test 11/7

Question 1

After being treated with heparin therapy for thrombophlebitis, a multiparous client who gave birth 4 days ago is to be discharged on oral warfarin. After teaching the client about the medication and possible effects, which client statement indicates successful teaching?

a. “I can take two aspirin if I get uterine cramps.”
b. “Protamine sulfate should be available if I need it.”
c. “I should use a soft toothbrush to brush my teeth.”
d. “I can drink an occasional glass of wine if I desire.”

Answer 1

c. “I should use a soft toothbrush to brush my teeth.”
Explanation:

Successful teaching is demonstrated when the client says, “I should use a soft toothbrush to brush my teeth.” Heparin therapy can cause the gums to bleed, so a soft toothbrush should be used to minimize this adverse effect. Use of aspirin and other nonsteroidal anti-inflammatory medications should be avoided because of the increased risk for possible hemorrhage. Protamine sulfate is the antidote for heparin therapy. Vitamin K is the antidote for warfarin excess. Alcohol can inhibit the metabolism of oral anticoagulants and should be avoided.

Question 2

An 80-year-old woman is receiving treatment with oral fluconazole for a fungal infection Following yesterday’s and today’s dose, she reports an upset stomach to the charge nurse. How should the nurse at the facility best respond to the woman’s report?

A. Assess the client for signs and symptoms of an infusion reaction.
B. Arrange for the client to receive intravenous fluconazole on an outpatient basis.
C. Stop administering the fluconazole and inform the client’s physician.
D. Provide food along with the fluconazole when administering it in the future.

Answer 2

D
Fluconazole has the potential to cause gastric distress, a problem that may be mitigated by administering the drug with food. Infusion reactions do not occur with the administration of fluconazole and it is likely unnecessary to arrange for IV administration, to stop the drug, or to immediately inform the resident’s physician.

Question 3

A client with right-sided heart failure is admitted to the medical-surgical unit. What information obtained from the client may indicate the presence of edema?

A. The client says that he has been urinating less frequently at night.
B.The client says he has been hungry in the evening.
C. The client says his rings have become tight and are difficult to remove.
D. The client says he is short of breath when ambulating.

Answer 3

C
Clients may observe that rings, shoes, or clothing have become tight. The client would most likely be urinating more frequently in the evening. Accumulation of blood in abdominal organs may cause anorexia, nausea, flatulence, and a decrease in hunger. Shortness of breath with ambulation would occur most often in left-sided heart failure.

Question 4

A client receiving morphine for long-term pain management develops tolerance. Tolerance is defined as:
A. a heightened response to a medication.
B. a diminished response to a drug so that more medication is required to achieve the same effect.
C. an allergic reaction to a medication.
D. an ability to take the same drug for extended periods.

Answer 4

B. a diminished response to a drug so that more medication is required to achieve the same effect.
Explanation:

Tolerance occurs when the body requires higher doses of substances, such as alcohol, opioids, or benzodiazepines, to achieve desired effects. Increased response indicates a need for less of a drug to achieve the same effects. Allergic reactions are autoimmune responses to a particular drug or class of drugs.

Question 5

A nurse notices repetitive late decelerations on the fetal heart monitor. The best initial actions by the nurse include:

A. prepare for birth, reposition the patient, and begin pushing.
B perform sterile vaginal examination, increase IV fluids, and apply oxygen.
C notify the provider, explain findings to the client, and begin pushing.
D. reposition the client, apply oxygen, and increase IV fluids.

Answer 5

D
Late decelerations on a fetal heart monitor indicate uteroplacental insufficiency. Interventions to improve perfusion include repositioning the client, oxygen, and IV fluids. A sterile vaginal exam is not indicated at this time. Late decelerations are not expected findings and do not indicate an imminent birth.

Question 6

Acetaminophen overdose has the potential to cause fatal:

A. kidney damage.
B. pancreas damage.
C. lung damage.
D. liver damage.

Answer 6

D
Potentially fatal hepatotoxicity is the main concern with acetaminophen overdose. It is most likely to occur with doses or 20 g or more.

Question 7

When assessing the skin of a client with allergic contact dermatitis, the nurse would most likley expect to find irritation at which area?

A. Lower arms
B. Ankles
C. Plantar aspects of the feet
D. Dorsal aspect of the hand

Answer 7

Dorsal aspect of the hand
Explanation:

With allergic contact dermatitis, irritation is most common on the dorsal aspects of the hand. Irritant, phototoxic, and photoallergic types of contact dermatitis are commonly seen on the hands and lower arms.

Question 8

Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality?
A. Calcium 
B. Magnesium 
C. Potassium 
D. Sodium

Answer 8

D
Sodium is the primary determinant of ECF osmolality. Sodium plays a major role in controlling water distribution throughout the body because it does not easily cross the intracellular wall membrane and because of its abundance and high concentration in the body. Potassium, calcium, and magnesium are not primary determinants of ECF osmolality.

Question 9

The nurse assists and educates clients about blood pressure regulation. Based on this information, the nurse asks the client what the number 80 in the blood pressure 120/80 represents. Which response by the client demonstrates correct understanding of the basic concepts of blood pressure?

A. Systolic pressure
B. Cardiac output
C. Pulse pressure
D. Diastolic pressure

Answer 9

D
Cardiac output is the amount of blood the ventricles pump out in 1 minute; normally, 4 to 6 L/minute. Blood pressure is the force exerted by the blood against the walls of the blood vessels. Systolic blood pressure, in this example 120, is the force during ventricular contraction. Diastolic blood pressure, in this example is 80, is the force during ventricular relaxation. The difference between systolic and diastolic pressure is called pulse pressure.

Question 10

A nursing diagnosis of “Ineffective coping” has been chosen for a client after receiving a diagnosis of prostate cancer. What assessments would the nurse consider as evidence for this diagnosis? (Select all that apply.)

A. The client asks for information relating to the cancer diagnosis.

B. The client reports an inability to get adequate restful sleep.

C. The client has difficulty concentrating on the details of treatment options.

D. The client states, “I can’t handle all of this.”

E. The client requests the minister of his church to visit.

Answer 10

B C D
Inability to sleep, difficulty concentrating, and the client’s verbalization of being overwhelmed are evidence of inability to cope. Seeking information related to the diagnosis and seeking out a spiritual adviser are positive ways of coping.

Question 11

A nursing instructor is giving a lecture on the immune system. Which of the following cells will the instructor include in her discussion on phagocytosis?
A. Plasma cells and memory cells 
B. Regulator T cells and Helper T cells 
C. Neutrophils and monocytes 
D. Lymphokines and Suppressor T cells

Answer 11

C

Neutrophils and monocytes are phagocytes, cells that perform phagocytosis.

Question 12

After teaching a group of students about the structure of the skin, the nursing instructor determines that the teaching was successful when the group identifies which of the following as the true skin?

A. Stratum corneum
B. Dermis
C. Epidermis
D. Papillary layer

Answer 12

B
The dermis is often referred to as the true skin. The epidermis is the outermost layer of the skin, with the stratum corneum as the outermost layer of the epidermis. The papillary layer is the outermost layer of the dermis that lieds directly beneath the epidermis.

Question 13

An 80-year-old woman is receiving treatment with oral fluconazole for a fungal infection Following yesterday’s and today’s dose, she reports an upset stomach to the charge nurse. How should the nurse at the facility best respond to the woman’s report?

A. Provide food along with the fluconazole when administering it in the future.
B. Stop administering the fluconazole and inform the client’s physician.
C. Arrange for the client to receive intravenous fluconazole on an outpatient basis.
D. Assess the client for signs and symptoms of an infusion reaction.

Answer 13

Provide food along with the fluconazole when administering it in the future.
Explanation:

Fluconazole has the potential to cause gastric distress, a problem that may be mitigated by administering the drug with food. Infusion reactions do not occur with the administration of fluconazole and it is likely unnecessary to arrange for IV administration, to stop the drug, or to immediately inform the resident’s physician.

Question 14

While reading a physician’s progress notes, a student notes that an assigned patient is having hypoxia. What abnormal assessments would the student expect to find?
A. diarrhea, flatulence, decreased skin turgor

B. dyspnea, tachycardia, cyanosis

C. abdominal pain, hyperthermia, dry skin

D. hypotension, reddened skin, edema

Answer 14

B
If a problem exists in ventilation, respiration, or perfusion, hypoxia (a condition in which an inadequate amount of oxygen is available to cells) may occur. The most common symptoms are dyspnea, elevated blood pressure, increased respirations and pulse, pallor, and cyanosis. Other common symptoms are anxiety and restlessness.

Question 15

A 65-year-old client has come to the emergency department reporting light-headedness, chest pain, and shortness of breath. As you finish your assessment, the physician enters and orders tests to ascertain what is causing the client's problems. In your client education, you explain the tests. Which test is used to identify cardiac rhythms?
A. Echocardiogram 
B. Electroencephalogram 
C. Electrocardiogram 
D. Electrocautery

Answer 15

C
An electrocardiogram is used to identify normal and abnormal cardiac rhythms. An electrocardiogram is the device used to identify normal and abnormal cardiac rhythms.

Question 16

The nurse is conducting the physical assessment of a client at the health care facility. The nurse uses the pulse oximetry technique to monitor the oxygen saturation in the client's blood. Which of the following pulse oximeter ranges indicates that the client is adequately oxygenated?
A. 80% to 90% 
B. 85% to 95% 
C. 95% to 100% 
D. 90% to 95%

Answer 16

C
If the client is adequately oxygenated, the pulse oximeter reading should be between 95% and 100%. Pulse oximetry is a noninvasive, transcutaneous technique for periodically or continuously monitoring the oxygen saturation in the blood. The normal range of oxygen saturation in the blood is between 95% and 100%. A sustained level of less than 90% is a cause for concern. If the oxygen saturation remains low, the client requires oxygen therapy.

Question 17

Which of the following is the hallmark symptom for peripheral arterial disease (PAD) in the lower extremity?

A.Intermittent claudication
B. Acute limb ischemia
C. Dizziness
D. Vertigo

Answer 17

A
The hallmark symptom of PAD in the lower extremity is intermittent claudication. This pain may be described as aching or cramping in a muscle that occurs with the same degree of exercise or activity and is relieved with rest. Acute limb ischemia is a sudden decrease in limb perfusion, which produces new or worsening symptoms that may threaten limb viability. Dizziness and vertigo are associated with upper extremity arterial occlusive disease.

Question 18

A 40-year-old client with a diagnosis of fibromyalgia has been prescribed cyclobenzaprine (Flexeril) as an adjunct to her existing drug regimen. What nursing diagnosis should the nurse prioritize for the nursing care plan for this client?

a. Risk for Injury related to CNS depressant effects
b. Diarrhea related to anticholinergic effects
c. Altered Nutrition, Less than Body Requirements, related to appetite suppression
d. Impaired Swallowing related to increased muscle tone

Answer 18

a
Risk for Injury related to CNS depressant effects
Explanation:

The CNS depression that is associated with the use of cyclobenzaprine constitutes a risk for injury. The anticholinergic effects of the drug constitute a risk for constipation, not diarrhea. Nutrition and swallowing are not typically affected by the use of cyclobenzaprine.

Question 19

A nurse is assessing a client’s fluid balance status. The nurse understands that which organ plays the major role in regulating fluid balance?

A. Intestines
B. Kidneys
C. Lungs
D. Skin

Answer 19

B
Although the skin, gastrointestinal tract, and lungs play a role in fluid balance, the kidneys are the major organs regulating fluid balance, conserving or excreting water and electrolytes as necessary to maintain homeostasis.

Question 20

A client's immune response include phagocytosis of the bacteria that have infected the client. What cells are capable of performing this role in the immune response?
A. Basophils 
B. Eosinophils 
C. Monocytes 
D. Immunoglobulins

Answer 20

C
Macrophages, or monocytes, are mature leukocytes capable of phagocytizing an antigen. Basophils are myelocytic leukocytes incapable of phagocytosis; some of them are fixed and do not circulate. Eosinophils are circulating myelocytic leukocytes whose function is unknown. Immunoglobulins are the released form of antibodies.

Question 21

The nurse is preparing to measure the depth of a client’s tunneled wound. Which implement should the nurse use to measure the depth accurately?
A. a small plastic ruler
B. an otic curette
C. a sterile tongue blade lubricated with water soluble gel
D. a sterile, flexible applicator moistened with saline

Answer 21

a sterile, flexible applicator moistened with saline
Explanation:

A sterile, flexible applicator is the safest implement to use. A small plastic ruler is not sterile. A sterile tongue blade lubricated with water soluble gel is too large to use in a wound bed. An otic curette is a surgical instrument designed for scraping or debriding biological tissue or debris in a biopsy, excision, or cleaning procedure and not flexible.

Question 22

Which education points would the nurse use to explain the development of pressure injuries to clients and how to prevent them? Select all that apply.

A.”The duration of pressure, compared to the amount of pressure, plays a larger role in pressure injury formation.”
B. “The skin can tolerate considerable pressure without cell death, but for short periods only.”
C. “Most pressure injuries occur over the trochanter and calcaneus.”
D. “The major predisposing factor for a pressure injury is internal pressure over an area, resulting in occluded blood capillaries and poor circulation to the tissues.”
E. “Generally, a pressure injury will not appear within the first 2 days in a person who has not moved for an extended period of time.”
F. “Pressure injuries usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue.”

Answer 22

A B F
Explanation:

Pressure injuries usually occur over bony prominences. The skin can tolerate considerable pressure without cell death, but for short periods only. The duration of pressure, compared to the amount of pressure, plays a larger role in pressure injury formation. Pressure injuries can develop in a variety of locations where bony prominences are located. The most common are the coccyx and sacrum. A pressure injury can appear in less than 2 hours of time, depending on the factors present. Most pressure injuries develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time, or when soft tissue undergoes pressure in combination with shear and/or friction.

Question 23

What is the function of the thymus gland?
A. Produces stem cells
B. Programs T lymphocytes to become regulator or effector T cells
C. Programs B lymphocytes to become regulator or effector B cells
D. Develops the lymphatic system

Answer 23

B
The thymus gland is located in the neck below the thyroid gland. It extends into the thorax behind the top of the sternum. The thymus gland produces lymphocytes during fetal development. It may be the embryonic origin of other lymphoid structures such as the spleen and lymph nodes. After birth, the thymus gland programs T lymphocytes to become regulator or effector T cells. The thymus gland becomes smaller during adolescence but retains some activity throughout the life cycle. Options A, B, and C are incorrect.

Question 24

Mr. Sanchez is a 56-year-old Mexican American who has a diagnosis of heart failure. The nurse's morning lung assessment of the client reveals crackles in the mid to lower lungs and respiratory rate of 32. The nurse notices that the client is restless, and his skin has an ashen appearance. Which nursing action is the priority intervention?
A. Limit the client's activity. 
B. Assess capillary refill. 
C. Assess fluid intake. 
D Obtain a pulse oximetry reading.

Answer 24

D
The focused assessment of the client?s respiratory status indicates signs of respiratory compromise and possible hypoxia, as evidenced by the client’s restlessness and the ashen appearance of the skin. To fully assess the respiratory status of the client, it is important to take the pulse oximetry measurement. Capillary refill and fluid intake assessment do not address the primary problem of respiratory compromise. Limiting activity is not an assessment.

Question 25

The nurse is caring for a client who has a pressure injury on the back. What nursing intervention would the nurse perform?

A. The nurse places a foam wedge under the body to keep body weight off the client’s back.
B. The nurse uses a ring cushion to protect reddened areas from additional pressure.
C. The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair.
D. The nurse increases the amount of time the head of the bed is elevated.

Answer 25

The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair.
Explanation:

Positioning devices such as pillows, foam wedges, or pressure-reducing boots can prove helpful to keep body weight off bony prominences. For example, a standard pillow placed under the calves raises the heels off the bed and alleviates pressure. The nurse should never use ring cushions, or “donuts,” because they increase venous pressure. The nurse should minimize the effects of shearing force by limiting the amount of time the head of the bed is elevated, when possible.

Question 26

The defense mechanism involving lymphoid cells, inflammatory cells, and hematopoietic cells stimulates production of antibodies and activated lymphocytes to destroy mutant body cells and pathogens is known as:

A. inflammatory response.
B. phagocytosis.
C. immune response.
D. cellular response.

Answer 26

C
The final defense mechanism is the immune response, and an effective response involves lymphoid cells, inflammatory cells, and hematopoietic cells.

Question 27

The nurse is educating a patient about the risks of stroke related to the new prescription for a COX-2 inhibitor and what symptoms they should report. Which COX-2 inhibitor is the nurse educating the patient about?

A, Ibuprofen (Motrin)
B.Celecoxib (Celebrex)
C. Piroxicam (Feldene)
D. Tolmetin sodium (Tolectin)

Answer 27

Celecoxib (Celebrex)
Explanation:

The COX-2 inhibitor celecoxib (Celebrex) is associated with an increased risk of cardiovascular events, including myocardial infarction and stroke.

Question 28

While examining a newborn, a nurse observes salmon patches on the nape of the neck and on the eyelids. Which is the most likely cause of these skin abnormalities?
A. bruising from the birth process
B. an immature autoregulation of blood flow
C. an allergic reaction to the soap used for the first bath
D. concentration of immature blood vessels

Answer 28

D
A concentration of immature blood vessels causes salmon patches. Bruising does not look like salmon patches but would be more bluish-purple in appearance. Harlequin sign is a result of immature autoregulation of blood flow and is commonly seen in low birth weight newborns. An allergic reaction would be more generalized and would not be salmon colored.

Question 29

A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time?

A. Impaired gas exchange related to increased blood flow
B. Excess fluid volume related to peripheral vascular disease
C. Risk for injury related to edema
D. Ineffective peripheral tissue perfusion related to venous congestion

Answer 29

Ineffective peripheral tissue perfusion related to venous congestion
Explanation:

Ineffective peripheral tissue perfusion related to venous congestion takes highest priority because venous inflammation and clot formation impede blood flow in a client with DVT. Impaired gas exchange related to increased blood flow is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Excess fluid volume related to peripheral vascular disease is inappropriate because there’s no evidence that this client has an excess fluid volume. Risk for injury related to edema may be warranted but is secondary to ineffective tissue perfusion.

Question 30

The azoles are a large group of antifungals used to treat systemic and topical fungal infections. Which are considered azoles? (Select all that apply.)

A. terbinafine (Lamisil) 
B. itraconazole (Sporanox) 
C. fluconazole (Diflucan) 
D. ketoconazole (Nizoral) 
E. caspofungin acetate (Cancidas)

Answer 30

A B C D
The azoles are a large group of antifungals used to treat systemic and topical fungal infections. The azoles include fluconazole (Diflucan), itraconazole (Sporanox), ketoconazole (Nizoral), posaconazole (Noxafil), terbinafine (Lamisil), and voriconazole (Vfend). Caspofungin acetate (Cancidas) is an Echinocandin antifungal.

Question 31

A client tells the nurse that she has taken several doses of over-the-counter fluconazole to treat a “yeast infection.” When assessing the client’s risk for drug toxicity, what aspect of the client’s health status should the nurse prioritize?

A. The client client has decreased renal function following recent pyelonephritis
B. The client has type 2 diabetes and takes oral hypoglycemics
C. The client has lost over 30 lbs. in the past four months through diet and exercise
D. The client experienced a transfusion reaction to packed red blood cells several years ago

Answer 31

The client client has decreased renal function following recent pyelonephritis
Explanation:

Fluconazole is excreted largely unchanged in the urine, so decreased renal function creates a significant risk for toxicity. This aspect of the client’s health history would likely create a greater risk than recent weight loss, type 2 diabetes or a history of transfusion reaction.

Question 32

A client is to receive enoxaparin (Lovenox). The nurse would administer this drug by which route?

A. Subcutaneous injection
B. Intramuscular injection
C. Intravenous infusion
D. Orally

Answer 32

Subcutaneous injection
Explanation:

Enoxaparin (Lovenox) is administered via subcutaneous injection. Intramuscular (IM) administration is avoided because of the possibility of the development of local irritation, pain, or hematoma (a collection of blood in the tissue). Intravenous infusions are used with several anticoagulants such as heparin. Warfarin is given orally.

Question 33

Which is the most common cause of esophageal varices?

A. Jaundice
B. Portal hypertension
C. Ascites
D. Asterixis

Answer 33

B
Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Jaundice occurs when the bilirubin concentration in the blood is abnormally elevated. Ascites results from circulatory changes within the diseased liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.

Question 34

The general adaptation syndrome (GAS) is a nonspecific physiologic response to a stressor. Select the stage listed below which is not a part of the process.
A.Stress awareness stage 
B. Alarm stage 
C. Exhaustion stage 
D. Resistance stage

Answer 34

A
The general adaptation syndrome can cycle many times through the alarm and resistance stages before reaching the exhaustion stage. The process occurs through the neuroendocrine and autonomic nervous systems.

Question 35

A 12-year-old boy taken to the emergency department after a soccer injury cries out, “Look, my leg is bigger now!” How will the nurse respond to the boy?

A. “Swelling is a normal response from your body to prepare for healing.”
B. “Yes. it is supposed to. This is a good thing.”
C. “Let me look at that. We may need to have the doctor examine you.”
D. “No need to worry. Soccer is a dangerous sport.”

Answer 35

A
Inflammation is a defensive reaction after injury that helps to prepare the site for repair. At the age of 12 years, children should be given age-appropriate responses for better understanding of what is happening to them. The correct choice is the best therapeutic communication response.

Question 36

A client tells the nurse that she has taken several doses of over-the-counter fluconazole to treat a “yeast infection.” When assessing the client’s risk for drug toxicity, what aspect of the client’s health status should the nurse prioritize?

A. The client has type 2 diabetes and takes oral hypoglycemics
B. The client experienced a transfusion reaction to packed red blood cells several years ago
C. The client has lost over 30 lbs. in the past four months through diet and exercise
D. The client client has decreased renal function following recent pyelonephritis

Answer 36

D
Fluconazole is excreted largely unchanged in the urine, so decreased renal function creates a significant risk for toxicity. This aspect of the client’s health history would likely create a greater risk than recent weight loss, type 2 diabetes or a history of transfusion reaction.

Question 37

A client tells the nurse that she has taken several doses of over-the-counter fluconazole to treat a “yeast infection.” When assessing the client’s risk for drug toxicity, what aspect of the client’s health status should the nurse prioritize?

A. The client has type 2 diabetes and takes oral hypoglycemics
B. The client experienced a transfusion reaction to packed red blood cells several years ago
C. The client has lost over 30 lbs. in the past four months through diet and exercise
D. The client client has decreased renal function following recent pyelonephritis

D
Fluconazole is excreted largely unchanged in the urine, so decreased renal function creates a significant risk for toxicity. This aspect of the client’s health history would likely create a greater risk than recent weight loss, type 2 diabetes or a history of transfusion reaction.

A client with a suspected pulmonary disorder undergoes pulmonary function tests. To interpret test results accurately, the nurse must be familiar with the terminology used to describe pulmonary functions. Which term refers to the volume of air inhaled or exhaled during each respiratory cycle?

A. Vital capacity
B. Tidal volume
C. Functional residual capacity
D. Maximal voluntary ventilation

Answer 37

B
Tidal volume refers to the volume of air inhaled or exhaled during each respiratory cycle when breathing normally. Normal tidal volume ranges from 400 to 700 ml. Vital capacity refers to the total volume of air that can be exhaled during a slow, maximal expiration after maximal inspiration. Functional residual capacity refers to the volume of air remaining in the lungs after a normal expiration. Maximal voluntary ventilation is the greatest volume of air expired in 1 minute with maximal voluntary effort.

Question 38

A nurse working in the clinic is seeing a client who has just been prescribed a new medication for hypertension. The client asks why hypertension is sometimes called the “silent killer.” The nurse’s correct response is which of the following?

A. “Hypertension often causes no symptoms.”
B. “Hypertension often kills early in the disease process.”
C. “Hypertension often causes no pain.”
D. “Hypertension is difficult to diagnose.”

Answer 38

“Hypertension often causes no symptoms.”
Explanation:

Hypertension is sometimes called the “silent killer” because people with it are often symptom free. Physical examination may reveal no abnormalities other than elevated blood pressure. People with hypertension may remain asymptomatic for many years. The usual consequences of prolonged, uncontrolled hypertension are myocardial infarction, heart failure, renal failure, strokes, and impaired vision. Pain is not usually an issue, but that is not why hypertension is called the “silent killer.” Hypertension is easily diagnosed by taking a series of blood pressure readings.

Question 39

Which is a cardiovascular response of the sympathetic nervous system?

A. Bradycardia
B. Hypotension
C. Tachycardia
D. Bradypnea

Answer 39

C
Tachycardia is a cardiovascular response of the sympathetic nervous system. Bradypnea, hypotension, and bradycardia are responses of the parasympathetic system. Sympathetic cardiovascular responses to stress include increased heart rate, cardiac contractility, and cardiac output; increased blood pressure; and peripheral vasoconstriction.

Question 40

A laboring mother asks the nurse if the baby will have immunity to some illnesses when born. What type of immunity does the nurse understand that the newborn will have?

A. Naturally acquired active immunity
B. There is no immunity passed down from mother to child.
C. Passive immunity transferred by the mother
D. Artificially acquired active immunity

Answer 40

Passive immunity transferred by the mother
Explanation:

Passive immunity develops when ready-made antibodies are given to a susceptible person. The antibodies provide immediate but short-lived protection from the invading antigen. Newborns receive passive immunity to some diseases for which their mothers have manufactured antibodies. Naturally acquired active immunity occurs as a direct result of infection by a specific micro organism. An example is the immunity to measles that develops after the initial infection. Not all invading microorganisms produce a response that gives lifelong immunity. Artificially acquired immunity is obtained by receiving a killed or weakened microorganism or toxoid.

Question 41

A client’s current immune response includes the release of basophils . What aspect of the client’s immune response will be performed by these leukocytes?

A. Antigen processing
B. Releasing histamine
C. Mediating an allergic reaction
D. Phagocytosis

Answer 41

B
Basophils contain chemical mediators important for initiating and maintaining an immune or inflammatory response, such as histamine. Neutrophils are responsible for phagocytosis. Basophils are not capable of phagocytosis. Macrophages process antigens. Eosinophils may be involved with allergic reactions, but their exact function is unknown.

Question 42

Which of the following conditions will lead to an increase in cardiac output?
A. Dehydration 
B. Exercise 
C. Decrease in blood pressure 
D. Sleep

Answer 42

B
Cardiac output increases during exercise and decreases during sleep. When cardiac output is decreased, blood pressure falls. Hemorrhage and dehydration can result in decreased cardiac output and decreased blood pressure.

Question 43

The nurse is creating a community teaching demonstration focusing on the cause of blood pressure. When completing the visual aid, which body structures represent the mechanism of blood pressure?
A. Heart and blood vessels 
B. Brain and sympathetic nervous system 
C. Lung and arteries 
D. Kidneys and autonomic nervous system

Answer 43

A
Blood pressure is the force produced by the volume of the blood in arterial walls. It is represented by the formula: BP= CO (cardiac output)× PR (peripheral resistance). To highlight the mechanism of cardiac output, a heart would be on the visual aid and blood vessels.

Question 44

A nurse is caring for clients on a medical surgical unit. Based on known risk factors, the nurse understands which client has the highest risk for developing a pressure ulcer?
A. 35-year-old client who was admitted after a motor vehicle accident and has bilateral casts
B. 70-year-old client with Alzheimer’s who wanders the nursing unit and refuses to sit and eat meals
C. 65-year-old incontinent client with a hip fracture on bed rest
D. 45-year-old client who has cancer, is receiving chemotherapy, and being admitted with leukopenia

Answer 44

65-year-old incontinent client with a hip fracture on bed rest
Explanation:

The 65-year-old client who is incontinent with a hip fracture would be at highest risk for developing a pressure ulcer. This client has several risk factors: age, incontinence, and decreased mobility related to the hip fracture. The client who had a car accident with bilateral casts does have decreased mobility but does not have as many risk factors as the hip fracture client. The client with cancer has a decreased immune system. However, the client has no immobility issues noted. The client with Alzheimer’s is ambulatory and has decreased nutrition. The risk for this client is not a great as the client with the hip fracture because of the mobility.

Question 45

A nurse is using a pulse oximeter to measure the arterial oxyhemoglobin saturation (SaO2 or SpO2) of a patient's arterial blood. What range is considered a normal value for SpO2?
A. 65% to 70% 
B. 85% to 90% 
C.75% to 80% 
D. 95% to 100%

Answer 45

D
A range of 95% to 100% is considered normal SpO2; values less than 85% indicate that oxygenation to the tissues is inadequate.

Question 46

The primary function of the thyroid gland includes which of the following?

a. Control of cellular metabolic activity
b. Reabsorption of water
c. Reduction of plasma level of calcium
d. Facilitation of milk ejection

Answer 46

A
The primary function of the thyroid hormone is to control cellular metabolic activity. Oxytocin facilitates milk ejection during lactation and increases the force of uterine contraction during labor and delivery. Antidiuretic hormone (ADH) release results in reabsorption of water into the bloodstream rather than excretion by the kidneys. Calcitonin reduces the plasma level of calcium by increasing its deposition in bone.

Question 47

What does the nurse understand will result if the patient has a deficiency in the normal level of complement?

A. Decrease in vascularity to the extremities
B. Increased susceptibility to infection
C. Development of congestive heart failure
D. Risk of stroke

Answer 47

Increased susceptibility to infection
Explanation:

The complement system is an integral part of the immune system, and deficiencies in normal levels of complement result in increased susceptibility to infectious diseases and immune-mediated disorders.

Question 48

Which individual will take longer to sense thirst?
A. 70-year-old 
B. 50-year-old 
C. 30-year-old 
D. 18-year-old

Answer 48

A
When adults older than 65 years of age were compared with younger adults, the plasma osmolarity at which the older group experienced thirst was increased, indicating an increased risk for development of a water deficit.