NCSBN 18' Exam 3 Flashcards
- A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every 2 hours. Which of the following outcome criteria would the nurse use?
❍ A. Body temperature of 99°F or less
❍ B. Toes moved in active range of motion
❍ C. Sensation reported when soles of feet are touched
❍ D. Capillary refill of < 3 seconds
Answer D is correct.
It is important to assess the extremities for blood vessel occlusion in the client with sickle cell anemia because a change in capillary refill would indicate a change in circulation. Body temperature, motion, and sensation would not give information regarding peripheral circulation; therefore, answers A, B, and C are incorrect.
- A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the best position for this client?
❍ A. Side-lying with knees flexed
❍ B. Knee-chest
❍ C. High Fowler’s with knees flexed
❍ D. Semi-Fowler’s with legs extended on the bed
Answer D is correct.
Placing the client in semi-Fowler’s position provides the bestoxygenation for this client. Flexion of the hips and knees, which includes the knee-chest position, impedes circulation and is not correct positioning for this client.
Therefore, answers A, B, and C are incorrect.
- A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?
❍ A. Taking hourly blood pressures with mechanical cuff
❍ B. Encouraging fluid intake of at least 200mL per hour
❍ C. Position in high Fowler’s with knee gatch raised
❍ D. Administering Tylenol as ordered
Answer B is correct.
It is important to keep the client in sickle cell crisis hydrated toprevent further sickling of the blood. Answer A is incorrect because a mechanical cuff places too much pressure on the arm. Answer C is incorrect because raising the knee gatch impedes circulation. Answer D is incorrect because Tylenol is too mild an analgesic for the client in crisis.
- Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?
❍ A. Peaches
❍ B. Cottage cheese
❍ C. Popsicle
❍ D. Lima beans
Answer C is correct.
Hydration is important in the client with sickle cell disease to prevent thrombus formation. Popsicles, gelatin, juice, and pudding have high fluid content. The foods in answers A, B, and D do not aid in hydration and are, therefore, incorrect.
- A newly admitted client has sickle cell crisis. He is complaining of pain in his feet and hands. The nurse’s assessment findings include a pulse oximetry of 92. Assuming that all the following interventions are ordered,
which should be done first?
❍ A. Adjust the room temperature
❍ B. Give a bolus of IV fluids
❍ C. Start O2
❍ D. Administer meperidine (Demerol) 75mg IV push
Answer C is correct.
The pulse oximetry indicates that oxygen levels are low; thus, oxygenation takes precedence over pain relief. Answer A is incorrect because although a warm environment reduces pain and minimizes sickling, it would not be a priority. Answer B is incorrect because although hydration is important, it would not require a
bolus. Answer D is incorrect because Demerol is acidifying to the blood and increases sickling.
- The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?
❍ A. Roast beef, gelatin salad, green beans, and peach pie
❍ B. Chicken salad sandwich, coleslaw, French fries, ice cream
❍ C. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie
❍ D. Pork chop, creamed potatoes, corn, and coconut cake
Answer C is correct.
Egg yolks, wheat bread, carrots, raisins, and green, leafy vegetables are all high in iron, which is an important mineral for this client. Roast beef, cabbage, and pork chops are also high in iron, but the side dishes accompanying these choices are not; therefore, answers A, B, and D are incorrect.
- Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?
❍ A. A family vacation in the Rocky Mountains
❍ B. Chaperoning the local boys club on a snow-skiing trip
❍ C. Traveling by airplane for business trips
❍ D. A bus trip to the Museum of Natural History
Answer D is correct.
Taking a trip to the museum is the only answer that does not pose a threat. A family vacation in the Rocky Mountains at high altitudes, cold temperatures, and airplane travel can cause sickling episodes and should be avoided; therefore, answers A, B, and C are incorrect.
- The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which finding reinforces the diagnosis of B12 deficiency?
❍ A. Enlarged spleen
❍ B. Elevated blood pressure
❍ C. Bradycardia
❍ D. Beefy tongue
Answer D is correct.
The tongue of the client with B12 insufficiency is red and beefy. A, B, and C incorrect because enlarged spleen, elevated BP, and bradycardia are not associated with B12 deficiency.
- The body part that would most likely display jaundice in the dark-skinned individual is the:
❍ A. Conjunctiva of the eye
❍ B. Soles of the feet
❍ C. Roof of the mouth
❍ D. Shins
Answer C is correct.
The oral mucosa and hard palate (roof of the mouth) are the best indicators of jaundice in dark-skinned persons. The conjunctiva can have normal deposits of fat, which give a yellowish hue; thus, answer A is incorrect. The soles of the feet can be yellow if they are calloused, making answer B incorrect; the shins would be an area of darker pigment, so answer D is incorrect.
- The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?
❍ A. BP 146/88
❍ B. Respirations 28 shallow
❍ C. Weight gain of 10 pounds in 6 months
❍ D. Pink complexion
Answer B is correct.
When there are fewer red blood cells, there is less hemoglobin and less oxygen. Therefore, the client is often short of breath, as indicated in answer B. The client with anemia is often pale in color, has weight loss, and may be hypotensive. Answers A, C, and D are within normal and, therefore, are incorrect.
- The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Which of the following statements by the client indicates a need for further teaching?
❍ A. “I will drink 500mL of fluid or less each day.”
❍ B. “I will wear support hose.”
❍ C. “I will check my blood pressure regularly.”
❍ D. “I will report ankle edema.”
Answer A is correct.
The client with polycythemia vera is at risk for thrombus formation. Hydrating the client with at least 3L of fluid per day is important in preventing clot formation, so the statement to drink less than 500mL is incorrect. Answers B, C, and D are incorrect because they all contribute to the prevention of complications. Support hose promotes venous return, the electric razor prevents bleeding due to injury, and a diet low in iron is essential to preventing further red cell formation.
- A 33-year-old male is being evaluated for possible acute leukemia. Which of the following findings is most likely related to the diagnosis of leukemia?
❍ A. The client collects stamps as a hobby.
❍ B. The client recently lost his job as a postal worker.
❍ C. The client had radiation for treatment of Hodgkin’s disease as a teenager.
❍ D. The client’s brother had leukemia as a child.
Answer C is correct.
Radiation treatment for other types of cancer can contribute to the development of leukemia. Some hobbies and occupations involving chemicals are
linked to leukemia, but not the ones in these answers; therefore, answers A and B are incorrect. Answer D is incorrect because the incidence of leukemia is higher in twins not siblings.
- Where is the best site for examining for the presence of petechiae in an African American client?
❍ A. The abdomen
❍ B. The thorax
❍ C. The earlobes
❍ D. The soles of the feet
Answer D is correct.
Petechiae are not usually visualized on dark skin. The soles of the feet and palms of the hand provide a lighter surface for assessing the client for petichiae. Answers A, B, and C are incorrect because the skin may be too dark to make an assessment.
- The client is being evaluated for possible acute leukemia. Which inquiry by the nurse is most important?
❍ A. “Have you noticed a change in sleeping habits recently?”
❍ B. “Have you had a respiratory infection in the last 6 months?”
❍ C. “Have you lost weight recently?”
❍ D. “Have you noticed changes in your alertness?”
Answer B is correct.
The client with leukemia is at risk for infection and has often had recurrent respiratory infections during the previous 6 months. Insomnolence, weight loss, and a decrease in alertness also occur in leukemia, but bleeding tendencies and infections are the primary clinical manifestations; therefore, answers A, C, and D are
incorrect.
- Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?
❍ A. Oral mucous membrane, altered related to chemotherapy
❍ B. Risk for injury related to thrombocytopenia
❍ C. Fatigue related to the disease process
❍ D. Interrupted family processes related to life-threatening illness of a family member
Answer B is correct.
The client with acute leukemia has bleeding tendencies due to decreased platelet counts, and any injury would exacerbate the problem. The client would require close monitoring for hemorrhage, which is of higher priority than the diagnoses in answers A, C, and D, which are incorrect.
- A 21-year-old male with Hodgkin’s lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this
client?
❍ A. Sexual dysfunction related to radiation therapy
❍ B. Anticipatory grieving related to terminal illness
❍ C. Tissue integrity related to prolonged bed rest
❍ D. Fatigue related to chemotherapy
Answer A is correct.
Radiation therapy often causes sterility in male clients and would be of primary importance to this client. The psychosocial needs of the client are important to address in light of the age and life choices. Hodgkin’s disease, however, has a good prognosis when diagnosed early. Answers B, C, and D are incorrect
because they are of lesser priority.
- A client has autoimmune thrombocytopenic purpura. To determine the client’s response to treatment, the nurse would monitor:
❍ A. Platelet count
❍ B. White blood cell count
❍ C. Potassium levels
❍ D. Partial prothrombin time (PTT)
Answer A is correct.
Clients with autoimmune thrombocytopenic purpura (ATP) have low platelet counts, making answer A the correct answer. White cell counts, potassium levels, and PTT are not affected in ATP; thus, answers B, C, and D are incorrect.
- The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client’s platelet count currently is 80,000. It will be most important to teach the client and family about:
❍ A. Bleeding precautions
❍ B. Prevention of falls
❍ C. Oxygen therapy
❍ D. Conservation of energy
Answer A is correct.
The normal platelet count is 120,000–400,000. Bleeding occurs in clients with low platelets. The priority is to prevent and minimize bleeding. Oxygenation in answer C is important, but platelets do not carry oxygen. Answers B and D are of lesser priority and are incorrect in this instance.
- The client has surgery for removal of a Prolactinoma. Which of the following interventions would be appropriate for this client?
❍ A. Place the client in Trendelenburg position for postural drainage
❍ B. Encourage coughing and deep breathing every 2 hours
❍ C. Elevate the head of the bed 30°
❍ D. Encourage the Valsalva maneuver for bowel movements
Answer C is correct.
A prolactinoma is a type of pituitary tumor. Elevating the head of the bed 30° avoids pressure on the sella turcica and helps to prevent headaches. Answers A, B, and D are incorrect because Trendelenburg, Valsalva maneuver, and coughing all increase the intracranial pressure.
- The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is:
❍ A. Measure the urinary output
❍ B. Check the vital signs
❍ C. Encourage increased fluid intake
❍ D. Weigh the client
Answer B is correct.
The large amount of fluid loss can cause fluid and electrolyte imbalance that should be corrected. The loss of electrolytes would be reflected in the vital signs. Measuring the urinary output is important, but the stem already says that the client has polyuria, so answer A is incorrect. Encouraging fluid intake will not correct the problem, making answer C incorrect. Answer D is incorrect because weighing the client is not necessary at this time.
- A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?
❍ A. Place the client in a sitting position.
❍ B. Administer acetaminophen (Tylenol).
❍ C. Pinch the soft lower part of the nose.
❍ D. Apply ice packs to the forehead.
Answer C is correct.
C is correct because direct pressure to the nose stops the bleeding. Answers A, B, and D are incorrect because they do not stop bleeding
- A client has had a unilateral adrenalectomy to remove a tumor. The most important measurement in the immediate post-operative period for the nurse to take is to:
❍ A. Check the blood pressure
❍ B. Monitor the temperature
❍ C. Evaluate the urinary output
❍ D. Check the specific gravity of the urine
Answer A is correct.
Blood pressure is the best indicator of cardiovascular collapse in the client who has had an adrenal gland removed. The remaining gland might have been sup-
pressed due to the tumor activity. Temperature would be an indicator of infection,decreased output would be a clinical manifestation but would take longer to occur than
blood pressure changes, and specific gravity changes occur with other disorders; therefore, answers B, C, and D are incorrect.
- A client with Addison’s disease has been admitted with a history of nausea and vomiting for the past 3 days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement?
❍ A. Glucometer readings as ordered
❍ B. Intake/output measurements
❍ C. Evaluate the sodium and potassium levels
❍ D. Daily weights
Answer A is correct.
IV glucocorticoids raise the glucose levels and often require coverage with insulin. Answer B is not necessary at this time, sodium and potassium levels would be monitored when the client is receiving mineral corticoids, and daily weights is unnecessary; therefore, answers B, C, and D are incorrect.
- A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurses’ next action be?
❍ A. Obtain a crash cart
❍ B. Check the calcium level
❍ C. Assess the dressing for drainage
❍ D. Assess the blood pressure for hypertension
Answer B is correct.
The parathyroid glands are responsible for calcium production and can be damaged during a thyroidectomy. The tingling can be due to low calcium levels.The crash cart would be needed in respiratory distress but would not be the next action to take; thus, answer A is incorrect. Hypertension occurs in thyroid storm and the
drainage would occur in hemorrhage, so answers C and D are incorrect.
- A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?
❍ A. Impaired physical mobility related to decreased endurance
❍ B. Hypothermia r/t decreased metabolic rate
❍ C. Disturbed thought processes r/t interstitial edema
❍ D. Decreased cardiac output r/t bradycardia
Answer D is correct.
The decrease in pulse can affect the cardiac output and lead to shock, which would take precedence over the other choices; therefore, answers A, B, and C are incorrect.
- The client presents to the clinic with a serum cholesterol of 275mg/dL and is placed on rosuvastatin (Crestor). Which instruction should be given to the client taking rosuvastatin (Crestor)?
❍ A. Report muscle weakness to the physician.
❍ B. Allow six months for the drug to take effect.
❍ C. Take the medication with fruit juice.
❍ D. Report difficulty sleeping.
Answer A is correct.
The client taking antilipidemics should be encouraged to report muscle weakness because this is a sign of rhabdomyolysis. The medication takes effect within 1 month of beginning therapy, so answer B is incorrect. The medication should be taken with water because fruit juice, particularly grapefruit, can decrease the effectiveness, making answer C incorrect. Liver function
studies should be checked before beginning the medication, not after the fact, making
answer D incorrect.
- The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration, the nurse should:
❍ A. Utilize an infusion pump
❍ B. Check the blood glucose level
❍ C. Place the client in Trendelenburg position
❍ D. Cover the solution with foil
Answer B is correct.
Hyperstat is given IV push for hypertensive crises, but it often causes hyperglycemia. The glucose level will drop rapidly when stopped. Answer A is incorrect because the hyperstat is given by IV push. The client should be placed in dorsal recumbent position, not Trendelenburg position, as stated in answer C. Answer D is incorrect because the medication does not have to be covered with foil.
- The 6-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate. Which finding should be reported to the doctor?
❍ A. Blood pressure of 126/80
❍ B. Blood glucose of 110mg/dL
❍ C. Heart rate of 60bpm
❍ D. Respiratory rate of 30 per minute
Answer C is correct.
A heart rate of 60 in the baby should be reported immediately. The dose should be held if the heart rate is below 100bpm. The blood glucose, blood pressure, and respirations are within normal limits; thus answers A, B, and D are incorrect.
- The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:
❍ A. Replenish his supply every 3 months
❍ B. Take one every 15 minutes if pain occurs
❍ C. Leave the medication in the brown bottle
❍ D. Crush the medication and take with water
Answer C is correct.
Nitroglycerine should be kept in a brown bottle (or even a special air- and water-tight, solid or plated silver or gold container) because of its instability and tendency to become less potent when exposed to air, light, or water. The supply should be replenished every 6 months, not 3 months, and one tablet should be taken every 5 minutes until pain subsides, so answers A and B are incorrect. If the pain does not subside, the client should report to the emergency room. The medication should be taken sublingually and should not be crushed, as stated in answer D.
- The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?
❍ A. Macaroni and cheese
❍ B. Shrimp with rice
❍ C. Turkey breast
❍ D. Spaghetti with meat sauce
Answer C is correct.
Turkey contains the least amount of fats and cholesterol. Liver, eggs, beef, cream sauces, shrimp, cheese, and chocolate should be avoided by the client; thus, answers A, B, and D are incorrect. The client should bake meat rather than frying to avoid adding fat to the meat during cooking.
- The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:
❍ A. Feet
❍ B. Neck
❍ C. Hands
❍ D. Sacrum
Answer B is correct.
The jugular veins in the neck should be assessed for distension.The other parts of the body will be edematous in right-sided congestive heart failure, not left-sided; thus, answers A, C, and D are incorrect.
- The nurse is checking the client’s central venous pressure. The nurse should place the zero of the manometer at the:
❍ A. Phlebostatic axis
❍ B. PMI
❍ C. Erb’s point
❍ D. Tail of Spence
Answer A is correct.
The phlebostatic axis is located at the fifth intercostals space midaxillary line and is the correct placement of the manometer. The PMI or point of maximal impulse is located at the fifth intercostals space midclavicular line, so answer B is incorrect. Erb’s point is the point at which you can hear the valves close simultaneously, making answer C incorrect. The Tail of Spence (the upper outer quadrant of the breast) is the area where most breast cancers are located and has nothing to do with placement of a manometer; thus, answer D is incorrect.
- The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:
❍ A. Question the order
❍ B. Administer the medications
❍ C. Administer separately
❍ D. Contact the pharmacy
Answer B is correct.
Zestril is an ACE inhibitor and is frequently given with a diuretic such as Lasix for hypertension. Answers A, C, and D are incorrect because the order is accurate. There is no need to question the order, administer the medication separately, or contact the pharmacy.
- The best method of evaluating the amount of peripheral edema is:
❍ A. Weighing the client daily
❍ B. Measuring the extremity
❍ C. Measuring the intake and output
❍ D. Checking for pitting
Answer B is correct.
The best indicator of peripheral edema is measuring the extremity. A paper tape measure should be used rather than one made of plastic or cloth, and the area should be marked with a pen, providing the most objective assessment. Answer A is incorrect because weighing the client will not indicate peripheral edema. Answer C is incorrect because checking the intake and output will not indicate peripheral edema. Answer D is incorrect because checking for pitting edema is less reliable
than measuring with a paper tape measure.
- A client with vaginal cancer is being treated with a radioactive vaginal implant. The client’s husband asks the nurse if he can spend the night with his wife. The nurse should explain that:
❍ A. Overnight stays by family members is against hospital policy.
❍ B. There is no need for him to stay because staffing is
adequate.
❍ C. His wife will rest much better knowing that he is at home.
❍ D. Visitation is limited to 30 minutes when the implant is in place.
Answer D is correct.
Clients with radium implants should have close contact limited to 30 minutes per visit. The general rule is limiting time spent exposed to radium, putting distance between people and the radium source, and using lead to shield against the radium. Teaching the family member these principles is extremely important. Answers A, B, and C are not empathetic and do not address the question; therefore, they are incorrect.
- The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client?
❍ A. Roast beef sandwich, potato chips, pickle spear, iced tea
❍ B. Split pea soup, mashed potatoes, pudding, milk
❍ C. Tomato soup, cheese toast, Jello, coffee
❍ D. Hamburger, baked beans, fruit cup, iced tea
Answer B is correct.
The client with a facial stroke will have difficulty swallowing and chewing, and the foods in answer B provide the least amount of chewing. The foods in
answers A, C, and D would require more chewing and, thus, are incorrect.
