NUR 203

Question 1

Is the following statement true or false?

The most common site for peptic ulcer formation is the pylorus

Answer 1

False

The most common site for peptic ulcer formation is not the pylorus. The most common site for peptic ulcer formation is the duodenum

Question 2

What is the best time to teach a client to take proton pump inhibitors?

a) 30 minutes before a meal
b) With a meal
c) Immediately after the meal
d) One to three hours after the meal

Answer 2

30 minutes before a meal

The best time for a client to take a proton pump inhibitor is before a meal. It is a delayed-release medication that is to be swallowed whole and taken before a meal

Question 3

Is the following statement true or false?

The average weight loss after bariatric surgery is 60% of previous body weight

Answer 3

True

The average weight loss after bariatric surgery is 60% of previous body weight

Question 4

What is a nasogastric tube?

a) Tube inserted through the nose into the beginning of the small intestine
b) Tube inserted through the nose into the stomach
c) Tube inserted through the nose into the second portion of the small intestine
d) Tube inserted through the mouth into the stomach

Answer 4

B) Tube inserted through the nose into the stomach

A nasoduodenal tube is inserted through the nose into the beginning of the small intestine. A nasogastric tube is inserted through the nose into the stomach. A nasojejunal tube is inserted through the nose into the second portion of the small intestine. An orogastric tube is inserted through the mouth into the stomach

Question 5

What is total nutrient admixture?

a) Method of supplying nutrients to the body by the intravenous route
b) An oil in water emulsion of oils, egg phospholipids and glycerin
c) A device designed and used for long-term administration of medications and fluids into central veins
d) An admixture of lipid emulsions, proteins, carbohydrates, electrolytes, vitamins, trace minerals and water

Answer 5

D) An admixture of lipid emulsions, proteins, carbohydrates, electrolytes, vitamins, trace minerals and water

Parenteral nutrition is a method of supplying nutrients to the body by the intravenous route. Intravenous fat emulsion is an oil-in-water emulsion of oils, egg phospholipids and glycerin. A central venous access device is designed and used for long-term administration of medications and fluids into central veins. Total nutrient admixture is lipid emulsions, proteins, carbohydrates, electrolytes, vitamins, trace minerals and water

Question 6

Is the following statement true or false?

The nasogastric tube is secured to the nose with tape to prevent injury to the nasopharyngeal passages

Answer 6

True

The nasogastric tube is secured to the nose with tape to prevent injury to the nasopharyngeal passages

Question 7

Is the following statement true or false?

Cyclic feedings are administered into the stomach in large amounts and at designated intervals

Answer 7

False

Bolus feedings are administered into the stomach in large amounts and at designated intervals. Cyclic feedings are periodic feedings given over a short period of time

Question 8

What position should the patient’s head be in when receiving a tube feeding to prevent aspiration?

a) Flat
b) 10–20 degree elevation
c) 30–45 degree elevation
d) 60–90 degree elevation

Answer 8

C) 30–45 degree elevation

The semi-Fowler position is necessary for an NG feeding with the patient’s head elevated at least 30 to 45 degrees to reduce the risk of aspiration

Question 9

What is an example of a laxative osmotic agent?

a) Bisacodyl (Dulcolax)
b) Dioctyl sodium sulfosuccinate (Coloxyl)
c) Magnesium hydroxide (Milk of Magnesia)
d) Polyethylene glycol and electrolytes (Colyte)

Answer 9

D) Polyethylene glycol and electrolytes (Colyte)

Polyethylene glycol and electrolytes (Colyte) are an osmotic agent. Bisacodyl (Dulcolax) is a stimulant laxative. Dioctyl sodium sulfosuccinate (Coloxyl) is a faecal softener. Magnesium hydroxide (Milk of Magnesia) is a saline agent

Question 10

Is the following statement true or false?

The most common site for diverticulitis is the ileum

Answer 10

False

The most common site for diverticulitis is the sigmoid

Question 11

Is the following statement true or false?

Abdominal pain and constipation are common clinical manifestations of Crohn’s disease

Answer 11

False

Abdominal pain and diarrhoea are common clinical manifestations of Crohn’s disease

Question 12

Is the following statement true or false?

Regular bowel habits can be established for a patient with an ileostomy

Answer 12

False

Regular bowel habits can NOT be established for a patient with an ileostomy

Question 13

Is the following statement true or false?

The autonomic nervous system regulates involuntary body functions

Answer 13

True

The autonomic nervous system regulates involuntary body functions

Question 14

How many cranial nerves does the nurse have to assess?

a) Ten
b) Eleven
c) Twelve
d) Thirteen

Answer 14

C) Twelve

There are twelve pairs of cranial nerves that emerge from the lower surface of the brain and pass through the foramina in the skull

Question 15

Is the following statement true or false?

Cerebral angiography is an x-ray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture

Answer 15

False

Myelography is an x-ray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture. Cerebral angiography is an x-ray study of the cerebral circulation with a contrast agent injected into a selected artery

Question 16

What findings can be identified with the use of a x-ray of the spine?

a) Fracture, dislocation, infection, osteoarthritis or scoliosis
b) Infections, tumours and bone marrow abnormalities
c) Soft tissue lesions adjacent to the vertebral column
d) Spinal nerve root disorders

Answer 16

A. Fracture, dislocation, infection, osteoarthritis or scoliosis

X-ray of the spine may demonstrate a fracture, dislocation, infection, osteoarthritis or scoliosis. Bone scan and blood studies may disclose infections, tumours and bone marrow abnormalities. Computed tomography is useful in identifying soft tissue lesions adjacent to the vertebral column. An electromyogram is used to evaluate spinal nerve root disorders

Question 17

Is the following statement true or false?

Proper standing posture occurs when the abdominal muscles contract, giving a feeling of upward pull and the gluteal muscles contract, giving a downward pull

Answer 17

True

Proper standing posture occurs when the abdominal muscles contract, giving a feeling of upward pull and the gluteal muscles contract, giving a downward pull

Question 18

What is bursitis?

a) Inflammation of a fluid-filled sac in the joint
b) New bone growth around a sequestrum
c) Disease of a nerve root
d) Inflammation of muscle tendons

Answer 18

A) Inflammation of a fluid-filled sac in the joint

Bursitis is inflammation of a fluid-filled sac in the joint. Involucrum is new bone growth around a sequestrum. Radiculopathy is disease of a nerve root. Tendinitis is inflammation of muscle tendons

Question 19

What is plantar fasciitis?

a) Flexion deformity of the interphalangeal joint that may involve several toes
b) Deformity in which the great toe deviates laterally
c) A swelling of the third branch of the median plantar nerve
d) An inflammation of the foot supporting fascia

Answer 19

D) An inflammation of the foot supporting fascia

Hammer toe is flexion deformity of the interphalangeal joint that may involve several toes. Hallux valgus is a deformity in which the great toe deviates laterally. The swelling of the plantar nerve is a Morton’s neuroma,

Question 20

How long does a patient taking bisphosphonates need to stay upright after administration?

a) 10 minutes
b) 20 minutes
c) 30 minutes
d) 120 minutes

Answer 20

C ) 30 minutes

Bisphosphonates are administered on arising in the morning with a full glass of water on an empty stomach and the patient must stay upright for 30–60 minutes

Question 21

Is the following statement true or false?

Melanocytes are receptors that transmit stimuli to the axon through a chemical synapse

Answer 21

False

Melanocytes are the special cells of the epidermis that are primarily involved in producing the pigment melanin. Merkel cells are receptors that transmit stimuli to the axon through a chemical synapse

Question 22

Which can cause hyperpigmentation of the skin?

a) Eczema
b) Fungal infection
c) Sun injury
d) Vitiligo

Answer 22

C. Sun injury

Hyperpigmentation can be a result of sun injury.

Hypopigmentation may be caused by a fungal infection, eczema or vitiligo

Question 23

Is the following statement true or false?

Tzanck smear is a test used to examine cells from blistering skin conditions

Answer 23

True

Tzanck smear is a test used to examine cells from blistering skin conditions

Question 24

What is the time frame for pain that can be classified as chronic?

a) 1 month
b) 2 to 3 months
c) 4 to 5 months
d) Longer than 6 months

Answer 24

D. Longer than 6 months

Rationale: Chronic pain is constant or intermittent pain that persists beyond the expected healing time and that can seldom be attributed to a specific cause or injury. Chronic pain may be defined as pain that lasts for 6 months or longer, although 6 months is an arbitrary period for differentiating between acute and chronic pain

Question 25

The RN asks a patient to describe the quality of pain. Which of the following is a descriptive term for the quality of pain?

a) Burning
b) Chronic
c) Intermittent
d) Severe

Answer 25

A. Burning

Rationale: A descriptive term for the quality of pain is burning. Chronic and intermittent pain are examples of types of pain. Severe is a descriptive term for the intensity of pain

Question 26

Is the following statement true or false?

Intraoperative phase: the period of time from the decision for surgery until the patient is transferred into the operating room

Answer 26

False

Rationale: The preoperative phase is the period of time from the decision for surgery until the patient is transferred into the operating room. The intraoperative phase is the period of time from when the patient is transferred to the operating room to the admission to post-anaesthesia care unit (PARU)

Question 27

Which medication classification must be assessed during the preoperative period because it can cause an electrolyte imbalance during surgery?

a) Corticosteroids
b) Diuretics
c) Phenothiazines
d) Insulin

Answer 27

B. Diuretics

Rationale: Diuretics during anaesthesia may cause excessive respiratory depression resulting from an associated electrolyte imbalance. Corticosteroids can cause cardiovascular collapse if discontinued suddenly. Phenothiazines may increase the hypotensive action of anaesthetics. Interaction between anaesthetics and insulin must be considered when a patient with diabetes mellitus undergoes surgery

Question 28

Is the following statement true or false?

The primary goal in withholding food before surgery is to prevent aspiration

Answer 28

True

Rationale: The primary goal in withholding food before surgery is to prevent aspiration

Question 29

Is the following statement true or false?

The primary oxygen administration method for a patient with COPD is a nasal cannula

Answer 29

False

The primary oxygen administration method for a patient with COPD is a Venturi mask, not a nasal cannula

Question 30

Is the following statement true or false?

A patient with hypoxemia will have an increase in the PaO2 level

Answer 30

False

A patient with hypoxemia will have a decrease in the PaO2 level, not an increase in the PaO2 level

Question 31

Is the following statement true or false?

The patient should be encouraged to use an incentive spirometer approximately 10 breaths per hour between treatments while awake

Answer 31

True

The patient should be encouraged to use an incentive spirometer approximately 10 breaths per hour between treatments while awake

Question 32

Is the following statement is true or false?

The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of laryngospasm

Answer 32

False

Rationale: The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of hypoxemia and hypercapnia, not laryngospasm

Question 33

Is the following statement true or false?

The most important nursing intervention when vomiting occurs postoperatively is to turn the patient’s head to prevent aspiration of vomitus into the lungs

Answer 33

True

Rationale: The most important nursing intervention when vomiting occurs postoperatively is to turn the patient’s head to prevent aspiration of vomitus into the lungs

Question 34

Which of the following occurs during the inflammatory stage of wound healing?

a) Blood clot forms
b) Granulation tissue forms
c) Fibroblasts leave wound
d) Tensile strength increases

Answer 34

A. Blood clot forms

Rationale: The blood clot forms during the inflammatory phase of wound healing. Granulation tissue forms during the proliferative phase. Fibroblasts leave the wound and tensile strength increases during the maturation phase of wound healing

Question 35

The nurse assesses a patient on the first post-op day. Signs of a local inflammatory response that the nurse expects too find are:

a) redness and heat of incision
b) leucocytosis with elevated monocytes
c) pain and purulent drainage of incision
d) fever and increased pulse and resp rate

Answer 35

The nurse assesses a patient on the first post-op day. Signs of a local inflammatory response that the nurse expects too find are:

a) redness and heat of incision *
b) leucocytosis with elevated monocytes
c) pain and purulent drainage of incision
d) fever and increased pulse and resp rate

Question 36

A paraplegic patient is admitted for intensive management of an open infected pressure ulcer on the left buttock at prominence of ischial tuberosity. The patients pressure sore indicates 5cm long by 2.5cm wide and 1.5cm deep. The base of the wound is yellow and involves subcutaneous tissue.
What stage is the pressure ulcer:

a) stage I
b) stage II
c) stage III
d) stage IV

Answer 36

A paraplegic patient is admitted for intensive management of an open infected pressure ulcer on the left buttock at prominence of ischial tuberosity. The patients pressure sore indicates 5cm long by 2.5cm wide and 1.5cm deep. The base of the wound is yellow and involves subcutaneous tissue.
What stage is the pressure ulcer:

a) stage I
b) stage II
c) stage III *
d) stage IV

Question 37

Initial evidence that would indicate to the nurse that a patient is experiencing a systemic anaphylaxis to an injected allergen is the development of;

a) dyspnoea (laboured breathing)
b) dilation of the pupils
c) itching and oedema at the injection site
d) a wheal and flare reaction at the injection site

Answer 37

Initial evidence that would indicate to the nurse that a patient is experiencing a systemic anaphylaxis to an injected allergen is the development of;

a) dyspnoea (laboured breathing) *
b) dilation of the pupils
c) itching and oedema at the injection site
d) a wheal and flare reaction at the injection site

Question 38

A patient with a severe allergic reaction is treated with epinephrine. The nurse recognises that the rationale for the use of epinephrine is that epinephrine opposes the effect of:

a) histamine
b) lymphokines
c) interleukin-2
d) lysosomal enzymes

Answer 38

A patient with a severe allergic reaction is treated with epinephrine. The nurse recognises that the rationale for the use of epinephrine is that epinephrine opposes the effect of:

a) histamine *
b) lymphokines
c) interleukin-2
d) lysosomal enzymes

Question 39

It is especially important for the nurse to determine the patients current use of medications during the pre-operative assessment because:

a) These medications may alter the patients perceptions about surgery
b) Anaesthetics alter renal and hepatic function, causing toxicity by other drugs
c) Other medications may cause interactions with anaesthetics, altering the potency and effect of the drugs
d) Routine medications are usually withheld the day of surgery, requiring dosage and schedule adjustments

Answer 39

It is especially important for the nurse to determine the patients current use of medications during the pre-operative assessment because:

Answer: C

a) These medications may alter the patients perceptions about surgery
b) Anaesthetics alter renal and hepatic function, causing toxicity by other drugs
c) Other medications may cause interactions with anaesthetics, altering the potency and effect of the drugs *
d) Routine medications are usually withheld the day of surgery, requiring dosage and schedule adjustments

Question 40

10 mins after a patient has received his pre-operative medication by IM injection, he asks to get up and go to the toilet to urinate. The most appropriate action by the nurse is to;

a) Offer him a urinal and position him in bed to promote voiding
b) Assist him to the bathroom and stay with him to protect him from falling
c) Tell him to try to hold the urine because he will be catheterised at the beginning of the surgical procedure
d) Allow him up to go to the bathroom because the onset of the effect of the medication takes more than 10mins

Answer 40

10mins after a patient has received his pre-operative medication by IM injection, he asks to get up and go to the toilet to urinate. The most appropriate action by the nurse is to;

a) Offer him a urinal and position him in bed to promote voiding *
b) Assist him to the bathroom and stay with him to protect him from falling ?*
c) Tell him to try to hold the urine because he will be catheterised at the beginning of the surgical procedure
d) Allow him up to go to the bathroom because the onset of the effect of the medication takes more than 10mins

Question 41

When a patient is transferred from a Post Anaesthetic Care Unit (PARU) to the clinical surgical unit, the first action by the nurse on the surgical unit should be to:

a) Assess the patients pain
b) Take the patients vital signs
c) Check the rate of the IV infusion
d) Check the physicians post-op orders

Answer 41

When a patient is transferred from a Post Anaesthetic Care Unit (PARU) to the clinical surgical unit, the first action by the nurse on the surgical unit should be to:

a) Assess the patients pain *2
b) Take the patients vital signs * 1
c) Check the rate of the IV infusion *4
d) Check the physicians post-op orders *3

Question 42

Post-op a patient is receiving Low Molecular Weight Heparin (LMWH). When administration this drug, the nurse;

a) Explains that the drug will help prevent clot formation in the legs
b) Administers the dose with meals to prevent GI irritation and bleeding
c) Checks the results of the partial thromboplastin time before administration
d) Informs the patient that blood will be drawn every 6hr to monitor the prothombin time

Answer 42

Post-op a patient is receiving Low Molecular Weight Heparin (LMWH). When administration this drug, the nurse;

a) Explains that the drug will help prevent clot formation in the legs *
b) Administers the dose with meals to prevent GI irritation and bleeding
c) Checks the results of the partial thromboplastin time before administration
d) Informs the patient that blood will be drawn every 6hr to monitor the prothombin time

Question 43

A patient is hospitalised with vomiting of ‘coffee ground’ emesis of unknown cause. The patient is very anxious about the source of the bleeding and asks the nurse whether it is possible to find the cause. The nurse’s response is based in the knowledge that the diagnostic test which can most accurately identify the source of the bleeding is;

a) An endoscopy
b) An angiography
c) A gastric analysis
d) Barium contrast studies

Answer 43

A patient is hospitalised with vomiting of ‘coffee ground’ emesis of unknown cause. The patient is very anxious about the source of the bleeding and asks the nurse whether it is possible to find the cause. The nurse’s response is based in the knowledge that the diagnostic test which can most accurately identify the source of the bleeding is;

a) An endoscopy *
b) An angiography
c) A gastric analysis
d) Barium contrast studies

Question 44

A dark skinned patient has been admitted to hospital in severe resp distress. To assess for cyanosis in the patient, the knows that:

a) Cyanosis in patients with dark skin an be seen only in the sclera
b) It is not possible to assess abnormal colour changes in patients with dark skin
c) Cyanosis can be seen in the lips and mucous membranes
d) Cyanosis will blanch out direct pressure to the soles of the feet in dark skinned patients

Answer 44

A dark skinned patient has been admitted to hospital in severe resp distress. To assess for cyanosis in the patient, the knows that:

a) Cyanosis in patients with dark skin an be seen only in the sclera
b) It is not possible to assess abnormal colour changes in patients with dark skin
c) Cyanosis can be seen in the lips and mucous membranes *
d) Cyanosis will blanch out direct pressure to the soles of the feet in dark skinned patients

Question 45

The best example of nursing documentation of a normal assessment of the skin is:

a) ‘skin warm and dry;turgor good; nails flat and pink; old surgical scars noted on abdomen
b) ‘Hx of allergic rashes; skin very fair with numerous freckles, warm and intact; no lesions noted’
c) ‘Skin brown, slightly moist and warm; turgor immediate return; no lesions noted. States no problems with skin’
d) ‘No Hx of skin problems; skin intact, pink, temp consistent over body; no lesions except numerous brown moles’

Answer 45

The best example of nursing documentation of a normal assessment of the skin is:

a) ‘skin warm and dry;turgor good; nails flat and pink; old surgical scars noted on abdomen
b) ‘Hx of allergic rashes; skin very fair with numerous freckles, warm and intact; no lesions noted’
c) ‘Skin brown, slightly moist and warm; turgor immediate return; no lesions noted. States no problems with skin’
d) ‘No Hx of skin problems; skin intact, pink, temp consistent over body; no lesions except numerous brown moles’ *

Question 46

During application of a wet dressing to the skin of a patient with impetigo (bacterial skin infection), it is most important for the nurse to:

a) Use cool solutions to debride the lesions
b) Use clean gloves to prevent the spread of the infection to others
c) Use sterile gloves and dressings to prevent infection of the lesions
d) Apply a prescribed topical antibiotic ointment before the application of the dressings

Answer 46

During application of a wet dressing to the skin of a patient with impetigo (bacterial skin infection), it is most important for the nurse to:

a) Use cool solutions to debride the lesions
b) Use clean gloves to prevent the spread of the infection to others
c) Use sterile gloves and dressings to prevent infection of the lesions
d) Apply a prescribed topical antibiotic ointment before the application of the dressings *

Question 47

A patient is scheduled for an outpatient U/S of gallbladder. The nurse instructs the patients that the evening before the test it will be necessary for her to:

a) Eat a high fat evening meal
b) Drink a liquid barium contrast medium
c) Use enemas until the return is clear of stool
d) Take nothing by mouth for 8hrs before the test

Answer 47

A patient is scheduled for an outpatient U/S of gallbladder. The nurse instructs the patients that the evening before the test it will be necessary for her to:

a) Eat a high fat evening meal
b) Drink a liquid barium contrast medium
c) Use enemas until the return is clear of stool
d) Take nothing by mouth for 8hrs before the test *

Question 48

Following diagnostic testing, a patient with recurring heartburn and indigestion is diagnosed with a hiatal hernia. The nurse explains to the patients that this condition involves:

a) Extension of the oesophagus through the diaphragm
b) Displacement of the duodenum through the stomach to the oesophagus
c) Twisting of the stomach around the oesophagus, occluding the oesophagus
d) Protrusion of the stomach into the oesophagus through an opening in the diaphragm

Answer 48

Following diagnostic testing, a patient with recurring heartburn and indigestion is diagnosed with a hiatal hernia. The nurse explains to the patients that this condition involves:

a) Extension of the oesophagus through the diaphragm
b) Displacement of the duodenum through the stomach to the oesophagus
c) Twisting of the stomach around the oesophagus, occluding the oesophagus
d) Protrusion of the stomach into the oesophagus through an opening in the diaphragm *

Question 49

A patient with upper GI bleeding is diagnosed with a duodenal ulcer following an endoscopy, and a histology of a mucosal specimen is positive for Helicobacter Pylori. When the nurse administers AB therapy for the H. Pylori, the patient asks if ulcers are caused by an infection. The best response by the nurse includes the information that:

a) H. pylori is strongly associated with gastric ulcers but it is rarely present in those with duodenal ulcers
b) Although H. pylori is believed to be a cause of gastritis, its role in the development of ulcers is not known
c) Because most of the population is infected with H. pylori, it is believed that other factors are responsible for ulcer development
d) infection with this bacteria in combination with other factors is believed to be a major cause of breakdown of the gastric mucosal barrier

Answer 49

A patient with upper GI bleeding is diagnosed with a duodenal ulcer following an endoscopy, and a histology of a mucosal specimen is positive for Helicobacter Pylori. When the nurse administers AB therapy for the H. Pylori, the patient asks if ulcers are caused by an infection. The best response by the nurse includes the information that:

Answer: B

a) H. pylori is strongly associated with gastric ulcers but it is rarely present in those with duodenal ulcers
b) Although H. pylori is believed to be a cause of gastritis, its role in the development of ulcers is not known *
c) Because most of the population is infected with H. pylori, it is believed that other factors are responsible for ulcer development
d) infection with this bacteria in combination with other factors is believed to be a major cause of breakdown of the gastric mucosal barrier

Question 50

A 78 y/o patient is transferred to the hospital from a nursing home upon developing abdominal pain and watery, incontinent diarrhoea following a course of AB therapy for pneumonia. Stool cultures reveal the presence of Clostridium Difficile. In planning care for the patient, the nurse recognises that a priority nursing goal is to:

a) maintain normal nutritional intake
b) prevent transmission of the microorganism to others
c) promote relief of abdo pain with comfort measures
d) control the diarrhoea with administration of antidiarrheal drugs

Answer 50

A 78 y/o patient is transferred to the hospital from a nursing home upon developing abdominal pain and watery, incontinent diarrhoea following a course of AB therapy for pneumonia. Stool cultures reveal the presence of Clostridium Difficile. In planning care for the patient, the nurse recognises that a priority nursing goal is to:
Answer: A & D
a) maintain normal nutritional intake
b) prevent transmission of the microorganism to others
c) promote relief of abdo pain with comfort measures
d) control the diarrhoea with administration of antidiarrheal drugs *

Question 51

While obtaining a nursing Hx from a patient with inflammatory bowel disease, the nurse recognises that the patient most likely has ulcerative colitis rather than Crohn’s disease, when the patient reports:

a) weight loss
b) bloody diarrhoea
c) abdominal pain and cramping
d) the onset of the disease at the age 20

Answer 51

While obtaining a nursing Hx from a patient with inflammatory bowel disease, the nurse recognises that the patient most likely has ulcerative colitis rather than Crohn’s disease, when the patient reports:

a) weight loss
b) bloody diarrhoea *
c) abdominal pain and cramping
d) the onset of the disease at the age 20

Question 52

An 81 y/o patient has a large bowel obstruction that occurred as a result of a faecal impaction. During nursing assessment of the patient, a finding by the nurse that is consistent with a large bowel obstruction includes

a) Metabolic alkalosis
b) referred pain to the back
c) rapid onset of copious vomiting
d) greatly increased abdominal distension

Answer 52

An 81 y/o patient has a large bowel obstruction that occurred as a result of a faecal impaction. During nursing assessment of the patient, a finding by the nurse that is consistent with a large bowel obstruction includes

a) Metabolic alkalosis
b) referred pain to the back
c) rapid onset of copious vomiting *
d) greatly increased abdominal distension *

Question 53

During the initial post-op assessment of a patient’s stoma formed with a transverse colostomy, the nurse finds it to be red with moderate oedema and a small amount of bleeding. The most appropriate interpretation of this finding by the nurse is that there is:

a) a viable stoma with high vascularity
b) obstruction of the stoma with venous congestion
c) inadequate blood supply to the stoma, caused by oedema
d) an abnormal stomal condition that should be reported to the surgeon

Answer 53

During the initial post-op assessment of a patient’s stoma formed with a transverse colostomy, the nurse finds it to be red with moderate oedema and a small amount of bleeding. The most appropriate interpretation of this finding by the nurse is that there is:

a) a viable stoma with high vascularity *
b) obstruction of the stoma with venous congestion
c) inadequate blood supply to the stoma, caused by oedema
d) an abnormal stomal condition that should be reported to the surgeon

Question 54

A patient has a newly formed ileostomy for treatment of ulcerative colitis. In teaching the patient about the care of her ileostomy, the nurse informs the patient that she should:

a) restrict fluid intake to prevent constant liquid drainage from the stoma
b) change the pouch every day to prevent leakage of contents onto the skin
c) maintain as normal a diet as possible, avoiding foods that cause gas or diarrhoea
d) irrigate the ileostomy daily or every other day having to wear a drainage appliance

Answer 54

A patient has a newly formed ileostomy for treatment of ulcerative colitis. In teaching the patient about the care of her ileostomy, the nurse informs the patient that she should:

a) restrict fluid intake to prevent constant liquid drainage from the stoma
b) change the pouch every day to prevent leakage of contents onto the skin *
c) maintain as normal a diet as possible, avoiding foods that cause gas or diarrhoea
d) irrigate the ileostomy daily or every other day having to wear a drainage appliance

Question 55

When the nurse applies a painful stimuli to an unconscious patient, the patient responds by stiffly extending and abducting the arms and hyperpronating the wrists. The nurse interprets the findings as:

a) decorticate posturing indicating an interruption of voluntary motor tracts
b) decerebrate posturing indicating an interruptions of voluntary tracts
c) decorticate posturing indicating a disruption of motor fibres in the midbrain and brainstem
d) decerebrate posturing indicating a disruption of motor fibres in the midbrain and brainstem

Answer 55

When the nurse applies a painful stimuli to an unconscious patient, the patient responds by stiffly extending and abducting the arms and hyperpronating the wrists. The nurse interprets the findings as:

a) decorticate posturing indicating an interruption of voluntary motor tracts
b) decerebrate posturing indicating an interruptions of voluntary tracts *
c) decorticate posturing indicating a disruption of motor fibres in the midbrain and brainstem
d) decerebrate posturing indicating a disruption of motor fibres in the midbrain and brainstem

Question 56

When assessing a patient with a neurological disorder using the Glasgow Coma Scale, the nurse is obtaining information related to the:

a) level of consciousness
b) presence of cerebral oedema
c) presence of corneal and pupillary reflexes
d) integrated functions of the cerebral cortex

Answer 56

When assessing a patient with a neurological disorder using the Glasgow Coma Scale, the nurse is obtaining information related to the:

a) level of consciousness *
b) presence of cerebral oedema
c) presence of corneal and pupillary reflexes
d) integrated functions of the cerebral cortex

Question 57

A 68 y/o man has had several transient ischemic attacks with temporary hemiparesis and dysarthria that have lasted up to an hr. The nurse encourages the patient to seek immediate medical assistance for any symptoms that last longer than an hour, explaining that permanent disability from a stroke may be reduced if therapy is initiated within 3hrs the use of:

a) IV heparin
b) transluminal angioplasty
c) a surgical endarterectomy
d) tissue plasminogen activator (TPA)

Answer 57

A 68 y/o man has had several transient ischemic attacks with temporary hemiparesis and dysarthria that have lasted up to an hr. The nurse encourages the patient to seek immediate medical assistance for any symptoms that last longer than an hour, explaining that permanent disability from a stroke may be reduced if therapy is initiated within 3hrs the use of:

a) IV heparin
b) transluminal angioplasty
c) a surgical endarterectomy
d) tissue plasminogen activator (TPA) *

Question 58

When taking a patient Hx during assessment of the musculoskeletal system, the nurse identifies an increased risk for the patient who reports a family Hx of:

a) osteoporosis
b) osteomalacia
c) ostepmyelitis
d) bony tuberculosis

Answer 58

When taking a patient Hx during assessment of the musculoskeletal system, the nurse identifies an increased risk for the patient who reports a family Hx of:

a) osteoporosis *
b) osteomalacia
c) ostepmyelitis
d) bony tuberculosis

Question 59

A patient is admitted to the emergency department, with possible fractures of the bones of the left lower extremity. Prior to initiating treatment for the patient, it is most important for the nurse to:

a) splint the lower leg
b) elevate the injured limb
c) check neurovascular status distal to the injury
d) assess the patient’s tetanus immunisation status

Answer 59

A patient is admitted to the emergency department, with possible fractures of the bones of the left lower extremity. Prior to initiating treatment for the patient, it is most important for the nurse to:

Answer: A, B & ?C

a) splint the lower leg
b) elevate the injured limb
c) check neurovascular status distal to the injury
d) assess the patient’s tetanus immunisation status