3/ Elevate the head of the bed 30 degrees
4/ Order an electrocardiogram (ECG)

Answer 1

2/ Notify Doc

Peritonitis and shock are potentially life-threatening complications following abdominal surgery; prompt, rigorous treatment is necessary. The surgeon should be notified Fluids, not blood, are needed to expand and maintain the circulating blood volume. The head of the bed should be flat to increase tissue perfusion and oxygenation to the vital organs. An ECG does not treat shock.

Question 2

When assessing an 85-year-old client’s vital signs, the nurse anticipates a number of changes in cardiac output that result from the aging process. The finding that is consistent with a pathologic condition rather than the aging process is:
1/ A pulse rate irregularity
2/ Equal apical and radial pulse rates
3/ A pulse rate of 60 beats per minute
4/ An apical rate obtainable at the fifth intercostal space and midclavicular line

Answer 2

1/

Dysrhythmias are abnormal and are associated with acute or chronic pathological conditions.

Question 3

Prednisone (Meticorten) (Canada: Winpred) is prescribed for a client with an exacerbation of colitis. Before administering the first dose, the nurse teaches the client that:
1/ Symptoms associated with the colitis will decrease slowly over time
2/ The client will be protected from getting an infection
3/ Although the medication causes anorexia, weight loss may not occur
4/ Although the medication decreases intestinal inflammation, it will not cure the colitis

Answer 3

4/ There is Ø cure

Prednisone inhibits phagocytosis and suppresses other clinical phenomena of inflammation; this is a symptomatic treatment that is not curative. The response usually is rapid. The drug suppresses the immune response and increases the potential for infection. Appetite is increased; weight gain may result from this or from fluid retention.

Question 4

A nurse notes that a client's urine has a sweet fruity odor. Which information is most important to evaluate when performing a further client assessment?
1/ Vital signs
2/ Fluid balance
3/ Serum glucose level
4/ Dietary calorie count

Answer 4

3/

Sweet fruity smelling urine is an indicator of ketoacidosis, which can result from uncontrolled diabetes. Hyperglycemia and hypoglycemia are assessed by serum glucose monitoring. Vital signs, fluid imbalance, and dietary counts have no relation to sweet fruity smelling urine.

Question 5

The nurse is caring for a client hospitalized with a severe myocardial infarction. Which analgesic is the drug of choice for this client?
1/ Diazepam (Valium)
2/ Meperidine (Demerol)
3/ Flurazepam 
4/ Morphine sulfate

Answer 5

4/ Morphine

Question 6

Which assessment should the nurse obtain before administering digoxin (Lanoxin) (Canada: Toloxin) to a client?
1/ Apical heart rate
2/ Radial pulse on the left side
3/ Radial pulse in both right and left arms
4/ Difference between apical and radial pulses

Answer 6

A/ Apical

Because digoxin slows the heart rate, the apical pulse should be counted for one minute before administration. If the apical rate is below a preset parameter (usually 60 bpm), digoxin should be withheld because its administration may further decrease the heart rate.

Question 7

A client is diagnosed with acute gastritis secondary to alcoholism and cirrhosis. The client reports frequent nausea, pain that increases after meals, and black tarry stools. The client recently joined Alcoholics Anonymous. The nurse should give priority to which patient history item?
1/ Pain that increases after meals
2/ Frequent nausea
3/ Black tarry stools
4/ Joining Alcoholics Anonymous

Answer 7

3/ Black tarry stool

Black (tarry) stools indicate upper gastrointestinal (GI) bleeding; digestive enzymes act on the blood, resulting in tarry stools. Hemorrhage can occur if erosion extends to blood vessels. Investigation of bleeding takes priority; later the nurse should help to identify irritating foods that are to be avoided.

Question 8

A client in the emergency department is diagnosed with atrial fibrillation. Initially the health care provider instructs the client to perform the Valsalva maneuver by holding the breath and bearing down. What should the nurse include in an explanation of how this may convert atrial fibrillation to a normal sinus rhythm?
1/ Vagus nerve is stimulated.
2/ Glottis closes momentarily.
3/ Thoracic pressure decreases.
4/ Respiratory pattern is interrupted.

Answer 8

1/ Vagus Stimulation

Inhaling and forcing the diaphragm and chest muscles against a closed glottis increase intrathoracic pressure, which affects the vagus nerve and slows the heart.

Question 9

A hospitalized client puts the call light on and reports a sudden onset of chest pain that feels like a pressure or weight on the chest. The client also states, “I feel nauseated and very weak.” What action should the nurse take?
1/ Call the rapid response team
2/ Perform a nutritional assessment
3/ Discuss possible sources of stress with the client
4/ Provide reassurance while helping the client to focus on pleasant topics

Answer 9

1/ Response team

These are classic symptoms of a myocardial infarction; further medical evaluation and intervention are needed immediately.

Question 10

On the morning of surgery a client is admitted for resection of an abdominal aortic aneurysm. While awaiting surgery, the client suddenly develops symptoms of shock. The nurse should:
1/ Prepare for blood transfusions
2/ Notify the surgeon immediately
3/ Give the client nothing by mouth (NPO)
4/ Administer the prescribed sedative

Answer 10

2/ Notify Surgeon

Immediate surgical intervention to clamp the aorta is necessary for survival; the aneurysm has ruptured. Preparing for blood transfusions may be done eventually, but notifying the surgeon is the priority. The client is already NPO. Sedatives mask important signs and symptoms.

Question 11

An 85-year-old client has a serum potassium level of 6.7 mEq/L (Canada: 6.7 mmol/L). Which nursing action is a priority at this time?
1/ Monitor for cardiovascular irregularities.
2/ Inquire about changes in bowel patterns.
3/ Assess client for leg muscle twitching or weakness.
4/ Assess client for signs and symptoms of dehydration

Answer 11

1/

Cardiovascular changes are the most severe problems of hyperkalemia and are the most common cause of death from hyperkalemia. Changes in bowel patterns and leg muscle twitching and weakness are signs of hyperkalemia, but are not life threatening. Dehydration may be a cause of hyperkalemia.

Question 12

A client is found unconscious and unresponsive. What should the nurse do first?
1/ Initiate a code.
2/ Check for a radial pulse.
3/ Compress the lower sternum.
4/ Give four full lung inflations.

Answer 12

1/

or Call Batman.

Additional help and a cardiac defibrillator must be obtained immediately. The carotid, not radial, pulse is used. Compressing the lower sternum is done after the nurse summons help. Two lung inflations are given after 30 chest compressions.

Question 13

A client with varicose veins is scheduled for sclerotherapy. What clinical finding does the nurse expect to identify when assessing the lower extremities of this client?
1/ Pallor
2/ Ankle edema
3/ Yellowed toenails
4/ Diminished pedal pulses

Answer 13

2/ Ankle Edema

Ankle edema results from venous pooling with increased hydrostatic pressure; fluid moves from intravascular to interstitial spaces. Pigmentation, not pallor, may occur with varicosities. Yellowed toenails occur with arterial, not venous, insufficiency. Diminished pedal pulses occur with arterial, not venous, insufficiency.

Question 14

The home health nurse is visiting a client with multiple health problems that include a history of chronic atrial fibrillation. The nurse obtains a radial rate of 136 beats per minute. What should the nurse do first?
1/ Obtain the other vital signs.
2/ Recheck the pulse to verify the rate.
3/ Stay with the client until an ambulance arrives.
4/ Alert the health care provider of the client’s status.

Answer 14

1/ Obtain other vitals

The radial pulse of a client with chronic atrial fibrillation may range from 50 to 180 beats per minute. Other vital signs should be assessed before notifying the health care provider. Although rechecking the pulse to verify the rate may be done, it is not necessary because a pulse of 136 beats per minute is not unusual for a client with chronic atrial fibrillation. Staying with the client until the ambulance arrives or alerting the health care provider are not the initial actions.

Question 15

A nurse begins to develop a plan of care with a client who has left ventricular heart failure that resulted from a myocardial infarction (MI). What should be the primary focus of the plan during the acute phase of recovery?
1/ Increasing activity tolerance
2/ Preventing cardiac dysrhythmias
3/ Promoting physical and emotional rest
4/ Maintaining potassium and sodium intake

Answer 15

3/ REST

The major goal is to decrease the workload of the heart; physical and emotional rest reduces cardiac oxygen demand. Increasing activity tolerance is the primary focus during the rehabilitative phase after an MI, not during the acute phase. There is no indication that the client has a history of dysrhythmias. Although maintaining potassium intake is important, sodium should be limited to minimize fluid retention, which increases the workload on the heart.

Question 16

A client appears anxious, with respirations that are shallow and 40 per minute. The client reports feeling dizzy and light-headed and having tingling sensations of the fingertips and around the lips. What does the nurse determine is the probable cause of these clinical manifestations?
1/ Hyperventilation
2/ Dyspnea
3/ Kussmaul respirations
4/ Carbon dioxide intoxication

Answer 16

1/ Hyperventilation

The client is hyperventilating and is blowing off excessive carbon dioxide, which leads to these symptoms; if uninterrupted, this can lead to respiratory alkalosis.

Question 17

When assessing a client with pleural effusion, the nurse expects to identify:
1/ Moist crackles at the posterior of the lungs
2/ Deviation of the trachea toward the involved side
3/ Reduced or absent breath sounds at the base of the lung
4/ Increased resonance with percussion of the involved area

Answer 17

3/ Reduced sounds at the base of the lungs

Compression of the lung by fluid that accumulates at the base of the lungs reduces lung expansion and air exchange. There is no fluid in the alveoli, so no cracklesare produced. If there is tracheal deviation, it is away from the involved side. Dullness is produced on percussion of the involved area.

Question 18

The nurse is caring for a client with a history of atrial fibrillation and a diagnosis of dehydration. The nurse anticipates that the plan of care will include:
1/ A glass of water every hour until hydrated
2/ Small, frequent intake of juices, broth, or milk
3/ Short-term nasogastric tube for replacement of fluids and nutrients
4/ A rapid intravenous (IV) infusion of an electrolyte and glucose solution

Answer 18

2/

Small, frequent intake of juices, broth, or milk will provide gradual replacement of both fluid and electrolytes without overloading the intravascular compartment. Water does not supply the necessary electrolytes, and hyponatremia may result. No data are present to indicate that the client cannot take fluids orally; a nasogastric tube is not necessary when the client can take fluids by mouth. Rapid correction of a fluid and electrolyte imbalance is dangerous; therapy should promote a gradual correction.

Question 19

A nurse in the emergency department is assigned to care for four clients with serious health problems. Which health problem should the nurse identify as the priority?
1/ Head injury
2/ Fractured femur
3/ Ventricular fibrillation
4/ Penetrating abdominal wound

Answer 19

3/ V-Fib

It’s bad news.

Ventricular fibrillation will cause irreversible brain damage and then death within minutes because the heart is not pumping blood to the brain. Defibrillation or CPR until defibrillation is possible must be initiated immediately. Although head injury, fractured femur, and penetrating abdominal wound require prompt treatment, death is not as imminent as with ventricular fibrillation.

Question 20

A nurse is providing discharge instructions about digoxin (Lanoxin) (Canada: Toloxin). Which response should a nurse include as a reason for a client to withhold the digoxin?
1/ Chest pain
2/ Blurred vision
3/ Persistent hiccups
4/ Increased urinary output

Answer 20

2/ Blurred Vision

Visual disturbances, such as blurred or yellow vision, may be evidence of digoxin toxicity.

Question 21

A client with an inferior myocardial infarction has a heart rate of 120 beats per minute. What is the goal of the medical regimen for this client?
1/ Increase left ventricular filling and improve cardiac output.
2/ Decrease oxygen needs of the vital organs and prevent cardiac dysrhythmias.
3/ Decrease the workload on the heart and promote maximum coronary artery filling.
4/ Increase venous return to the right atrium and increase pulmonary arterial blood flow.

Answer 21

3/

With a myocardial infarction, circulation of blood to cardiac muscle is reduced, depriving it of oxygen; therefore, the oxygen demands of the body need to be decreased to reduce stress on the heart and reduce cardiac output. Increased coronary artery filling allows more blood and, therefore, oxygen to reach cardiac muscle; this increases myocardial efficiency.

Question 22

A client with a history of cirrhosis of the liver develops heart failure and is experiencing bigeminal premature ventricular complexes. What should the nurse expect about the dose of lidocaine (Xylocaine) prescribed by the health care provider?
1/ Higher to compensate for the impaired liver function
2/ Lower because the drug is metabolized at a diminished rate
3/ Reduced because other organs will compensate for the sluggish liver
4/ Equal to that needed for other clients to provide a loading dose for the myocardium

Answer 22

2/

The client has heart failure, which causes liver congestion, further compromising liver function; therefore, less than the usual adult dose will be prescribed because the liver will not be able to break down lidocaine as effectively as necessary.

Question 23

A client is prescribed prolonged bed rest after surgery. Which complication does the nurse expect to prevent by teaching this client to avoid pressure on the popliteal space?
1/ Cerebral embolism
2/ Pulmonary embolism
3/ Dry gangrene of a limb
4/ Coronary vessel occlusion

Answer 23

2/ Pulmonary Embolism

The pulmonary capillary beds are the first small vessels that the embolus encounters once it is released from the calf veins.

Question 24

While a pacemaker catheter is being inserted, the client's heart rate drops to 38 beats/min. What medication should the nurse expect the health care provider to prescribe?
1/ Digoxin 
2/ Lidocaine 
3/ Amiodarone 
4/ Atropine

Answer 24

4/ Atropine

Atropine blocks vagal stimulation of the sinoatrial (SA) node, resulting in an increased heart rate.

Question 25

A client with chronic obstructive pulmonary disease (COPD) reports chest congestion, especially upon wakening in the morning. The nurse should suggest that the client:
1/ Use a humidifier in the bedroom
2/ Sleep with two or more pillows
3/ Cough regularly even if the cough does not produce sputum
4/ Cough and deep breathe each night before going to sleep

Answer 25

1/ Humidify

A humidifier will help liquefy secretions and promote their expectoration.

Question 26

The nurse is caring for a client who has a peripherally inserted central catheter (PICC). The client notifies the nurse that the catheter got tangled up in his bed clothes and part of it has broken off. What should the nurse do first?
1/ Inspect catheter
2/ Notify the health care provider
3/ Clamp the remaining device
4/ Assess respiratory status

Answer 26

4/ Resp Status

The nurse should first think about the “ABC’s” (airway, breathing, and circulation). Anything that damages the catheter during insertion, dressing change, or excessive force may cause a catheter embolism. This could be a life threatening situation. Therefore, the nurse should do a quick respiratory assessment, inspect the catheter to determine how much may have embolized, clamp the remaining device if possible, and then notify the health care provider.

Question 27

A client’s laboratory report indicates hyperkalemia. Which responses should the nurse expect the client to exhibit? Select all that apply.

Anorexia
Vomiting
Constipation
Muscle weakness
Irregular heart rate

Answer 27

Vomiting
Muscle Weakness
Irregular Heart Rate

Bouts of nausea and vomiting are common with hyperkalemia. Because of potassium’s role in the sodium-potassium pump, an increase in potassium interferes with muscle contractions; it results in muscle weakness and areflexia. An increase in potassium can cause muscle twitching. The heart is a muscle and hyperkalemia can cause palpitations and cardiac dysrhythmias. On an ECG tracing the T wave will be peaked with hyperkalemia. Anorexia occurs with hypokalemia, not hyperkalemia. Diarrhea, not constipation, occurs with hyperkalemia.

Question 28

A nurse is caring for a client whose laboratory values indicate the presence of hyponatremia. For which risk factors should the nurse assess the client that most likely may have caused the hyponatremia? Select all that apply.

Diabetes insipidus

Profuse diaphoresis

Excess sodium intake

Removal of the parathyroid glands

Rapid IV infusion of 5% dextrose in water

Answer 28

Profuse Diaphoresis
Rapid IV infusion of D5W

Perspiration contains high levels of sodium. An infusion of an electrolyte-free solution (e.g., D5/W) can cause dilution of serum electrolytes. Diabetes insipidus results in inadequate antidiuretic hormone (ADH), causing water loss and hypernatremia. Excess sodium intake can lead to hypernatremia. Removal of the parathyroid glands can lead to hypocalcemia.

Question 29

Surgery is performed on a client with a parotid tumor. Postoperative arterial blood gas values are pH 7.32, PCO2 53 mm Hg, and HCO3 25 mEq/L (Canada: 25 mmol/L). What nursing action should be taken?
1/ Obtain a prescription for a diuretic.
2/ Obtain a prescription for an alkalinizing agent.
3/ Have the client breathe into a rebreather bag at a slow rate.
4/ Encourage the client to cough and then take deep breaths between coughs.

Answer 29

4/ Cough

The client is in respiratory acidosis, probably caused by depressant effects of the anesthetic or a plugged airway; coughing clears the airway, and deep breaths blow off carbon dioxide.

Question 30

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). During assessment, the nurse expects to auscultate:
1/ Diminished breath sounds
2/ Pleural friction rub
3/ Crackles and gurgles
4/ Expiratory wheeze and cough

Answer 30

1/ decreased breath sounds

Breath sounds will be decreased in clients with COPD because of reduced airflow, pleural effusion, or lung parenchymal destruction. A pleural friction rub occurs when one layer of the pleural membrane slides over the other during breathing; this is associated with pleurisy. Crackles indicate fluid in the alveoli, which is associated with heart failure or infection; rhonchi signifies airway obstruction, not COPD. Expiratory wheezing and coughing are associated with asthma or bronchitis.

Question 31

To begin the administration of total parental nutrition (TPN), a client has a right subclavian central venous access device inserted. Immediately after insertion of the catheter, the priority nursing action is to:
1/ Obtain a chest x-ray to determine placement
2/ Auscultate the lungs to evaluate breath sounds
3/ Draw a blood sample to assess blood glucose level
4/ Assess the right upper extremity for neurological deficits

Answer 31

2/ Auscultate

The most significant and life-threatening complication of insertion of a subclavian catheter is a pneumothorax because of the proximity of the subclavian vein and the apex of the upper lobe of the lung; a client’s respiratory status always is the priority.