NP III & IV Flashcards
0
Q
- Which of the following statements by a 25 year old woman indicates that she understands BSE?
A. I will perform BSE every 3 months
B. I will wear latex gloves when doing BSE
C. I will do complete BSE on both breasts 7 to 10 days after menses
D. I will use the palms of my hands to perform BSE
A
C. I will do complete BSE on both breasts 7 to 10 days after menses
RATIONALE
A Correct: Perform BSE MONTHLY
B Correct: Without gloves
D Correct: Use fingerpads
1
Q
- The nurse is instructing the client to perform a TSE. The nurse tells the client
A. To examine the testicles at bedtime while lying down
B. That the best tine for TSE is after a warm shower
C. To gently feel the testicles with one finger to feel for a growth
D. That TSE should be done at least every 6 months
A
B. That the best time for TSE is after a warm shower
RATIONALE
A Correct: To examine the testicles after warm bath/shower
C Correct: Use 2 hands
D Correct: Done MONTHLY on the same day
2
Q
- A nurse is instructing a patient about a mammogram. Which of the following instructions should the nurse include during patient teaching?
A. Do not drink fluids for hours prior to the test
B. Do not use deodorant in the underarm area before the test
C. The x-ray procedure should be completed within one hour
D. No pain or discomfort will be experienced during the procedure
A
B. Do not use deodorant in the underarm area before the test
RATIONALE
It may cause false positive because it contains aluminum
A Correct: No GIT preparation
C Correct: Within few minutes only
D Correct: No pain but may cause discomfort during compression
3
Q
- A client has a routine Pap smear test during a yearly gynecologic examination. The result reveals a class V finding. What should the nurse tell the client about this finding?
A. It’s normal and requires no action
B. It calls for a repeat Pap smear in 3 months
C. It calls for a repeat Pap smear in 6 weeks
D. It calls for a biopsy ASAP
A
D. It calls for a biopsy ASAP
RATIONALE
It is classified possibly malignant.
A Class I
B Class II
C Class III
4
Q
- The physician wants to examine a client’s prostate gland. What equipment will be necessary for the exam?
A. Stethoscope
B. Lubricant and gloves
C. Thermometer and BP apparatus
D. Tuning fork and percussion hammer
A
B. Lubricant and gloves
RATIONALE
The physician will perform Digital Rectal Examination.
5
Q
- A client undergoes a biopsy of a suspected lesion. The biopsy classifies the lesion according to the TNM staging system as follows: Tis, N0, M0. What does this classification mean?
A. No advance of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis
B. Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis
C. Can’t assess tumor or regional lymph nodes and no evidence of metastasis
D. Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis
A
B. Carcinoma in situ [Tis], no abnormal regional lymph nodes [N0], and no evidence of distant metastasis [M0]
RATIONALE
A T0, N0, M0
C Tx, Nx, M0
D Tis, N1, M1
6
Q
- A nurse is reviewing the diagnostic test results of a client who had a pap smear performed. The nurse notes that the physician has documented stage 1 cancer of the cervix. The nurse interprets that this finding indicates that the carcinoma:
A. Has extended beyond the cervix but not extended to the pelvic wall
B. Is confined to the cervix
C. Has extended to the pelvis wall and lower third of vagina
D. Has extended beyond the true pelvis or has involved the bladder or rectal wall
A
B. Is confined to the cervix
RATIONALE
A Stage 2
C Stage 3
D Stage 4
7
Q
- Which statement by the client indicates to the nurse that the patient understands precautions necessary during sealed radiation therapy for cancer of the cervix?
A. “I should get out of bed and walk around in my room”
B. “My 7 year old twins should not come to visit me while I’m receiving treatment”
C. “I will not try to cough, because the force might make me expel the application”
D. “I know that my primary nurse has to wear one of those badges like the people in the x-ray department, but they are not necessary for anyone else who comes in here”
A
B. “My 7 year old twins should not come to visit me while I’m receiving treatment”
RATIONALE
Pregnant women and children is contraindicated to visit the patient.
A Patient should be in CBR
C Sealed RT is an implant
D Anyone should follow the STD principles
8
Q
- The nurse is preparing a plan of care for a client who will be hospitalized for insertion of an internal cervical radiation implant. Which nursing intervention the nurse implements in preparation for the arrival of the client?
A. Prepare private room at the end of the hallway
B. Place a sign on the door that indicates that visitors are limited to 60 minutes visit per day
C. Assign one primary nurse to care for the client during the hospital stay
D. Have long handed forceps and trash bin available inside the room of patient
A
A. Prepare private room at the end of the hallway
RATIONALE
B Correct: Visitors are limited only to 30 minutes per day
C Correct: Nursing assignment is Rotational
D Correct: Long handed forceps and LEAD CONTAINER
9
Q
- An adult is scheduled for a radioactive implant for treatment of cervical cancer. The nurse has instructed the client about care following the procedure. The nurse determines that the client has understood the instructions when she says,
A. “I will not be able to have any visitors when the implant is in place”
B. “I will need to use a bedside commode for bowel movements”
C. “I will have an indwelling catheter while the implant is in place”
D. “I will need to eat a high fiber diet while I am on bed”
A
C. “I will have an indwelling catheter while the implant is in place”
RATIONALE
A Correct: Visitors are allowed only for 30 minutes per day
B Correct: Bedside commode is not used since patient has already undergone cleansing enema before RT
D Correct: It should be low-fiber diet to minimize residue formation that could lead to defecation
10
Q
- A client is in isolation after receiving an internal radioactive implant to treat cancer. 2 hours later, the nurse discovers the implant in the bed linens. What should the nurse do first?
A. Stand as far away as possible and call for help
B. Pick up the implant with long handed forceps and place it in a lead-lined container
C. Leave the room and notify the radiation therapy department immediately
D. Put the implant back in place, using forceps and shield for protection, and call for help
A
B. Pick up the implant with long handed forceps and place it in a lead-lined container
11
Q
- Which statement by a client undergoing external radiation therapy indicates the need for further teaching?
A. “I will wash my skin with water only”
B. “I will not use my heating pad during my treatment”
C. “I will wear protective clothing when outside”
D. “I will expose my family to radiation”
A
D. “I will expose my family to radiation”
RATIONALE
Patient is not radioactive.
12
Q
- Which of the following is true regarding external therapy?
A. It is called teletherapy and the most common complaint is an abnormal skin pigmentation
B. It is called brachytherapy and the most common complaint is having opportunistic infection
C. It is called chemotherapy and the most common complaint is having sore throat
D. It is called biotherapy and the most common complaint is having an abnormal skin pigmentation
A
A. It is called teletherapy and the most common complaint is an abnormal skin pigmentation
13
Q
- A client with renal cancer is being treated preoperatively with radiation therapy. The nurse evaluates that the client has an understanding of proper care of the skin over the treatment field if the client states to:
A. Apply lotion to the affected skin
B. Wear tight clothing over the skin site to provide support
C. Avoid skin exposure to direct sunlight
D. Wash the ink marks off the skin
A
C. Avoid skin exposure to direct sunlight
RATIONALE
A Correct: Lotion is contraindicated, unless prescribed
B Correct: Loose clothing
D Correct: Avoid washing off/remove markings
14
Q
- The nurse includes which of the following in the teaching plan related to external beam radiation?
A. “You will be placed on low protein diet”
B. “You will not be radioactive because of the treatment”
C. “An implant will be inserted in your body cavity”
D. “Only your body fluids are radioactive”
A
B. “You will not be radioactive because of the treatment”
RATIONALE
A Internal - Sealed
C Internal - Sealed
D Internal - Unsealed
15
Q
- A client received chemotherapy 24 hours ago. Which precautions are necessary when caring for the client?
A. Wear sterile gloves
B. Place incontinence pads in the regular trash container
C. Wear personal protective equipment when handling blood, body fluids, and feces
D. Provide a urinal or bedpan to decrease the likelihood of soiling linens
A
C. Wear personal protective equipment when handling blood, body fluids, and feces
A Not necessary
B Correct: Radioactive container
D Not necessary
16
Q
- Cytarabine (Cytosar) is prescribed for a client with acute lymphocytic leukemia. A nurse understands that this medication is classified as an antimetabolite and is:
A. Cell cycle phase non-specific medication
B. Cell cycle phase specific medication affecting the M phase
C. Cell cycle phase specific medication affecting the S phase
D. Medication that affects cells in any phase of the cell reproductive cycle
A
C. Cell cycle phase specific medication affecting the S phase
17
Q
- The nurse is giving a patient with cancer the medication cyclophosphamide. Which of the following is incorrect about the medication?
A. Increase oral fluid intake
B. Observe patient for weight gain, crackles and edema
C. The medication can cause hemorrhagic cystitis
D. Observe for painless hematuria
A
B. Observe patient for weight gain, crackles and edema
RATIONALE
It refers to Anti-Tumor Antibiotics such as Doxurubicin (Adriamycin) which can cause CHF.
18
Q
- The nurse is giving discharge planning to a cancer patient on doxorubicin (Adriamycin). What is important to tell to the client?
A. Report symptoms of hematuria
B. Increase oral fluids
C. Observe patient for staggering balance
D. Report symptoms of dyspnea
A
D. Report symptoms of dyspnea
RATIONALE
Doxorubicin (Adriamycin) causes CHF and manifestations such as crackles, edema, and dyspnea may be observed.
A and B refer to Cyclophosphamide (Cytoxan), an Alkylating agent
C Refers to Fluorouracil (5FU), an Antimetabolite
19
Q
- A client with ovarian cancer is being treated with Vincristine (Oncovin). A nurse monitors the client, knowing that which of the following is a side effect specific to this medication?
A. Diarrhea
B. Numbness
C. Chest pain
D. Hair loss
A
B. Numbness
RATIONALE
Vincristine (Oncovin) is toxic to the nerves which may cause Peripheral Neuritis. Numbness, paresthesia, and tingling are the signs and symptoms.
20
Q
- A chemotherapeutic agent, Methotrexate is ordered for a client. Which of the following statements is true about chemotherapy?
A. It affects only the tumor cells
B. It causes very few side effects
C. It can destroy all cancer cells in one exposure
D. It affects both cancer cells and normal cells
A
D. It affects both cancer cells and normal cells
21
Q
- The nurse is reviewing the laboratory results of a client receiving chemotherapy. On review the nurse notes that the WBC count is low. The client is placed on neutropenic precaution. Which intervention is incorrect component of neutropenic precautions?
A. Allowing fresh fruits in the client’s room
B. Removing fresh-cut flowers from the client’s room
C. Instructing family members to wear mask when entering the client’s room
D. Instructing family members on proper technique for hand washing
A
A. Allowing fresh fruits in the client’s room
RATIONALE
Fresh fruits can harbor microorganisms.
22
Q
- While a client is receiving intravenous doxorubicin (Adriamycin), the nurse observes that there is an absence of blood return from the IV catheter. The nurse should:
A. Stop the administration of the drug immediately
B. Notify the client’s physician
C. Continue to administer the drug and assess for edema
D. Apply a warm compress to the site
A
A. Stop the administration of the drug immediately
RATIONALE
It must be immediately stop as it may cause extravasation.
23
Q
- A young boy, who is receiving chemotherapy, develops alopecia and says to the nurse, “I’m so ugly. I’ve lost all my hair.” Which of the following responses would be appropriate for the nurse to make to the child?
A. “Did you know that because of you hair fell out, we know that the medicine is working to make you better?”
B. “Would you like to see some pictures of famous men who are bald?”
C. “You look awesome.”
D. “You can wear a baseball cap until your hair grows back.”
A
D. “You can wear a baseball cap until your hair grows back.”
24
25. A client is receiving chemotherapy with several anti-neoplastic agents. Which nursing observation considers side effect of chemotherapy?
A. Slow slurred speech
B. Increased leukocytes on CBC
C. Dry mouth and oral ulcers
D. Sinus dysrhythmias with bradycardia
C. Dry mouth and oral ulcers
RATIONALE
GIT effects of chemotherapy include xerostomia (dry mouth), stomatitis (mouth ulcers) and altered taste.
25
26. While Mrs. Enriquez is receiving chemotherapy. Which of the following will you include in the plan of care to address her nutritional needs?
A. Administer antiemetic
B. Enrich diet with beef
C. Serve hot soup and food
D. Increase the amount of spice in the diet
A. Administer antiemetic
RATIONALE
As Nausea and vomiting side effects of chemotherapy, the patient should be given anti-emetic.
Choices B, C and D are incorrect. Diet of patient receiving chemotherapy should be BLAND.
26
27. The nurse is conducting an education session for a group of smokers in a "stop smoking" class. Which finding would the nurse state as a common symptom of lung cancer?
A. Dyspnea on exertion
B. Foamy, blood-tinged sputum
C. Wheezing sound in inspiration
D. Cough or change in a chronic cough
D. Cough or change in a chronic cough
RATIONALE
Nagging cough or hoarseness — one of the 7 WARNING SIGNS of Cancer (CAUTION).
27
28. The nurse is caring for a client with bronchogenic carcinoma. Which nursing diagnosis takes the highest priority?
A. Anxiety
B. Body image disturbance
C. Ineffective airway clearance
D. Altered nutrition, less than body requirement
C. Ineffective airway clearance
28
29. Ms. Evans undergoes a right pneumonectomy for lung cancer. Which of the following positions shouldn't be used when repositioning her immediately following the procedure?
A. Semi-fowler's position
B. Left side-lying position
C. Right side-lying position
D. High fowler's position
B. Left side-lying position
RATIONALE
In pneumonectomy post-op, the unaffected lung should be above the affected lung to maximize its expansion, as it is the only lung that is functioning.
29
30. An oncology nurse educator is speaking to a women's group about breast cancer. Various members of the audience have made all of the following statements. Which one is accurate?
A. Mammography is the most reliable method of detecting breast cancer
B. Breast cancer is the leading killer of women of childbearing age
C. Breast cancer requires a mastectomy
D. Men can develop breast cancer
D. Men can develop breast cancer
RATIONALE
A Correct: Biopsy
B Correct: #1 common in women, #2 killer
C Not necessary
30
31. Beverly, a post mastectomy patient, stated, "I know I am not attractive anymore." The best response of the nurse will be:
A. "Would you wish to discuss this with me?"
B. "That's not important. You may not be attractive anymore but you are still a beautiful person inside."
C. "Of course you're still attractive. Don't listen to what other people are saying."
D. "Let's not talk about this. We need to focus on more important things. Being ugly is only a minor thing."
A. "Would you wish to discuss this with me?"
31
32. Lymphedema is the most common postop complication following axillary lymph node resection. Which of the following actions would not minimize this problem?
A. Wearing of gloves when washing dishes
B. Arm elevation above heart level
C. Wearing thimble when sewing
D. BP taking on the arm on affected side
D. BP taking on the arm on affected side
32
33. Hormone therapy is prescribed as the mode of treatment for a client with prostate cancer. The nurse understands that the goal of this form of treatment is to:
A. Limit the amount of circulating androgen
B. Increase the amount of circulating androgen
C. Increase testosterone levels
D. Increase prostaglandin levels
A. Limit the amount of circulating androgen
RATIONALE
Prostate cancer is a cancer in men notable to have an increase in androgen hormones.
33
34. A client with prostate cancer is treated with hormone therapy consisting of diethylstilbestrol (DES), 2mg daily. The nurse should instruct the client that the medication can cause
A. Tenderness of the scrotum
B. Tenderness of the breasts
C. Loss of pubic hair
D. Decreased BP
B. Tenderness of the breasts
RATIONALE
DES, a synthetic estrogen decreases androgen hormone. Side effects include gynecomastia, high-pitched voice, and broader hips.
34
35. The physician schedules Mr. Pama for a transurethral resection of the prostate (TURP) under spinal anesthesia. Before surgery, the nurse should tell the patient that:
A. He may receive continuous bladder irrigation after the procedure
B. The procedure may cause impotency
C. Sterility is a common complication of this procedure
D. The physician will remove the entire prostate during this procedure
A. He may receive continuous bladder irrigation after the procedure
RATIONALE
CBI is performed as the bladder will be contained with blood from prostate resection which may form clots.
B and C is incorrect. It may not cause impotence and sterility.
D Correct: Part of the prostate that obstructs the bladder and urethra is only removed.
35
36. The nurse is conducting a screening for colorectal cancer. The client with the highest risk of colorectal cancer is a:
A. 52-year old man with a family history of polyposis
B. 32-year old woman with a history of skin cancer
C. 61-year old man with a history of gastric ulcers
D. 42-year old man following a low-fat, 1,800-calorie diet
A. 52-year old man with a family history of polyposis
RATIONALE
2 counts: Age (⬆️50yo) and polyposis (colon cysts)
B No risk
C 1 count: Age
D No risk
36
37. Which of the following symptoms is a client with colon cancer most likely to exhibit?
A. A change in appetite
B. A change in bowel habits
C. An increase in body weight
D. An increase in body temperature
B. A change in bowel habits
RATIONALE
Change in bowel habits— one of the 7 WARNING SIGNS of Cancer (CAUTION).
37
38. The symptoms of colon cancer vary depending on where in the colon lesion is located. Which would not be a classic symptom of colon cancer?
A. Change in bowel habits
B. Tenesmus
C. Pain on the right upper quadrant of the abdomen
D. Rectal bleeding
C. Pain on the right upper quadrant of the abdomen
RATIONALE
Unrelated.
38
39. The clinic nurse has conducted a health screening clinic to identify female clients at risk for developing cervical cancer. The nurse is reviewing the assessment findings in the records of the clients who attended the clinic. Which client is at least risk for developing cervical cancer?
A. A client who had early, frequent intercourse with multiple sexual partners
B. A multiparity client
C. A client with a history of chronic cervicitis
D. A single male smoker with sexually transmitted infection
D. A single male smoker with sexually transmitted infection
RATIONALE
Cervix cancer is a cancer in women only. NOT IN MEN.
39
40. A nurse is counseling a client about decreasing the risk for cervical cancer. Which statement by the client indicates a need for further counseling?
A. "I need to keep my appointments for Pap smear at the frequency advised by my Dr."
B. "I need to seek prompt treatment for vaginitis."
C. "Condoms are needed only if I don't trust a male partner."
D. "A partner who is uncircumcised will present an increased risk."
C. "Condoms are needed only if I don't trust a male partner."
40
41. The woman tells the nurse that she is always nervous about gynecological examinations because "there has been a lot of cancer in my family". The nurse should be aware that a late sign of cervical cancer is?
A. A thick, foul-smelling vaginal discharge
B. Bleeding after intercourse
C. A change in the menstrual cycle
D. Watery vaginal discharge
A. A thick, foul-smelling vaginal discharge
41
42. The client reports to the nurse that when performing TSE, he found a lump the size and shape of a pea. The most important response to the client is which of the following?
A. "That is important to report even though it might not be serious."
B. "That could be cancer. Ask the doctor to examine you."
C. "Let me know if it gets bigger next month."
D. "Lumps like that are normal. Don't worry."
A. "That is important to report even though it might not be serious."
42
43. A nurse recognizes that testicular cancer:
A. Is most common among men over 65 years of age
B. Is one of the most curable solid tumors
C. Generally produces a painful enlargement of the testis
D. Tend to metastasize late in the development of the disease
B. Is one of the most curable solid tumors
RATIONALE
A Correct: Common among young adults (20's)
C Correct: PAINLESS enlargement of testis
D Correct: Rarely metastasize
43
44. Which of the following conditions, reported to a nurse by a 20-year old male patient, would indicate a risk for development of testicular cancer?
A. Genital herpes
B. Undescended testicle
C. Measles
D. Hydrocele
B. Undescended testicle
44
45. Which finding is an early indicator of bladder cancer?
A. Painless hematuria
B. Occasional polyuria
C. Nocturia
D. Dysuria
A. Painless hematuria
RATIONALE
It is the hallmark sign of bladder cancer.
45
46. A client with bladder cancer undergoes a total cystectomy and ileal conduit. Postoperatively, the nurse notes mucus in the client's urine. Which nursing intervention is most appropriate?
A. Informing the physician that the client has a urinary tract infection
B. Obtaining a urine specimen for C/S
C. Monitoring for other S/Sx of infection
D. Explaining to the client that this is normal after this type of surgery
D. Explaining to the client that this is normal after this type of surgery
46
47. The oncology nurse is providing a teaching session to a group of nursing students regarding the risks and causes of bladder cancer. Which statement if made by the student indicates a need for further teaching?
A. "Bladder cancer most often occurs in women."
B. "Bladder cancer generally is seen in clients older than 40."
C. "Environmental health hazards have been attributed as a cause."
D. "Using cigarettes, artificial sweeteners, and coffee can increase the risk."
A. "Bladder cancer most often occurs in women."
RATIONALE
Bladder cancer is common in men.
47
48. Which of the following clients is at most risk for developing Hodgkin's disease?
A. A 22-year old man with a history of mononucleosis
B. A 25-year old man who smokes a pack of cigarettes a day
C. A 33-year old man with a sister of Hodgkin's lymphoma
D. A 40-year old woman with a history of human immunodeficiency virus (HIV) infection
A. A 22-year old man with a history of mononucleosis
RATIONALE
2 counts: Age (20's) and a history of mononucleosis (d/t Epstein Barr Virus)
B 1 count: Age
C and D have no risk
48
49. The nurse provides an educational session to nursing staff regarding the characteristics of Hodgkin's disease. The nurse determines that further education is needed if a nursing staff member states that which of the following is a characteristic of the disease?
A. Presence of Reed Sternberg cells
B. Involvement of lymph node, spleen and liver
C. Occurs most often in older clients
D. Prognosis depends on the stage of the disease
C. Occurs most often in older clients
RATIONALE
It occurs both in young adults (20's) and older clients (50's).
49
50. A client admitted with newly diagnosed with Hodgkin's diesease. Which of the following would the nurse expect the client to report?
A. Lymph node pain
B. Weight gain
C. Night sweats
D. High fever
C. Night sweats
RATIONALE
Early symptoms of Hodgkin's disease include painless LN swelling, anorexia, unexplained pruritus, and the systemic "B symptoms" Night Sweats, Low grade fever, and weight loss.
50
51. A nurse is conducting a health screening for osteoporosis. The nurse would interpret that which of the following clients is at greatest risk of developing this disorder?
A. A sedentary 36 year old male alcoholic with asthma
B. A sedentary 65 year old female smoker
C. A sedentary 25 year old Asian female
D. A sedentary 75 year old male who drinks excess alcohol
B. A sedentary 65 year old female smoker
RATIONALE
4 counts: Sedentary, Age, Female, Smoker
Risk factors
• Age: ⬆️40
• Gender: Female (⬇️Estrogen: promotes Ca resorption)
• Race: Caucasians/Asians
• Diet: ⬇️Calcium
• Sedentary lifestyle (inactivity/immobility: no stress in bones
promotes resorption)
• ⬆️Intake of
51
52. Primary prevention of osteoporosis, includes which of the following measures?
A. Place items within reach of the client
B. Install bars in the bathroom to prevent falls
C. Maintain the optimal calcium intake
D. AOTA
C. Maintain the optimal calcium intake
RATIONALE
A and B refers to prevention of injury
D Incorrect
52
53. The nurse knows that a 60-year old female client's susceptibility to osteoporosis is most likely not related to:
A. Estrogen deficiency
B. Hormonal disturbances
C. Cessation of menstruation
D. Genetic predisposition
D. Genetic predisposition
RATIONALE
Risk factors
• Age: ⬆️40
• Gender: Female (⬇️Estrogen: promotes Ca resorption)
• Race: Caucasians/Asians
• Diet: ⬇️Calcium
• Sedentary lifestyle (inactivity/immobility: no stress in bones
promotes resorption)
• ⬆️Intake of
53
54. Alvin, a client with lactose intolerance requires dietary teaching. Which of the following foods should the nurse advise him to eat to ensure adequate calcium intake?
1. Bananas and avocados
2. Beef liver and broccoli
3. Cheese and yogurt
4. Malunggay and kangkong
A. 3 and 4
B. Except 1, 2 and 3
C. 3 only
D. 1 and 2
B. Except 1, 2 and 3
RATIONALE
1 Rich in potassium
2 Rich in iron
3 Rich in calcium but client is lactose intolerant
54
55. For a client with osteoporosis, the nurse shouldn't provide which dietary instruction?
1. "Limit intake of liver and beans."
2. "Eat more dairy products to increase your calcium intake."
3. "Decrease your intake of popcorn, nuts, and seeds."
4. "Avoid eating fresh fruits and vegetables."
A. 1 and 2
B. 2 only
C. 1,3 and 4
D. 1,2 and 3
C. 1,3 and 4
RATIONALE
1 Not limit
3 Increase
4 Not avoid
55
56. All of the following are manifestations of fractures EXCEPT:
A. Crepitus
B. Decrease in length of the affected extremity
C. Bruising
D. Osteophytes
D. Osteophytes
RATIONALE
Osteophytes are new bone formation, commonly found in osteoarthritis.
S/Sx
1. Pain (sharp, increases with movement)
2. Loss of function/movement
3. Deformity
4. Crepitus (d/t friction of bones)
5. Ecchymosis (bleeding/bruising)
6. Swelling
7. Shortening (muscle spasm)
56
57. A client comes to the emergency department complaining of dull, deep bone pain unrelated to movement. Which of the following statements is correct to help decide if the bone pain is caused by a fracture?
A. These are classic symptoms of a fracture
B. Fracture pain is sharp and related to movement
C. Fracture pain is sharp and unrelated to movement
D. Fracture pain is dull and deep and related to movement
B. Fracture pain is sharp and related to movement
57
58. The client with fractured tibia has been taking Methocarbamol (Robaxin). When teaching the client about this drug, which of the following would the nurse include as the drug's primary effect?
A. Reduces swelling
B. Control bleeding
C. Relief of shortening
D. Killing of microorganism
C. Relief of shortening
```
RATIONALE
Methocarbamol (Rubaxin) is a muscle relaxant, decreases muscle spasm relieving shortening.
```
58
59. Emergency management of fracture includes the following, EXCEPT:
1. Immobilize the body part
2. Support affected extremity using splint
3. Assess for sensation on the distal part of the affected extremity
4. NOTA
A. 1 and 3
B. 2 and 3
C. 1 only
D. 4 only
D. 4 only
59
60. Which of the following characteristics applies to a closed fracture?
A. One side of the bone is broken while the other part is bent
B. Increased risk of infection
C. Same as for a compound fracture
D. Intact skin over the fracture site
D. Intact skin over the fracture site
RATIONALE
A Greenstick fracture
B and C Open/Complex/Compound Fracture
60
61. A client sustained a right femoral neck fracture after falling at home. Initial assessment of the fracture would most likely reveal:
A. Internal rotation and abduction of the right leg, which is shorter than the left leg
B. Lateral rotation and adduction of the right leg, which is shorter than the left leg
C. Internal rotation and abduction of the left leg, which is shorter than the right leg
D. Lateral rotation and adduction of the left leg, which is shorter than the right leg
B. Lateral rotation and adduction of the right leg, which is shorter than the left leg
```
RATIONALE
Appearance of affected leg (Hip and femoral fracture)
Shortening
A
D
Duction
External/Lateral
Rotation
```
61
62. A patient is 1 day post-op after hip replacement. During meals, the patient should be placed on which of the following positions?
A. Lithotomy
B. Semi-fowler's
C. Trendelenburg
D. Orthopneic
B. Semi-fowler's
RATIONALE
A Irrelevant
C Risk for aspiration
D Risk for dislocation
62
63. A client is admitted to the hospital for a THR. The nurse's preoperative teaching plan for the early postoperative period should not include which of the following instructions?
1. External rotation of the affected leg
2. Abduction of the operative hip
3. Internal rotation of the affected leg
4. Hip flexion of more than 90 degrees on the operative side
A. 1 and 2
B. 2 and 3
C. 1,3 and 4
D. 2 only
C. 1,3 and 4
RATIONALE
✅ Abduction ❌ Adduction
✅ Pillows/Abductor splint between legs
✅ Neutral ❌ Lateral Rotation: Internal/External
✅ TURN: Unaffected side ❌ Affected side
✅ HIP FLEXION: 90°
• SF • Orthopneic
• Supine • HF/sitting
• Raised seats • Low seats
• Cross-sitting
63
64. A 35-year old female client with a hip fracture has undergone total hip replacement surgery. Which of the following shouldn't the client perform?
A. Sitting on a raised commode seat
B. Crossing the legs while sitting down
C. Placing pillows between legs
D. Maintain legs on neutral position
B. Crossing the legs while sitting down
RATIONALE
✅ Abduction ❌ Adduction
✅ Pillows/Abductor splint between legs
✅ Neutral ❌ Lateral Rotation: Internal/External
✅ TURN: Unaffected side ❌ Affected side
✅ HIP FLEXION: 90°
• SF • Orthopneic
• Supine • HF/sitting
• Raised seats • Low seats
• Cross-sitting
64
65. The nurse is caring for an elderly client who had just had a prosthetic hip implant. The nurse should position the client:
A. Side lying on the unaffected side with the affected hip internally rotated and flexed
B. With the affected hip adducted when turned
C. In the supine position with the knees elevated 90 degrees
D. Side-lying on the unaffected side with the affected hip in position of abduction
D. Side-lying on the unaffected side with the affected hip in position of abduction
RATIONALE
✅ Abduction ❌ Adduction
✅ Pillows/Abductor splint between legs
✅ Neutral ❌ Lateral Rotation: Internal/External
✅ TURN: Unaffected side ❌ Affected side
✅ HIP FLEXION: 90°
• SF • Orthopneic
• Supine • HF/sitting
• Raised seats • Low seats
• Cross-sitting
A ✅ Side lying on the unaffected side with the affected hip ❌internally rotated and flexed
B With the affected hip ❌adducted when turned
C In the ✅ supine position with the knees ❌ elevated 90 degrees
65
66. Nursing care specific for an adult in Buck's Traction would not include:
A. Checking site of pins for bleeding or infection
B. Making sure traction weight hangs freely at all times
C. Maintaining proper alignment of patient
D. Observing for developing pressure ulcer on the sacral area
A. Checking site of pins for bleeding or infection
RATIONALE
Buck's traction is a skin traction.
66
67. An infant with a dislocated hip is placed in Bryant's Traction. The nurse plans to assess which if the following while the infant is in traction?
A. Skin integrity over the scapulae
B. Pin sites at the tibia
C. Security of the halter strap
D. NOTA
A. Skin integrity over the scapulae
RATIONALE
Bryant's traction is a skin traction.
67
68. When a client has cervical halter traction to immobilize the cervical spine counteraction is provided by:
A. Elevating the foot of the bed
B. Elevating the head of the bed
C. Application of the pelvic girdle
D. Lowering the head of the bed
B. Elevating the head of the bed
68
69. Which nursing intervention is appropriate for a client with skeletal traction?
A. Pin care
B. Prone positioning
C. Intermittent weights
D. 5lb weight limit
A. Pin care
RATIONALE
B Supine position
C Continuous weight
D 15-25 lbs
69
70. To promote skin integrity of a patient who is in Russell's traction, which of the following measures should be included in the plan of care?
A. Having the patient lie on the right side for 20 minutes every 2 to 3 hours
B. Placing the pillow under the patient's sacral and scapular area
C. Massaging the patient's back and buttocks frequently
D. Applying an antiseptic solution to the patient's bony prominences after bathing
C. Massaging the patient's back and buttocks frequently
70
71. Which of the following manifestations signify possible infection in a patient with a spica cast?
A. Presence of "hot shots"
B. Body temperature of 37.2 degrees
C. Warm and mobile fingers
D. Foul smelling odor from cast
D. Foul smelling odor from cast
71
72. A client has a long leg plaster cast applied. What nursing actions are implemented while the cast is still wet?
A. Use only fingertips when moving the cast
B. Keep the client and cast covered with blankets
C. Use palms or support the cast on pillows
D. Place a heat lamp directly over the cast
C. Use palms or support the cast on pillows
RATIONALE
A Indentions can cause compartment syndrome
B and D The increase in heat sensation can cause burns
72
73. A client has fiberglass cast on the right arm. Which action should the nurse include in the plan of care?
1. Keeping the casted arm warm by covering it with a light blanket
2. Avoiding handling the cast for 24 hours
3. Evaluating pedal and posterior tibial pulse every 2 hours
4. Assessing movement and sensation in the fingers of the right hand
A. 1,2 and 4
B. 4 only
C. 2 and 4
D. 3 and 4
B. 4 only
RATIONALE
1 Correct: Exposed/Air Dry
2 Fiberglass cast dries after 10-15 minutes
3 Irrelevant. Cast is on right arm
73
74. A patient with plaster of Paris cast applied to his left arm is receiving pain medication. Which of the following assessment would best detect early manifestation of compartment syndrome?
A. Check the odor and appearance of the dressing
B. Observe color of the fingers
C. Palpate the pedal pulse
D. Evaluate the response to analgesics
B. Observe color of the fingers
74
75. A client has sustained a right tibial fracture and has just had a cast applied. Which instruction should the nurse provide in his cast care?
A. "Cover the cast with a blanket until the cast dries."
B. "Keep your right leg above the heart level."
C. "Use a knitting needle to scratch inches inside the case."
D. "A foul smelling from the cast is normal."
B. "Keep your right leg above the heart level."
RATIONALE
A Exposed/Air dry
C Never insert anything inside
D Indicates infection
75
76. While attending a client who has just been amputated, you hear the client says, "I hate the idea of being an invalid after they cut off my leg." Which of the following would be your MOST therapeutic response?
A. "Look at the sky, it is so beautiful."
B. "Tell me more about you're feeling."
C. "Why did they cut your leg?"
D. "At least you will still have one good leg to use. Don't complain."
B. "Tell me more about you're feeling."
RATIONALE
Promotes verbalization.
76
77. To prevent a hip flexion contracture following an amputation of the lower limb, the nurse should teach the client to:
A. Sit on a chair for 30 minutes TID
B. Lie on the abdomen 30 minutes QID
C. Turn from side to side every 2 hours
D. Quadriceps setting exercises BID
B. Lie on the abdomen 30 minutes QID
RATIONALE
Management to prevent flexion contracture of the hip is by extending the legs or avoiding elevating or by maintaining 180°, e.g. Through prone positioning.
77
78. A client who is admitted with an above-the-knee amputation tells the nurse that his foot hurts and itches. Which response by the nurse indicates understanding of the phantom limb pain?
A. "The pain will go away in a few days."
B. "The pain is due to peripheral nervous system interruptions. I will get you some pain medication."
C. "The pain is psychological because your foot is no longer there."
D. "The pain and itching are due to the infection you had before the surgery."
B. "The pain is due to peripheral nervous system interruptions. I will get you some pain medication."
78
79. A client with arterial insufficiency undergoes below-knee amputation of the right leg. Which action shouldn't the nurse include in the post-op care plan?
A. Elevating the slump for the first 24 hours
B. Monitoring for bleeding
C. Applying heat to the stump as the client desires
D. Managing phantom limb sensation
C. Applying heat to the stump as the client desires
RATIONALE
Heat promotes bleeding. Instead, ice should be used.
79
80. Emergency department nurse teaches patients with sports injuries to remember the acronym RICE, which stands for which of the following combinations of treatment?
A. Rest, ice, compression, elevation
B. Rotation, immersion, compression, elevation
C. Rest, ice, circulation, examination
D. Rotation, ice, compression, examination
A. Rest, ice, compression, elevation
80
81. Vincent, a basketball superstar, sprained his right ankle after he stepped on another player's foot during the game. Which of the following is an appropriate first aid management of sprained ankle?
A. Apply warm compress to the area
B. Perform ROM of the affected joint
C. Elevate affected extremity
D. Apply splint on his arm
C. Elevate affected extremity
RATIONALE
Tip: Use RICE
A Correct: Ice
B Correct: Rest
D Irrelevant; sprain is on e right ankle
81
82. Immediate management of sprain will include the following EXCEPT?
A. Elevation of the affected body part
B. Wrapping the affected body part using an elastic bandage from proximal to distal
C. Immobilize using a splint
D. Ice compress on the sprained area
B. Wrapping the affected body part using an elastic bandage from proximal to distal
RATIONALE
Correct: Distal to proximal
82
83. A client has been diagnosed with gout and wants to know why colchicine is used in the treatment of gout. Which of the following actions of colchicine explains why it's effective for gout?
1. Decreases uric acid production
2. Increases excretion of uric acid
3. Decreases inflammation
4. Prevents deposition of uric acid into the joints
A. 1 and 2
B. 1 and 4
C. 2 and 3
D. 3 and 4
D. 3 and 4
RATIONALE
1 Refers to Allopurinol
2 Refers to Probenecid
83
84. Jim is a 40-year old man who presents to the emergency department with an acute gout attack in his right knee. Which treatment option would NOT be indicated at this time?
A. Encourage the client to maintain a fluid restriction
B. Encourage the client to avoid excessive alcohol intake
C. Encourage the client to avoid purine rich foods
D. AOTA
A. Encourage the client to maintain a fluid restriction
RATIONALE
Correct: Encourage fluid intake
84
85. A client with gouty arthritis is prescribed a low-purine diet. The nurse should instruct the client to avoid:
A. Organ meats
B. Citrus foods
C. Green vegetables
D. Fresh milk
A. Organ meats
85
86. Client education about gout includes which of the following information?
A. Good foot care will reduce complications
B. Increased dietary intake of purine is needed
C. Production of uric acid in the kidney affects joints
D. Uric acid crystals cause inflammatory destruction of the joint
D. Uric acid crystals cause inflammatory destruction of the joint
RATIONALE
Uric acid crystals, also known as Tophi, is the hallmark sign of Gouty Arthritis.
A Refers to DM management
B Purine diet is avoided
C Production of uric acid is through purine metabolism
86
87. When caring for a client experiencing an acute gout attack, the nurse anticipates administering which medication?
A. Allopurinol
B. Alendronate
C. Colchicine
D. Prednisone
C. Colchicine
RATIONALE
Colchicine prevents deposition of uric acid in the joints and is used in acute gout attack.
A Decreases uric acid production
B Medical management for osteoporosis
D Anti-inflammatory
87
88. A 45-year old female client with rheumatoid arthritis tells the nurse, "I know how important it is to exercise my joints so that I won't lose mobility. But they are so stiff and painful that exercising is difficult." Which of the following is the MOST appropriate response of the nurse?
A. "You are probably exercising too much. Reduce your exercise to every other day."
B. "Tell the doctor about your symptoms. Maybe your analgesic medication can be increased."
C. "Take a warm tub bath or shower before exercising. This may help you with your discomfort."
D. "Stiffness and pain are part of the disease. Learn to cope by focusing on activities you enjoy."
C. "Take a warm tub bath or shower before exercising. This may help you with your discomfort."
RATIONALE
Promotes muscle relaxation.
88
89. The following statements are TRUE concerning rheumatoid arthritis EXCEPT:
A. It most often affects smaller joints
B. It should be treated initially by corticosteroid
C. It is frequently associated with joint pain
D. It is in inflammatory process
B. It should be treated initially by corticosteroid
RATIONALE
1st Line: NSAIDs
2nd Line: Corticosteroids
3rd line: DMARDs (Hydroxychloroquine, Methotrexate,
Aurothyoglucose)
89
90. Which type of medication is most commonly used to treat RA?
A. Glucocorticoids
B. NSAIDs
C. Anti-malarial drugs
D. Gold salts
B. NSAIDs
RATIONALE
1st line of drugs is often used. Increasing line of drugs increases side effects.
A 2nd line
C and D 3rd line
90
91. Ralph is studying for his nursing boards when he comes upon different types of arthritis. At the course it was recommended to study the differences between osteoarthritis and rheumatoid arthritis. Which statement, if made by Ralph, demonstrates that further teaching is needed?
A. "RA is inflammatory; OA is degenerative."
B. "The risk factors or causes of RA are probably autoimmune or due to emotional stress, whereas OA may be due to age, obesity, trauma, or occupation."
C. "The disease pattern of RA is usually unilateral and in single joint, whereas OA is usually bilateral, symmetric, and in multiple joints."
D. "The typical onset of RA is between 35 and 45 years of age, whereas the typical onset of OA is in clients older than 60 years of age."
C. "The disease pattern of RA is usually unilateral and in single joint, whereas OA is usually bilateral, symmetric, and in multiple joints."
RATIONALE
RA is bilateral and in multiple joints.
OA is unilateral, assymetric, and in single joint.
91
92. Rheumatoid arthritis is currently attributed to:
A. Uric acid deposition into the joints
B. Acceleration of bone resorption
C. Occurrence of an autoimmune response
D. Occurrence of a degeneration reaction
C. Occurrence of an autoimmune response
RATIONALE
A Refers to Gouty Arthritis
B Refers to Osteoporosis
D Refers to Osteoarthritis
92
93. A 69-year old client asks the nurse what the difference between OA and RA. Which response is correct?
A. "OA is non-inflammatory joint disease. RA is characterized by inflamed, swollen joints."
B. "OA and RA are very similar. OA affects smaller joints and RA affects larger, weight bearing joints."
C. "OA affects joints on both sides of the body. RA is usually unilateral."
D. "OA is more common in women. RA is more common in men."
C. "OA affects joints on both sides of the body. RA is usually unilateral."
RATIONALE
B Correct: OA affects larger, weight bearing joints. RA affects smaller joints
C Correct: OA is unilateral. RA is bilateral
D Correct: Both OA and RA are common in women. ⬆️30 yo in RA, and ⬆️50 yo in OA
93
94. A client with possible osteoarthritis is having X-rays performed on both knees. X-rays of an ostoeoarthritic joint reveal:
A. Enlargement of the joint space or margin
B. Uric acid crystals
C. Osteophyte formation
D. Cartilage growths at weight-bearing joints
C. Osteophyte formation
RATIONALE
A Osteoarthritis reveals narrowing of joint space
B Refers to gouty arthritis
D Normal joints
94
95. Which of the following conditions or actions can cause primary osteoarthritis?
A. Overuse of joints, aging, and obesity
B. Obesity, DM, aging
C. Congenital abnormality, aging, overuse of joints
D. DM, congenital abnormality, aging
A. Overuse of joints, aging, and obesity
RATIONALE
Causes of osteoarthritis include Degeneration (most common), idiopathic, repetitive use, and trauma.
Obesity can cause trauma to joints.
95
96. A patient is seen at the clinic with an aching pain on the left hip. The physician's diagnosis is osteoarthritis of the left hip. Expected findings during the nursing assessment would include:
A. Bilateral joint involvement
B. Pannus formation
C. Joint effusions
D. Morning stiffness lasting 30 minutes
D. Morning stiffness lasting 30 minutes
RATIONALE
A, B, and C refer to RA.
96
97. Which of the following is not related to Osteoarthritis?
A. It is common in older clients
B. It is common in obese clients
C. It is manifested with Bouchard and Heberden's node
D. It is characterized by a positive ANA test result
D. It is characterized by a positive ANA test result
RATIONALE
ANA Test or Antinuclear Antibody Test is a diagnostic test for RA to check the presence of antibody.
97
98. The nurse is preparing a client with SLE for discharge. Which instruction should the nurse include in the teaching plan?
A. Exposure to sunlight will help control skin rashes
B. There are no activity limitations between flare ups
C. Monitor body temperature
D. Corticosteroids may be stopped when symptoms are relieved
C. Monitor body temperature
RATIONALE
A Exposure to sunlight exacerbates skin rashes
B Stress exacerbates condition
D Corticosteroids are used for life
98
99. In assessing a young woman just diagnosed with SLE, what characteristic observation is the nurse most likely to assess?
A. Butterfly rashes
B. Osteoarthritis in the fingers
C. Progressive neurological deficits
D. Diaper rashes
A. Butterfly rashes
99
100. The teaching program of a patient with SLE should include emphasis on which of the following?
A. Take prednisone with low potassium diet
B. Increase sodium and water intake
C. Walk in shaded areas
D. Avoid going to the beach
C. Walk in shaded areas
100
1. Which of the following symptoms would suggest to the nurse that Mr. Aquino is in the early stages of hepatic encephalopathy?
A. The patient's respirations are 32, and he appears to be drowsy
B. The patient's abdomen is distended when a protruding umbilicus
C. The patient's upper extremities are adducted, and his lower extremities are internally rotated
D. The patient has difficulty describing what he does at work
D. The patient has difficulty describing what he does at work
RATIONALE
Earliest sign: Altered LOC
A Respiration is unrelated
B It is a sign of ascites
C It is asterixis
101
2. Mr. Aquino with cirrhosis is at risk for developing complications. Which condition is the most serious and potentially life-threatening?
A. Peripheral edema
B. Esophageal varices
C. Ascites
D. Hepatic encephalopathy
D. Hepatic encephalopathy
RATIONALE
It can damage the CNS.
102
3. The nurse is reviewing the record of a patient with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence?
A. Dorsiflex the patient's foot
B. Measure the abdominal girth
C. Ask the patient to extend the arms
D. Instruct the patient to lean forward
C. Ask the patient to extend the arms
RATIONALE
When patient extends the arms, flapping tremors occur.
103
4. Lactulose (Cephulac) is ordered for the client with cirrhosis. Which of the following serum laboratory tests should the nurse monitor to determine if the drug is having the desired effect?
A. Albumin
B. Ammonia
C. Sodium
D. Lactate
B. Ammonia
```
RATIONALE
Lactulose (Cephulac) binds ammonia to GIT and excretes through defecation.
```
104
SITUATION: Ms. Ramos is admitted with complaints of right upper quadrant pain. The client reports tea-colored urine and clay colored stool. Ms. Ramos is diagnosed with Cholecystitis.
5. Ms. Ramos is undergoing assessment. Her right lower quadrant is being palpated and she is asked to breathe deeply. Which if the following is being assessed?
A. Turner's sign
B. Psoas sign
C. Murphy's sign
D. Cullen's sign
C. Murphy's sign
RATIONALE
When patient is positive for Murphy's sign, he cannot perform deep breathing upon palpation of RUQ.
A
B Refers to appendicitis
D Refers to pancreatitis
105
SITUATION: Ms. Ramos is admitted with complaints of right upper quadrant pain. The client reports tea-colored urine and clay colored stool. Ms. Ramos is diagnosed with Cholecystitis.
6. Which of the following would not be expected in assessing Ms. Ramos?
A. RUQ pain 2 — 4 hours after eating fatty foods
B. Bluish discoloration around the umbilicus
C. Elevated temperature
D. Steatorrhea
B. Bluish discoloration around the umbilicus
RATIONALE
It indicates positive Cullen's sign in pancreatitis.
106
SITUATION: Ms. Ramos is admitted with complaints of right upper quadrant pain. The client reports tea-colored urine and clay colored stool. Ms. Ramos is diagnosed with Cholecystitis.
7. Which of the following would not be included in the health teaching of Ms. Ramos?
A. To avoid gas forming foods like cabbage, peanuts and sweet potato
B. To take prescribed anticholinergic Pro-Banthine (propantheline) 30 min before meals
C. To eat small meals when possible
D. Eating cheese burger and French fries for lunch
D. Eating cheese burger and French fries for lunch
RATIONALE
They are high fat foods.
107
SITUATION: Ms. Ramos is admitted with complaints of right upper quadrant pain. The client reports tea-colored urine and clay colored stool. Ms. Ramos is diagnosed with Cholecystitis.
8. Ms. Ramos underwent cholecystectomy. The nurse will anticipate that the major postoperative complication following a cholecystectomy is
A. Atelectasis
B. Thrombophlebitis
C. Hemorrhage
D. Dumping syndrome
A. Atelectasis
RATIONALE
In cholecystectomy post-op, patient may have abdominal pain upon deep breathing which prompt him to do shallow breathing instead, preventing lung expansion and eventually lung collapse (Atelectasis).
108
SITUATION: A 26 year old pregnant housewife with a 3 year old daughter comes to the prenatal clinic with complains of chronic fatigue and dyspnea. She states that she sometimes feels her heartbeat rapidly. Assessment reveals extreme pallor and glossitis. The physician suspects iron deficiency anemia. Answer the following questions.
9. The physician prescribes ferrous sulfate tablets to take home twice a day. Which information should the nurse give her about this iron preparation?
A. It will turn her stool black
B. It may stain her teeth
C. It will concentrate in the urine
D. AOTA
A. It will turn her stool black
RATIONALE
B Happens on liquid preparation only
C Unrelated
109
SITUATION: A 26 year old pregnant housewife with a 3 year old daughter comes to the prenatal clinic with complains of chronic fatigue and dyspnea. She states that she sometimes feels her heartbeat rapidly. Assessment reveals extreme pallor and glossitis. The physician suspects iron deficiency anemia. Answer the following questions.
10. The microscopic features of RBC with iron deficiency is
A. Macrocytic hypochromic
B. Microcytic hypochromic
C. Megaloblastic
D. Microcytic hyperchromic
B. Microcytic hypochromic
RATIONALE
Microcytic: small
Hypochromic: pale
110
SITUATION: A 26 year old pregnant housewife with a 3 year old daughter comes to the prenatal clinic with complains of chronic fatigue and dyspnea. She states that she sometimes feels her heartbeat rapidly. Assessment reveals extreme pallor and glossitis. The physician suspects iron deficiency anemia. Answer the following questions.
11. Priority nursing diagnosis for this patient is
A. Fatigue/Activity Intolerance
B. Ineffective tissue perfusion
C. Imbalance nutrition less than body requirements
D. Ineffective airway clearance
B. Ineffective tissue perfusion
111
SITUATION: Because of difficulties of hemodialysis. Mike is admitted to the hospital for insertion of Tenckhoff catheter and continuous ambulatory peritoneal dialysis.
12. Which nursing diagnosis is important for Mike while he undergoes continuous peritoneal dialysis?
A. Altered urinary elimination
B. Activity intolerance
C. Self-care deficit
D. Risk for infection
D. Risk for infection
112
SITUATION: Because of difficulties of hemodialysis. Mike is admitted to the hospital for insertion of Tenckhoff catheter and continuous ambulatory peritoneal dialysis.
13. Mike has developed faulty red blood cell production. The nurse should monitor him for:
A. Nausea and vomiting
B. Dyspnea and tachypnea
C. Fatigue and weakness
D. Thrush and fever
C. Fatigue and weakness
113
SITUATION: Because of difficulties of hemodialysis. Mike is admitted to the hospital for insertion of Tenckhoff catheter and continuous ambulatory peritoneal dialysis.
14. The doctor prescribes recombinant erythropoietin alfa (epogen) for Mike. Which of the following should the nurse teach him about this drug?
A. The drug will help with the bleeding problems associated with kidney damage
B. Epoetin alfa should reduce fatigue and improve energy level
C. Taking this drug may reduce need for dialysis
D. Once a good blood level is established, the injectable form will be changed to oral form
B. Epoetin alfa should reduce fatigue and improve energy level
114
SITUATION: Nurse Belle is assigned in Burn Unit caring for clients with various burn conditions.
15. Which of the following statements is true regarding pain severity in burns?
A. Pain is directly proportional to the depth of injury
B. Pain is inversely proportional to the depth of injury
C. Pain severity increases as the depth of injury increases
D. Pain is not related to the depth of injury
B. Pain is inversely proportional to the depth of injury
RATIONALE
Pain is felt only at superficial layers because of the presence of nerve fiber endings. In deep layers, there will be no pain felt.
115
SITUATION: Nurse Belle is assigned in Burn Unit caring for clients with various burn conditions.
16. When assessing a client with deep partial-thickness burn, which of the following wound appearance would Nurse Belle expect to find?
A. Blisters
B. White
C. Charred
D. Erythema
B. White
RATIONALE
1° Partial Thickness Superficial - Epidermis - Redness
2° Partial Thickness Deep - Up to dermis - Blisters
3° Full thickness - Up to SQ - White
4° Full thickness - Up to muscles/bones - Charred/Black
116
SITUATION: Nurse Belle is assigned in Burn Unit caring for clients with various burn conditions.
17. Which of the following clusters of symptoms would Nurse Belle note when suspecting a client suffering from deep partial-thickness burn?
A. Tingling and hyperesthesia
B. Pain, hyperesthesia, sensitivity to cold air
C. Pain free and shock
D. Hyperesthesia and pain that is soothed by cooling
B. Pain, hyperesthesia, sensitivity to cold air
RATIONALE
2° is the most painful because nerve fiber endings are exposed to the external environment.
117
SITUATION: Nurse Belle is assigned in Burn Unit caring for clients with various burn conditions.
18. When a nurse encounters a running burning client, which of the following immediate nursing actions is appropriate to intervene in the burn scene?
A. Advise the client to stop, drop on the ground and roll
B. Immediately find a blanket nearby to smother the flames
C. Tell client that guided imagery is effective
D. Tell the client to remove the clothing immediately
A. Advise the client to stop, drop on the ground and roll
118
19. When teaching the patient about preventing recurrent UTIs, the nurse should include the following statements:
A. Bathe daily
B. Avoid voiding immediately after sexual intercourse
C. Drink liberal amounts of fluids
D. Void every 6 to 8 hours
C. Drink liberal amounts of fluids
RATIONALE
A Not a basis
B Encouraged
D Too long
119
20. The nurse instructs a client with a history of frequent UTIs to drink cranberry juice to:
A. Decrease the urinary pH
B. Exert a bactericidal effect
C. Improve glomerular filtration
D. Relieve symptoms of dysuria
A. Decrease the urinary pH
```
RATIONALE
Goals in UTI management: Increase acidity to kill bacteria
Diet: Acid ash diet
• Cranberry
• Plums
• Prunes
```
120
21. A client is diagnosed with cystitis. Client teaching aimed at preventing a recurrence should include which of the following instructions?
A. Bath in the tub
B. Wear cotton underwear
C. Use feminine hygiene spray
D. Limit your intake of cranberry juice
B. Wear cotton underwear
RATIONALE
It absorbs moisture.
A Discouraged
C Discouraged
D Increase
121
22. A client complains of severe burning sensation on urination. Which of the following instructions is best to give the client?
A. Wear nylon panties
B. Drink coffee to increase urination
C. Soak in warm water with bubble bath
D. Drink 2,500 to 3,000 ml of water per day
D. Drink 2,500 to 3,000 ml of water per day
RATIONALE
A Nylon panties cannot absorb moisture. Correct: Cotton panties
B Discouraged. Coffee, cola, tea, and alcohol alike are urinary irritants
C Discouraged
122
23. Nursing management with a client with UTI includes:
A. Taking medication until feeling better
B. Restricting fluid
C. Decreasing caffeine drinks and alcohol
D. Douching daily
C. Decreasing caffeine drinks and alcohol
RATIONALE
They are urinary irritants and need to be decreased.
A Complete treatment course
B Increase fluids
D Discouraged
123
SITUATION: Juan de la Cruz, 59 years old, is hospitalized with mild ascites, bruising and jaundice. He has a 20-year history of alcohol abuse, and is diagnosed with cirrhosis.
24. Juan has esophageal varices. Which of the following may cause the varices to rupture?
A. Lifting heavy objects
B. Walking
C. Ingestion of antacids
D. Ingestion of sedatives
A. Lifting heavy objects
RATIONALE
Increases BP that could lead to rupture.
124
SITUATION: Juan de la Cruz, 59 years old, is hospitalized with mild ascites, bruising and jaundice. He has a 20-year history of alcohol abuse, and is diagnosed with cirrhosis.
25. Due to his history of alcohol abuse, Juan will most likely have deficiency of the following nutrients:
A. Thiamine and folic acid
B. Folic acid and Vitamin A
C. Vitamin A and pyridoxine
D. Thiamine and pyridoxine
A. Thiamine and folic acid
125
SITUATION: Juan de la Cruz, 59 years old, is hospitalized with mild ascites, bruising and jaundice. He has a 20-year history of alcohol abuse, and is diagnosed with cirrhosis.
26. Juan begins to exhibit signs of hepatic coma. Which of the following is an early sign of impending hepatic coma?
A. Hiccups
B. Anorexia
C. Confusion
D. Fetor hepaticus
C. Confusion
RATIONALE
Early sign: Altered LOC
126
27. The physician orders neomycin 0.5g every 6 hours to prevent hepatic coma. Neomycin decreases serum ammonia levels by:
A. Decreasing nitrogen-forming bacteria in the intestines
B. Acidifying colon contents by causing ammonia retention in the colon
C. Decreasing the uptake of Vitamin D, thereby drawing more water into the colon
D. Irritating the bowel and promoting evacuation of stool
A. Decreasing nitrogen-forming bacteria in the intestines
127
28. Diet therapy for renal calculi of calcium phosphate composition would probably be:
A. High calcium and phosphorus, alkaline ash
B. High calcium and phosphorus, acid ash
C. Low purine and phosphorus, alkaline ash
D. Low calcium and phosphorus, acid ash
D. Low calcium and phosphorus, acid ash
128
29. A client passed a kidney stone. The nurse sends the specimen to the laboratory so it can be analyzed for which of the following factors?
A. Antibodies
B. Type of infection
C. Composition of stones
D. Size and no. of stones
C. Composition of stones
129
30. The nurse is providing post-procedure care for a client who underwent extracorporeal shock wave lithotripsy. In this procedure, an ultrasonic probe inserted that generates ultra-high-frequency sound waves to shatter renal calculi. The nurse should instruct the client to:
A. Limit oral fluid intake for 1 to 2 weeks
B. Report the presence of fine, sand-like particles through the nephrostomy tube
C. Notify the physician about cloudy or foul-smelling urine
D. Report bright pink urine within 24 hours after the procedure
C. Notify the physician about cloudy or foul-smelling urine
RATIONALE
It indicates infection.
A Increased
B and D are normal findings
130
33. Cataracts result in opacity of the crystalline lens. Which of the following best explains the functions of the lens?
A. The lens controls stimulation of the retina
B. The lens orchestrates eye movement
C. The lens focuses light rays on the retina
D. The lens magnifies small objects
C. The lens focuses light rays on the retina
131
34. Cataract manifestations include all but one:
A. Blurring of vision
B. Absence of red reflex
C. Appearance of milky white in the eye
D. Decreased sensitivity to light
D. Decreased sensitivity to light
RATIONALE
Correct: Photosensitivity
132
35. The nurse has just completed teaching about postoperative activity to a client who is going to have a cataract surgery. The nurse knows the teaching has been effective if the client:
A. Coughs and deep breathes postoperatively
B. Ties his own shoes
C. Asks his wife to pick up his shirt from the floor after he drops it
D. States that he doesn't need to wear an eye patch
C. Asks his wife to pick up his shirt from the floor after he drops it
RATIONALE
Post-op management:
1. Avoid activities that may increase IOP.
2. Wear eye patch on the affected side.
133
36. A client with cataract has undergone intracapsular cataract extraction. Which of the following post-op care is appropriate?
A. Leave the side rails down
B. Remove the eye patch and orient the client to the environment
C. Turn the client on the operative side
D. Elevate the head of the bed 30-45 degrees
D. Elevate the head of the bed 30-45 degrees
RATIONALE
Post-op management: Position Semi-Fowlers on the unaffected side
A Not safety
B Wear eye patch on the affected side
C Unaffected/Unoperative side
134
37. A client underwent cataract removal with an intraocular lens implant. The nurse is giving the client discharge instructions, these instructions should include which of the following?
A. Avoid lifting objects weighing more than 5 lb (2.27kg)
B. Lie on your abdomen when in bed
C. Keep rooms brightly lit
D. Avoid straining during bowel movement or bending at the waist
D. Avoid straining during bowel movement or bending at the waist
RATIONALE
Prevents increase in IOP.
A Correct: 10 lbs or more
B Correct: Semi-fowlers unaffected side
C Increases stimuli: ⬆️IOP
135
38. Which of the following is true about glaucoma?
A. It is characterized by irreversible blindness
B. It is treated with mydriatics
C. The IOP is 14-21 mmHg
D. Central vision is lost initially, followed by the peripheral vision
A. It is characterized by irreversible blindness
RATIONALE
B Correct: Miotics (pupil constrictor)
C Correct: ⬆️21 mmHg
D Correct: Peripheral vision initially
136
39. A client with open-angle glaucoma will manifest the following symptoms:
A. "I noticed that my eyes turned to become milky."
B. "I need to turn my head each time I locate my things on the side."
C. "I have a sore and pinky eye."
D. "I can feel a sense of coating of veil in the line of my vision."
B. "I need to turn my head each time I locate my things on the side."
RATIONALE
It is because of the peripheral vision loss.
A Refers to cataract
C Refers to conjunctivitis
D Refers to retinal detachment
137
40. Which one of the following statements regarding pilocarpine is true?
A. It is a sympathomimetic drug
B. It causes pupil dilation
C. It can be employed in the treatment of glaucoma
D. It reduces production of aqueous humor
C. It can be employed in the treatment of glaucoma
RATIONALE
Pilocarpine is a miotic drug and can be used to treat glaucoma.
A Correct: Cholinergic - PNS
B Correct: Pupil constriction
D Refers to Timolol, a beta blocker
138
41. The following drugs may be administered to the client with glaucoma EXCEPT:
A. Diamox
B. Pilocarpine
C. Atropine SO4
D. Timolol
C. Atropine SO4
Tip: Meds should function as Parasympathetic.
139
42. A 55-year old male client has been diagnosed with open-angle glaucoma. The physician's orders include one drop of Pilocarpine (Pilocar) 1% in each eye every 6 hours. The client states that he doesn't understand the need for medication because he doesn't have symptoms of an eye problem. Which of the following nursing diagnoses would be most appropriate?
A. Noncompliance related to refusal to use eye drops
B. Deficient knowledge related to the disease
C. Anxiety related to a new health problem
D. Disturbed body image related to the need for medication
B. Deficient knowledge related to the disease
140
43. Jessie is diagnosed with retinal detachment. Which intervention is the most important for this client?
A. Admitting him to the hospital on strict bed rest
B. Patching both of his eyes
C. Referring him to an opthalmologist
D. Preparing him for surgery
D. Preparing him for surgery
RATIONALE
Retinal detachment needs an immediate surgery.
141
44. Which of the following symptoms wouldn't occur in a client with a detached retina?
A. Floaters
B. Photopsia
C. Eye pain
D. Curtain vision
C. Eye pain
RATIONALE
Happens only on Close-angle glaucoma.
142
45. Signs and symptoms of retinal detachment include:
A. Painless decrease in vision, veil over the visual field, and flashing lights
B. Veil over the visual field, increased intraocular pressure, and yellow-green halos around visual images
C. Photophobia, yellow-green halos around visual images and blurred vision
D. Unilateral eye inflammation, cloudy cornea, and moderately dilated pupil
A. Painless decrease in vision, veil over the visual field, and flashing lights
RATIONALE
B. Veil over the visual field [RD], increased intraocular pressure [G], and yellow-green halos around visual images [G]
C. Photophobia [C], yellow-green halos around visual images [G] and blurred vision [C]
D. Unilateral eye inflammation [Conjunctivitis], cloudy cornea [C], and moderately dilated pupil [Unrelated]
143
46. Which of the following statements would provide the BEST guide for activity for a client who has been treated for retinal detachment during his rehabilitation period?
A. Activity level is determined by the client's tolerance; she can be as active as she wishes
B. Activity can be returned to normal and may include regular aerobic exercises
C. Activity is resumed gradually, and the client can resume her unusual activities in 5 to 6 weeks
D. Activity levels will be restricted for several months, so she should plan on being sedentary
C. Activity is resumed gradually, and the client can resume her unusual activities in 5 to 6 weeks
144
47. Scleral buckling, a procedure used to treat retinal detachment, involves:
A. Creating a splint to hold the retina together until a scar can form and seal off the tear
B. Removing the torn segment of the retina and stitching down the remaining segment
C. Stitching the retina firmly to the optic nerve to give it support
D. Replacing the torn segment of the retina with a strip of retina from a donor
A. Creating a splint to hold the retina together until a scar can form and seal off the tear
145
48. The patient was diagnosed to have hyperopia. You expect that the patient's condition is due to:
A. A long eyeball
B. A short eyeball
C. Abnormal curvature of the cornea
D. Inability of the lens to accommodate
B. A short eyeball
Tip: Inversely proportional
Myopia (NEARsightedness) = LONG eyeball
Hyperopia (FARsightedness) = SHORT eyeball
146
49. The following are considered incorrect about myopia:
1. This is otherwise known as farsightedness
2. The bending of light is in front of the retina
3. Corrected by using a concave lens
4. 20/10 is the result on Snellen's hart
A. 1,2
B. 1,4
C. 2,3
D. 3,4
B. 1,4
RATIONALE
1 and 4 refers to hyperopia.
147
50. In the client with astigmatism, the light rays will
A. Focus directly on the retina
B. Focus behind the retina
C. Focus in front of the retina
D. Refract onto the retina unequally
D. Refract onto the retina unequally
148
1. Breeja who has COPD has RR of 24 breaths per minute, bilateral crackles and cyanosis and is coughing and is unable to expectorate sputum. Which nursing diagnosis is the priority for this client?
A. Risk for decreased cardiac output secondary to cor pulmonale
B. Impaired gas exchange related to ventilation-perfusion mismatch
C. Ineffective breathing pattern related to increase work of breathing
D. Ineffective airway clearance related to inability to expectorate sputum
D. Ineffective airway clearance related to inability to expectorate sputum
149
2. A long term COPD client is receiving oxygen at 1L/minute. Her visiting cousin decides she "doesn't look too good" and increases her oxygen to 7L/minute. What should the nurse's initial action be?
A. Thank the client's cousin and continue to observe the client
B. Immediately decrease the oxygen
C. Notify the physician
D. Elevate the client's head and take VS
B. Immediately decrease the oxygen
RATIONALE
Oxygen administration should be kept low to prevent suppression of hypoxic drive.
150
3. Carlo is admitted to the hospital with a diagnosis of bronchial asthma, the nurse understands that Carlo may have difficulty of breathing because of:
A. A too rapid expulsion of air
B. Spasm of the bronchi, which trap the air
C. Hyperventilation due to an anxiety reaction
D. An increase in the vital capacity of the lung
B. Spasm of the bronchi, which trap the air
151
4. A patient with asthma is producing thick, white secretions. Which of the following nursing measures would be most appropriate for the nurse to induce in her plan of care?
A. Increase fluid intake
B. Promote exercise
C. Administer oxygen
D. Encourage coughing
A. Increase fluid intake
RATIONALE
It thins the secretions.
152
5. A nurse assesses Lyle who may have a flail chest injury. Which of the following findings would support this diagnosis?
A. Cough productive sputum
B. Pulse oximeter reading of 95%
C. Respiration of 20/minute
D. Assymetrical expansion of the thorax
D. Asymmetrical expansion of the thorax
RATIONALE
A Refers to TB or COPD
B and C are normal findings
153
6. Mang Sebastian who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect?
A. Pulmonary embolism
B. Myocardial infarction
C. Heart failure
D. Pneumothorax
D. Pneumothorax
RATIONALE
Highlight: Unequal breath sounds
154
7. Mang Sebastian came to emergency room with multiple abrasions, complaining of SOB. According to Mang Sebastian, he fell from the roof of their house while cleaning the gutter. Mang Sebastian's chest X-ray reveals a right pneumothorax. With this in mind, the nurse should first:
A. Help the patient turn, cough, and deep breathe
B. Prepare a chest drainage system
C. Prepare the patient for a CT scan
D. Prepare for urinary catheter placement
B. Prepare a chest drainage system
155
8. An adult has a chest tube to a Pleur-evac drainage system attached to a wall suction. An order to ambulate the client safely, the nurse should:
A. Clamp the chest tube and carefully ambulate the client a short distance
B. Question the order to ambulate the client
C. Carefully ambulate the client, keeping the Pleur-evac lower than Mr. E's chest
D. Disconnect the Pleur-evac from the client's chest tube, leave it attached to the bed, ambulate the client and then reconnect the chest tube when he is returned to bed
C. Carefully ambulate the client, keeping the Pleur-evac lower than Mr. E's chest
156
9. The nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess a client for pneumothorax resolution, the nurse can anticipate that he'll require:
A. Monitoring of arterial oxygen saturation (SaO2)
B. ABG studies
C. Chest auscultation
D. A chest X-ray
D. A chest X-ray
157
10. A client's chest X-ray reveals bilateral white-outs, indicating ARDS. This syndrome results from:
A. Cardiogenic pulmonary edema
B. Respiratory Alkalosis
C. Increased pulmonary capillary permeability
D. Renal failure
C. Increased pulmonary capillary permeability
RATIONALE
In ARDS, there is a leakage of fluid in the alveoli due to the damage of the alveolar capillary membrane causing increased pulmonary capillary permeability.
A It is the complication of ARDS
B and D are irrelevant
158
11. You are caring for Cardo who has respiratory failure. He is connected to mech vent. During your midmorning rounds, you identified the nursing diagnosis of ineffective airway clearance related to thick respiratory secretions for Cardo. Which intervention will be the MOST effective in resolving this problem?
A. Turn the patient every 2 hours
B. Increase the amount of water in the patient's enteral feedings
C. Suction the patient more frequently
D. Instill 5 mL of sterile saline into the ET before suctioning
D. Instill 5 mL of sterile saline into the ET before suctioning
RATIONALE
Thins the secretions.
159
12. Which of the following characteristics of dyspnea and cough should you consider as a manifestation of pulmonary edema?
A. Unrelieved exertional dyspnea with hemoptysis
B. Severe dyspnea with persistent non-productive cough
C. Paroxysmal nocturnal dyspnea with productive cough of frothy pink sputum
D. Dyspnea at rest with productive cough and non purulent sputum
C. Paroxysmal nocturnal dyspnea with productive cough of frothy pink sputum
RATIONALE
Highlight: Frothy pink sputum (Sign of pulmonary edema)
160
13. A community health nurse is conducting am educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is
A. A bloody, productive cough
B. A cough with the expectoration of mucoid sputum
C. Chest pain
D. Dyspnea
B. A cough with the expectoration of mucoid sputum
RATIONALE
1st sign of TB: Mucoid sputum
Other options are late signs.
161
14. Staff nurses learn that a patient they had been caring for during the last few weeks has just been diagnosed with tuberculosis. When the nurses express concern about contracting TB themselves, the charge nurse's response should be base on which of the following statements?
A. TB is easily treated with a short course of antibiotics
B. The Mantoux test is used to confirm diagnosis of TB
C. TB is not highly infectious when airborne precautions are followed
D. Vaccination with BCG will be used to immunize the nurses against infection
C. TB is not highly infectious when airborne precautions are followed
RATIONALE
B Mantoux test is used only to indicate exposure. X is the confirmatory test
D BCG is effective only on immunization stage (during pedia)
162
15. Margarette is being admitted to the nursing unit with a diagnosis of pneumonia. She has a history of arrested TB. When planning care for this client, the nurse's initial action should be to:
A. Place the client in respiratory isolation
B. Encourage cough and deep breathing
C. Force fluids
D. Administer O2
A. Place the client in respiratory isolation
163
16. A 30-year old client had cholesterol blood test before admission to the hospital. The nurse in charge would teach the family and SOs that exercise can help to keep the total cholesterol to desired level of:
A. 140mg/dL
B. 200mg/dL
C. 250mg/dL
D. 300mg/dL
A. 140mg/dL
RATIONALE
Normal Cholesterol level: ⬇️200 mg/dL
164
17. The nurse is caring for a client on the 3rd post-op day after coronary artery bypass graft (CABG) surgery. Because an important diagnosis for post-CABG client is ineffective breathing pattern, what is the best plan by the nurse?
A. Ensure that the client performs deep breathing and vigorous coughing every hour
B. Ensure that the client uses the incentive spirometer every hour
C. Premedicate the client before ambulation
D. Auscultate lungs once per shift
B. Ensure that the client uses the incentive spirometer every hour
165
18. James states that anginal pain increases after activity. The nurse should realize that angina pectoris is a sign of:
A. Mitral insufficiency
B. Myocardial ischemia
C. Myocardial infarction
D. Coronary thrombosis
B. Myocardial ischemia
RATIONALE
Angina pectoris happens when there is partial obstruction of arteries that carry blood to the heart causing lack of oxygen in the myocardium, termed as ischemia, and happens less than 3 hours.
166
19. On the cardiac monitor, ECG changes were observed such as, flattened T waves and depressed ST segments. Which of the following will you consider as the probable condition responsible for the ECG changes?
A. Premature ventricular contraction
B. Atrial fibrillation
C. Myocardial ischemia
D. Hyperkalemia
C. Myocardial ischemia
RATIONALE
Tip: Angina Pectoris = Myocardial ischemia
ECG showing the manifestations of Angina Pectoris include:
• T wave inversion
• ST depression
A Early QRS wave
B Disorganized P wave
D ⬆️PR QRS[T] ⬇️P
167
20. A nurse working in a long-term care facility is assessing Marlon experiencing chest pain. The nurse would interpret that the pain is most likely due to MI on the basis of which of the following assessment findings?
A. The client is not experiencing nausea and vomiting
B. The client says the pain began while she was trying to open a stuck dresser drawer
C. The pain has not been relieved by rest and 3 nitroglycerin tablets
D. The client is not experiencing dyspnea
C. The pain has not been relieved by rest and 3 nitroglycerin tablets
RATIONALE
Other options are signs of Angina pectoris.
168
21. Nurses must be aware that pain in MI may occur without cause primarily during what time of the day?
A. Anytime of the day
B. Usually after a day's work
C. Early at night before eating
D. Early in the morning
D. Early in the morning
169
22. Which if the following statements, if made by a patient who is suspected of having congestive heart failure, would support the diagnosis?
A. "I sleep using two pillows."
B. "My weight has gone down."
C. "My ears have a ringing sensation."
D. "I am not able to tolerate pain."
A. "I sleep using two pillows."
RATIONALE
DOB is experienced during supine position in patients with CHF.
B Correct: Sudden Weight gain
C and D are irrelevant
170
23. Which statement made by the patient would alert the nurse to the possibility of right-sided heart failure?
A. "I sleep with four pillows at night."
B. "My shoes fit really tight."
C. "I wake up coughing every night."
D. "I have trouble catching my breath."
B. "My shoes fit really tight."
RATIONALE
In right sided heart failure, manifestations are systemic.
L sided HF, manifestations are pulmonary.
171
24. Francis is admitted with congestive heart failure. He has shortness of breath, and a +3-4 peripheral edema. The care plan to reduce the client's edema should include the nursing strategies for:
A. Establishing limits on activity
B. Fostering a relaxed environment
C. Identifying goals for self-care
D. Restricting IV fluids
D. Restricting IV fluids
RATIONALE
Prevents exacerbation of edema.
A and B Activity is encouraged
C Not priority
172
25. A client with a history of IV drug abuse is admitted to the medical surgical unit for evaluation for infective endocarditis. Nursing assessment is most likely to reveal that this client has:
A. Retrosternal pain that worsens during supine positioning
B. Pulsus paradoxus
C. A scratchy pericardial friction rub
D. Osler's nodes splinter hemorrhages
D. Osler's nodes splinter hemorrhages
RATIONALE
In endocarditis, lesions are formed due to bacteria's embolization to the palms and soles (painless, known as Janeway's lesion) and/or to fingers and toes (painful, known as Osler's nodes)
A Refers to Angina Pectoris
C Refers to Pericrditis
173
26. A client remains in atrial fibrillation with rapid ventricular response despite pharmacological intervention. Synchronous cardioversion is scheduled to convert the rapid rhythm. The nurse plans to implement which important action to ensure safety and prevent complication of this procedure?
A. Give lidocaine
B. Ensure that emergency equipment is available
C. Ensure that the defibrillator is set on the synchronous mode
D. Cardiovert the client at 360 joules
C. Ensure that the defibrillator is set on the synchronous mode
174
27. Which of the following questions is most important for a nurse to ask when gathering information from a patient who has a history of Buerger's Disease?
A. "Have you had recent lapses of memory?"
B. "Do you require several pillows to sleep?"
C. "Have you noticed weakness in your legs?"
D. "Do you have pain in your calves when you walk?"
D. "Do you have pain in your calves when you walk?"
RATIONALE
In Buerger's Disease, there is idiopathic inflammation of arteries (common) and veins in the legs and feet and occlusion happens eventually. Pain occurs during activity and relieves during rest, also known as intermittent claudication.
175
28. The client with Raynaud's Disease complains of cold and numbness in her fingers. The nurse assesses the client for effects of vasoconstriction. Which of the following is an early sign of vasoconstriction?
A. Cyanosis
B. Gangrene
C. Pallor
D. Rubor
C. Pallor
RATIONALE
Color changes in Raynaud's disease in order:
• White (pallor) - severe spasm
• Blue (cyanosis) - pooling of UnO2 blood
• Red (rubor) - rebound circulation
176
29. Daniela seeks treatment in a physician's office for unsightly varicose veins, and sclerotherapy is recommended. Before leaving the examining room, the client says to the nurse, "Can you tell me again how sclerotherapy is done?" Which of the following statements would reflect accurate teaching by the nurse?
A. "The varicose is surgically removed."
B. "The vein is tied off at the upper end to prevent stasis from occuring."
C. "The vein is tied off at the lower end to prevent stasis from occuring."
D. "An agent is injected into the vein to damage the vein wall and close the vein off."
D. "An agent is injected into the vein to damage the vein wall and close the vein off."
177
30. After abdominal surgery, which factor would predispose a client to DVT?
A. The client is 5'9" tall and weighs 128 lbs.
B. The client has been pregnant four times
C. The client usually walks 3 miles a day
D. The client will be immobile during and shortly after surgery
D. The client will be immobile during and shortly after surgery
178
31. Alma, 36 years old, has had multiple sclerosis. Clients with multiple sclerosis experience many different symptoms. As part of the rehabilitation planned for Alma, the nurse suggested therapy and hobbies to help her:
A. Strengthen muscle coordination
B. Establish routine
C. Develop perseverance and motivation
D. Establish good health habits
A. Strengthen muscle coordination
RATIONALE
In MS, the demyelination of myelin sheath (CNS) causes generalized muscle weakness.
179
32. To which of the following nursing diagnoses would a nurse give priority in the care plan of a patient who is being treated for GBS?
A. Ineffective airway clearance
B. Self-care deficit: feeding
C. Fluid Volume Deficit
D. Risk for Injury
A. Ineffective airway clearance
RATIONALE
In GBS, the demyelination of PNS causes ascending muscle weakness.
180
33. The nurse is leading a support group for clients affected by myasthenia gravis. For what group of individuals does the nurse understand that the incidence if myasthenia gravis is highest?
A. Males age 15 to 35
B. Children age 5 to 15
C. Females age 20 to 40
D. Both sexes equally before age 40
C. Females age 20 to 40
181
34. Which of the following statements, if made by Nick who has myasthenia gravis, would indicate correct understanding of necessary adaptations of the disease?
A. "My activity tolerance will increase during the day."
B. "My diet should include high-protein foods."
C. "I will avoid fruits and vegetables."
D. "I should avoid people who have colds."
D. "I should avoid people who have colds."
```
RATIONALE
Health Education in patients with Myasthenia gravis:
Avoid:
• Fatigue
• Infection (colds, flu)
• Stress
• Temperature (extreme)
```
182
35. A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order:
A. Electromyography (EMG)
B. Doppler scanning
C. Doppler ultrasonography
D. Quantitative special phonoangiography
A. Electromyography (EMG)
183
36. Paul was seen in the ER for a mild concussion. The X-rays and physical exam were normal and he was discharged. Which statement indicates that Paul needs further instruction?
A. "I should sleep as much as possible since I need the rest."
B. "I should report any vomiting episodes."
C. "I should be seen in 1 or 2 days for a follow-up exam."
D. "I can have acetaminophen (Tylenol) as needed for pain."
A. "I should sleep as much as possible since I need the rest."
184
37. As Kevin's nurse, your goal is to prevent increased ICP. Which of the following independent nursing interventions is NOT suited for him?
A. Do oropharyngeal suction every 15 minutes to prevent pulmonary aspiration
B. Keep head of bed 30-45 degrees elevated
C. Maintain Kevin's head in straight alignment and prevent hip flexion
D. Prevent constipation and increase in intra-abdominal pressure
A. Do oropharyngeal suction every 15 minutes to prevent pulmonary aspiration
RATIONALE
Suctioning increases ICP.
185
38. Kevin, 22 years old swerved his car and hit a tree head on when he avoided a dog crossing the street. Kevin lost consciousness, sustained several cuts on his forehead and was bleeding from his nose and mouth. He was diagnosed in the emergency department with traumatic brain injury (TBI). Which of the following interventions can the nurse include in the plan of care for Kevin?
1. Maintain his head and neck in neutral position
2. Initiate measures to enhance valsalva maneuver
3. Administer O2 to maintain PaO2>90 mmHg
4. Elevate HOB as prescribed
A. 1 and 2
B. 3 and 4
C. All except 2
D. AOTA
C. All except 2
RATIONALE
Goal for this patient: Prevent ⬆️ ICP
Valsalva maneuver increases ICP
186
39. The nurse is caring for an adult with a T4 spinal cord transection. Which activity by the client indicates adequate learning regarding urinary tract care?
A. Avoiding the valsalva maneuver when the bladder is full
B. Cleaning the urinary meatus every 2 hours
C. Checking the bladder distention frequently
D. Limiting fluids to 100 ml per 24 hours
C. Checking the bladder distention frequently
RATIONALE
This intervention prevents occurrence of autonomic dysreflexia.
187
40. The client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measure to minimize the risk of recurrence?
A. Strict adherence to bowel retraining program
B. Limiting bladder catheterization to once every 12 hours
C. Keeping the linen wrinkle-free under the client
D. Preventing unnecessary pressure on the lower limbs
B. Limiting bladder catheterization to once every 12 hours
RATIONALE
Bladder catheterization is kept to avoid distention.
188
1. A client with COPD is evaluated for lung transplant. The nurse performs physical assessment, which S/Sx should the nurse expect to find?
1. Decreased RR
2. Dyspnea on exertion
3. Barrel chest
4. Shortened expiratory rate
5. Clubbed fingers
6. Fever
A. 234
B. 345
C. 235
D. 123
C. 235
RATIONALE
1 Correct: ⬆️RR
6 Correct: No Fever
189
2. For you to evaluate Ben's oxygenation and ventilation status, which of the following results would be the MOST useful?
A. Hemodynamic monitoring
B. Pulse oximetry
C. ABG analysis
D. Chest X-ray
C. ABG analysis
190
3. The physician orders low concentration oxygen to be given continuously for Breeja who has a COPD to prevent:
A. Excessive drying of the respiratory mucosa
B. Depression of the respiratory center
C. Rupture of emphysematous bullae
D. A decrease in RBC formation
B. Depression of the respiratory center
191
4. A client with COPD tells the nurse she feels SOB. The client's RR is 36 bpm and the nurse auscultates diffuse wheezes. Her arterial oxygen saturation is 84%. The nurse calls the assigned respiratory therapist to administer a prescribed nebulizer treatment. The therapist says, "I have several nebulizer treatments to do on the unit where I am now. As soon as I'm done, I'll come assess the client." The nurse most appropriate action is to:
A. Notify the primary physician immediately
B. Stay with the client until the therapist arrive
C. Administer the treatment by metered-dose inhaler
D. Give the nebulizer treatment herself
C. Administer the treatment by metered-dose inhaler
192
5. Which of the following activities is appropriate for a 12-year old child with asthma?
A. Soccer
B. 1,500 meter run
C. Baseball
D. Long distance biking
C. Baseball
RATIONALE
In Asthma, the risk factor is strenuous activities and nursing management includes avoidance of these activities.
193
6. A nurse witnesses an accident whereby a pedestrian is hit by an automobile. The nurse stops at the scene and assesses the victim. The nurse notes that the victim, Lyle is responsive and has trauma to the thorax resulting in a flail chest involving at least 3 ribs. The nurse does which of the following to assist Lyle's respiratory status until help arrives?
A. Assist the victim to sit up
B. Turns the victim onto the side with the flail chest
C. Remove the victim's shirt
D. Applies firm but gentle pressure with the hands to the flail segment
D. Applies firm but gentle pressure with the hands to the flail segment
RATIONALE
Avoids tension pneumothorax.
194
7. Lyle is admitted with a flail chest following a car accident. He is intubated with an endotracheal tube and is placed on a mech vent (control mode, positive pressure). Which physical finding alerts the nurse to an additional problem in respiratory function?
A. Dullness to percussion in the third to fifth intercostal space, midclavicular line
B. Decreased paradoxical motion
C. Louder breath sounds on the right chest
D. pH of 7.36 in arterial blood gases
C. Louder breath sounds on the right chest
RATIONALE
Indicates misplacement or displacement of Et tube.
195
8. Mang Sebastian experienced an open pneumothorax and a chest wound, which has been covered with an occlusive dressing. He begins to experience severe dyspnea, and BP begins to fall. The nurse should first:
A. Remove the dressing
B. Reinforce the dressing
C. Call the physician
D. Measure oxygen saturation by oximetry
A. Remove the dressing
RATIONALE
The patient may have experience tension pneumothorax.
196
9. The client admitted 2 days earlier with a lung resection accidentally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes?
A. Order a chest X-ray
B. Reinsert the tube
C. Cover the insertion site with a Vaselinized gauze
D. Call the doctor
C. Cover the insertion site with a Vaselinized gauze
197
10. The health care team is discussing the condition of Cardo with ARDS. The physician states that as a result of fluid in the alveoli, surfactant production is falling. The nurse interprets that the natural consequence of insufficient surfactant is:
A. Collapse of the alveoli and decreased compliance
B. Bronchoconstriction and stridor
C. Decreased ciliary action and retained secretions
D. Atelectasis and viral infection
A. Collapse of the alveoli and decreased compliance
198
11. Cardo is admitted to the ICU with a diagnosis of ARDS. When assessing Cardo, you would expect to find:
A. An altered mental status
B. HPN
C. Labored breathing
D. Tenacious secretions
C. Labored breathing
RATIONALE
The damage of alveolar capillary membrane in ARDS could lead to the damage of Type 2 Pneumocyte which decreases lung surfactant, thereby decreasing lung expansion. Hence, patient compensates through labored breathing.
199
12. You recognize that pulmonary edema in ARDS may develop because of which of the following?
A. Low plasma protein levels decreasing plasma osmotic pressure
B. Increased capillary permeability due to lung inflammation
C. Increased hydrostatic pressure in the pulmonary capillaries
D. Increased surface tension in the alveoli
B. Increased capillary permeability due to lung inflammation
200
13. A nurse working on a medical respiratory nursing unit is caring for several clients with respiratory disorders. The nurse would determine that which of the following clients on the nursing unit is at the lowest risk for infection with TB?
A. An uninsured man who is homeless
B. A newly immigrated woman from Vietnam
C. A man who is an inspector for the US Postal service
D. An older woman admitted from a long-term care facility
C. A man who is an inspector for the US Postal service
```
RATIONALE
Risk factors of TB include:
• Homeless/prisoners
• Age ⬆️60 and ⬇️5 years old
• Immunosuppresed
• Race: South American and Southeast Asians
```
201
14. Nurse Ron performed Mantoux skin test today (Monday) to a male adult client. Which statement by the client indicates that he understood the instruction well?
A. I will come back later
B. I will come back next month
C. I will come back on Friday
D. I will come back on Wednesday, same time, to read the result
D. I will come back on Wednesday, same time, to read the result
RATIONALE
Interpretation of Mantoux Test is within 48-72 hours.
202
15. Margarette is admitted to the medical surgical floor with a diagnosis of bacterial pneumonia. The most common causative organism of community-acquired bacterial pneumonia is:
A. Streptococcus pneumoniae
B. Proteus species
C. Haemophilus influenzae
D. Escherichia coli
A. Streptococcus pneumoniae
203
16. Which of the following statements, if made by the patient during a nursing assessment, would indicate risk factor for CAD?
A. "I have a cholesterol level of 190 mg/dL."
B. "I had a parent diagnosed with angina at age 40 years."
C. "My BP is consistently 100/60 mmHg."
D. "I had a recent weight loss of 15 lbs."
B. "I had a parent diagnosed with angina at age 40 years."
```
RATIONALE
Risk factors for CAD include:
1. Hereditary
2. Ethnic/Race: Blacks/African
3. Aging
4. Alcohol
5. Result of DM
6. Type A personality
7. Smoking
8. Sedentary Lifestyle
9. Severe obesity
10. Sex: Male
```
204
17. Which of the following is the medical treatment of CAD includes?
A. Cardiac catheterization
B. Coronary Artery Bypass graft
C. Oral medication administration
D. Percutaneous Transluminal Coronary Angioplasty
C. Oral medication administration
RATIONALE
Other options are surgical treatments.
205
18. When assessing James who reports recent chest pain, the nurse obtains a thorough history. Which statement by James most strongly suggests angina pectoris?
A. "The pain lasted about 45 minutes."
B. "The pain resolved after I ate sandwich."
C. "The pain got worse when I took deep breath."
D. "The pain occurred while I was mowing the lawn."
D. "The pain occurred while I was mowing the lawn."
RATIONALE
Angina happens on exertional activities, excessive eating, exposure to cold, excessive smoking, and emotional stress.
A Correct:
206
19. An adult is admitted to the coronary care unit to rule out MI. The client states "I am not sure of this is just angina, and I cannot understand the difference between angina and heart attack pain." Which response is most appropriate for the nurse to make?
A. Anginal pain usually lasts only 3-5 minutes
B. Anginal pain produces clenching of the fists over the chest while acute MI path does not
C. Anginal pain requires morphine for relief
D. Anginal pain radiates to the left arm while acute MI pain does not
A. Anginal pain usually lasts only 3-5 minutes
RATIONALE
B Correct: Clenching of fist over chest is a sign of MI
C Correct: Morphine is for MI
D Correct: Both radiates to the left arm
207
20. A nurse is taking a history from a patient who has just been admitted to the hospital with an acute MI. Which of the following questions would be most important for the nurse to ask?
A. "At what time did the pain start?"
B. "When did you eat your last meal?"
C. "Have you experienced a pounding?"
D. "Have you felt fluttering in your chest?"
A. "At what time did the pain start?"
RATIONALE
Time is important to assess to provide immediate intervention because MI is deadly when not given prompt interventions.
208
21. A client with MI is going into cardiogenic shock. Because of the risk of Myocardial ischemia, for which of the following should the nurse carefully assess the client?
A. Bradycardia
B. Ventricular dysrhythmias
C. Rising diastolic BP
D. Falling CVP
B. Ventricular dysrhythmias
RATIONALE
Tip: Process of elimination
Shock: Hypo, Tachy, Tachy
A and C are incorrect manifestations of shock.
D Irrelevant
209
22. A client with MI asks when his sex activity can be resumed. The nurse's response is accurate when she says sex activity maybe resumed if client:
A. Can run 2 meters on a flat surface without developing chest pain
B. Can climb 2 flights of stairs without dyspnea
C. Can carry a 20-lb load without chest pains
D. Can finish repetition in a stress test
B. Can climb 2 flights of stairs without dyspnea
210
23. A male client is returning from the OR after surgery. The nurse notes that he has fluid volume excess from the operation and is at risk for left-sided heart failure. Which S/Sx indicates left-sided heart failure?
A. Jugular vein distention
B. Right upper quadrant pain
C. Bibasilar fine crackles
D. Coarse crackles
C. Bibasilar fine crackles
211
24. A nurse reviews the dietary history of a patient with CHF. The nurse should instruct the patient to eliminate which of the following foods to comply with a sodium-restricted diet?
A. Skim milk and breakfast cereals
B. Fresh and frozen fruits and vegetables
C. Luncheon meat sandwiches and dill pickles
D. Baked turkey and fish
C. Luncheon meat sandwiches and dill pickles
RATIONALE
Processed foods are rich in sodium.
212
25. George Clooney, age 45, is admitted to the medical-surgical floor with weakness and left-sided chest pain. The symptoms have been present for several weeks after a viral illness. Which assessment finding is most symptomatic of pericarditis?
A. "I will need to wear a Holter monitor to determine how well I am doing."
B. "I will have to take antibiotics for the rest of my life."
C. "I will have to avoid going out in crowded places."
D. "I will have to inform my dentist of my condition before treatment."
D. "I will have to inform my dentist of my condition before treatment."
RATIONALE
To prevent infection relapses due to causative agents.
213
26. Sandy explained to Connie that patient experienced a vasovagal reaction. Which if the following vital signs will the nurse expect?
A. Normal BP but with increased pulse
B. Decreased BP, decreased cardiac rate
C. Increased BP, tachycardia
D. Normal pulse but with increased BP
B. Decreased BP, decreased cardiac rate
214
27. Derrick, who has no known history of peripheral vascular disease, comes to the emergency room complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses, paresthesia and a mottled, cyanotic, cold, cadaverous left calf. While the physician determines the appropriate management, you should:
A. Shave the affected leg in anticipation of surgery
B. Place a heating pad around the calf
C. Keep the affected leg level or slightly dependent
D. Elevate the affected calf as high as possible
C. Keep the affected leg level or slightly dependent
RATIONALE
Prevents pulmonary embolism.
215
28. A nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse plans to tell the client to:
A. Stop smoking because it causes vasospasm
B. Always wear warm clothing even in warm climates to prevent vasoconstriction
C. Use nail polish to protect the nail beds from injury
D. Wear gloves for all activities involving use of both hands
A. Stop smoking because it causes vasospasm
RATIONALE
B Warm climates causes vasodilation
C Nail polish functions not in preventing injury but only aesthetically
D Not always (extreme)
216
29. A client with venous insufficiency develops varicose veins in both legs. Which statement about varicose veins is accurate?
A. Varicose veins are more common in men than in women
B. Primary varicose veins are caused by DVT and inflammation
C. Sclerotherapy is used to cure varicose veins
D. The severity of discomfort isn't related to the size of varicosities
D. The severity of discomfort isn't related to the size of varicosities
RATIONALE
Tip: Process of elimination
A Correct: More common in women
B Correct: Primary - Congenital/Familial, Secondary - r/t disease process
C Correct: Sclerotherapy can treat but cannot cure
217
30. A nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred over the varicosities as a result of secondary infection. A priority intervention in the plan of care is to:
A. Keep the legs aligned with the heart
B. Position the client onto the side every shift
B. Clean the skin with alcohol every hour
D. Elevate the legs higher than the heart
D. Elevate the legs higher than the heart
RATIONALE
Goal: Increase venous return.
218
31. Which clinical indicator should the nurse expect Alma with an exacerbation of MS to experience?
A. Double vision
B. Resting tremors
C. Flaccid paralysis
D. Mental retardation
A. Double vision
RATIONALE
Tip: Process of elimination
B Correct: Intentional Tremors
C Correct: Spastic Paralysis
D Irrelevant
219
32. A client is admitted to the hospital with a diagnosis of GBS. The nurse inquires during the nursing admission interview if the client has a history of
A. Back injury or trauma to the spinal cord
B. Seizures or trauma to the brain
C. Respiratory or GI infection during the previous month
D. Meningitis during the last 5 years
C. Respiratory or GI infection during the previous month
220
33. The nurse is admitting a client with GBS to the nursing unit. The client has ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse brings which of the following items into the client's room?
A. Nebulizer and pulse oximeter
B. Flashlight and incentive spirometer
C. Suction machine and intubation tray
D. BP cuff and flashlight
C. Suction machine and intubation tray
221
34. To what does the nurse attribute the increased risk of respiratory complications to Nick who has Myasthenia gravis?
A. Narrowed airways
B. Impaired immunity
C. Ineffective coughing
D. Viscosity of secretions
C. Ineffective coughing
RATIONALE
Because Myasthenia gravis has classic descending paralysis, respiratory function is monitored.
222
35. The nurse has instructed Nick who has myasthenia gravis about ways to manage the client's own health at home. The nurse determines that Nick needs more information if he made which of the following statements?
A. "I should take my medications 30 minutes before mealtime."
B. "I've made arrangements to get a portable resuscitation bag and home suction equipment."
C. "Going to the beach will be a nice, relaxing form of activity."
D. "Here's the Medic-Alert bracelet I obtained."
C. "Going to the beach will be a nice, relaxing form of activity."
RATIONALE
Health education in patients with MG includes rest and avoidance of fatigue.
223
36. During admission, Paul was suspected of having severe head injury to the emergency department. The nurse places the highest priority on assessment for:
A. Presence of neck injury
B. Neurological status with GCS
C. CSF leakage from ears or nose
D. Patency of airway
D. Patency of airway
RATIONALE
Tip: ABC
224
37. A patient who has a left frontal lobe injury and bleeding has a supratentorial craniotomy. Four hours after surgery, the following data are obtained by the nurse. Which of the following data would be most indicative of increasing ICP?
A. The patient's BP is 130/90mmHg
B. The patient is difficult to rouse
C. The patient's Babinski reflex is negative
D. The patient is incontinent of urine
B. The patient is difficult to rouse
RATIONALE
Early sign of ⬆️ICP: Altered LOC
225
38. The nurse is caring for a client with a head injury and increased ICP. Which intervention should the nurse include in the care plan to reduce ICP?
A. Encourage coughing and deep breathing
B. Position the client with the head turned toward the side of the brain tumor
C. Administer stool softener
D. Provide sensory stimulation
C. Administer stool softener
RATIONALE
Stool softener prevents patient to perform Valsalva maneuver which could lead to an ⬆️ICP.
226
39. To which of the following nursing diagnoses should a nurse give priority in the care of a patient who is suspected of having a spinal cord injury at C4?
A. Altered health maintenance
B. Impaired skin integrity
C. Altered sensory perception: tactile
D. Ineffective breathing pattern
D. Ineffective breathing pattern
RATIONALE
Tip: ABC
227
40. On entering the room, the nurse notes that the client is diaphoretic with a flushed face and neck and complains of a severe headache. The PR is 40 bpm and BP is 230/100 mmHg. The nurse acts quickly, knowing that the client is experiencing
A. Spinal shock
B. Malignant hypertension
C. Pulmonary embolism
D. Autonomic dysreflexia
D. Autonomic dysreflexia
228
1. The primary cause of Chronic Bronchitis is cigarette smoking. Breeja admits to smoking one pack of cigarettes per day for the past 10 years. The nurse determines that the client has a smoking history of how many pack-years?
A. 7.5
B. 10
C. 15
D. 20
B. 10
229
2. A home care nurse visits a client with COPD who requires oxygen. Which statement by the client indicates the need for additional teaching about home oxygen use?
A. "I lubricate my lips and nose with KY jelly."
B. "I make sure my oxygen mask is on tightly so it won't fall while I nap."
C. "I have a "no smoking" sign posted at my front entry-way to remind guest not to smoke."
D. "I clean my mask with water after meal."
B. "I make sure my oxygen mask is on tightly so it won't fall while I nap."
RATIONALE
Oxygen mask is fitted snugly, not tightly as it may cause skin breakdown.
230
3. A nurse teaches purse-lip breathing to Breeja who has COPD. Which of the following statements indicates the patient understands the instructions?
A. "I will maintain a supine position during the exercise."
B. "I will alternate positions during exercise."
C. "I will exhale for twice as long as I inhale."
D. "I will inhale and exhale through the nose."
C. "I will exhale for twice as long as I inhale."
RATIONALE
A Correct: Leaning forward position
B Correct: Same position
D Correct: Inhale through the nose and exhale through the mouth
231
4. Carlo was admitted with a history of asthma presents with respiratory distress with labored breathing, using of accessory muscles and audible expiratory wheezes. Which of the following would indicate his condition is worsening?
A. Audible expiratory wheezes with lessening inspiratory wheezes
B. Increasing expectoration of thick, tenacious sputum with decreasing wheezing lung sounds
C. Sudden absence of audible expiratory wheezes
D. Decreasing respiratory rate with decreased use of accessory muscles
C. Sudden absence of audible expiratory wheezes
RATIONALE
Indicates total obstruction of the airway due to bronchospasm.
232
5. Carlo asked you what breathing techniques he can best practice when asthmatic attack starts. What will be the best position?
A. Sit in high-Fowler's position with extended legs
B. Sit up with shoulders back
C. Push on abdomen during exhalation
D. Lean forwards 30-40 degrees
D. Lean forwards 30-40 degrees
233
6. Which intervention should the nurse discuss with Carlo who has asthma and is requesting information for allergy symptom control?
1. Instructing the client to refrain from using air conditioning or humidifiers in the house
2. Instructing the client to use curtains instead of pull shades over windows
3. Instructing the client to cover the mattress with hypoallergenic cover
4. Instructing the client to wear a mask when cleaning
5. Instructing the client to avoid sprays, powder and perfumes
6. Instructing the client to change detergents frequently
A. 1456
B. 3456
C. 345
D. 45
C. 345
RATIONALE
1 Correct: Use humidifiers
2 Correct: Use pull shades instead of curtains as it harbors dust
6 Correct: Limit use of detergents
234
7. Lyle is injured in an accident and was brought to the hospital. The nurse assesses him and observes use of accessory muscles, severe chest pain, agitation, SOB. The nurse suspects flail chest. Based on these observations, the nurse's best initial action is to:
A. Apply a sandbag to the flail side of his chest
B. Prepare for intubation and mechanical ventilation
C. Prepare for chest tube placement
D. Administer pain medication
B. Prepare for intubation and mechanical ventilation
235
8. A nurse has assisted the physician and the anesthesiologist with placement of an endotracheal (ET) tube in a client in respiratory distress. Which of the following is the initial nursing action to evaluate proper tube placement?
A. Ask the radiology department to obtain a stat portable radiograph at the client's bedside
B. Use an ambu (resuscitation) bag to ventilate and assess for bilateral breath sounds
C. Tape the ET tube in place and note the centimeter marking at the tip line
D. Attach the ET tube to the ventilator and determine if the client is able to tolerate the tidal volume prescribed
B. Use an ambu (resuscitation) bag to ventilate and assess for bilateral breath sounds
236
9. An emergency room nurse is assessing a client who sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client?
A. A sucking sound at the site of injury
B. Diminished breath sounds
C. A low respiratory rate
D. The presence of a barrel chest
B. Diminished breath sounds
237
10. The morning duty nurses endorse, "Monitor and report sign and symptoms of pneumothorax." Which of the following when manifested would you report STAT to the physician? Select all that apply.
1. Decreased oxygen saturation
2. Decreased respiration
3. Reduced breath sounds on the affected side
4. Prominence on one side of the chest
5. SOB
6. Bluish mucous membrane
A. 245 and 6
B. 134 and 5
C. 135 and 6
D. 123 and 5
C. 135 and 6
RATIONALE
2 Increased respiration is expected to patients with pneumothorax
4 Although a manifestation of pneumothorax, i.e. Mediastinal shift, it is observed only in X-ray
238
11. The nurse is caring for a client who has had a chest tube inserted and connected to portable water-seal drainage. The nurse determines the drainage system is functioning correctly when which of the following is observed?
A. Continuous bubbling in the water-seal chamber
B. Fluctuation in the water-seal chamber
C. Suction tubing attached to a wall unit
D. Vesicular breath sounds throughout the lung fields
B. Fluctuation in the water-seal chamber
239
12. The chest tube drainage of Tirso has continuous bubbling in the water seal drainage. Which of the following condition is the possible cause of the malfunctioning sealed drainage?
A. A suction being too high
B. An air leak
C. A tube being too small
D. A tension pneumothorax
B. An air leak
240
13. A client with a chest tube attached to a Pleurevac drainage system wants to get out of bed. While the nurse is assisting the client, the chest tubing accidentally gets caught in the bed rail and disconnects and the Pleurevac drainage system falls over and cracks. The nurse takes which immediate action?
A. Clamps the chest tube
B. Applies a petroleum gauze over the end of the chest tube
C. Immerses the chest tube in a bottle of sterile normal saline
D. Calls the physician
C. Immerses the chest tube in a bottle of sterile normal saline
RATIONALE
A Clamping is contraindicated
B Gauze should never be applied as it leaves fiber droppings on the tube
D Done after independent interventions are performed
241
14. The nurse may expect a client with suspected early ARDS to exhibit which of the following?
A. PaO2 of 90, PaCO2 of 45, X-ray showing enlarged heart and bradycardia
B. Thick green sputum production, PaO2 of 75 and pH 7.45
C. Restlessness, suprasternal retractions and PaO2 of 65
D. Wheezes, slow deep respirations, PaCO2 of 55 and pH of 7.25
C. Restlessness, suprasternal retractions and PaO2 of 65
242
15. An adult is to have a pulse oximeter applied to assess arterial oxygen saturation level. The nurse knows that correct application includes:
A. Placement over the apical area of the chest
B. Covering the probe with an opaque material
C. Insertion of an arterial catheter
D. Insertion of a venous catheter
B. Covering the probe with an opaque material
RATIONALE
Pulse oximeter device is sensitive to light and heat
243
16. You are caring for Hermie who has acute pulmonary edema. To immediately promote oxygenation and relief of dyspnea, you should first:
A. Perform chest physiotherapy
B. Have her take deep breaths and cough
C. Place Hermie on high Fowler's position
D. Administer oxygen
C. Place Hermie on high Fowler's position
RATIONALE
Patient is positioned first.
A, B, and D are done after positioning.
244
17. A nurse in medical unit is caring for Hermie with heart failure. She suddenly develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the physician and prepares to implement which priority interventions? Select all that apply
1. Administering oxygen
2. Inserting Foley catheter
3. Administer furosemide (Lasix)
4. Administering morphine sulfate intravenously
5. Transporting the client to the coronary care unit
6. Placing the client in the Low fowler's side lying position
A. 134
B. 1234
C. 1236
D. 1356
B. 1234
RATIONALE
Tip: Process of elimination
6 Correct: High-fowler's side lying position
245
18. Miss Jill, age 45, is being evaluated to rule out pulmonary tuberculosis. Which finding is MOST closely associated with TB?
A. Green – colored sputum
B. Night sweats
C. Leg cramps
D. Skin discoloration
B. Night sweats
```
RATIONALE
Signs and symptoms of TB
• 1st/early: mucoid sputum
• Late: cough with bloody sputum (hemoptysis), low grade fever in the afternoon, unexplained night sweats
• Dyspnea
• Fatigue
• Anorexia (leading to weight loss)
```
246
19. A positive Mantoux test indicates that a client:
A. Is actively immune to tuberculosis
B. Has produced an immune response
C. Will develop full–blown tuberculosis
D. Has active tuberculosis
B. Has produced an immune response
RATIONALE
Mantoux test determines if an individual has exposed to TB.
247
20. An 86-year-old female was admitted to the hospital two days ago with pneumonia. She now has in order to be up in the chair as much as possible. The nurse plans to get her up and help her with her morning care. The best plan to accomplish this would be to:
A. Get her up before breakfast. Have her eat in the chair, then bathe while still up.
B. Allow her to eat breakfast in bed, rest for 30 minutes, get up in the chair and rest for a few minutes. Allow her to wash her hands and face - nurse to complete bath
C. Allow her to eat in bed, get her up and provide her with a pan of water for her to bathe.
D. Get her up before breakfast, have her bath before breakfast, eat in the chair, the a rest in the chair.
B. Allow her to eat breakfast in bed, rest for 30 minutes, get up in the chair and rest for a few minutes. Allow her to wash her hands and face - nurse to complete bath
RATIONALE
Provide rest in between activities.
248
21. Which of the following measures would a nurse give priority when planning care for a patient who has undergone a cardiac catheterization via a femoral approach?
A. Encouraging fluid intake
B. Keeping the affected leg flexed
C. Assessing the patient's apical pulse
D. Monitoring the patient's serum glucose level
A. Encouraging fluid intake
RATIONALE
Cardiac catheterization involves using a dye. Post-op management includes removal of the dye out of the body through fluid intake.
249
22. A patient who is on a low fat-diet asks a nurse if dairy products can be included in the meal plan. Which of these responses should the nurse make?
A. "You can have dairy products as long as you don't exceed 50 grams of fat per day."
B. "You will need to take calcium supplements of 1500 mg daily in place of dairy products."
C. "You don't have to limit the amount of dairy products that you eat."
D. "You can substitute goat's milk for the cow's milk in dairy products."
A. "You can have dairy products as long as you don't exceed 50 grams of fat per day."
250
23. 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
C. Turkey breast
251
24. A client is admitted for treatment of Prinzmetal Angina. When developing the care plan, the nurse keeps in mind that this type of angina is triggered by:
A. Activities that increased myocardial oxygen demand
B. An unpredictable amount of activity
C. Coronary artery spasm
D. The same type of activity that caused previous angina episodes
C. Coronary artery spasm
RATIONALE
A and B are Unstable Angina
D is Stable Angina
252
25. A nurse is teaching the client with angina pectoris about disease management and lifestyle changes that are necessary to control disease progression. Which statement by the client indicates a need for further instruction?
A. "I will take the nitroglycerin whenever chest discomfort begins."
B. "I will use muscle relaxation to cope with stressful situations."
C. "It is best to exercise once a week for one hour."
D. "I would avoid using table salt with meals."
C. "It is best to exercise once a week for one hour."
RATIONALE
Exercise is done 30-45 minutes, 3-4 times a week
253
26. Later in the acute phase of myocardial infarction, which of the following typically appears as the first sign of tissue death?
A. ST segment suppression
B. Short T wave
C. Prolonged PR interval
D. Pathologic Q wave
D. Pathologic Q wave
RATIONALE
Tissue death or necrosis or infarction is seen on ECG as having pathologic Q wave.
A and B refer to ischemia
C Refers to hyperkalemia
254
27. A client with severe angina and electrocardiogram changes is seen by a nurse practitioner in the emergency department. In terms of serum testing, it's most important for the nurse to order:
A. Creatinine kinase
B. Lactate dehydrogenase
C. Myoglobin
D. Troponin
D. Troponin
RATIONALE
All is correct but Troponin is the most reliable as it has a longer duration (7 days).
255
28. A patient who had an acute myocardial infarction complains of severe substernal pain. Which of the following nursing interventions would the most appropriate?
A. Administering the prescribed morphine
B. Obtaining an electrocardiogram
C. Encouraging slow, deep breathing
D. Eliminating environmental stressors
A. Administering the prescribed morphine
256
29. Which client is at most risk of developing left – sided heart failure?
A. Middle-aged woman with aortic stenosis
B. Middle-aged man with pulmonary hypertension
C. Older woman who smokes two packs of cigarettes daily
D. Older man who had a right ventricular myocardial infarction
A. Middle-aged woman with aortic stenosis
RATIONALE
Aortic stenosis causes impediment of blood flow towards the body causing backflow of blood to the left ventricles, thus left congestive heart failure will occur.
257
30. The patient's central venous pressure is monitored every hour. When you measure the CVP, using a water manometer, you are expected to observe which of the following to ensure accuracy of CVP measurement?
A. Maintain the client on a Fowler's position
B. Use a one way stopcock to regulate flow of IV fluids to the water manometer
C. Immobilize the client's right arm
D. Keep the zero point of the manometer in level with the client's right atrium
D. Keep the zero point of the manometer in level with the client's right atrium
258
31. Francis is admitted with congestive heart failure. He has SOB, and a +3-4 peripheral edema. The care plan to reduce the client's edema should include the nursing strategies for:
A. Establishing limits on activity
B. Fostering a relaxed environment
C. Identifying goals for self-care
D. Restricting IV fluids
D. Restricting IV fluids
RATIONALE
Based on the problem, the patient has right-sided CHF, management includes avoiding exacerbation of edema.
259
32. A white male, age 43, with a tentative diagnosis of infective endocarditis is admitted to an acute care facility. His medical history reveals diabetes mellitus, hypertension, and pernicious anemia; he underwent an appendectomy 20 years ago and an aortic valve replacement 2 years ago. Which history finding is a major risk factor for infective endocarditis?
A. Race
B. Age
C. History of DM
D. History of aortic valve replacement
D. History of aortic valve replacement
RATIONALE
Risk factors of Endocarditis
• ❤️ valve stenosis
• IV drug abuser: sharing of
260
33. The nurse is aware that pericarditis pain varies from mild to severe and is typically aggravated by:
A. Coughing, talking, and eating
B. Inspiration, coughing, and movement of the upper body
C. Breathing, coughing and voiding
D. Coughing, inspiration and movement of the lower extremities
B. Inspiration, coughing, and movement of the upper body
261
34. Which signs cause the nurse to suspect cardiac tamponade after the client has cardiac surgery? Select all that apply.
1. Tachycardia
2. Hypertensive
3. Increased CVP
4. Increase urine output
5. Jugular vein distention
A. 134
B. 125
C. 234
D. 135
D. 135
```
RATIONALE
S/Sx of cardiac tamponade
• ⬆️CVP
• Tachycardia; muffled ❤️ sounds
• Distended jugular veins
```
262
35. A client is rushed in the emergency department complaining of chest pain, shortness of breath and low blood pressure. ECG tracing reveals atrial flutter. Atrial flutter has the following ECG tracing characteristic:
A. A saw-toothed shaped tracing
B. It has no discernible P wave
C. A P wave that is always in front of the QRS complexes
D. Irregular, undulating waves without recognizable QRS complex
A. A saw-toothed shaped tracing
RATIONALE
B Ventricular tachycardia
C Normal
D Ventricular fibrillation
263
36. A nurse is assisting in the care of a client schedules for cardioversion. The nurse plans to set the defibrillator to which of the following starting energy range levels, depending on the specific physician order?
A. 50 to 100 joules
B. 150 to 200 joules
C. 250 to 300 joules
D. 350 to 400 joules
A. 50 to 100 joules
264
37. The nurse is teaching a group of clients with peripheral vascular disease to stop smoking. Which physiologic effects of nicotine should the nurse explain to the group?
A. Constriction of the superficial vessels, dilating the deep vessels
B. Constriction of the peripheral vessels, increasing the force of flow
C. Dilation of the superficial vessels with constriction of the collateral circulation
D. Dilation of the peripheral vessels, causing a reflex constriction ofvisceral vessels
B. Constriction of the peripheral vessels, increasing the force of flow
265
38. A home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about homecare management and self – care management. Which statement is made by the client indicates a need for further teaching?
A. "I need to be sure not to go barefoot around the house."
B. "I need to be sure I elevate my leg above my heart level for at least an hour everyday."
C. "If I cut my toenails, I need to be sure that I cut them straight."
D. "It is alright to apply lanolin to my feet, but I shouldn't place it between my toes."
B. "I need to be sure I elevate my leg above my heart level for at least an hour everyday."
RATIONALE
May lead to pulmonary embolism.
266
39. A nurse has given instructions about making appropriate lifestyle changes to a patient who has varicose. Which of the following comments, if made by the patient, would indicate compliance with instructions?
A. "I eat fried chicken during the week."
B. "I put girdle in the morning."
C. "I place a stool under my legs when I sit."
D. "I drink beer every night after eating."
C. "I place a stool under my legs when I sit."
RATIONALE
Legs should be elevated to promote venous return.
267
40. A client is admitted with a diagnosis of DVT. Which finding should the nurse report immediately when assessing the patient?
A. Shortness of breath
B. Increased skin temperature of the affected leg
C. Calf tenderness
D. Reddened skin
A. Shortness of breath
RATIONALE
May indicate pulmonary embolism.
268
41. The healthcare provider prescribes bedrest for a client in whom a deep vein thrombosis develops after surgery. From the following list, select all appropriate nursing interventions to include in this client's plan of care.
1. Place in Fowler's position for eating
2. Encourage increased oral intake of water daily
3. Encourage coughing and deep breathing
4. Please thigh-length elastic stockings on the client
5. Encourage intake of dark, green leafy vegetables
6. Place sequential compression boots on the client
A. 1234
B. 2346
C. 245
D. 234
D. 234
RATIONALE
1 Correct: High Fowlers or sitting position
5 Rich in Vitamin K; exacerbates the clot
6 Can cause constriction of feet
269
42. The nurse is teaching a client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to:
A. Take a hot bath
B. Rest in an air-conditioned room
C. Increase the dose of muscle relaxants
D. Avoid naps during the day
B. Rest in an air-conditioned room
270
43. A patient was numbness and weakness of both feet is hospitalized with Guillain-Barré syndrome. The nurse would anticipate the need to teach the patient about:
A. Intubation and mech vent
B. Administration of IV corticosteroids
C. Insertion of NG feeding tube
D. IV infusion of immunoglobulin
D. IV infusion of immunoglobulin
RATIONALE
DOC for GBS. Option A is expected to prepare when weakness/paralysis is on the trunk.
271
44. Nick, a client with myasthenia gravis asks the nurse why the disease has occurred. What pathology underlies the nurse's reply?
A. A genetic defect in the production of Ach
B. An inefficient use of the neurotransmitter Ach
C. A decreased number of functional Ach receptors
D. An inhibition of the enzyme AchE, leaving the end plates folded
C. A decreased number of functional Ach receptors
RATIONALE
In MG, cholinesterase attacks Ach receptors.
272
45. Nick who has myasthenia gravis is having difficulty speaking. The speech is dysarthric and has a nasal tone. The nurse would avoid using which of the following communication strategies when working with this client?
A. Repeating what the client said to verify the message
B. Encouraging the client to speak quickly
C. Using communication board when necessary
D. Asking yes and no question when able
B. Encouraging the client to speak quickly
273
46. The nurse is teaching the client with myasthenia gravis about prevention of myasthenic and cholinergic crisis. The nurse tells the client that this is most effectively done by
A. Doing all chores early in the day while less fatigued
B. Taking medications on time to maintain therapeutic blood levels
C. Doing muscle strengthening exercises
D. Eating large, well balanced meals
B. Taking medications on time to maintain therapeutic blood levels
274
47. Paul, who has been severely beaten is admitted to the emergency department. The nurse suspects a basiliar skull fracture after assessing:
A. Raccoon's eye and Battle sign
B. Nuchal rigidity and Kernig's sign
C. Motor loss in the legs that exceeds that in the arm
D. Papillary changes
A. Raccoon's eye and Battle sign
RATIONALE
B Refers to meningitis
C Refers to spinal injury
D Irrelevant
275
48. The nurse is caring for a client following a supratentorial craniotomy in which a large clot and tumor was removed from the left side. Select the positions in which the nurse can safely place the client.
1. On the left side
2. With the neck flexed
3. Supine on the left side
4. With extreme hip flexion
5. In a semi Fowler's position
6. With the head in the midline position
A. 156
B. 23
C. 34
D. 56
D. 56
276
49. The nurse is to begin bladder training with Iressa, who has a T2 spinal cord injury. What should the nurse plan to do?
A. Teach her to change the indwelling catheter drainage bag to a leg bag at night
B. Plan a consistent intermittent catheterization schedule with her and teach her self catheterization technique
C. Plan to place her on the bedside commode to void every 2 hours until consistent urination is achieved
D. Clamp the indwelling catheter for longer periods of time each day until a bladder capacity of 1500ml is achieved
B. Plan a consistent intermittent catheterization schedule with her and teach her self catheterization technique
277
50. The nurse is caring for a client with a complete T5 spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above T5, and the blood pressure of 162/96. The client reports a severe pounding headache. Which nursing interventions would be appropriate for this client? Select all that apply.
1. Elevating the head of the bed 90°
2. Loosening constrictive clothing
3. Using a fan to reduce diaphoresis
4. Assessing for bladder distention and bowel impaction
5. Administering antihypertensive medication
6. Placing the client in the supine position with legs elevated
A. 2456
B. 2345
C. 1245
D. 1234
C. 1245
RATIONALE
3 Insignificant
6 Correct: Elevated HOB
278
1. Which of the following is a common cause of pre-renal acute renal failure?
A. Glomerulonephritis
B. Decreased cardiac output
C. Prostatic hypertrophy
D. Anitbiotics
B. Decreased cardiac output
RATIONALE
A Intra-renal
C Post-renal
D Intra-renal
279
2. If the patient develops nephrotoxicity and eventually lead to renal failure, where are you going to classify such?
A. Pre-renal
B. Intra-renal
C. Post-renal
D. AOTA
B. Intra-renal
280
3. Which of the following condition is a common cause of pre-renal acute renal failure?
A. Aminoglycoside use
B. Decreased cardiac output
C. Prostatic hypertrophy
D. Bladder cancer
B. Decreased cardiac output
RATIONALE
A Intra-renal
C and D are Post-renal
281
4. A client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. Which assessment findings suggests that the client is experiencing acute renal failure (ARF)?
A. BUN level of 22 mg/dL
B. T 100.2°F (37.8°C)
C. Serum creatinine level of 1.2 mg/dL
D. Urine output of 400 ml/24 hours
D. Urine output of 400 ml/24 hours
RATIONALE
Indicates oliguria. Normal is 30mL/hr.
```
A Normal (5-25 mg/dL)
B Normal
C Normal (0.5-1.5 mg/dL)
```
282
5. A client with chronic renal failure asks the nurse why he has developed anemia. The most accurate response by the nurse is:
A. "The increase in nitrogen waste in your blood destroys your bone marrow."
B. "A hormone in your kidney that stimulate your bone marrow is lacking."
C. "You have lost some blood through your urine."
D. "The low protein diet that you are on causes the anemia."
B. "A hormone in your kidney that stimulate your bone marrow is lacking."
283
6. The physician orders regular insulin, 10 units added to 50ml of 50% dextrose to be given intravenously to a patient with chronic renal failure. The expected outcome of this is to:
A. Lower the blood sugar
B. Decrease the serum potassium
C. Reduced cerebral edema
D. Prevent tetany
B. Decrease the serum potassium
RATIONALE
In chronic renal failure, there is hyperkalemia. Insulin is used to transport excess K+ to the cells.
284
7. The nurse should expect a patient who has a renal failure to be given epoetin alfa (Epogen) to:
A. Elevate the WBC count
B. Enhance the maturation of thrombocytes
C. Increase the production of platelets
D. Stimulate the synthesis of RBCs
D. Stimulate the synthesis of RBCs
285
8. The physician orders aluminum hydroxide (Amphojel) with each meal for a patient with end stage renal disease. This drug is given to:
A. Remove protein waste of metabolism
B. Bind phosphorus in the GI tract
C. Exchange sodium for potassium in the colon
D. Inhibit development of a stress ulcer
B. Bind phosphorus in the GI tract
Tip: Am"PH"ojel = phosphorus
286
9. Which of the following clinical findings would the nurse look for in a client with chronic renal failure?
A. Hypotension
B. Uremia
C. Metabolic alkalosis
D. Polycythemia
B. Uremia
RATIONALE
Since urine is not excreted, possible that is reabsorbed in the blood, thus, uremia or azotemia.
287
10. In assessing the laboratory findings, which result would the nurse most likely expect to find in a client with chronic renal failure?
A. BUN 10 to 30 mg/dL, potassium 4.0 mEq/L, creatinine 0.5 to 1.5 mg/dL
B. Decreased serum calcium, blood pH 7.2, potassium 6.5 mEq/L
C. BUN 15 mg/dL, increased serum calcium, creatinine 1.0 mg/dL
D. BUN 35 to 40 mg/dL, potassium 3.5 mEq/L, pH 7.35, decreased serum calcium
B. Decreased serum calcium, blood pH 7.2, potassium 6.5 mEq/L
RATIONALE
In chronic renal failure, there is ⬇️Ca due to the absence of activation of Vit D needed to absorb Ca. There is also metabolic acidosis due to inability of the kidney to excrete acid wastes. There is hypokalemia due to inability of the kidney to excrete excess potassium.
A ✅⬆️BUN, ❌N°Potassium (should be ⬆️), ❌N°Creatinine (should be ⬆️)
C ❌N°BUN (should be ⬆️), ❌⬆️Ca (should be ⬇️), ❌N°Creatinine (should be ⬆️)
D ✅⬆️BUN, ❌N°Potassium (should be ⬆️), ❌N°pH (should be ⬇️ or acidic), ✅⬇️Ca
```
NORMAL VALUES
BUN: 5-25 mg/dL
Creatinine: 0.5-1.5 mg/dL
Blood pH: 7.35-7.45
Potassium: 3.5-5 mEq/L
```
288
11. The patient is undergoing Hemodialysis because of chronic renal failure. You are asked by the relative on the chances of recovery for this patient, based on your knowledge your best response would be
A. The patient has few months to live
B. He has to be maintained on hemodialysis or else he will die
C. He has to undergo hemodialysis to excrete his waste because the kidneys are not functioning
D. A kidney transplant can improve his condition
C. He has to undergo hemodialysis to excrete his waste because the kidneys are not functioning
289
12. A client recently started on hemodialysis wants to know how the dialysis will take the place of his kidneys. The nurse's response is based on the knowledge that the hemodialysis works by:
A. Passing water through a dialyzing membrane
B. Eliminating plasma proteins from the blood
C. Lowering the pH by removing non-volatile acid
D. Filtering waste through a dialyzing membrane
D. Filtering waste through a dialyzing membrane
290
13. A home health nurse is assessing a client who has begun using a peritoneal dialysis. The nurse would determine that which of the following manifestations noted in the client would most likely indicate the onset of peritonitis?
A. Temperature of 99°F oral
B. History of GI upset 1 week ago
C. Cloudy dialysate output
D. Presence of crystals in dialysate output
C. Cloudy dialysate output
291
14. During the first peritoneal dialysis exchange, the fluid that drains from the outflow tubing is tinged with blood. The nurse should:
A. Realize that this is a normal occurrence for the first few exchanges
B. Apply a pressure dressing to the insertion site
C. Recognize that the abdominal blood vessels have been inadvertently punctured
D. Check the urine output for hematuria
A. Realize that this is a normal occurrence for the first few exchanges
RATIONALE
It is due to the puncture of small blood vessels at the site.
292
15. Which outcome should the nurse expect after peritoneal dialysis?
A. Decreased serum urea nitrogen concentration
B. Stimulated urine formation from external kidney pressure
C. Increased serum urea nitrogen concentration
D. Removal of excess serum parathyroid hormone
A. Decreased serum urea nitrogen concentration
RATIONALE
In renal failure, kidneys are unable to excrete urea. After dialysis, the urea is excreted through the dialysate, thus ⬇️ BUN is expected.
293
16. A client with chronic renal failure is on continuous ambulatory peritoneal dialysis. Which nursing diagnosis should have the highest priority?
A. Powerlessness
B. High risk for infection
C. Altered nutrition: Less than body requirements
D. High risk for fluid volume deficit
B. High risk for infection
294
17. A home care nurse is making a follow up visit to a client following renal transplant. The nurse assesses the client for which signs of acute graft rejection?
A. Hypotension, graft tenderness, and anemia
B. Fever, hypertension, graft tenderness and malaise
C. Fever, hypertension, vomiting, copious amounts of dilute urine
D. Fever, hypotension, graft tenderness and malaise
B. Fever, hypertension, graft tenderness and malaise
295
18. The nurse is aware that the client is receiving Azathioprine (Imuran), cyclosporine and prednisone before a kidney transplant surgery to:
A. Stimulate leukocytosis
B. Provide passive immunity
C. Prevent iatrogenic infections
D. Reduce antibody production
D. Reduce antibody production
296
19. A client is scheduled for a kidney transplant. A medication she will probably take on a long term basis that require specific client teaching to ensure compliance is:
A. Corticosteroids
B. Antibiotics
C. Anticoagulants
D. Gamma globulin
A. Corticosteroids
RATIONALE
These medications are used throughout life to suppress antibody formation to prevent graft rejection.
297
20. A client has a chronic renal failure and receives hemodialysis three times a week through an AV fistula in the left arm. Which of the following interventions is included in this client's care?
A. Keep the AV fistula dry
B. Keep the AV fistula wrapped in gauze
C. Take the BP in the left arm
D. Assess the AV fistula for a bruit and thrill
D. Assess the AV fistula for a bruit and thrill
298
21. The presence of calculi in the urinary tract is called:
A. Cholelithiasis
B. Nephrolithiasis
C. Ureterolithiasis
D. Urolithiasis
D. Urolithiasis
RATIONALE
It is the general term. Specific sites have specific terms as well.
A Stones in the gallbladder
B Stones in the kidney
C Stones in the ureter
299
22. Diet therapy for renal calculi of calcium phosphate composition would probably be:
A. High calcium and phosphorus, alkaline ash
B. High calcium and phosphorus, acid ash
C. Low purine and phosphorus, alkaline ash
D. Low calcium and phosphorus, acid ash
D. Low calcium and phosphorus, acid ash
300
23. A client passed a kidney stone. The nurse sends the specimen to the laboratory so it can be analyzed which of the following factors?
A. Antibodies
B. Type of infection
C. Composition of stones
D. Size and number of stones
C. Composition of stones
301
24. Which of the following interventions will be done for a client with urinary calculus?
A. Save any stone larger than 0.25 cm
B. Strain the urine, limit oral fluids, give pain medication
C. Encourage fluid intake, strain the urine, give pain medication
D. Insert an indwelling urinary catheter, check I and O, give pain medications
C. Encourage fluid intake, strain the urine, give pain medication
RATIONALE
A Insignificant
B ✅Strain the urine, ❌Limit oral fluids (should be encouraged), ✅give pain medications
D ❌Insert indwelling catheter, ❌Check I and O, ✅give pain medications
302
25. Patient comes to the hospital complaining of severe pain in the right flank, nausea and vomiting. The doctor tentatively diagnoses right ureterolithiasis (Renal calculi). When planning the patient's care, the nurse should assign the highest priority to which diagnosis?
A. Pain
B. Risk for infection
C. Altered urinary elimination
D. Altered nutrition: less than body requirements
A. Pain
303
26. Joseph was brought to the hospital with second-degree burns coming from a residential fire. What type of burn does the patient to sustain?
A. Radiation
B. Chemical
C. Electrical
D. Thermal
D. Thermal
304
27. A client is admitted to the hospital following a burn injury to the left hand and arm. The client's burn is described as white and leathery with no blisters. Which degree of severity is this burn?
A. First degree burn
B. Second degree burn
C. Third degree burn
D. Fourth degree burn
C. Third degree burn
RATIONALE
1° Superficial Partial Thickness, Epidermis, Redness
2° Deep Partial Thickness, Up to dermis, Blisters
3° Full Thickness, Up to SQ, White Leathery
4° Full thickness, Up to muscles/bones, Charred/Black
305
28. Sergio is brought to the emergency room after a burn injury accident. Based on the assessment of the Physician, Sergio sustained superficial partial thickness burns on his trunk, right upper extremities and right lower extremities. His wife asks what that mean. Your most accurate response would be:
A. Structures beneath the skin are damaged
B. Dermis is partially damaged
C. Epidermis and dermis are both damaged
D. Epidermis is damaged
D. Epidermis is damaged
RATIONALE
1° Superficial Partial Thickness, Epidermis, Redness
2° Deep Partial Thickness, Up to dermis, Blisters
3° Full Thickness, Up to SQ, White Leathery
4° Full thickness, Up to muscles/bones, Charred/Black
306
29. The client suffered burn injury on the anterior trunk, genitalia, left anterior thigh and left posterior leg. What is the classification and the estimated TBSA burned using the rule of nine?
A. 32.5% moderate burns
B. 32.5% major burns
C. 28% moderate burns
D. 28% major burns
A. 32.5% moderate burns
```
RATIONALE
Anterior trunk=18%
Genitalia=1%
Left anterior thigh=4.5%
Left posterior leg=9%
```
TOTAL 32.5% Major Burns
Major (>25% TBSA)
Moderate (15-25% TBSA)
Minor (
307
30. Palm method in determining the extent of burn uses the:
A. Palm of the examiner in patient with scattered burn injury
B. Palm of the patient with scattered burn injury
C. Palm of the examiner with one-sided burn injury
D. Palm of the patient with one sided burn injury
B. Palm of the patient with scattered burn injury
308
31. Christina is a 37 year old cook. She is admitted for treatment of partial and full thickness burns of her entire right lower extremity and the anterior portion of her right upper extremity. Her respiratory status is compromised, and she is in pain and anxious. Performing immediate appraisal, using the rule of nines, the nurse estimates the percent of Christina's body surface that is burned is:
A. 4.5%
B. 9%
C. 18%
D. 22.5%
D. 22.5%
RATIONALE
Entire right lower extremity = 18%
Anterior portion of right upper extremity = 4.5%
TOTAL 22.5%
309
32. Nursing care planning is based on the knowledge that the first 48 hours post burn are characterized by:
A. An increase in the total volume of intracranial plasma
B. Excessive renal perfusion with diuresis
C. Fluid shift from interstitial space
D. Fluid shift from intravascular space to the interstitial space
D. Fluid shift from intravascular space to the interstitial space
RATIONALE
First 48 hours post-burn is known as Emergent phase.
310
33. After 48 hours postburn, which of the following isn't an expected manifestation of the client?
A. Polyuria
B. Hypokalemia
C. Metabolic alkalosis
D. Hemodilution
C. Metabolic alkalosis
RATIONALE
Metabolic acidosis should be expected due to low sodium carrying the Bicarbonate ions.
311
34. During the shock phase of burns, all but one is expected.
A. Hypovolemia, increase Hct
B. Decreased u/o, fluid overload
C. Hyperkalemia, hyponatremia
D. Fluid shifts from IVC to ISC
B. Decreased u/o, fluid overload
RATIONALE
Correct: Decreased u/o, fluid loss (due to shifting from IVC to ISC)
312
35. In the acute phase of a burn the nurse should assess which of the following?
A. Dehydration status because of fluid shifting
B. Circulatory status because of fluid overload
C. ABG due to metabolic alkalosis
D. Hematocrit level due to hypovolemia
B. Circulatory status because of fluid overload
RATIONALE
A Happens in emergent/shock phase
C Correct: metabolic acidosis
D Happens in emergent/shock phase
313
36. During the first 24 hours after thermal injury, you should assess a burn patient for:
A. Hypokalemia and hypernatremia, metabolic acidosis
B. Hypokalemia and hyponatremia, metabolic alkalosis
C. Hyperkalemia and hyponatremia, metabolic acidosis
D. Hyperkalemia and hyponatremia, metabolic alkalosis
C. Hyperkalemia and hyponatremia, metabolic acidosis
RATIONALE
A ❌Hypokalemia and ❌hypernatremia, ✅metabolic acidosis
B ❌Hypokalemia and ✅hyponatremia, ❌metabolic alkalosis
D ✅Hyperkalemia and ✅hyponatremia, ❌metabolic alkalosis
314
37. Using the Parkland and Baxter formula, how much fluid must be given to a client with TBSA 40%, weight is 60 kg during the first 16 hours?
A. 2400 ml
B. 4800 ml
C. 7200 ml
D. 9600 ml
C. 7200 ml
RATIONALE
FORMULA: 4mL/kg %TBSA x weight (kg) x %TBSA
```
4mL x 60 x 40 = 9600 mL
1st 8° = 4800mL
2nd 8° = 2400mL
---------------------->1st 16° = 7200 mL
3rd 8° = 2400 mL
```
315
38. The client has wet extensive body burns. Which of the following nursing action is most appropriate when applying antimicrobials in the area?
A. Use cotton swabs
B. Use 4" by 4" gauze
C. Use sterile gloves
D. Use tongue blade
C. Use sterile gloves
RATIONALE
Sterile technique is implemented to prevent patient from acquiring infection.
316
39. Mechanical Debridement of burns is done by which of the following method?
A. Dry to dry dressing
B. Wet to wet dressing
C. Dry to wet dressing
D. Wet to dry dressing
D. Wet to dry dressing
317
40. The nurse is giving home care instructions to a client who recently had skin grafts. Which of the following is the MOST important instruction?
A. Continue physical therapy
B. Protect the graft from direct sunlight
C. Use cosmetic camouflage techniques
D. Apply lubricating lotion to the graft site
B. Protect the graft from direct sunlight
318
46. A nurse provides medication instructions to a client with peptic ulcer disease. Which statement, if made by the client, indicates the best understanding of the medication therapy?
A. "The cimetidine (Tagamet) will cause me to produce less stomach acid."
B. "Sucralfate (Carafate) will change the fluid in the stomach."
C. "Antacids will coat my stomach."
D. "Omeprazole (Prilosec) will coat the ulcer and help it heal."
A. "The cimetidine (Tagamet) will cause me to produce less stomach acid."
RATIONALE
It is an antihistamine/H2 blocker - produces less acid in the stomach
B Cytoprotective agent - blocks and coats the ulcer
C Antacids neutralize the acidity of the stomach
D Proton pump inhibitor - decreases the amount of acid in the stomach
319
47. A patient has a vagotomy with antrectomy to treat a duodenal ulcer. Postoperatively, the patient develops dumping syndrome. Which of the following statements, if made by the patient, should indicate to the nurse that further dietary teaching is necessary?
A. "I should eat bread with each meal."
B. "I should eat smaller meals more frequently."
C. "I should lie down after eating."
D. "I should avoid drinking fluids with my meals."
A. "I should eat bread with each meal."
RATIONALE
Diet should include ⬇️CHO and ⬆️CHON.
320
48. A nurse obtains a diet history from a patient who has ulcerative colitis. The nurse should determine that the patient needs teaching if the patient indicated which of these foods as being part of the diet?
A. Celery
B. Bananas
C. White rice
D. Roast chicken
A. Celery
RATIONALE
High fiber vegetables such as brocolli, brussels sprouts, celery and cabbage are not easily digested and can cause gas, bloating, and cramping.
321
49. Crohn's Disease can be described as chronic relapsing disease. Which of the following areas of the GI system may be involved with this disease?
A. The entire length of the large colon
B. Any segment of the alimentary canal
C. The entire large colon through the layers of the mucosa and submucosa
D. The small intestine and colon, affecting the entire thickness of the bowel
D. The small intestine and colon, affecting the entire thickness of the bowel
RATIONALE
Crohn's disease affects proximal to distal colon, is patchy, transmural (deep layers are involved), will give semi-solid stools, may present mucus and pus, and RLQ pain.
322
50. Which of the following symptoms may cause hemorrhoids?
A. Epigastric pain
B. Diverticulosis
C. Portal Hypertension
D. Rectal bleeding
B. Diverticulosis
323
1. A client is scheduled for an EEG early in the morning. The nurse working the night shift prior to the procedure would write a note to do which of the following per protocol order in the early morning on the day of the test?
A. Instruct the client to refrain from washing the hair
B. Hold the daily dose of anticonvulsant
C. Place the client on NPO status
D. Reinforce client teaching that the test is only mildly uncomfortable
B. Hold the daily dose of anticonvulsant
324
2. A client has undergone insertion of an ICP monitoring device. The nurse would become most concerned if the ICP readings measured which of the following for a prolonged period of time?
A. 3 mmHg
B. 7 mmHg
C. 10 mmHg
D. 22 mmHg
D. 22 mmHg
RATIONALE
N° ICP: 0-10 mmHg
325
3. The nurse reads in an admission note that the physical examination of a client revealed an impairment of cranial nerve II. The nurse instructs ancillary caregivers to do which of the following when caring for this client?
A. Whisper to the client
B. Serve food at room temperature
C. Clear the client's path of obstacles
D. Test the temperature of any running water
C. Clear the client's path of obstacles
RATIONALE
CN 2 Optic nerve is for vision
326
4. A nurse is planning to test the function of the trigeminal nerve (CN V). The nurse would gather which of the following items to perform the test?
A. Flashlight, pupil size chart or millimeter ruler
B. Tuning fork and audiometer
C. Safety pin, hot and cold water in test tubes, cotton wisp
D. Snellen's chart, ophthalmoscope
C. Safety pin, hot and cold water in test tubes, cotton wisp
327
5. A nurse is testing the coordinated functioning of cranial nerves III, IV, and VI. To do this correctly, the nurse would test the:
A. Corneal reflex
B. Six cardinal fields of gaze
C. Pupil response to light
D. Pupil response to light and accommodation
B. Six cardinal fields of gaze
328
6. A nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain?
A. Sternal rub
B. Pressure on the orbital rim
C. Squeezing of the sternocleidomastoid muscle
D. Nail bed pressure
D. Nail bed pressure
329
7. A client admitted with a neurological problem indicates to the nurse that MRI may be done. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the client's history of:
A. Hypertension
B. COPD
C. Heart failure
D. Prosthetic valve replacement
D. Prosthetic valve replacement
RATIONALE
It may have magnets which are contraindicated for MRI.
330
8. A client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure?
A. Side lying, with legs pulled up and head bent down onto chest
B. Side lying, with a pillow under the hip
C. Prone, in slight Trendelenburg
D. Prone, with a pillow under the abdomen
A. Side lying, with legs pulled up and head bent down onto chest
RATIONALE
Otherwise known as knee chest position or shrimp position.
331
9. The nurse asks a school aged child with GBS to cough and also assess the child's speech for decreased volume and clarity. The underlying rationale for these assessments is to determine which of the following?
A. Inflammation of the larynx and the epiglottis
B. Increased ICP
C. Involvement of the facial and cranial nerves
D. Regression to an earlier developmental phase
C. Involvement of the facial and cranial nerves
332
10. A client is admitted to the hospital with a diagnosis of GBS. The nurse inquires during the nursing admission interview whether the client has a history of:
A. Back injury or trauma to the spinal cord
B. Seizures or trauma to the brain
C. Respiratory infection during the previous month
D. Meningitis during the last 5 years
C. Respiratory infection during the previous month
333
11. A client with GBS has ascending paralysis and is intubated and receiving mechanical ventilation. Which of the following strategies would the nurse incorporate in the plan of care to help the client cope with this illness?
A. Giving client full control over care decisions and restricting visitors
B. Providing information, giving positive feedback, and using distraction
C. Providing TV sedatives, reducing distractions, and limiting visitors
D. Providing positive feedback and encouraging active ROM
B. Providing information, giving positive feedback, and using distraction
334
12. A nurse is administering a client with GBS to the nursing unit. The client has an ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse brings which of the following items into the client's room?
A. Nebulizer and pulse oximeter
B. Flashlight and incentive spirometer
C. ECG monitoring electrodes and intubation tray
D. Blood pressure cuff and flashlight
C. ECG monitoring electrodes and intubation tray
335
13. A nurse is evaluating the respiratory outcomes for a client with GBS. The nurse would evaluate that which of the following is the least optimal outcome for the client?
A. Adventitious breath sounds
B. Spontaneous breathing
C. Oxygen saturation 98%
D. Vital capacity within normal range
A. Adventitious breath sounds
336
14. The client with GBS is complaining of SOB and seems confused. The nurse should:
A. Call for the code team
B. Suction the client's oropharynx
C. Perform a mental status exam
D. Auscultate breath sounds
D. Auscultate breath sounds
RATIONALE
Reassess patient's subjective cues for objective cues.
337
15. All of the following factors can cause exacerbation of Multiple Sclerosis, except?
A. Fatigue
B. Hot bath or shower
C. Stress
D. High protein diet
D. High protein diet
338
16. Hermione experienced many different symptoms. Which one is atypical of MS?
A. Double vision
B. Sudden burst of energy
C. Weakness in extremities
D. Muscle tremors
B. Sudden burst of energy
339
17. Baclofen (Lioresal) is prescribed for Hermione who has MS. The nurse will evaluate that the drug is accomplishing its intended purpose when it:
A. Induces sleep
B. Stimulates the client's appetite
C. Relieve muscle spasticity
D. Reduces the urine bacterial content
C. Relieve muscle spasticity
340
18. Hermione has received various drug therapies for multiple sclerosis over the years. It is difficult to evaluate the effectiveness of any particular drug, because clients with MS tend to:
A. Exhibit tolerance to many drugs
B. Exhibit spontaneous remissions from time to time
C. Require multiple drugs that are used simultaneously
D. Endure long periods of exacerbation before illness responds to a particular drug
B. Exhibit spontaneous remissions from time to time
341
19. Hermione has slurred speech. When the nurse talks with her, it will be contraindicated to?
A. Encouraging her to speak slowly
B. Encouraging her to speak distinctly
C. Asking her to repeat indistinguishable words
D. Asking her to speak louder
D. Asking her to speak louder
342
20. Hermione's hands trembles severely whenever she writes. She spills her milk twice and couldn't button her blouse securely. Which of the following nurse's notes offers the best accounts of these observations?
A. "Has an intention tremor on the right hand."
B. "Right hand tremor worsens with purposeful acts."
C. "Needs assistance in dressing and eating due to severe trembling and clumsiness."
D. "Slight shaking of the right hand increases to severe tremor when client tries to button her clothes and drink from a cup."
D. "Slight shaking of the right hand increases to severe tremor when client tries to button her clothes and drink from a cup."
RATIONALE
Proper documentation requires what the nurse has actually seen from the patient, not what the nurse "thinks"happened to the patient.
343
21. Hermione has MS. As Hermione prepares for discharge, the nurse should encourage her to:
A. Accept the necessity for a quiet and inactive lifestyle
B. Keep active while avoiding emotional upset and fatigue
C. Follow good health habits to change the course of the disease
D. Practice using mechanical aids that she will need when future disabilities arise
B. Keep active while avoiding emotional upset and fatigue
344
22. A client is admitted with an exacerbation of MS. The nurse is assessing the client for possible precipitating risk factors. Which of the following factors, if stated by the client, would the nurse assess as being unrelated to the exacerbation?
A. A stressful week at work
B. Ingestion of more fruits and vegetables
C. A recent bout of the flu
D. Inability to sleep well
B. Ingestion of more fruits and vegetables
345
23. The nurse admitting a client with a history of trigeminal neuralgia (Tic Douloureux) would question the client about which of the following manifestations?
A. Facial drooping accompanied by numbness and tingling
B. Stabbing pain that occurs with twitching of the part of the face
C. Aching pain and ptosis of the eyelid
D. Burning pain and intermittent facial paralysis
B. Stabbing pain that occurs with twitching of the part of the face
346
24. A client newly diagnosed with trigeminal neuralgia asks the nurse to explain why it hurts so much when an episode occurs. The nruse would explain that the pain of trigeminal neuralgia is the result of which of the following?
A. Stimulation of the nerve by temperature or pressure
B. Irritation due to cellular effects of hypoglycemia
C. Release of epinephrine during the fight-or-flight response
D. An immune system reaction to cold and influenza viruses
A. Stimulation of the nerve by temperature or pressure
347
25. A nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse would evaluate that the client needs reinforcement of information if the client made which of the following statements?
A. "I will wash my face with cotton pads."
B. "I'll have to start chewing on the unaffected side."
C. "I should rinse my mouth sometimes if toothbrushing is painful."
D. "I'll try to eat my food either very warm or very cold."
D. "I'll try to eat my food either very warm or very cold."
348
26. The nurse is instructing the client with Bell's Palsy information regarding medications that might reduce nerve tissue edema. The nurse would explain the actions and side effects of which of the following medications?
A. Acetaminophen (Tylenol)
B. Ibuprofen (Advil)
C. Aspirin
D. Prednisone (Deltasone)
D. Prednisone (Deltasone)
349
27. A client with Bell's Palsy asks a nurse what caused this problem to occur. The nurse's response is based on an understanding that the etiology is:
A. Unknown, but possibly includes ischemia, viral infection, or am autoimmune problem
B. Unknown, but possibly includes long term tissue malnutrition and cellular hypoxia
C. Primarily genetic in origin, but triggered by exposure to neurotoxins
D. Primarily genetic in origin, but triggered by exposure to meningitis
A. Unknown, but possibly includes ischemia, viral infection, or am autoimmune problem
350
28. A client with an onset of Bell's Palsy is very upset and crying about the change in facial appearance. The nurse plans to emotionally support the client by telling the client that:
A. This is similar to a CVA, but all symptoms will reverse without treatment
B. This is not a CVA, and many clients recover in 3 to 5 weeks
C. This is caused by a small tumor, which can be easily removed
D. This is a temporary problem, with treatment similar to that of migraine headaches
B. This is not a CVA, and many clients recover in 3 to 5 weeks
351
29. A nurse has given a client with Bell's Palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse evaluates that the client needs additional information if the client states that he or she should:
A. Expose the face to cold and drafts
B. Massage the face with a gentle upward motion
C. Wrinkle the forehead, blow out the cheeks, and whistle
D. Use a device for electrical stimulation of the face
A. Expose the face to cold and drafts
RATIONALE
Options B, C, and D are management for Bell's Palsy.
352
30. A client with diplopia has been taught to use an eye patch to promote better vision and prevent injury. The nurse would evaluate that the client has correct understanding of the use of the patch if the client states that he or she should:
A. Use the patch only when vision is especially troublesome
B. Wear the patch for 1 hour at a time
C. Wear the patch continuously, alternating eyes each day
D. Wear the patch continuously, alternating eyes each week
C. Wear the patch continuously, alternating eyes each day
353
31. A client receives a dose of edrophonium (Tensilon) intravenously. The client shows improvement in muscle strength for a period of time following the injection. The nurse interprets that this finding is compatible with:
A. Multiple sclerosis
B. Amyotrophic lateral sclerosis
C. Myasthenia gravis
D. Muscular dystrophy
C. Myasthenia gravis
354
32. A client with Myasthenia gravis is having difficulty in speaking. The speech is dysarthric and has a nasal tone. The nurse would plan to avoid using which of the following communication strategies when working with this client?
A. Repeating what the client said to verify the message
B. Encouraging the client to speak quickly
C. Using a communication board when necessary
D. Asking yes and no questions when able
B. Encouraging the client to speak quickly
355
33. A client with myasthenia gravis has nursing diagnosis of Risk for Ineffective Airway Clearance and Risk for Ineffective Breathing Pattern. The nurse would keep which of the following available at the client's bedside?
A. Incentive spirometer and cough pillow
B. Oxygen and metered dose inhaler
C. Pulse oximeter and a cardiac monitor
D. Ambu bag and suction equipment
D. Ambu bag and suction equipment
356
34. A client has experienced an episode of myasthenic crisis. The nurse would assess whether the client has precipitating factors such as:
A. Too little exercise
B. Increased intake of fatty foods
C. Omitted doses of medication
D. Excess medication
C. Omitted doses of medication
357
35. A nurse is teaching a client with myasthenia gravis about prevention of myasthenic and cholinergic crisis. The nurse tells the client that this is most effectively done by:
A. Doing all chores early in the day while less fatigued
B. Taking medications on time to maintain therapeutic blood levels
C. Doing muscle strengthening exercises
D. Eating large, well balanced meals
B. Taking medications on time to maintain therapeutic blood levels
358
36. A home health nurse is visiting a client with myasthenia gravis and is discussing methods to minimize the risk of aspiration during meals because of decreased muscle strength. Which of the following suggestions would the nurse avoid giving to the client?
A. Sit straight up in the chair while eating
B. Cut food into very small pieces, chewing thoroughly
C. Swallow when the chin is tipped slightly downward to the chest
D. Lift the head while swallowing liquids
D. Lift the head while swallowing liquids
359
37. A nurse has instructed a client with myasthenia gravis about ways to manage health at home. The nurse would evaluate that the client needs more information if the client made which of the following statements?
A. "I should take my medications an hour before mealtime."
B. "I've made arrangements to get a portable resuscitation bag and home suction equipment."
C. "Going to the beach will be a nice, relaxing form of activity."
D. "Here's the Medic-Alert Bracelet I obtained."
C. "Going to the beach will be a nice, relaxing form of activity."
```
RATIONALE
Health education involves avoiding:
• Fatigue
• Infection
• Stress
• Temperature (extreme)
```
360
38. A client with Parkinson's disease has a nursing diagnosis of Risk for Falls related to an abnormal gait documented in the nursing care plan. The nurse assesses the client, expecting to observe which type of gait?
A. Broad based and waddling
B. Accelerating with walking on toes
C. Unsteady and staggering
D. Shuffling and propulsive
D. Shuffling and propulsive
361
39. A client with Parkinson's disease is embarrassed about the symptoms of disorder, and is bored and lonely. The nurse would plan which of the following approaches as most therapeutic in assisting the client to cope with the disease?
A. Plan only a few activities for the client during the day
B. Assist the client with ADLs as much as possible
C. Encourage and praise perseverance in exercising and performing ADLs
D. Cluster activities at the end of the day when the client is most bored
C. Encourage and praise perseverance in exercising and performing ADLs
362
40. A nurse has given instructions to a client with Parkinson's disease about maintaining mobility. The nurse would evaluate that the client understood the directions if the client stated he or she should:
A. Exercise in the evening to combat fatigue
B. Rock back and forth to start movement with bradykinesia
C. Sit in soft, deep chairs
D. Buy clothes with many buttons to maintain finger dexterity
B. Rock back and forth to start movement with bradykinesia
363
1. Which of the following clients is at highest risk for developing fluid volume deficit?
A. A 78-year-old client who has an NGT to low suction following colon cancer surgery
B. A thin 55-year-old client who smokes and takes glucocorticosteroids for chronic lung disease
C. A 1-year-old child being treated in the clinic for a runny nose and ear infection
D. A 30-year-old client jogging in 50 degree weather
A. A 78-year-old client who has an NGT to low suction following colon cancer surgery
RATIONALE
Age and surgery.
Options B, C, and D have lesser risk.
364
2. Which of the following statements should not be included in an education program for the elderly about prevention of dehydration during hot weather?
A. "Observe your urine and immediately drink more fluid if its tarts getting darker."
B. "Keep a variety of fluids in your home and drink them frequently throughout the day."
C. "Popsicles, gelatin, and ice cream provide fluid intake as well as liquids you drink."
D. "Use your thirst as a guide to the amount of fluid you should be drinking."
D. "Use your thirst as a guide to the amount of fluid you should be drinking."
RATIONALE
The elderly has decreased thirst mechanism.
365
3. An adult client in a clinic complains of a cough, fever, and nausea and vomiting for 3 days. Examination reveals dry tongue and oral mucosa, and concentrated urine. The client also reports feeling weak and dizzy. Which vital sign measurement would provide the best indicator of current fluid status?
A. Respiratory rate and depth
B. Temperature
C. BP and pulse in standing and lying position
D. Pulse oximetry reading at rest
C. BP and pulse in standing and lying position
366
4. A 40-year-old-client is hospitalized for GI bleeding. Orders include NGT placement with irrigations until the returns are clear. Which fluid should be used for NG irrigations?
A. 3% saline
B. D5W
C. Normal saline
D. Plain water
C. Normal saline
RATIONALE
It is isotonic.
367
5. A 45-year-old client diagnosed with fluid volume overload due to acute kidney dysfunction is placed on a 1000-mL fluid restriction per 24-hr period. The client asks the nurse, "Why there is such a severe fluid restriction when I already have dry lips and mouth?" Which response by the nurse is best?
A. "The doctor ordered the restriction, so you must comply with those orders."
B. "Your kidneys are not able to eliminate extra fluids right now, so fluid intake has to be limited to protect your heart and lungs from being overloaded with fluid."
C. "You probably drank too much fluid before you got sick, so you can't compare your usual intake to your limitations now that your kidneys are not working."
D. "Too much fluid will cause your heart to fail and your lungs to fill with water, which could be fatal."
B. "Your kidneys are not able to eliminate extra fluids right now, so fluid intake has to be limited to protect your heart and lungs from being overloaded with fluid."
368
6. Which if the following is the best indicator of an excessive response to diuretic therapy?
A. Elevated BUN and hematocrit and an 8-pound weight loss in 24 hours
B. Elevated BUN and HCT and an 8-pound weight gain in 24 hours
C. Decreased BUN and HCT and an 8-pound weight loss in 24 hours
D. Decreased BUN and HCT and an 8-pound weight gain in 24 hours
A. Elevated BUN and hematocrit and an 8-pound weight loss in 24 hours
RATIONALE
This is a sign of hypovolemia, due to fluid volume loss brought about by the diuretic therapy.
369
7. A client is receiving an IV infusion of 0.225% NS at 50ml/hr. During such infusion, what is especially important to monitor to detect complications of therapy?
A. Urine output and concentration
B. Legs and arm for edema
C. Tongue and mouth for dryness
D. Mental status and orientation
D. Mental status and orientation
RATIONALE
0.225% saline solution is hypotonic, which increases fluid and electrolyte concentration in the cells causing cellular swelling. Mental status and orientation is monitored as it may indicate cerebral swelling which is fatal.
370
8. A client who is 3 hours post-Tonsillectomy has had minimal blood loss. The client has consumed 12 cups of ice chips to soothe throat discomfort and has received 3 liters of D5W during this time frame. What fluid imbalance is the client at risk for developing?
A. Isotonic fluid volume deficit
B. Hypertonic dehydration
C. Isotonic fluid volume deficit
D. Hypotonic overhydration
D. Hypotonic overhydration
371
9. A 56-year-old client with a history of heart failure and hypertension is hospitalized following abdominal surgery. Vital signs have been stable and D5 1/2 NS is infusing at 80ml/hr. The client awakens in the middle of the night complaining of trouble breathing. Which assessment by the nurse should take priority at this time?
A. Review intake and output record
B. Assess extremities for edema
C. Count apical heart rate
D. Auscultate lung fields
D. Auscultate lung fields
RATIONALE
Verify patient's subjective data for a possible risk for fluid overload.
372
10. Which of the following clients is at the greatest risk for developing fluid volume deficit and dehydration?
A. A 2-month old with vomiting
B. A 30-year old with pneumonia
C. A 45-year old with diarrhea
D. A 70-year old arthritis
A. A 2-month old with vomiting
```
RATIONALE
A Age and vomiting = 2
B Has no risk = 0
C Diarrhea = 1
D Age = 1
```
373
11. The nurse is helping a client who was recently placed on a low-sodium diet to choose foods for lunch. Which lunch menu would be best for this client?
A. Grilled chicken sandwich on white bread, apple, salad, and iced tea
B. Bologna sandwich on wheat bread, canned fruit cocktail, salad, and a soda
C. Canned ham and bean soup, fresh fruit salad, pickles, and a diet soda
D. Fast food cheeseburger, grapes, fresh pineapple, and tomato juice
A. Grilled chicken sandwich on white bread, apple, salad, and iced tea
RATIONALE
B and C have canned foods which are high in sodium.
D Has fastfood meal which is high in sodium.
374
12. A client has just finished an hour of strenuous exercise. Which of the following laboratory results would the nurse expect?
A. Increased hemoglobin
B. Decreased creatinine
C. Decreased osmolality
D. Increased osmolality
D. Increased osmolality
RATIONALE
After strenuous exercise, there may be significant body fluid loss.
A Correct: decreased hemoglobin
B Correct: increased. Creatinine is one by product of muscle metabolism, thus, increases after strenuous exercises.
C Correct: increased (hemoconcentrated blood) due to loss of body fluid from strenuous exercise
375
13. Which of the following clients would be most at risk to develop a sodium imbalance?
A. An adult client taking corticosteroid therapy
B. An elderly client who drinks 8 glasses (8 ounces each) of water each day
C. A diabetic client who is under glycemic control
D. A teenager who is drinking Gatorade during exercise workouts
A. An adult client taking corticosteroid therapy
RATIONALE
Corticosteroids increases concentration of sodium.
B Refers to fluid imbalance
C Refers to glucose imbalance
D May have no imbalance as the teenager compensates fluid loss through electrolyte/energy drinks
376
14. A 70-year-old client is admitted with nausea, vomiting, and hyponatremia. The nurse would write which of the following in the care plan about weighing this client?
A. Obtain a physician order to measure daily weight
B. Rotate the scales used on a daily basis
C. Weigh the client at the same time each day
D. Weigh the client without clothing
C. Weigh the client at the same time each day
RATIONALE
Same patient, same weighing scale, same time of day, same thpe of clothing.
A Weighing patient may not need a physician's order as it may sometimes be an independent intervention
B Use same scale all throughout
D Only same type of clothing
377
15. A client with abnormal sodium loss is receiving a regular diet. To encourage foods high in sodium, the nurse would provide:
A. An American cheese and ham sandwich
B. Chicken salad on lettuce
C. Tossed salad with vinegar dressing
D. White fish and plain baked potato
A. An American cheese and ham sandwich
RATIONALE
Processed foods are high in sodium content.
378
16. The nurse provided client teaching about dietary sodium modifications for a client with CHF. Which of the following menu selections indicates that the client needs further education?
A. Broiled chicken breast
B. Salad
C. Pork chop
D. Toast with margarine
C. Pork chop
379
17. A client receiving treatment for hypernatremia is being monitored for signs and symptoms of complications of therapy. The nurse knows that one of the primary risks when treating hypernatremia is:
A. Cellular dehydration
B. Cerebral edema
C. RBC destruction
D. Renal shutdown
B. Cerebral edema
RATIONALE
The goal of the therapy is to transport sodium from intravascular to intracellular, thus cellular edema such that of in the brain, should be closely monitored.
380
18. Which of the following statements made by the nurse is correct when performing client education regarding oral potassium supplementation?
A. "When you take your potassium pill, if you can't swallow it, you can crush it up and put it in orange juice."
B. "Potassium should only be taken in the morning on an empty stomach."
C. "Take your potassium tablet after you have eaten breakfast."
D. "You can continue to use salt substitute while you are taking your potassium supplement."
C. "Take your potassium tablet after you have eaten breakfast."
RATIONALE
Oral potassium is upsetting to stomach.
381
19. Which of the following client would be most likely to develop hyperkalemia?
A. A client with chronic renal failure
B. A client just diagnosed with cirrhosis
C. A client with intestinal and nasogastric suctioning
D. A client who has had diarrhea for the last 4 days
A. A client with chronic renal failure
RATIONALE
Patients with chronic renal failure are unable to excrete excess potassium in the blood.
382
20. A client in renal failure has an abnormally high potassium level. Which of the following is a priority nursing intervention?
A. Obtain an ECG
B. Evaluate LOC
C. Measure urinary output
D. Draw ABG
A. Obtain an ECG
RATIONALE
Too much potassium in the blood can affect heart's conduction and shows ECG tracing of ⬆️PR QRS[T] ⬇️P
383
21. The nurse should include diet teaching regarding adding potassium rich foods if which of the following diuretics is ordered?
A. Hydrochlorothiazide (HCTZ)
B. Spironolactone (Aldactone)
C. Maxicide (Triamterene with HCTZ)
D. Midamor (Amiloride)
A. Hydrochlorothiazide (HCTZ)
```
RATIONALE
HCTZ belongs to thiazide class of diuretics which inhibits the reabsorption of sodium and chloride. It also causes loss of blood potassium in the urine.
```
B A potassium-sparing diuretic
C The Triamterene component of Maxicide minimizes the potassium loss caused by Thiazide diuretics
D A potassium-sparing diuretic
384
22. The nurse anticipates using which of the following as the most effective route to administer sodium polystyrene sulfonate (Kayexalate) ordered for a client who has a serum potassium level of 5.0 mEq/L?
A. IV
B. Rectal
C. Oral
D. SC
B. Rectal
385
23. A client with hypokalemia must be assessed carefully for which of the following that can occur because of this electrolyte imbalance?
A. Perforated bowel
B. Paralytic ileus
C. Renal failure
D. Diabetes
B. Paralytic ileus
RATIONALE
Potassium levels in the body affects GI motility.
⬆️ potassium = ⬆️ GI motility
⬇️ potassium = ⬇️ GI motility
386
24. What is the expected result when calcium gluconate is given intravenously to a client with hyperkalemia?
A. Increased excretion of potassium in the urine
B. Increased excretion potassium via the stools
C. Reversing the effects of the potassium on the heart's conduction system
D. Pulling potassium back into the intracellular fluid to reduce the serum potassium
C. Reversing the effects of the potassium on the heart's conduction system
RATIONALE
A Diuretics
B Kayexalate
D Insulin
387
25. Which of the following statements by a client indicates a need for further instruction regarding treatment for hypokalemia?
A. "I will eat more bananas and cantaloupes for breakfast."
B. "I will eat more bran flakes to increase my potassium level."
C. "I will take my potassium in the morning after breakfast so it doesn't upset my stomach."
D. "I will tell my doctor if I start having any of the symptoms on the list you gave me."
B. "I will eat more bran flakes to increase my potassium level."
388
26. Which of the following is the best response by the nurse to the daughter of a 46-year old client who was admitted with hypokalemia and is complaining of being dizzy upon standing?
A. "Your mother has just stayed in bed too long and when she stands up she will get dizzy."
B. "The level of your mother's potassium is making her dizzy."
C. "Your mother is probably dizzy because her heart is not pumping as effectively, making her BP low."
D. "Your mother is dizzy because her nervous system isn't functioning correctly; once her potassium level goes up, she will improve."
C. "Your mother is probably dizzy because her heart is not pumping as effectively, making her BP low."
389
27. A client has been taking a corticosteroid for 6 months. Which of the following ECG findings would indicate to the nurse a serious side effect of this medication?
A. Flattened T waves and depressed ST segments
B. Tall, peaked T waves and depressed ST segments
C. Prolonged ST segments and U waves
D. Flattened T waves and flattened U waves
A. Flattened T waves and depressed ST segments
RATIONALE
Corticosteroids increase sodium concentration while decreasing potassium concentration.
⬇️K = ⬆️U ⬇️S[T]
390
28. A client is being treated for diabetic ketoacidosis (DKA) with large doses of regular insulin. The nurse should observe for which of the following electrolyte imbalances?
A. Hyperkalemia
B. Metabolic alkalosis
C. Hypernatremia
D. Hypokalemia
D. Hypokalemia
RATIONALE
Potassium attaches to the insulin along with glucose to be transported intracellularly.
391
29. Which if the following statements by the nurse demonstrates an understanding of why a client with hypokalemia is constipated?
A. "The low potassium causes the bowel to stop acting and one gets constipation from this."
B. "The level of potassium makes the stools very hard and difficult to expel."
C. "The potassium pulls the fluid from the bowel, leading to constipation."
D. "Your potassium level makes your bowel less active and may make you constipated."
D. "Your potassium level makes your bowel less active and may make you constipated."
Potassium levels in the body affects GI motility.
⬆️ potassium = ⬆️ GI motility
⬇️ potassium = ⬇️ GI motility
392
30. Which of the following interventions would be appropriate for the client with hypokalemia who has a nursing diagnosis of High Risk for Injury related to skeletal muscle weakness?
A. Administer KCl 20 mEq by mouth daily as ordered
B. Assist the client with ambulation
C. Encourage a diet intake high in fiber and fruit
D. Monitor the client's ECG for conduction changes
B. Assist the client with ambulation
RATIONALE
Independent interventions first. Options A, C, and D may apply but all are dependent interventions which may be done after independent interventions are carried out.
393
31. Which of the following statements by the nurse to a client indicates an understanding of potassium's importance to body functioning?
A. "Muscles are dependent on large amounts of potassium in order to work effectively."
B. "It is vital that the body have enough potassium so that the kidneys can function effectively to prevent salt and fluid retention."
C. "Potassium is important because it makes the muscle tissue work faster so the heart can pump effectively."
D. "Potassium is vital to support the muscles by making them contract more effectively, including the muscles of the heart."
D. "Potassium is vital to support the muscles by making them contract more effectively, including the muscles of the heart."
RATIONALE
Potassium influences both skeletal and cardiac muscles.
394
32. The nurse is instructing a client diagnosed with hyperkalemia about foods to avoid. Which of the following statements by the client indicates a need for further instruction?
A. "I should avoid eating a lot of bananas."
B. "I guess I can't eat all the tomatoes I want this summer."
C. "I can still use my salt substitute instead of real salt."
D. "No more avocado salads for me."
C. "I can still use my salt substitute instead of real salt."
RATIONALE
Salt substitute is a low-sodium salt alternative that contains potassium chloride. Using it may aggravate the already high potassium level.
395
33. A client receiving hydrochlorothiazide (HCTZ) should be instructed to report which of the following symptoms to the healthcare provider?
A. Leg cramps and muscle weakness
B. Muscle weakness and diarrhea
C. Fatigue and irritability
D. Nausea and irritability
A. Leg cramps and muscle weakness
RATIONALE
HCTZ removes blood sodium, chloride and especially potassium. Deficiency of these electrolytes could lead to leg cramps, and low potassium predisposes muscle weakness.
B ⬇️K predisposes constipation, not diarrhea.
C and D are more related to other nutrient deficiencies.
396
34. Which of the following foods should the client who is taking spironolactone (Aldactone) be advised to avoid?
A. Bread
B. Cantaloupe
C. Green beans
D. Squash
B. Cantaloupe
```
RATIONALE
Spironolactone (Aldactone) is a potassium-sparing diuretic. Clients should be instructed to avoid potassium-rich food to prevent hyperkalemia. Some foods that are rich in potassium include:
• Avocado
• Banana
• Cantaloupe
```
397
35. The results of a client's laboratory tests show an elevated ionized calcium and parathyroid hormone (PTH). The nurse suspects that the cause is:
A. Hypoparathyroidism
B. A malignancy
C. Hyperparathyroidism
D. Vitamin D deficiency
C. Hyperparathyroidism
RATIONALE
Directly proportional:
Parathyroid gland (secretes PTH) = calcium
```
Inversely proportional:
Thyroid gland (secretes calcitonin) ∝ calcium
```
398
36. The nurse is assessing a client with hypercalcemia. The nurse expects neuromuscular examination to show:
A. Tetany
B. A positive Trousseau's sign
C. Muscle weakness
D. Hyperactive deep tendon reflexes
C. Muscle weakness
RATIONALE
Options A, B, and D are signs and symptoms of hypocalcemia.
399
37. A nurse is caring for a client with a diagnosis of hypercalcemia. Which of the following cardiac signs should the nurse monitor on the ECG?
A. Development of atrial fibrillation
B. Shortening of the QT interval
C. Hypotension
D. Prolonged QT interval
B. Shortening of the QT interval
RATIONALE
⬆️Ca = ⬆️T ⬇️ST (⬇️QT)
A Unrelated
C Unrelated
D Hypocalcemia
400
38. A nurse prepares to administer calcium gluconate to a client post-thyroidectomy. The nurse explains to the LPN that the rationale for this replacement therapy is:
A. Because of accidental removal of the parathyroid gland
B. Related to increase parathyroid hormone release during surgery
C. To prevent complications from immobility postoperatively
D. Due to hypophosphatemia after this type of surgery
A. Because of accidental removal of the parathyroid gland
401
39. A client presents with complaints of fatigue, headache, and increasing muscle weakness. The nurse anticipates medical management to include:
A. Thiazide diuretics
B. Vitamin D supplements
C. Fluid restriction
D. Increased hydration
D. Increased hydration
RATIONALE
A Thiazide diuretics can lead to hypokalemia; aggravates muscle weakness and fatigue
B Vitamin D supplements can lead to hypercalcemia; aggravates muscle weakness
C INCORRECT; Fluid intake may help balance electrolyte imbalances
402
40. The nurse evaluates that discharge teaching has been effective when the client with hypocalcemia states:
A. "I shouldn't take antacids such as TUMs."
B. "I should notify my healthcare provider if I start to feel tingling or numbness around my mouth."
C. "I'll need to cut down on the protein in my diet."
D. "I will watch my urine for signs of kidney stones."
B. "I should notify my healthcare provider if I start to feel tingling or numbness around my mouth."
It may indicate Chvostek's sign which is one of the sign of hypocalcemia.
A Antacids such as Tums may be prescribed to increase calcium level
C Unrelated
D May refer to hypercalcemia
403
1. The client who has liver disease asks the nurse why he bruises so easily. Which of the following information should the nurse include in the response?
A. "You liver is unable to make the proteins that are needed to making clotting factors."
B. "Your liver can no longer metabolize drugs and render them inactive."
C. "Your liver is breaking down blood cells too rapidly."
D. "Your liver can't store vitamin C any longer."
A. "You liver is unable to make the proteins that are needed to making clotting factors."
404
2. A nurse is reviewing the laboratory results of a client with cirrhosis and notes that the ammonia level is elevated. Which of the following diets would the nurse anticipate would likely be prescribed for the patients?
A. High carbohydrates
B. Moderate fats
C. High protein
D. Low protein
D. Low protein
405
3. A nurse is monitoring a client with cirrhosis of the liver for signs of hepatic encephalopathy. Which assessment finding would the nurse note as an early sign of hepatic encephalopathy?
A. Restlessness
B. The presence of asterixis
C. Decreased serum ammonia levels
D. Complaints of fatigue
A. Restlessness
RATIONALE
Early sign: Altered LOC
Later signs: Asterixis, fetor hepaticus
406
4. The nurse administers Neomycin to a client with hepatic cirrhosis to prevent the formation of:
A. Bile
B. Ammonia
C. Urea
D. Nitrogen
B. Ammonia
RATIONALE
Neomycin kills bacteria producing ammonia.
407
5. You're developing a care plan for a 67-year-old client with hepatic encephalopathy. Which of the following do you include?
A. Administering a Lactulose enema as ordered
B. Encourage a protein-rich diet
C. Administering sedatives, as necessary
D. Encouraging ambulation at least four times a day
A. Administering a Lactulose enema as ordered
RATIONALE
Lactulose binds ammonia from blood to GIT to be excreted through defecation.
B Correct: Patient should be prescribed on a low protein diet
C Rest is important but sedatives are unnecessary
D Correct: Patient should have adequate rest
408
6. The nurse should assess the client with cirrhosis for signs of hepatic coma. The classic sign of hepatic coma is:
A. Bile-colored stools
B. Elevated cholesterol
C. Flapping hand tremors
D. Depressed muscle reflex
C. Flapping hand tremors
RATIONALE
Also known as Asterixis, usually manifested when patient extends his/her arms.
409
7. Hepatic encephalopathy is a neurologic syndrome that results from the liver's failure to detoxify noxious agents that come from the GI tract. Hepatic encephalopathy develops when the blood level of which substance increases?
A. Ammonia
B. Amylase
C. Calcium
D. Potassium
A. Ammonia
410
8. The nurse notes that there is documentation of the presence of asterixis. To check for the presence of this sign, the nurse would do which of the following?
A. Ask the client to extend arms
B. Check for the presence of Homan's sign
C. Instruct the client to lean forward
D. Measure the abdominal girth
A. Ask the client to extend arms
411
9. The ascites seen in cirrhosis results in part from:
A. The escape of lymph into abdominal cavity directly from the inflamed liver sinusoid
B. Increased plasma colloid osmotic pressure due to excessive liver growth and metabolism
C. The decreased levels of ADH and aldosterone due to increasing metabolic activity in the liver
D. Compression of the portal vein with resultant increased back pressure in the portal veins system
D. Compression of the portal vein with resultant increased back pressure in the portal veins system
412
10. A client with cirrhosis of the liver develops ascites. Which measure is used to decrease this excessive accumulation of serous fluid in the peritoneal cavity?
A. Restrict fluids
B. Encourage ambulation
C. Increase sodium in the diet
D. Give antacids as prescribed
A. Restrict fluids
413
11. What instructions should the client be given before undergoing a paracentesis?
A. NPO 12 hours before procedure procedure
B. Empty bladder before procedure
C. Strict bed rest following procedure
D. Empty bowel before procedure
B. Empty bladder before procedure
RATIONALE
Patient is instructed to empty bladder before procedure because there is a chance that distended bladder will be punctured.
414
12. The nurse is caring for a client who has ascites, and the healthcare provider prescribes spironolactone (Aldactone). The clients asks why the drug is being used. Which is the best response by the nurse?
A. "This drug will increase the level of protein in your blood."
B. "This drug will cause an increase in the amount of hormone aldosterone your body produces."
C. "This medication is a diuretic but does not make the kidneys excrete potassium."
D. "This will help you excrete larger amount of ammonia."
C. "This medication is a diuretic but does not make the kidneys excrete potassium."
415
13. A nurse is preparing to care for a client with esophageal varices who has just had a Sengstaken-Blakemore tube inserted. The nurse gathers supplies, knowing that which of the following items must be kept at bedside at all times?
A. An irrigation set
B. A pair of scissors
C. A Kelly clamp
D. An obturator
B. A pair of scissors
416
14. A client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted to control the bleeding. The most important assessment is for the nurse to:
A. Check that a hemostat is at the bedside
B. Monitor IV fluids for the shift
C. Regularly assess respiratory status
D. Check that the balloon is deflated on a regular basis
C. Regularly assess respiratory status
417
15. A client with cirrhosis is admitted to the hospital. Which of the following assessments made by the nurse would indicate the development of portal hypertension?
A. Hematemesis
B. Asterixis
C. Fetal hepaticus
D. Confusion
A. Hematemesis
418
16. Which of the following is a concern for persons whose gallbladder dysfunction causes impaired metabolism of fats and fat-soluble vitamins?
A. Potential for bleeding
B. Increased risk for infection
C. Potential for delayed healing
D. Increased risk for thrombus
A. Potential for bleeding
RATIONALE
Vitamin K, one of the fat soluble vitamins (ADEK), will be affected potentiating bleeding disorders.
419
17. A client with cholelithiasis experience discomfort after ingesting fatty foods because:
A. Fatty foods are hard to digest
B. Bile flow into the intestine is obstructed
C. The liver is manufacturing inadequate bile
D. There is inadequate closure of the Ampulla of Vater
B. Bile flow into the intestine is obstructed
420
18. Following an abdominal cholecystectomy, the nurse should assess for signs of respiratory complications because the:
A. Incision is in close proximity to the diaphragm
B. Length of time required for surgery is prolonged
C. Client's resistance is lowered because of bile in the blood
D. Bloodstream is invaded by microorganisms from the biliary tract
A. Incision is in close proximity to the diaphragm
421
19. Immediately after cholecystectomy, the nursing action that should assume the highest priority is:
A. Encouraging the client to take adequate deep breaths by mouth
B. Encouraging the client to cough and deep breathe
C. Changing the dressing at least BID
D. Irrigate the T-tube frequently
B. Encouraging the client to cough and deep breathe
422
20. In client with cholecystitis, the utilization of bile is interfered. The ejection of bile into the alimentary canal is controlled by the hormone:
A. Gastrin
B. Secretin
C. Enterocrenin
D. Cholecystokinin
D. Cholecystokinin
423
21. The nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice?
A. Straw-colored urine
B. Reduced hematocrit
C. Clay-colored stools
D. Elevated urobilinogen in the urine
C. Clay-colored stools
424
22. An acute attack of pancreatitis may be precipitated by heavy drinking because:
A. Promotes the formation of calculi in the cystic duct
B. The pancreas is stimulated to secrete more insulin than it can immediately produce
C. The alcohol alters the composition of enzymes so they are capable of damaging pancreas
D. Alcohol increases enzymes secretion and pancreatic duct pressure, which causes backflow of enzymes into the pancreas
D. Alcohol increases enzymes secretion and pancreatic duct pressure, which causes backflow of enzymes into the pancreas
425
23. As a client's symptoms of pancreatitis subside, it is most important that the nurse instruct the client to:
A. Avoid eating hot spicy food
B. Avoid ingesting alcoholic beverages
C. Eat a bland diet with 6 meals a day
D. Eat a high carbohydrate, low fat, low protein diet
B. Avoid ingesting alcoholic beverages
426
24. The nurse is aware that the laboratory test result that most likely would indicate acute pancreatitis is an elevated
A. Blood glucose levels
B. Serum amylase level
C. Serum bilirubin level
D. WBC count
B. Serum amylase level
427
25. The client with acute pancreatitis is experiencing severe pain from the disorder. The nurse determines that the client understood suggestions for positioning to reduce pain if the client avoided
A. Lying flat
B. Sitting up
C. Drawing the legs up to the chest
D. Leaning forward
A. Lying flat
428
26. Hormone that stimulates the flow of pancreatic enzymes is:
A. Enterocrinin
B. Pancreozymim
C. Enterogastrone
D. Cholecystokinin
B. Pancreozymim
429
27. A female client has an acute pancreatitis. Which of the following signs and symptoms the nurse would expect to see?
A. Constipation
B. Hypertension
C. Ascites
D. Jaundice
A. Constipation
430
28. Ferrous sulfate was prescribed to the client due to iron deficiency anemia; the nurse knows that the best time to administer the ferrous sulfate tablets is:
A. In the morning upon awakening
B. Before meals
C. At night
D. At bedtime
B. Before meals
431
29. A client with anemia has hemoglobin level of 6.5 g/dL. The client is experiencing symptoms of cerebral tissue hypoxia. Which of the following nursing interventions would be the most important in providing care?
A. Providing rest periods throughout the day
B. Instituting energy conservation techniques
C. Assisting in ambulation to the bathroom
D. Checking temperature of water prior to bathing
C. Assisting in ambulation to the bathroom
RATIONALE
Normal Hemoglobin Level:
MALE 13 - 18 g/dL
FEMALE 12 - 16 g/dL
Prioritization:
1 Safety
2 Rest
432
30. The patient has been diagnosed with anemia. As a nurse, you understand that iron deficiency anemia is caused by:
A. Inadequate intake of iron-rich food
B. Inadequate intake of Vitamin C-rich food
C. Inadequate calcium intake
D. Inadequate magnesium intake
A. Inadequate intake of iron-rich food
433
31. The following are nursing consideration when administering oral iron preparation, EXCEPT:
A. Use straw when taking liquid iron preparation
B. Take the medication with orange juice
C. Inform that stool may become black and tarry
D. Take the medication with meals for better absorption
D. Take the medication with meals for better absorption
RATIONALE
Correct: Before meals. Iron is best absorbed on an acidic environment.
434
32. Bone marrow aspiration reveals pancytopenia and fatty marrow, confirming aplastic anemia. Because of the patient's granulocytopenia, the nurse should try to prevent:
A. Hemmorhage
B. Bruises
C. Infection
D. Fatigue
C. Infection
435
33. A nurse devises a teaching plan for the patient with aplastic anemia. Which of the following is the most important concept to teach for health maintenance?
A. Eat animal protein and dark leafy vegetables daily
B. Avoid exposure to others with acute infections
C. Practice yoga and meditation to decrease stress and anxiety
D. Get 8 hours of sleep at night and take naps during the day
B. Avoid exposure to others with acute infections
RATIONALE
Priority nursing intervention for patients with aplastic anemia is preventing infection due to agranulocytopenia.
436
34. The rationale for administering injections of Vitamin B12 to patients with pernicious anemia is that:
A. The patient's body does not normally manufacture enough Vitamin B12
B. The patient may lack intrinsic factor necessary for Vitamin B12 absorption
C. Vitamin B12 is found in very small quantities in the patient's body
D. Vitamin B12 is a mineral necessary to aid in the formation of strong bones
B. The patient may lack intrinsic factor necessary for Vitamin B12 absorption
437
35. Which of the following observations of a patient who has pernicious anemia would indicate that the goal of care has been achieved?
A. The patient's skin has no petechiae
B. The patient's tongue has lost it's beefy red color
C. The patient has no dependent edema
D. The patient has a good appetite
B. The patient's tongue has lost it's beefy red color
438
36. Schilling's Test was ordered for a client suspected of having pernicious anemia, the nurse prepares for collection of
A. Venous blood
B. 24 hour urine specimen
C. Arterial blood
D. Stool
B. 24 hour urine specimen
439
37. Which assessment finding is not a clinical manifestation of folic acid deficiency anemia?
A. Paresthesia
B. Dyspnea
C. Fatigue
D. Tachycardia
A. Paresthesia
```
RATIONALE
Signs and symptoms that are common to all anemia include:
• Fatigue
• Weakness
• Pallor
• Dizziness
• Dyspnea
• Tachycardia
```
440
38. The client has been diagnosed to have polycythemia Vera. Which of the following measures is not included in the nursing care plan of the client?
A. Increase fluid intake
B. Monitor the client for signs and symptoms of thromboembolism
C. Advise the client to avoid high altitude
D. Implement isolation precaution
D. Implement isolation precaution
441
39. The nurse is caring for Joana, 45 years old, diagnosed with polycythemia vera. The nurse knows that in polycythemia vera:
A. The erythrocyte and leukocyte counts are elevated while the platelet count is low
B. The erythrocyte count is low while leukocyte and platelet counts are elevated
C. The erythrocyte, leukocyte, and platelet counts are elevated
D. The erythrocyte, leukocyte, and platelet counts are low
C. The erythrocyte, leukocyte, and platelet counts are elevated
442
40. A 35-year-old man is seen in an urgent care clinic. He presents with symptoms of polycythemia vera. The laboratory value that would confirm the possible diagnosis is an extremely:
A. High hemoglobin level
B. Low platelet count
C. Low white cell count
D. High iron level
A. High hemoglobin level
