NP III & IV Flashcards
- 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
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
- 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
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
- 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
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
- 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
D. It calls for a biopsy ASAP
RATIONALE
It is classified possibly malignant.
A Class I
B Class II
C Class III
- 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
B. Lubricant and gloves
RATIONALE
The physician will perform Digital Rectal Examination.
- 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
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
- 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
B. Is confined to the cervix
RATIONALE
A Stage 2
C Stage 3
D Stage 4
- 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”
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
- 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. 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
- 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”
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
- 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
B. Pick up the implant with long handed forceps and place it in a lead-lined container
- 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”
D. “I will expose my family to radiation”
RATIONALE
Patient is not radioactive.
- 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. It is called teletherapy and the most common complaint is an abnormal skin pigmentation
- 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
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
- 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”
B. “You will not be radioactive because of the treatment”
RATIONALE
A Internal - Sealed
C Internal - Sealed
D Internal - Unsealed
- 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
C. Wear personal protective equipment when handling blood, body fluids, and feces
A Not necessary
B Correct: Radioactive container
D Not necessary
- 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
C. Cell cycle phase specific medication affecting the S phase
- 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
B. Observe patient for weight gain, crackles and edema
RATIONALE
It refers to Anti-Tumor Antibiotics such as Doxurubicin (Adriamycin) which can cause CHF.
- 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
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
- 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
B. Numbness
RATIONALE
Vincristine (Oncovin) is toxic to the nerves which may cause Peripheral Neuritis. Numbness, paresthesia, and tingling are the signs and symptoms.
- 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
D. It affects both cancer cells and normal cells
- 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. Allowing fresh fruits in the client’s room
RATIONALE
Fresh fruits can harbor microorganisms.
- 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. Stop the administration of the drug immediately
RATIONALE
It must be immediately stop as it may cause extravasation.
- 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.”
D. “You can wear a baseball cap until your hair grows back.”
- 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.
- 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.
- 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).
- 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
- 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.
- 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
- 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?”
- 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
- 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.
- 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.
- 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.
- 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
- 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).
- 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.
- 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.
- 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.”
- 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
- 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.”
- 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
- 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
- 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.
- 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
- 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.
- 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
- 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).
- 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.
- 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
- 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
- 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
- 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?
- Bananas and avocados
- Beef liver and broccoli
- Cheese and yogurt
- 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
- For a client with osteoporosis, the nurse shouldn’t provide which dietary instruction?
- “Limit intake of liver and beans.”
- “Eat more dairy products to increase your calcium intake.”
- “Decrease your intake of popcorn, nuts, and seeds.”
- “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
- 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
- Pain (sharp, increases with movement)
- Loss of function/movement
- Deformity
- Crepitus (d/t friction of bones)
- Ecchymosis (bleeding/bruising)
- Swelling
- Shortening (muscle spasm)
- 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
- 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.
- Emergency management of fracture includes the following, EXCEPT:
- Immobilize the body part
- Support affected extremity using splint
- Assess for sensation on the distal part of the affected extremity
- NOTA
A. 1 and 3
B. 2 and 3
C. 1 only
D. 4 only
D. 4 only
- 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
- 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
- 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
- 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?
- External rotation of the affected leg
- Abduction of the operative hip
- Internal rotation of the affected leg
- 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
- 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
- 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
- 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.
- 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.
- 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
- 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
- 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
- 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
- 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
- A client has fiberglass cast on the right arm. Which action should the nurse include in the plan of care?
- Keeping the casted arm warm by covering it with a light blanket
- Avoiding handling the cast for 24 hours
- Evaluating pedal and posterior tibial pulse every 2 hours
- 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
- 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
- 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
- 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.
- 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.
- 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.”
- 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.
- 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
- 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
- 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
- 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?
- Decreases uric acid production
- Increases excretion of uric acid
- Decreases inflammation
- 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
- 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
- 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
- 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
- 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
- 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.
- 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)
- 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
- 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.
- 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
- 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
- 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
- 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.
- 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.
- 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.
- 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
- 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
- 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
- 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
- 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.
- 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.
- 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.
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.
- 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
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.
- 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.
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.
- 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.
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.
- 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).
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.
- 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
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.
- 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
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.
- 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
SITUATION: Because of difficulties of hemodialysis. Mike is admitted to the hospital for insertion of Tenckhoff catheter and continuous ambulatory peritoneal dialysis.
- 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
SITUATION: Because of difficulties of hemodialysis. Mike is admitted to the hospital for insertion of Tenckhoff catheter and continuous ambulatory peritoneal dialysis.
- 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
SITUATION: Because of difficulties of hemodialysis. Mike is admitted to the hospital for insertion of Tenckhoff catheter and continuous ambulatory peritoneal dialysis.
- 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
SITUATION: Nurse Belle is assigned in Burn Unit caring for clients with various burn conditions.
- 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.
SITUATION: Nurse Belle is assigned in Burn Unit caring for clients with various burn conditions.
- 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
SITUATION: Nurse Belle is assigned in Burn Unit caring for clients with various burn conditions.
- 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.
SITUATION: Nurse Belle is assigned in Burn Unit caring for clients with various burn conditions.
- 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
- 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
- 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
- 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
- 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
- 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
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.
- 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.
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.
- 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
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.
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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.
- 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
- 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
- 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
- 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
- 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
- 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.
- 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
- 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.
- 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.
- 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]
- 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
- 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
- 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
- The following are considered incorrect about myopia:
- This is otherwise known as farsightedness
- The bending of light is in front of the retina
- Corrected by using a concave lens
- 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.
- 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
- 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
- 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.
- 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
- 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.
- 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
- 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
- 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
- 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
- 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
- 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
- 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.
- 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)
- 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.
- 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)
- 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
- 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
- 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
- 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.
- 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
- 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.
- 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
- 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
- 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.
- 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
- 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
- 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
- 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.
- 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
- 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.”
