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The best explanation of how the kidneys accomplish regulation of pH is that they a. Secrete hydrogen ions and sodium. b. Secrete ammonia. c. Exchange hydrogen and sodium in the kidney tubules. d. Decrease sodium ions, hold on to hydrogen ions, and then secrete sodium bicarbonate. Answer: d Rationale: By decreasing NA+ ions, holding onto hydrogen ions, and secreting sodium bicarbonate, the kidneys can regulate pH. Therefore, this is the most complete answer, and while this buffer system is the slowest, it can completely compensate for acid-base imbalance. 2. The nurse explains to a client who has just received the diagnosis of Noninsulin-Dependent Diabetes Mellitus (NIDDM) that sulfonylureas, one group of oral hypoglycemic agents, act by a. Stimulating the pancreas to produce or release insulin b. Making the insulin that is produced more available for use c. Lowering the blood sugar by facilitating the uptake and utilization of glucose d. Altering both fat and protein metabolism Answer: a Rationale: Sulfonylurea drugs, Orinase for example, lowers the blood sugar by stimulating the beta cells of the pancreas to synthesize and release insulin. 3. Myasthenic crisis and cholinergic crisis are the major complications of myasthenia gravis. Which of the following is essential nursing knowledge when caring for a client in crisis? a. Weakness and paralysis of the muscles for swallowing and breathing occur in either crisis b. Cholinergic drugs should be administered to prevent further complications associated with the crisis c. The clinical condition of the client usually improves after several days of treatment d. Loss of body function creates high levels of anxiety and fear Answer: a Rationale: The client cannot handle his own secretions, and respiratory arrest may be imminent. Atropine may be administered to prevent crisis. Anticholinergic drugs are administered to increase the levels of acetylcholine at the myoneural junction. Cholinergic drugs mimic the actions of the parasympathetic nervous system and would not be used. 5. A 54-year-old client was put in Quinidine (a drug that decreases myocardial
excitability) to prevent atrial fibrillation. He also has kidney disease. The nurse is aware that this drug, when given to a client with kidney disease, may a. Cause cardiac arrest b. Cause hypotension c. Produce mild bradycardia d. Be very toxic even in small doses Answer: a Rationale: Kidney disease interferes with metabolism and excretion of Quinidine, resulting in higher drug concentrations in the body. Quinidine can depress myocardial excitability enough to cause cardiac arrest. 6. A client is about to be discharged on the drug bishydroxycoumarin (Dicumarol). Of the principles below, which one is the most important to teach the client before discharge? a. He should be sure to take the medication before meals b. He should shave with an electric razor c. If he misses a dose, he should double the dose at the next scheduled time d. It is the responsibility of the physician to do the teaching for this medication Answer: b Rationale: Dicumarol is an anticoagulant drug and one of the dangers involved is bleeding. Using a safety razor can lead to bleeding through cuts. The drug should be given at the same time daily but not related to meals. Due to danger of bleeding, missed doses should not be made up. 7. A cyanotic client with an unknown diagnosis is admitted to the emergency room. In relation to oxygen, the first nursing action would be to a. Wait until the client's lab work is done b. Not administer oxygen unless ordered by the physician c. Administer oxygen at 2 liters flow per minute d. Administer oxygen at 10 liters flow per minute and check the client's nail beds Answer: c Rationale: Administer oxygen at 2 liters per minute and no more, for if the client is emphysemic and receives too high a level of oxygen, he will develop CO2 narcosis and the respiratory system will cease to function 8. A client with a diagnosis of gout will be taking colchicine and allopurinol bid to prevent recurrence. The most common early sign of colchicine toxicity that the nurse will assess for is a. Blurred vision b. Anorexia c. Diarrhea
d. Fever Answer: c Rationale: Diarrhea is by far the most common early sign of colchicine toxicity. When given in the acute phase of gout, the dose of colchicine is usually 0.6 mg (PO) q hr (not to exceed 10 tablets) until pain is relieved or gastrointestinal symptoms ensue. 9. A client has chronic dermatitis involving the neck, face and antecubital creases. She has a strong family history of varied allergy disorders. This type of dermatitis is probably best described as a. Contact dermatitis b. Atopic dermatitis c. Eczema d. Dermatitis medicamentosa Answer: b Rationale: Atopic dermatitis is chronic, pruritic and allergic in nature. Typically it has a longer course than contact dermatitis and is aggravated by commercial face or body lotions, emotional stress, and, in some instances, particular foods. 12. The nurse would expect to find an improvement in which of the blood values as a result of dialysis treatment? a. High serum creatinine levels b. Low hemoglobin c. Hypocalcemia d. Hypokalemia Answer: a Rationale: High creatinine levels will be decreased. Anemia is a result of decreased production of erythropoietin by the kidney and is not affected by hemodialysis. Hyperkalemia and high base bicarbonate levels are present in renal failure clients. 13. A 24-year-old client is admitted to the hospital following an automobile accident. She was brought in unconscious with the following vital signs: BP 130/76, P 100, R 16, T 98F. The nurse observes bleeding from the client's nose. Which of the following interventions will assist in determining the presence of cerebrospinal fluid? a. Obtain a culture of the specimen using sterile swabs and send to the laboratory b. Allow the drainage to drip on a sterile gauze and observe for a halo or ring around the blood c. Suction the nose gently with a bulb syringe and send specimen to the laboratory d. Insert sterile packing into the nares and remove in 24 hours Answer: b
Rationale: The halo or "bull's eye" sign seen when drainage from the nose or ear of a head-injured client is collected on a sterile gauze is indicative of CSF in the drainage. The collection of a culture specimen using any type of swab or suction would be contraindicated because brain tissue may be inadvertently removed at the same time or other tissue damage may result. 14. A 24-year-old male is admitted with a possible head injury. His arterial blood gases show that his pH is less than 7.3, his PaCO2 is elevated above 60 mmHg, and his PaO2 is less than 45 mmHg. Evaluating this ABG panel, the nurse would conclude that a. Edema has resulted from a low pH state b. Acidosis has caused vasoconstriction of cerebral arterioles c. Cerebral edema has resulted from a low oxygen state d. Cerebral blood flow has decreased Answer: c Rationale: Hypoxic states may cause cerebral edema. Hypoxia also causes cerebral vasodilatation particularly in response to a decrease in the PaO2 below 60 mmHg. 16. A client is admitted following an automobile accident in which he sustained a contusion. The nurse knows that the significance of a contusion is a. That it is reversible b. Amnesia will occur c. Loss of consciousness may be transient d. Laceration of the brain may occur Answer: d Rationale: Laceration, a more severe consequence of closed head injury, occurs as the brain tissue moves across the uneven base of the skull in a contusion. Contusion causes cerebral dysfunction which results in bruising of the brain. A concussion causes transient loss of consciousness, retrograde amnesia, and is generally reversible. 17. A client with tuberculosis is given the drug pyrazinamide (Pyrazinamide). Which one of the following diagnostic tests would be inaccurate if the client is receiving the drug? a. Liver function test b. Gall bladder studies c. Thyroid function studies d. Blood glucose Answer: a Rationale: Liver function tests can be elevated in clients taking pyrazinamide. This drug is used when primary and secondary antitubercular drugs are not effective. Urate levels may be increased and there is a chemical interference with urine ketone levels if these
Arterial saturations have a close correlation with the reading from the pulse oximeter as long as the arterial saturation is above 70 percent. Hypothermia d. Carefully insert about 100 mL of aqueous Zephiran into the bladder. 20. While on a camping trip. a friend sustains a snake bite from a poisonous snake. There is a physician's order to irrigate a client's bladder. It is never advisable to force fluids into a tubing to check for patency. Vasodilation c. 21. then NPO . Artificial nails b. Sterile water and aqueous Zephiran will affect the pH of the bladder as well as cause irritation. allow it to remain for 10 hour. Provide a high fat diet for dinner. The most effective initial intervention would be to a. the nursing intervention would be to a. Vasoconstriction can cause an inaccurate reading of oxygen saturation. Apply a small amount of pressure to push the mucus out of the catheter tip if the tube is not patent c. Artificial nails may distort a reading if a finger probe is used. Elevate the bite area above the level of the heart c. Prior to the test. A female client has orders for an oral cholecystogram. Immobilize the limb Answer: a Rationale: A restrictive band 2 to 4 inches above the snake bite is most effective in containing the venom and minimizing lymphatic and superficial venous return. Which one of the following nursing measures will ensure patency? a. and then siphon it out d. Movement of the head Answer: c Rationale: Hypothermia or fever may lead to an inaccurate reading. 19. Which one of the following conditions could lead to an inaccurate pulse oximetry reading if the sensor is attached to the client's ear? a. Place a restrictive band above the snake bite b. Irrigate with 20mL's of normal saline to establish patency Answer: d Rationale: Normal saline is the fluid of choice for irrigation. Position the client in a supine position d.tests are done while the client is on the drug. 18. Use a solution of sterile water for the irrigation b. Elevation of the limb or immobilization would not be effective interventions.
Administer enemas until clear Answer: b Rationale: Diarrhea is a very common response to the dye tablets. The other positions will not be effective in achieving these goals. Supine to maintain blood pressure d. therefore. 22. 23. In preparation for discharge of a client with arterial insufficiency and Raynaud's disease. 25. Keeping the heat up so that the environment is warm c. In Fowler's position to facilitate ventilation c. mercury-filled ballooned tube used to resolve bowel obstructions. Administer the dye tablets following a regular diet for dinner d. thus promoting hemostasis and preventing hemorrhage. There is no evidence of shock or fluid overload in the client. because it is based on the weight of the client. the nurse will position the client a. A Miller-Abbott tube is a weighted. client teaching instructions should include a.b. Immediately following the procedure. Using hydrotherapy for increasing oxygenation . Assisting in inserting an arterial pressure line c. an arterial line is not appropriate at this time and an IV is optional. Each dye tablet is given at 5 minute intervals. The physician has just completed a liver biopsy. the nurse would expect a priority intervention to be a. A dinner of tea and toast is usually given to the client. When a client has peptic ulcer disease. Walking several times each day as a part of an exercise routine b. Inserting an IV Answer: c Rationale: An NG tube insertion is the most appropriate intervention because it will determine the presence of active gastrointestinal bleeding. Inserting a nasogastric tube d. Explain that diarrhea may result from the dye tablets c. On his right side to promote hemostasis b. Assisting in inserting a Miller-Abbott tube b. Wearing TED hose during the day d. In Sims' position to prevent aspiration Answer: a Rationale: Placing the client on his right side will allow pressure to be placed on the puncture site. usually with 1 glass of water following each tablet. The number of tablets prescribed will vary.
Which of the following statements supports this answer? a. behavioral changes b. weakness. diminished deep tendon reflexes. irregular pulse. 27. and leads eventually to blindness. Frequent urination. Weakness. even if one negative sputum is obtained b. due to the slow reproduction of the bacillus c. She explains that if left untreated. Myopia c. Walking will most likely increase pain. and socks will also be useful in preventing vasoconstriction. warm clothes. A positive reaction to a tuberculosis skin test indicates that the client has active tuberculosis. A positive sputum culture takes at least 3 weeks. Uveitis Answer: a Rationale: The increase in intraocular pressure causes atrophy of the retinal ganglion cells and the optic nerve. Because small lesions are hard to detect on chest x-rays.Answer: b Rationale: The client's instructions should include keeping the environment warm to prevent vasoconstriction. A client with a positive smear will have to have a positive culture to confirm the diagnosis Answer: b Rationale: Answer b is correct because the culture takes 3 weeks to grow. The nurse is counseling a client with the diagnosis of glaucoma. A positive skin test indicates the person only has been infected with tuberculosis but may not necessarily have active disease (a). flushed face. Wearing gloves. When a client asks the nurse why the physician says he "thinks" he has tuberculosis. Abdominal pain. chest x-rays do not need to be repeated frequently (c). Retrolental fibroplasia d. pleural friction rub c. the nurse explains to him that diagnosis of tuberculosis can take several weeks to confirm. Clients may have positive smears but negative cultures if they have been on medication (d). lassitude. but TED hose would not be therapeutic. x-rays usually need to be repeated during several consecutive weeks d. A nursing assessment for initial signs of hypoglycemia will include a. dilated pupils . blurred vision. Usually even very small lesions can be seen on x-rays due to the natural contrast of the air in the lungs. 28. therefore. Pallor. Blindness b. this condition leads to a. double vision d. 26.
. The purpose of these tongs is to a. The most appropriate nursing intervention for a client requiring a finger probe pulse oximeter is to a. Both (a) and (c) are incorrect because they might cause further damage (d) is incorrect because the client cannot sit up with the tongs in place. fainting. 30. Allow the client to sit up and move without twisting his spine Answer: b Rationale: The purpose of the tongs is to decompress the vertebral column through hyperextending it.hypoglycemia. Apply the sensor probe over a finger and cover lightly with gauze to prevent skin breakdown b. Tested. After the first discarded specimen. Decompress the spinal nerves d. After explaining the procedure to the client. Discarded. Set alarms on the oximeter to at least 100 percent c. Dyes use colors that tint the blood which leads to inaccurate readings. This specimen is then a. The physician will use Crutchfield tongs. Saved as part of the 24-hour collection c. a client is admitted with a head injury and concurrent cervical spine injury. 29. Hyperextend the vertebral column c. Remove the sensor between oxygen saturation readings Answer: c Rationale: Clients may experience inaccurate readings if dye has been used for a diagnostic test. pallor and perspiration are all common symptoms when there is too much insulin or too little food . urine is collected for 24 hours. The signs and symptoms in answers (b) and (c) are indicative of hyperglycemia. The physician has ordered a 24-hour urine specimen. blurred vision. Hypoextend the vertebral column b. Identify if the client has had a recent diagnostic test using intravenous dye d. then the collection begins b.Answer: a Rationale: Weakness. the nurse collects the first specimen. Following an accident. only the head of the bed can be elevated. Placed in a separate container and later added to the collection Answer: a Rationale: The first specimen is discarded because it is considered "old urine" or urine that was in the bladder before the test began. 31. then discarded d.
49.49. Check that the balloon is deflated on a regular basis Answer: c Rationale: The respiratory system can become occluded if the balloon slips and moves up the esophagus. The most important assessment is for the nurse to a. pH 7. 33.26. Check that a hemostat is at the bedside b. PCO2 46 d. A client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted to control the bleeding.26. The client's activity at this time should be a. PCO2 30 c. HCO3 14. 34. and PCO2 35 to 45 mmHg. Monitor IV fluids for the shift c. 35. HCO3 24. Bedrest in supine position c. This would result in respiratory distress and should be assessed frequently. Up ad lib and right side-lying position in bed d. pH 7. This is a safety intervention. Regularly assess respiratory status d. putting pressure on the trachea. HCO3 14.35 to 7. Correct the hyperglycemia that occurs with acute renal failure b. Ambulation as desired b. Facilitate the intracellular movement of potassium . The nurse understands that the rationale for this therapy is to a.45. HCO3 23 to 27 mEg. A client in acute renal failure receives an IV infusion of 10% dextrose in water with 20 units of regular insulin. Of the following blood gas values. The client is more comfortable sitting up and leaning forward. pH 7. Normal values are pH 7. PCO2 30 Answer: d Rationale: The client with acute renal failure would be expected to have metabolic acidosis (low HCO3) resulting in acid blood pH (acidemia) and respiratory alkalosis (lowered PCO2) as a compensating mechanism. Scissors should be kept at the bedside to cut the tube if distress occurs. pH 7. A 55-year-old client with sever epigastric pain due to acute pancreatitis has been admitted to the hospital. Bedrest in Fowler's position Answer: d Rationale: The pain of pancreatitis is made worse by walking and supine positioning. HCO3 24. the one the nurse would expect to see in the client with acute renal failure is a.32. PCO2 46 b.
as is mucus from the stoma. Feces in the drainage appliance Answer: d Rationale: The ileal conduit procedure incorporates implantation of the ureters into a portion of the ileum which has been resected from its anatomical position and now functions as a reservoir or conduit for urine. This type of infusion is often administered before cardiac surgery to stabilize irritable cells and prevent arrhythmias. Which of the following symptoms indicates an unexpected outcome and requires priority care? a. The nurse observes this client for complications in the postoperative period. as they increase the chances of the client developing a urinary tract infection. 38. Redness of the stoma d. Limiting fluid intake to 1500 mL per day Answer: b Rationale: Allowing the client to void naturally will be done prior to removal of the catheter to ensure adequate emptying of the bladder. A client has had a cystectomy and ureteroileostomy (ileal conduit). fluids should be encouraged (unless contraindicated) to prevent stone formation. A nursing care plan for a client with a suprapubic cystostomy would include a. For a client who has ataxia. Placing a urinal bag around the tube insertion to collect the urine b.c. 40. which of the following tests would be . Feces should not be draining from the conduit. 39. in this case KC1 is also added to the infusion. Mucus in the drainage appliance c. Force potassium into the cells to prevent arrhythmias Answer: b Rationale: Dextrose with insulin helps move potassium into cells and is immediate management therapy for hyperkalemia due to acute renal failure. Catheter irrigations every 4 hours to prevent formation of urinary stones d. Provide calories to prevent tissue catabolism and azotemia d. Clamping the tube and allowing the client to void through the urinary meatus before removing the tube c. An exchange resin may also be employed. Any time a client has an indwelling catheter in place. Irrigations are not recommended. Edema of the stoma b. The proximal and distal ileal borders can be resumed. Edema and a red color of the stoma are expected outcomes in the immediate postoperative period.
Pulmonary embolism could result from deep vein thrombosis. Prevent footdrop c. Anchor the traction b. 43. The team leader asks the nurse to place a footplate on the affected side at the bottom of the bed. Hoffmann's Answer: b Rationale: Romberg's test is the ability to maintain an upright position without swaying when standing with feet close together and eyes closed. Pulmonary embolism Answer: c Rationale: Pneumonia is a major complication of unresolved atelectasis and must be treated along with vigorous treatment for atelectasis. etc. Which of the following neurological checks will give the nurse the best information about the extent of bleeding? a. A client admitted to a surgical unit for possible bleeding in the cerebrum has vital signs taken every hour to monitor to neurological status. The purpose of this action is to a.performed to assess the ability to ambulate? a. Riley-Day's d. Evaluation of extrapyramidal motor system Answer: a Rationale: Pupillary checks reflect function of the third cranial nerve. Hemorrhage b. Romberg's c. Pneumonia d. 41. 42. the nurse knows that a complication likely to occur following unresolved atelectasis is a. Pupillary checks b. Prevent pressure areas on the foot . Kernig's b. Deep tendon reflexes d. is pain in the hamstring muscle when attempting to extend the leg after flexing the thigh. Kernig's sign. Hemorrhage and infection are not related to this condition. Infection c. which stretches as it becomes displaced by blood. Keep the client from sliding down in bed d. Spinal tap c. a reflex contraction. tumor. Assessing for immediate postoperative complications. A young client is in the hospital with his left leg in Buck's traction.
Clocks and daily schedules would be helpful for reorienting the client and promoting optimal cognitive function. keep the client from sliding down in bed. Headache and mood swings occurring about 10 days prior to menses C. Discarding all used equipment in a container marked “isolation” C. the nurse should implement which nursing intervention? A. Maintaining a daily routine would be helpful for ensuring consistency and promoting optimal functioning. weight gain. When disposing of the plastic bags. Only personnel trained in the proper handling of antineoplastic agents should . Using short sentences with simple words would be appropriate for maximizing effective communication. 3. Painful menstruation and a large menstrual flow are not associated with PMS. and poisoning precautions.200 to 2. Mood swings and breast tenderness with the onset of menses D. syringes. fatigue. mood swings. This will not anchor the traction. and keeping the bed in a low position. Medical and Surgical Nursing Practice Questions with Rationale 1. Which nursing intervention would be most appropriate for promoting the environmental safety of a client with a cognitive disorder? A. Placing a clock and a daily schedule in the client’s room D. or prevent pressure areas. 2. irritability. Avoiding contact with the equipment by allowing housekeeping to remove it B. Using short sentences with simple words when speaking with the client Correct Answer: A Rationale: Applying an identification bracelet on the client would be most effective in helping to ensure environmental and client safety should the client wander. providing adequate lighting. placing the items in a container marked “bio-health hazard” is appropriate because these containers can be incinerated at a temperature of 2. Disposing of all equipment in a container marked “bio-health hazard” D. and gloves used to administer antineoplastic drugs. tubing. and full. Fatigue and weight gain on the day prior to menses B. PMS is manifested by complaints of headache. instituting injury.Answer: b Rationale: The purpose of the footplate is to prevent footdrop while the client is immobilized in traction. occurring approximately 10 days before menses in each cycle. Which client complaint would lead the nurse to suspect premenstrual syndrome (PMS)? A. fire. Painful menstruation and large menstrual flow Correct Answer: B Rationale: Typically. Applying an identification bracelet on the client B.500° F so that there is no residue. Maintaining daily routine care for the client C. Disposing of all used equipment in the regular trash receptacles Correct Answer: C Rationale: Any disposable equipment and supplies used for chemotherapy must be disposed of in a manner that protects the environment. tender breasts. Other measures include installing alarms.
residue is possible after incineration at these temperatures.700 to 1. such as keeping the client on nothing-by-mouth status. and maintaining nasogastric suctioning and bedrest. the client’s abdomen should be soft.000 mm Correct Answer: D Rationale: One day after abdominal surgery. . Complaints of abdominal pain as an C. A high-fiber diet would be indicated for diverticulosis. Continuation of client’s nothing-by-mouth status D. but this type of diet would not be appropriate during an acute attack. special precautions are required. Which assessment data for a client who is 1 day postabdominal surgery would warrant immediate nursing intervention? A. Administering stimulant laxatives may be appropriate for restoring the client’s normal bowel elimination. Hypoactive bowel sounds would be expected 1 day after abdominal surgery.V. Increased fluid intake would be appropriate for diverticulosis. the WBC count may be slightly elevated in response to the surgery.800° F. administering I. A lumbar puncture is not a diagnostic procedure for intervertebral disc herniation. but an elevation of 20.handle the wastes. Because the equipment has been contaminated with material that is carcinogenic. but their use during an acute attack would only serve to irritate the bowel further. Preparing the client for lumbar puncture Correct Answer: C Rationale: Positioning the client with the head of the bed elevated and his knees slightly flexed increases the disc space and may help to decrease the client’s pain. measures focus on resting the colon. Blood pressure of 110/70 mm Hg and hematocrit of 42% B.7 mEq/L D. boardlike abdomen and a white blood cell (WBC) count of 20. The client’s blood pressure and hematocrit are within normal limits. 6. Increased fluid intake C. hard. Skeletal traction is not a treatment of choice for a herniated disc. Infectious waste is incinerated at 1. The client’s hemoglobin level is within normal limits. Encouraging the client to ambulate as much as possible C. abdominal incisional pain would be expected and often is rated as high when using a scale from 1 to 10. Hypoactive bowel sounds and a serum potassium of 3. Rigid. Positioning the client with his knees slightly flexed and the head of bed elevated D.000 mmis highly suggestive of an infectious process. Administration of stimulant laxatives B. fluids. Assessing the skeletal traction insertion sites for infection B. 4. 5. High-fiber diet Correct Answer: C Rationale: During an acute episode of diverticulitis. boardlike abdomen in conjunction with a seriously elevated WBC count suggests peritonitis and requires immediate intervention. One day after surgery. making it an inappropriate method for the disposal of antineoplastic equipment and supplies. The nurse would include which nursing intervention in the care plan for a client with an L5-S1 intervertebral disc herniation? A. The client’s potassium level is within normal limits. The client with an intervertebral disc herniation should be kept on bedrest. not rigid or hard. The nurse would include which nursing intervention for a client diagnosed with acute diverticulitis? A. Also. A rigid.
Anticholinesterase agents B. including irrigations Correct Answer: D Rationale: The client with a rectovaginal fistula may experience fecal drainage via the vagina. such as eating chocolate and candy. Helping the client to maintain appropriate body position is important. preventing infection by keeping the vaginal area clean with irrigation. Which intervention would be the most important aspect of preventative nursing care? A. but evidence has shown that acne involves multiple factors. A 16-year-old client asks the nurse. and bacterial infections. Helping the client to maintain appropriate body position C. The client with a rectovaginal fistula is at high risk for infection. “Acne is caused by an excess production of sebum.” B. Massaging reddened areas as soon as they are noted D.” C. Reddened areas should never be massaged because this increases tissue damage. Excess production of sebum results in seborrhea. “What caused me to have acne?” Which statement would be the nurse’s best response? A. “Acne is caused by not cleaning your face thoroughly every day. Ensuring adequate rest to enhance healing C. Administering antibiotics and ensuring adequate rest may be useful in promoting healing. 8. but this action is not always relevant for every client and thus is not the most important. but it must be done in conjunction with frequent turning. douches. Anticonvulsants . such as genetics. but they are not preventative measures. 10. Monitoring for symptoms of infection is important. is one of the single most important interventions in preventing pressure ulcers because it helps to minimize the effects of pressure on the skin.” Correct Answer: D Rationale: The exact cause of acne is not known. maintaining body position without frequent turning would not be beneficial.” D. and sitz baths would be most important. Administering antibiotics B. but perineal hygiene is more effective as a preventative measure. Applying an external urine collection device would be appropriate if the client is incontinent. Performing perineal hygiene. Turning the client every 2 hours Correct Answer: D Rationale: Turning the client frequently. 9. The client with a head injury is experiencing increased intracranial pressure (ICP). “Eating lots of chocolate and candy causes you to have acne. such as every 2 hours. Which intervention would most important in the prevention of pressure ulcers? A. do not cause acne. Uncleanliness and dietary indiscretions. Applying external urine collection devices B. “The exact cause of acne is not really known. hormonal factors.7. Monitoring temperature and white blood cell (WBC) count D. allowing pressure to be redistributed with each turn. Which medication would the nurse anticipate administering? A.
Optional monthly BSE. it may be performed once the chest tube has been inserted and the initial build of pressure has been relieved. Which intervention would the nurse anticipate as the initial action to be included in the care plan for a client experiencing a tension pneumothorax? A. Applying an occlusive dressing will increase the pressure in the chest and worsen the tension pneumothorax. Thus. Obtaining a chest X-ray wastes precious minutes that may permit the client to decompensate. Anticholinesterase agents are used in the management of myasthenia gravis and are not helpful in decreasing ICP. 2. Removal of an occlusive dressing Correct Answer: D Rationale: A tension pneumothorax occurs when the pressure increases in the pleural space. It is a medical emergency that can quickly be fatal. Loop diuretics D. When providing postoperative care after a bowel resection to a client with a pre-existing history of chronic obstructive pulmonary disease (COPD) with frequent exacerbations. 3. Application of on occlusive petroleum dressing B. Yearly BSE and follow up clinical examinations after onset of menses Correct Answer: B Rationale: The ACS recommends a yearly clinical examination and yearly mammograms in clients older than age 40. Obtaining a chest X-ray D. removing an occlusive dressing will release the increased pressure in the pleural space and help resolve the tension. there is a 1 in 8 risk of developing breast cancer. Which recommendation would the nurse include in the teaching program? A.C. but they are not a first-line agent. Monthly self-breast examination is an option for women starting in their 20s. yearly clinical examination. Airway obstruction . decrease ICP. Osmotic diuretics Correct Answer: D Rationale: Osmotic diuretics such as mannitol are the preferred diuretic in the management of increased ICP to decrease cerebral edema and. The risk of breast cancer increases with age. Quarterly BSE until the age of 70 after which breast health awareness is no longer necessary D. Loop diuretics can be given in cases of increased ICP. the health care provider will insert a large bore needle initially and then a chest tube to aid in reinflating the lung. An occlusive dressing would be appropriate for an open pneumothorax. Increasing the ventilator’s tidal volume C. the nurse follows the American Cancer Society (ACS) recommendations. At age 80. Typically. The diagnosis of a tension pneumothorax is based on the client’s clinical presentation. Sample Review Questions on Medical and Surgical Nursing Part 1 1. worsening the tension pneumothorax. Anticonvulsant medications would be used to treat seizure activity and are not helpful in decreasing ICP. Bimonthly BSE and yearly mammograms beginning after the woman has had her first child B. and yearly mammograms after age 40 C. Acute respiratory failure B. for which complication should the nurse be alert? A. When teaching a group of women about breast health awareness and breast self-examination (BSE) at a local community center. therefore. Increasing the tidal volume on the ventilator will increase the volume delivered to the chest.
“Because my valve is from a pig. Which collaborative intervention would be included in the care plan for a client with a venous stasis ulcer to assist with healing? A. The boot is then wrapped in plastic wrap and hardens like a cast promoting venous return and preventing stasis. the anesthesia used during surgery. A plaster cast sock is usually applied to a residual limb following amputation to reduce edema. Antiembolism stockings are fit tightly and can traumatize an ulcer when applied. “I will always need to take anticoagulants to prevent the formation of blood clots. clients need to be educated about the need for lifelong oral anticoagulant therapy. it requires that the client be admitted to a critical care unit for constant monitoring due to the potential for complications. Increases the client’s carbon dioxide . Transcutaneous electrical nerve stimulator (TENS) D. Airway obstruction and atelectasis are postoperative complications. it would have no effect on healing. “I need to make sure I have someone to care for me after this same-day surgery procedure. and the experience of surgery. the nurse would indicate which rationale as its major purpose? A.C. Prophylactic antibiotics. Rejection of the artificial valve is not a major problem associated with valve replacement surgery.” B.” C. 5. I need to take precautions to prevent rejection of the valve. Which client statement indicates effective teaching? A. The operative procedure and the client’s medical history would not place this client at a greater risk for postoperative pneumothorax as compared to any other postoperative client. TENS is used as a pain relief measure. (Povine or bovine valve replacements do not require anticoagulants. 6. but there is no evidence that this client would be at greater risk for these complication than anyone else. Atelectasis D. Increases pulmonary capillary pressure C.” Correct Answer: B Rationale: Following mechanical valve replacement surgery. “I will need to take several days of steroids each time I have major dental work done. Antiembolism stockings B. 4. Unna boot Correct Answer: D Rationale: An Unna boot is medicated gauze applied to the affected limb from the toes to the knees after the ulcer is cleaned. When explaining to a student about the rationale for using PEEP. Improves area available for gas exchange D. A client with pulmonary edema is receiving mechanical ventilation with positive end-expiratory pressure (PEEP).) Valve replacement surgery is not performed as a day surgery procedure. not steroids. are needed after valve replacement surgery.” D. The nurse is doing preoperative teaching for a client about to have a mechanical valve replacement. Plaster cast sock C. Pneumothorax Correct Answer: A Rationale: The client is at high risk for developing acute respiratory failure because of his history of chronic lung disease requiring frequent intubations. Allows the client to obtain needed rest B.
Adhesive bandages irritate the skin.” B. Hypnotics and sedatives such as sleeping pills depress respirations and should be avoided. 8.” C. Applies lotions to keep the skin from cracking B. in fact. increasing the area available for gas exchange. . A client with a history of bigeminy who is on a lidocaine drip complains of light-headedness. An ECG is not needed for diagnosis of arrhythmia when a rhythm strip will suffice.” Correct Answer: A Rationale: Secretions are often very thick and difficult to expectorate for clients with COPD. and decreases the client’s carbon dioxide level by increasing the area for gas exchange. Having the client lie down and administering atropine Correct Answer: B Rationale: Before doing anything else. Elevates the residual limb on a pillow following surgery C. Atropine is the drug of choice for sinus bradycardia. Using lotions keeps the skin soft. not premature ventricular contractions. however. “I should do everything in the morning so I can rest later on. Lies prone for several hours each day D. the skin needs to become tough. New guidelines recommend elevating the foot of the bed because a pillow can cause flexion contractures of the hip. The client is not exhibiting signs of lidocaine toxicity and. leading to sores. 7. the lidocaine may need to be increased. drinking at least 2 liters of fluid per day will help to thin the secretions and aid in expectoration. Decreasing the lidocaine and instituting seizure precautions D. The nurse knows a client with chronic obstructive pulmonary disease (COPD) understands the discharge teaching when he makes which statement? A. The client should eliminate exposure to irritants such a smoking. thus improving the client’s oxygenation. decreases pulmonary capillary pressure.Correct Answer: C Rationale: PEEP helps keep the alveoli expanded. The nurse teaches a client about residual limb care following an amputation and assesses that he understood the teaching when he demonstrates which behavior? A. breakdown. “I should smoke only when I am not having difficulty breathing. Wraps the residual limb in adhesive bandages Correct Answer: C Rationale: Lying prone for several hours each day helps prevent hip contractures and demonstrates compliance with the treatment regimen. Calling the health care provider and getting a stat electrocardiogram (ECG) B. Checking the rhythm strip and assessing blood pressure C. Which intervention would the nurse implement A. following an amputation. the nurse needs to check the rhythm strip and assess the client’s blood pressure to determine the possible cause of the client’s complaints and gather additional data so that a full report can be made to the health care provider. The client needs to pace himself and his activities to minimize energy expenditures and prevent exertion. 9. “I need to drink at least 2 liters of fluid every day.” D. and infection. PEEP has no effect on the client’s ability to rest. “I need to take a sleeping pill every night so I wake up rested.
ordered for an elderly client is achieving its intended results? A. the client’s medication regime needs to be adjusted or changed. Which intervention should the nurse implement first? A. Maintenance of the client in a supine position to improve peripheral blood flow D. Changing positions frequently and elevating the legs above the heart to promote venous return in the legs B. Elevating the foot of the bed about 6″ while the client is sleeping to promote venous return is appropriate for the client with deep vein thrombosis. Relief of nocturnal leg cramping D. Which assessment finding indicates that furosemide (Lasix). Nontender calf muscles on palpation C. the dressing inadvertently comes off the stump. a systolic blood pressure of 150 mm Hg would be considered normal and thus indicative that the drug therapy is effective. Before a tourniquet would be applied. the nurse should wrap the limb with an elastic compression bandage immediately. When caring for a client with arterial occlusive disease of the extremities. Systolic blood pressure of 150 mm Hg Correct Answer: D Rationale: Furosemide is commonly used as an initial step in treating hypertension. 2.10. While caring for a client with a new amputation.2 cm) while the client is sleeping to promote venous return D. what would the nurse include in the client’s teaching plan? A. Elevating the arm on a pillow with the elbow higher than the shoulder and the hand higher than the elbow C. Keeping the legs in a dependent position in relationship to the heart to improve peripheral blood flow Correct Answer: D Rationale: The client with arterial occlusive disease needs to enhance the blood supply to the body parts affected. +4 pitting edema in both legs B. keeping legs in a dependent position in relationship to the heart to improve peripheral blood flow enhances the blood flow to the extremities. Elevating the foot of the bed about 6″ (15. Elevation of the limb above heart level to promote venous return C. Elevating the arm on a pillow with the elbow higher than the shoulder and hand higher than the elbow helps to promote lymphatic drainage. a loop-diuretic. Pitting edema of +4 indicates that the drug is not achieving its intended result because fluid is still present. For the elderly client. Bedside application of a large tourniquet to prevent massive hemorrhage B. the nurse would need to assess the client for signs and symptoms of bleeding . Sample Review Questions on Medical and Surgical Nursing Part 2 1. resulting in delays in rehabilitation. relief of tenderness in the calf is seen in deep vein thrombosis. Furosemide has no effect on calf muscle. Changing positions frequently and elevating the legs above the heart to promote venous return in the legs should be included in teaching for the client with varicose veins. Loop diuretics do not typically relieve cramping. Immediate application of an elastic compression bandage wrapped around the limb Correct Answer: D Rationale: Because excessive edema will develop in a short time.
venous return is not a major concern. Distant breath sounds Correct Answer: D Rationale: With emphysema. Cor pulmonale (right-sided heart failure) is more commonly associated with chronic bronchitis than emphysema. Prolonged periods of uncontrolled coughing D. Complaints of pain at the needle insertion site C. and neurovascular assessments are important. air trapping and chronic hyperexpansion of the lungs lead to distant breath sounds.1° C). Symmetrical respirations Correct Answer: C Rationale: Uncontrolled coughing in the client following a thoracentesis may indicate the development of pulmonary edema that requires immediate attention. 3. 5. Following a thoracentesis. Bilateral crackles may indicate underlying inflammation or congestion. Level of consciousness D. Copious amounts of sputum are produced with chronic bronchitis. may occur. in this case. Which complication would the nurse suspect? A. which assessment finding would warrant immediate intervention by the nurse? A.6° F (38. but immediate attention is not necessary. The nurse needs to keep the stump elevated by raising the foot of the bed. chest. Complaints of pain at the needle insertion site and symmetrical respirations are normal findings. Polycythemia. but emphysema does not lead to anemia.because applying a tourniquet could compromise the circulatory and neurologic status of the limb. and is moderately dyspneic. A client arrives in the emergency department following a motor vehicle accident with multiple injuries to the head. The supine position is contraindicated. Which would the nurse assess first? A. an increase in red blood cells. and circulation — are the priorities and must be maintained first. Which assessment finding would the nurse expect to assess in a client with emphysema? A. Cor pulmonale C. Blood pressure C. Elevating the limb above heart level could cause contractures. Copious sputum B. 4. but in this case. sputum production is usually scant. Aspiration pneumonia B. and extremities with minimal bleeding. Anemia D. 6. breathing. Airway status B. Auscultation of crackles bilaterally B. with emphysema. Quality of peripheral pulses Correct Answer: A Rationale: When dealing with an emergency. A client receiving nasogastric tube feedings for the past 48 hours develops a hacking cough. a fever of 100. neurological. the ABCs — airway. Blood pressure. Chronic obstructive pulmonary disease (COPD) . airway is the priority.
Dandruff shampoo includes harsh chemicals that could damage already fragile skin. While performing a physical assessment. Phantom pain is pain noted following a limb amputation. Pulselessness Correct Answer: D Rationale: Pulselessness is one of the common manifestations of acute arterial occlusion secondary to cessation of blood flow distal to the occlusion. Avoiding eating within 2 hours of bedtime B. A scalp ointment to prevent dryness B. the area being irradiated should be washed with water and the skin patted dry. what would the nurse expect to observe? A. which are petroleum-based. Clients with COPD have a chronic cough and usually are afebrile. and moderate dyspnea. hats and scarves also help to foster a positive body image. Clients with pneumoconioses present with chronic cough and progressive dyspnea. Completing all antibiotics D. A client is admitted to the health care facility with a diagnosis of acute arterial occlusion. Ointments. A client with leukemia is undergoing radiation therapy to the brain and spinal cord. Sleeping with the head of the bed flat Correct Answer: A Rationale: Clients with GERD should avoid eating prior to retiring or lying down to decrease the incidence of reflux. the nurse would include which nursing intervention? A. Clients with pleural effusion usually have no cough and are afebrile. Cramping is a common complaint associated with varicose veins. Elephatism C. low-grade fever. Not allowing the client to use a hat or scarf D. could cause a radiation burn to the area. The client with GERD will be prescribed a low-fat. high-fiber diet.C. although antibiotics are used for clients with <i>Helicobacter pylori</i> . Cramping B. Pneumoconioses Correct Answer: A Rationale: Nasogastric tube feedings may result in aspiration leading to pneumonia. Antibiotics are not used to treat GERD. Which intervention would the nurse include in the teaching plan for a client diagnosed with gastroesophageal reflux disease (GERD)? A. A dandruff shampoo twice daily Correct Answer: B Rationale: The marks made by the radiation oncologist guide the technician in configuring the external beam to irradiate the area in question without causing damage to other tissues. In planning care for this client. Elephantism is an indication of secondary lymphedema. These marks must remain in place and should not be washed off. 9. The client should be encouraged to use a hat or scarf when in the sun to prevent damage to the scalp skin and at night to prevent loss of body heat through the scalp. 8. 7. low-fiber diet C. Avoiding washing off the target’s marksC. Phantom pain D. Pleural effusion D. suggested by the hacking cough. Eating a high-fat.
Postural drainage usually is recommended for clients diagnosed with bronchitis and emphysema. Mechanical squeezing of the tissues is performed for lymphedema. the nurse would be correct in withholding the medication if which assessment data is present? A. increasing fluid intake will help thin secretions. not PTT.infection and peptic ulcer disease. For a client receiving oral anticoagulant therapy for chronic atrial fibrillation. Using warm water when bathing D. 10. Instructions about increasing fluid intake Correct Answer: D Rationale: Pneumonia typically causes thick secretions that may be difficult for the elderly client to expectorate. thereby increasing blood flow. Anticoagulant therapy is given to prevent clots from forming in the atria. also. It should not be held related to heart rate. Partial thromboplastin time (PTT) of 25 seconds Correct Answer: C Rationale: The INR value for a client with chronic atrial fibrillation receiving oral anticoagulants should be kept between 2 and 3. any value above 3 would place the client at risk for hemorrhage. a PTT value of 25 seconds is considered within the normal range. is used to monitor the effectiveness of oral anticoagulants. 2. Demonstration of pursed lip breathing C.) ESR is not an indicator of anticoagulant effectiveness and has no bearing on whether or not the drug should be held.Demonstration of postural drainage techniques B. Which discharge teaching would be most appropriate to promote vasodilation in a client with arterial occlusion? A. especially if anticoagulant therapy was continued. The client with GERD should elevate the head on pillows or use blocks under the head of the bed to minimize reflux. . A client with pneumonia typically does not require oxygen at home. ultimately aiding in their removal. Elevated erythrocyte sedimentation rate (ESR) C. Using antiembolism stockings C. Apical heart rate below 60 beats per minute B. Walking with a heel-toe gait Correct Answer: C Rationale: Using warm water when bathing is helpful because heat causes vessels to dilate. make sure that the client knows not to use hot water because of his decreased temperature sensation. International Normalized Ratio (INR) above 5 D. Sample Review Questions on Medical and Surgical Nursing Part 3 1. Discussion of proper use of oxygen therapy D. Which would the nurse include in the discharge teaching plan for an elderly client diagnosed with pneumonia? A . Mechanically squeezing the affected tissue B. Pursed lip breathing and oxygen therapy usually are recommended for clients with chronic obstructive pulmonary disease. Prothrombin time. (Digoxin is sometimes held for heart rates below 60 beats per minute.
not plan for retirement activities. Which intervention should the nurse include in the discharge plan for a client who has experienced a myocardial infarction (MI)? A. low-cholesterol. Teaching the client about food choices for a high-fiber. Administrating oxygen during episodes of pain B. especially after eating a heavy meal. which helps decrease the pain. Oxygen will not help relieve pain. 6. but I still have difficulty breathing sometimes. Although high fiber is encouraged to minimize straining with stool. high-protein diet Correct Answer: B Rationale: Encouraging the client’s family to take a CPR course is important to ensure that the family is prepared to give CPR should the client experience another MI. a low-sodium. Complaints of pain in the right upper rib region and back. 5. Which electrocardiogram change would the nurse expect to assess in a client complaining of chest pain and experiencing myocardial ischemia? . Encouraging the client to cough and deep-breathe C. Coughing and deep-breathing is necessary. The nurse should discuss ways to prevent complications secondary to coronary artery disease. Reports of feeling the heart beating in the abdomen when lying down are commonly seen with aortic aneurysm. Difficulty breathing even after smoking cessation may suggest pulmonary problems that are unrelated to peripheral vascular function.” B. Which nursing intervention would be most appropriate for relieving the pain? A. but it will help to relieve dyspnea and hypoxemia. but these typically will increase the client’s pain. protein intake does not need to be increased. not relieve it. “I get pain in my legs when I walk down the street more than two blocks. Walking with a heel-toe gait is suggested for clients with deep vein thrombosis. Encouraging the client’s family to take a cardiopulmonary resuscitation (CPR) course C. The client should participate in a cardiac rehabilitation program.Antiembolism hose are not indicated for use with arterial occlusions and should be avoided. “I can feel my heart beating in my abdomen when I am lying down. 3.” D. Assisting the client in planning for retirement activities B.” C. A client diagnosed with pneumonia is experiencing pleuritic pain located on the right side of his chest. Which client statement would indicate a possible problem with peripheral vascular function? A. Instructing the client to have cardiac enzymes checked monthly D. Encouraging the client to lay on the right side D. Giving an ordered opioid analgesic around the clock Correct Answer: C Rationale: Splinting the affected side.” Correct Answer: B Rationale: Complaints of pain in the legs with activity are a cardinal sign of arterial insufficiency. “I stopped smoking last year. Opioid analgesics should be administered with caution to prevent depression of the cough reflex and respiratory drive. “I often have pain near my upper right rib and back after eating a heavy meal. restricts expansion and reduces friction between pleurae. such as by having the client lie on the right side. and low-fat diet is recommended after an MI. Typically. suggest biliary colic. but monthly testing of cardiac enzymes is unnecessary. 4.
7. Orthopnea and crackles Correct Answer: C Rationale: In right-sided heart failure. Notifying the health care provider of possible pacer malfunction Correct Answer: A Rationale: The client’s pacemaker is a demand type pacemaker that senses the heart’s intrinsic rhythm. D. Nothing should be changed and there is no need to contact the health care provider. Widening QRS complexes Correct Answer: A Rationale: Inverted T waves are a sign of ischemic changes. A heart sound. low gas-producing diet and increase. ST-segment elevation D. Which instruction would the nurse include when teaching clients diagnosed with irritable bowel syndrome (IBS)? A. if a problem occurs. Two days following insertion of a temporary demand pacemaker set at 60 beats per minute. low gas-forming foods. Further monitoring of the client’s vital signs as ordered B. Prolonged PR intervals signal a delay in atrioventricular junction. Increasing the pacemaker setting to 70 beats per minute D. Inverted T waves B. Which data would the nurse expect to assess in a client admitted with right-sided heart failure? A. Decrease fluid intake during meals. tachycardia. Take antianxiety agents. it will only function if the client’s own heart rate falls below the predetermined set rate.) 9. the nurse assesses the client’s heart rate at 85 beats per minute. Because the client’s heart rate is 85. the nurse would not change any settings without the health care provider’s order. Heart sound and tachycardia B. Congestion in the lungs in left-sided heart failure produces orthopnea and crackles. (However. Decreased urinary output and restlessness C. ST-segment elevation suggests cardiac muscle injury. There is nothing wrong in this situation. the pacemaker will not fire and there will be no pacemaker spikes to see on an ECG. Correct Answer: C Rationale: Clients with IBS should eat a high-fiber. not decrease. Prolonged PR intervals C. Which intervention should the nurse implement? A. Getting an electrocardiogram (ECG) to verify pacemaker capture C. Eat a bland diet. B. No supportive evidence exists that a bland diet helps to alleviate the . Nausea and anorexia D. decreased blood flow to the kidneys causing decreased urinary output. and restlessness due to impaired gas exchange and tissue oxygenation occur with leftsided heart failure. their fluid intake. C. Widened QRS complexes suggest bundle-branch blocks and ventricular beats.A. the viscera and peripheral tissues become congested. 8. Venous engorgement and venous stasis in the abdominal organs lead to nausea and anorexia in right-sided heart failure. Eat high-fiber.
Calling the surgeon in anticipation of an appendectomy D. aching. Weight gain of 3 pounds in one day Correct Answer: B Rationale: Fatigue may be associated with decreased cardiac output. 10. fever. Increased ability to walk to the bathroom without fatigue C. nausea. A decrease in intermittent claudication indicates improved peripheral perfusion. which requires surgery as soon as possible. Decreased intermittent claudication B. rebound tenderness. notifying the surgeon should be the nurse’s first action. fever. and gnawing pain. . Weight gain indicates fluid retention and a worsening of the client’s heart failure. A high Fowler’s position would not alleviate pain produced by a peptic ulcer. Ankle edema is typically seen with varicose veins. Which assessment finding would be an appropriate indicator for evaluating a client with heart failure and a nursing diagnosis of decreased cardiac output? A. 2. but it does not demonstrate increased cardiac output. an increase in the client’s ability to ambulate to the bathroom without fatigue indicates improvement in cardiac output. diarrhea. and malaise. which includes burning. Rebound tenderness is not associated with gastroenteritis. Bluish-white skin C. Advising the client to assume a high Fowler’s position for a peptic ulcer C. Suggesting a course of antibiotics to treat peritonitis Correct Answer: C Rationale: The client is exhibiting classic findings associated with appendicitis. and vomiting has a low-grade fever. which is indicated by diffuse abdominal pain. which is characterized by generalized abdominal cramping.symptoms of IBS. Bluish-white skin is typically seen with frostbite. Chronic swollen limbs are associated with chronic venous insufficiency. Stress can cause exacerbations of IBS. Ankle edema B. A client has a diagnosis of hypertension based on three systolic blood pressure readings above 90 mm Hg. Which intervention should the nurse perform first? A. rebound tenderness. Which data would the nurse expect to find on assessment? A. No abnormal symptoms Correct Answer: D Rationale: Hypertension usually produces no symptoms until vascular changes occur. Chronic swollen limbs D. The body normally responds to a decrease in cardiac output by increasing the heart rate. Administering antacids for gastroenteritis B. but administration of antianxiety agents is usually not necessary. A client who is complaining of right lower quadrant pain. and an elevated white blood cell (WBC) count. Nausea and vomiting are not generally associated with peritonitis. Increased heart rate by 10 beats per minute D. and an elevated WBC count. Sample Review Questions on Medical and Surgical Nursing Part 4 1.
“This will relieve your distress and help you to be more comfortable. cold. Postphlebitic syndrome is characterized by a brownish discoloration of the skin. Preventative surgery is done to remove tissue prior to its becoming cancerous. Warm. which nursing intervention should the nurse implement? A.” B. followed by hyperemia. 5. numb. Gentle massage of the affected area D. and pulse accompanied by the sudden onset of pain (the classic “P’s” of assessment) all suggest an acute arterial occlusion. Raynaud’s phenomenon involves the episodic constriction of the small arteries or arterioles of the extremities. which may produce rubor. Sodium bicarbonate is indicated for the treatment of hypothermia. not the legs. Dental surgery in the recent past B. Administration of sodium bicarbonate B. epigastric region. which information from the client interview would the nurse consider as most significant? A.” D. A client with deep venous thrombosis develops a sudden onset of severe leg pain. Palliative surgery is used to relieve the client’s distress and help make him more comfortable. History of coronary artery disease (CAD) .” C. whether or not the mass is precancerous has yet to be determined. Dissecting aneurysm C. Reconstructive surgery provides a more realistic look to a body part. Which statement would be the nurse’s best response? A. A client who has frostbite is complaining of pain. or abdomen is common. “This is diagnostic surgery done to confirm or rule out malignancy. Elevation of the body part C. the hallmark sign. toes and. The limb becomes pale. and pulseless. Raynaud’s phenomenon Correct Answer: A Rationale: The change in color. resulting in intermittent pallor and cyanosis of the skin. Postphlebitic syndrome D. Massaging the affected area may result in further tissue damage. fingers. 6. a tearing or ripping sensation of pain in the anterior chest. What medical condition would the nurse suspect? A. humidified oxygen is used as treatment for hypothermia. When obtaining the history of a client admitted with endocarditis. “The physician removes the precancerous mass to prevent cancer from occurring. “This will provide a more realistic look to the body part. sensation.” Correct Answer: B Rationale: A biopsy is performed to aid in diagnosing whether a mass is benign or malignant. In addition to giving medication.3. Acute arterial occlusion B. the ears or nose. possibly. A client scheduled for a biopsy of a mass asks the nurse to explain why this surgery is necessary. A dissecting aneurysm usually occurs in the chest. humidified oxygen Correct Answer: B Rationale: Elevation of the body part helps to reduce the edema associated with frostbite. 4. temperature. Administration of warmed. back.
the condition is irreversible. History of marijuana use D. Prolonged use of steroid therapy Correct Answer: A Rationale: Dental surgery is one of the predisposing factors for the development of endocarditis because it may create a portal of entry for microorganisms. 9. Which client would require the nurse to be on highest alert for the development of a pulmonary embolism (PE)? A. The client is encouraged to remove the oxygen as often as possible. The oxygen must be administered at a low rate. antibiotic therapy (not steroid therapy) are predisposing factors for endocarditis. Paresthesias and loss of position sense C. intermittent oxygen is not effective. and the prolonged period of immobility that results from the injuries and their treatment further compounds the client’s risk. Correct Answer: D Rationale: The primary stimulus to breathe for the client with COPD is hypoxia. and prolonged I. Which scientific rationale must the nurse keep in mind when administering oxygen to a client with chronic obstructive pulmonary disease (COPD)? A. Due to loss of supporting structures and narrowing of airways.V. When assessing a client diagnosed with an abdominal aortic aneurysm. A client who has experienced multiple trauma and fractures Correct Answer: D Rationale: A client with massive trauma and multiple orthopedic injuries is at increased risk for developing a PE. Paresthesias and loss of position sense are associated with peripheral arterial occlusive disease as well as neurovascular and neurologic conditions. If oxygen were administered at too high a rate. Women on hormonal contraceptives have a slightly . 8. 7. The increased effectiveness of using a facemask as opposed to a nasal cannula has not been proven.V.C. Oxygen is reserved for use when the client is short of breath. Pulsatile mass and systolic bruit Correct Answer: D Rationale: A pulsatile mass and systolic bruit are classic signs of an abdominal aortic aneurysm. the nurse monitors the client for which signs and symptoms? A. D. I. A history of valvular heart disease (not CAD). the client’s respiratory drive would be depressed. The injury may predispose the client to fat emboli and bony fragments that can become emboli. Intermittent episodes of high fever with chills B. Intermittent episodes of high fever with chills are associated with secondary lymphedema or other infections. A positive Homans’ sign and calf pain are symptoms of deep vein thrombosis. Positive Homans’ sign and calf pain D. A facemask is necessary for delivery of adequate B. C. A client with arterial vascular disease and difficulty walking D. drug use (not marijuana use). A woman who has taken hormonal contraceptives for the past 2 years B. A client who has had laparoscopic gallbladder surgery C.
When auscultating the breath sounds of a client with bacterial pneumonia. Sample Review Question for Medical and Surgical Nursing Part 5 1. Wheezing with expiration more prolonged than inspiration Correct Answer: B Rationale: In normal. Barrel chest B. exudate fills the air spaces producing consolidation and bronchial breath sounds over these areas. Wheezing with expiration that is more prolonged than inspiration is indicative of chronic obstructive pulmonary disease. Bronchial breath sounds over consolidated lung fields C. adequacy of gas exchange is best evaluated by objective findings. would be indicative of acute respiratory failure. The risk for cardiovascular complications increases after age 35 in women who smoke and after age 40 in women who do not smoke. Laparoscopic cholecystectomy is now considered a relatively minor procedure requiring a short hospitalization.higher risk for PE. bronchial breath sounds would be heard over the large airways and vesicular breath sounds would be heard over the clear lungs. Funnel chest D. Which assessment finding would be the most appropriate indicator for evaluating the adequacy of gas exchange for the postoperative client with a thoracotomy? A. which term would the nurse use? A. evidenced by objective parameters including oxygen saturation. usually in an outclient department. Pigeon chest Correct Answer: A Rationale: Barrel chest is a term that refers to an increase in the anteroposterior diameter of the . Effective coughing and deep-breathing B. Decreased breath sounds with crackles and a pleural friction rub would suggest a pulmonary embolism. the goal is to promote adequate gas exchange. but they do not ensure adequate gas exchange. but pain relief is not a reliable indicator of adequate gas exchange. including crackles and wheezes. Although client reports of breathing without difficulty are an important assessment. Effective coughing and deep breathing help to maintain a patent airway and promote lung expansion. Report of breathing without difficulty D. Flail chest C. clear lungs. normal blood gases. Adventitious breath sounds with crackles and wheezes B. and breath sounds. but this risk is not as great as that for the client experiencing multiple trauma and fractures. Oxygen saturation level of 98% C. Assessment and pain relief is important. When documenting the assessment finding of a client with emphysema who has an increase in the anteroposterior diameter of the chest. 10. the nurse would expect to find which assessment data? A. Decreased breath sounds with crackles and a pleural friction rub D. A client with arterial vascular disease may be at increased risk for pulmonary emboli but PE usually develops in the venous system. Report of pain relief Correct Answer: B Rationale: Following a thoracotomy. With pneumonia. Adventitious breath sounds. 2.
When evaluating risk for developing cancer. air accumulation in the tissues giving a crackling sensation when palpitated. Breast-feeding does not increase the client’s risk of developing cancer. such as pulmonary embolism and lung cancer. some processed meats contain chemicals that have been implicated in the development of cancer. An oncology nurse who takes vitamins C and E daily D. A vegetarian who works at a convenience store Correct Answer: A Rationale: Exposure to certain chemicals such as tar. 5. Plus. which intervention should the nurse implement first? A. is usually associated with chest trauma. Also. soot. 3. which assessment data would lead the nurse to suspect that the client is experiencing a tension pneumothorax? A. A new breast-feeding mother who works in a bank C. A client with a history of coronary artery disease begins to experience chest pain. A pigeon chest refers to an anterior displacement of the sternum protruding beyond the abdominal plane. Subcutaneous emphysema. A flail chest results from fractured ribs when a portion of the chest pulls inward upon inspiration. asphalt. which leads to a tension pneumothorax. resulting from overinflation of the lungs. Calling the health care provider B. Working with cancer clients does not increase a person’s risk for developing cancer. and sunlight put this occupation at the highest risk. the nurse should obtain the results of the 12-lead ECG so that these . obtaining a 12-lead ECG is a priority to reveal possible changes occurring during an acute anginal attack that will be helpful in treatment. which client would the nurse identify as having the highest risk? A. Before calling the health care provider. Cruciferous vegetables have been shown to be preventative. An asphalt road construction worker who eats meats and potatoes B. When caring for a client with a chest tube inserted in the right chest wall. A cough with purulent sputum is usually seen in clients diagnosed with pneumonia. Getting a 12-lead electrocardiogram (ECG) D.chest. oils. A cough with purulent sputum B. 4. Hemoptysis is indicative of lung disease. Working in a convenience store does not increase risk. Markedly decreased ventilation in the left lung D. contributing to the risk of cancer. A vegetarian diet is considered to be a healthier diet for deduction of cancer risk because it provides increased fiber. Preparing the client for angioplasty Correct Answer: C Rationale: For the client experiencing chest pain. A funnel chest refers to a depression of the lower part of the sternum. Frothy pink-tinged sputum C. Vitamins C and E have been shown to demonstrate preventative attributes. meats and potatoes are low in fiber. Office work also is not considered a risk factor. Subcutaneous emphysema in the chest wall Correct Answer: C Rationale: Decreased ventilation in the opposite lung is indicative of a mediastinal shift. Checking the heart’s creatine kinase MB (CK-MB) level C. After putting the client on bedrest and administering a nitroglycerin tablet sublingually.
Crushing chest pain and diaphoresis are signs of myocardial infarction. 8. 7. frothy sputum C. Diastolic blood pressure of 84 mm Hg D.4 B. Mitral stenosis Correct Answer: D Rationale: Mitral stenosis is an obstruction of blood flowing from the left atrium into the left ventricle. Mitral insufficiency refers to the backflow of blood from the left ventricle and aorta. Capillary refill time of less than 3 seconds C. and fainting. . Pulses graded as +4 are considered normal. Aortic stenosis C. Pulses graded as being +4 Correct Answer: A Rationale: The ankle arm index is an objective indicator of arterial disease. Which valvular disorder would the nurse suspect in a client presenting with fatigue. A CK-MB level may be ordered later and the client may need angioplasty in the near future. Normal value is 1. many clients experience no symptoms early on.0. and dyspnea on exertion secondary to pulmonary venous hypertension. Aortic insufficiency B. a complication of left-sided heart failure. except for a complaint of a forceful heartbeat. many clients experience no symptoms early on. Aortic insufficiency refers to the backflow of blood from the aorta into the left ventricle during diastole.results can be communicated to him. but eventually develop exertional dyspnea. and dyspnea on exertion? A. Tachycardia and oliguria Correct Answer: C Rationale: A major complication associated with pericarditis is pericardial effusion or cardiac tamponade manifested by hypotension and muffled heart sounds. Ankle arm index pressure of 0. hemoptysis. but eventually develop exertional dyspnea. but getting the 12-lead ECG during the chest pain is the most important priority. most clients are asymptomatic. Hypotension and muffled heart sounds D. dizziness. and fainting. Mitral insufficiency D. A diastolic blood pressure of 84 mm Hg is considered within the normal range. Which assessment finding would the nurse identify as indicative of a client’s altered peripheral vascular function? A. Crushing chest pain and diaphoresis B. frothy sputum are signs of acute pulmonary edema. A capillary refill time of less than 3 seconds is considered normal. Dyspnea and copious blood-tinged. 6. Which signs and symptoms would alert the nurse to the possibility of a major complication in a client with pericarditis? A. Tachycardia and oliguria are signs of hemorrhagic shock. dizziness. Values less than 0. hemoptysis. commonly manifested by progressive fatigue due to low cardiac output. Aortic stenosis refers to a narrowing of the orifice between the left ventricle and the aorta.5 indicate ischemic rest pain. Dyspnea and copious blood-tinged.
g. 2. and allergies). Turning on the patient’s room ventilator 3. An anticoagulant D. Performance of deep-breathing and coughing exercises D. A bronchodilator B. but they are not used prophylactically. the health care provider would order a bronchodilator to open the airways and ease dyspnea. not as an initial drug.. When developing a teaching plan for clients with chronic obstructive pulmonary disease (COPD) about the prevention of acute exacerbations. Sample Nursing Board Exam Review Questions 1 1. Corticosteroids may be ordered for the client with COPD. which topic should be included? A. Coughing and deep breathing may help clients clear their airways and prevent further atelectasis. such as broken skin 2. for the client newly diagnosed with COPD. element in the circular chain of infection can be eliminated by preserving skin integrity? Host Reservoir Mode of transmission Portal of entry Correct Answer: D. A corticosteroid C. but they will not prevent exacerbation. Prevention would focus on eliminating these irritants. such as that occurring with pneumonia. Opening the patient’s window to the outside environment 2. it is not a preventative measure. Which medication would the nurse expect the health care provider to order immediately for a client who is newly diagnosed with chronic obstructive pulmonary disease (COPD)? A. occupational irritants. Although oxygen is used in managing acute exacerbations. smoke. Elimination of exposure to pulmonary irritants Correct Answer: D Rationale: One aspect of exacerbation prevention focuses on eliminating the causes and contributory factors associated with COPD. such as pulmonary irritants (e. In the circular chain of infection. air pollution. Administration of oxygen as needed C. 4. Anticoagulants interfere with the clotting cascade and would be ordered for a client with an embolic disorder such as pulmonary embolism. but they are usually used for acute exacerbations. 3. pathogens must be able to leave their reservoir and be transmitted to a susceptible host through a portal of entry.9. Which of the following will probably result in a break in sterile technique for respiratory isolation? 1. Opening the door of the patient’s room leading into the hospital corridor . Administration of antibiotics B. Which 1. An antitussive agent Correct Answer: A Rationale: Initially. An antitussive agent would be used for the client with coughing. 10. Antibiotics are used to treat bronchial infection during exacerbations.
Soaps and detergents are used to help remove bacteria because of their ability to lower the surface tension of water and act as emulsifying agents. 5. 3. 6. Leukopenia is a decreased number of leukocytes (white blood cells). taking broad-spectrum antibiotics might actually reduce the infection risk. Respiratory isolation. 7. Which 1. Any procedure that involves entering this system must use surgically aseptic measures to maintain a bacteria-free state. 2. hand washing may last from 10 seconds to 4 minutes. the patient’s room should be well ventilated. Failing to wear gloves when administering a bed bath Correct Answer: C. After routine patient contact. 2. of the following procedures always requires surgical asepsis? Vaginal instillation of conjugated estrogen Urinary Catherization Nasogastric tube insertion Colostomy Irrigation Correct Answer: B. requires that the door to the door patient’s room remain closed.4. Strict isolation is required 2. However. After routine patient contact. Effective hand washing requires the use of: 1. Sterile technique is used whenever: 1. Hot water to destroy bacteria 3. 4. 30 seconds 2. Which 1. but good hand washing is important for all types of isolation. 4. 1 minute 3. Soap or detergent to promote emulsification 2. Hot water may lead to skin irritation or burns. 3 minutes Correct Answer: A. The urinary system is normally free of microorganisms except at the urinary meatus. 3. 2 minute 4. which are important in resisting infection. hand washing for 30 seconds effectively minimizes the risk of pathogen transmission. Terminal disinfection is performed . All of the above Correct Answer: A. like strict isolation. 3. A disinfectant to increase surface tension 4. The nurse does not need to wear gloves for respiratory isolation. so opening the window or turning on the ventricular is desirable. of the following patients is at greater risk for contracting an infection? A patient with leukopenia A patient receiving broad-spectrum antibiotics A postoperative patient who has undergone orthopedic surgery A newly diagnosed diabetic patient Correct Answer: A. 4. hand washing should last at least: 1. Depending on the degree of exposure to pathogens. None of the other situations would put the patient at risk for contracting an infection.
gloves. Which of the following constitutes a break in sterile technique while preparing a sterile field for a dressing change? 1. 9. In the operating room. Pouring out a small amount of solution (15 to 30 ml) before pouring the solution into a sterile container Correct Answer: C. the nurse should be careful that the first thing she touches is the: . require sterile technique to maintain a sterile environment. All invasive procedures. Hiccupping 4. Sample Nursing Board Exam Review Questions 2 1. A natural body defense that plays an active role in preventing infection is: 1. When removing a contaminated gown. rather than sterile gloves. but not sterile. 2. 3. Body hair 3. to handle a sterile item 2. Terminal disinfection is the disinfection of all contaminated supplies and equipment after a patient has been discharged to prepare them for reuse by another patient. the nurse and physician are required to wear sterile gowns. such as the nose. The second glove should be picked up by inserting the gloved fingers under the cuff outside the glove. masks. Rapid eye movement marks the stage of sleep during which dreaming occurs. The first glove should be picked up by grasping the inside of the cuff. Hair on or within body areas. All equipment must be sterile. and shoe covers for all invasive procedures. Yawning and hiccupping do not prevent microorganisms from entering or leaving the body. Placing a sterile object on the edge of the sterile field 4. Using sterile forceps. The inside of the glove is always considered to be clean. masks. When sterile items are allowed to come in contact with the edges of the field. Invasive procedures are performed Protective isolation is necessary Correct Answer:C. including surgery. 10. Touching the outside wrapper of sterilized material without sterile gloves 3. Yawning 2. The inside of the glove is considered sterile Correct Answer: D. catheter insertion. Rapid eye movements Correct Answer: B. Strict isolation requires the use of clean gloves. All of the following statement are true about donning sterile gloves except: 1. the sterile items also become contaminated.3. and the nurse and the physician must wear sterile gloves and maintain surgical asepsis. gowns and equipment to prevent the transmission of highly communicable diseases by contact or by airborne routes. and administration of parenteral therapy. traps and holds particles that contain microorganisms. The gloves should be adjusted by sliding the gloved fingers under the sterile cuff and pulling the glove over the wrist 4. hair covers. 4. The edges of a sterile field are considered contaminated. The purpose of protective (reverse) isolation is to prevent a person with seriously impaired resistance from coming into contact who potentially pathogenic organisms. 8.
2. blood-to-blood contact occurs most commonly when a health care worker attempts to cap a used needle. Wearing gloves is not always necessary when administering an I. Providing meticulous skin care Correct Answer: A. Which 1. after removing gloves and washing hands. Using a water or air mattress 3. slowly move backward away from the gown. 2. If the blood specimens are incompatible. 3. Enteric precautions prevent the transfer of pathogens via feces. the nurse should untie the back of the gown.M. Which of the following nursing interventions is considered the most effective form or universal precautions? 1. holding the inside of the gown and keeping the edges off the floor. 5. Follow enteric precautions Correct Answer: B. Discard all used uncapped needles and syringes in an impenetrable protective container 3. turn and fold the gown inside out. Therefore. 4. of the following blood tests should be performed before a blood transfusion? Prothrombin and coagulation time Blood typing and cross-matching Bleeding and clotting time Complete blood count (CBC) and electrolyte levels. This is done by blood typing (a test that determines a person’s blood type) and cross-matching (a procedure that determines the compatibility of the donor’s and recipient’s blood after the blood types has been matched). Potential for clot formation 2. hemolysis and antigen-antibody reactions will occur. All of the following measures are recommended to prevent pressure ulcers except: 1. Nurses and other health care professionals previously believed that massaging a reddened area with lotion would promote venous return and reduce edema to the area. injection. 3. the front is contaminated. then wash her hands again. the blood of the donor and recipient must be checked for compatibility. labeled container. 4. The primary purpose of a platelet count is to evaluate the: 1. 3. Cap all used needles before removing them from their syringes 2. Before a blood transfusion is performed. instead they should be inserted in a specially designed puncture resistant. Adhering to a schedule for positioning and turning 4. 2. Wear gloves when administering IM injections 4. Potential for bleeding .1. However. Correct Answer: B. discard it in a contaminated linen container. Massaging the reddened are with lotion 2. used needles should never be recapped. 4. research has shown that massage only increases the likelihood of cellular ischemia and necrosis to the area. So. According to the Centers for Disease Control (CDC). Waist tie and neck tie at the back of the gown Waist tie in front of the gown Cuffs of the gown Inside of the gown Correct Answer: A. The back of the gown is considered clean.
Presence of an antigen-antibody response Presence of cardiac enzymes Correct Answer: A. After aerosol therapy . Hypokalemia 2. count of less than 20. however. the patient should remove all jewelry. Normal WBC counts range from 5. These symptoms probably indicate that the patient is experiencing: 1. Eating.000 to 100. 3. Anorexia is another symptom of hypokalemia. Pregnancy or suspected pregnancy is the only contraindication for a chest X-ray. the patient can wear a lead apron to protect the pelvic region from radiation. Which 1. which is a potential side effect of diuretic therapy. After the patient eats a light breakfast 3. The most appropriate time for the nurse to obtain a sputum specimen for culture is: 1. 4. A platelet count determines the number of thrombocytes in blood available for promoting hemostasis and assisting with blood coagulation after injury. a count of 25. of the following white blood cell (WBC) counts clearly indicates leukocytosis? 4. muscle cramping and muscle weakness. 4. A signed consent is not required because a chest X-ray is not an invasive examination. drinking and medications are allowed because the X-ray is of the chest. and muscle weaknesses are symptoms of hypokalemia (an inadequate potassium level). Thus.000/mm³ 25. Dysphagia Correct Answer: A. Leukocytosis is any transient increase in the number of white blood cells (leukocytes) in the blood. Early in the morning 2.000/mm³ Correct Answer: D. Fatigue. A count of 100.3. this is not its primary purpose. The physician usually orders supplemental potassium to prevent hypokalemia in patients receiving diuretics. drinking. Dysphagia means difficulty swallowing. and buttons would interfere with the Xray and thus should not be worn above the waist. 8. metallic objects. A signed consent is not required 4. if a chest X-ray is necessary. Jewelry. 6. The normal count ranges from 150.000/mm3. Anorexia 4. 7. 9.500/mm³ 7. 2.000/mm³ 10. and buttons above the waist 3. Eating. Hyperkalemia 3. metallic objects.000/mm3 or less indicates a potential for bleeding. Which of the following statements about chest X-ray is false? 1. not the abdominal region.000/mm3 is associated with spontaneous bleeding. Platelets are disk-shaped cells that are essential for blood coagulation.000/mm3. a patient begins to exhibit fatigue.000 to 350. Before the procedure. No contradictions exist for this test 2. However. After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily. muscle cramping.000/mm3 indicates leukocytosis. It also is used to evaluate the patient’s potential for bleeding. and medications are allowed before this test Correct Answer: A.
Administer the medication and notify the physician 3. injections because it has relatively few major nerves and blood vessels. Sample Nursing Board Exam Review Questions 3 1. Use a needle that’s a least 1” long 3.M. even in individuals who have not been allergic to it previously. This procedure seals medication deep into the muscle. injection is to: 1. Locate the upper aspect of the upper outer quadrant of the buttock about 5 to 8 cm below the iliac crest 2. The middle third of the muscle is recommended as the injection site. Obtaining a sputum specimen early in this morning ensures an adequate supply of bacteria for culturing and decreases the risk of contamination from food or medication 10. is viewed by many clinicians as the site of choice for I. A patient with no known allergies is to receive penicillin every 6 hours.M. . All of the following nursing interventions are correct when using the Z-track method of drug injection except: 1. After chest physiotherapy Correct Answer: A. thick muscle that extends the full length of the thigh. Divide the area between the greater femoral trochanter and the lateral femoral condyle into thirds. a long. thereby minimizing skin staining and irritation. and select the middle third on the anterior of the thigh Correct Answer: D. The most appropriate nursing action would be to: 1. Withhold the moderation and notify the physician 2. Administer the medication with an antihistamine 4. When administering the medication. Palpate the lower edge of the acromion process and the midpoint lateral aspect of the arm 3. The patient can be in a supine or sitting position for an injection into this site. who may choose to substitute another drug. injection technique in which the patient’s skin is pulled in such a way that the needle track is sealed off after the injection.M. it is not the nurse’s top priority in such a potentially lifethreatening situation. The Z-track method is an I. he nurse should withhold the drug and notify the physician. Palpate a 1” circular area anterior to the umbilicus 4. Because of the danger of anaphylactic shock. 2. Initial sensitivity to penicillin is commonly manifested by a skin rash. Administering an antihistamine is a dependent nursing intervention that requires a written physician’s order. Aspirate for blood before injection 4. Although applying corn starch to the rash may relieve discomfort. Apply corn starch soaks to the rash Correct Answer: A. Prepare the injection site with alcohol 2. the nurse observes a fine rash on the patient’s skin. Rub the site vigorously after the injection to promote absorption Correct Answer: D.4. Rubbing the injection site is contraindicated because it may cause the medication to extravasate into the skin. The correct method for determining the vastus lateralis site for I. The vastus lateralis.
a small-bore 25G needle is recommended. A 25G. 7.M. A 20G needle is usually used for I. injections because it: 1. Because an intradermal injection does not penetrate deeply into the skin. 5/8” needle is the recommended size for insulin injection because insulin is administered by the subcutaneous route. IM injection or an IV solution 2. 22G. 26G Correct Answer: D. and a 25G needle.M. injections. The appropriate needle size for insulin injection is: 1. 5/8” long Correct Answer: D. Can accommodate only 1 ml or less of medication 2. 0.M. 25G 4. Parenteral penicillin can be administered as an: 1. injections in children. 1” long 3. for subcutaneous insulin injections. 20G 2. 1 ½” long 4. 10 mg 3. injections of oil-based medications. The equivalent dose in milligrams is: 1. Parenteral penicillin can be administered I. 4. which are typically administered in the vastus lateralis or ventrogluteal site. The mid-deltoid injection site can accommodate only 1 ml or less of medication because of its size and location (on the deltoid muscle of the arm. 6. 60 mg 4. The mid-deltoid injection site is seldom used for I.3. Intradermal or subcutaneous injection 4. a 22G needle for I. Bruises too easily 3. An 18G. 5.V. This type of injection is used primarily to administer antigens to evaluate reactions for allergy or sensitivity studies.M.M.6 mg 2. A 22G. or added to a solution and given I. 600 mg Correct Answer: D. 25G.M. 1 ½” needle is usually used for adult I. The physician orders gr 10 of aspirin for a patient. Does not readily parenteral medication Correct Answer: A. 1 ½” needle is usually used for I. IM or a subcutaneous injection Correct Answer: A. gr 10 x 60mg/gr 1 = 600 mg . IV or an intradermal injection 3. close to the brachial artery and radial nerve). typically in the vastus lateralis. injections. 1 ½” long 2. Can be used only when the patient is lying down 4. injections. for I. The appropriate needle gauge for intradermal injection is: 1. 22G 3. 18G. 22G. It cannot be administered subcutaneously or intradermally.M. and a 25G needle.
insertion site. Ask the patient if he/she has used ear drops before 2. Which 1. limiting the patient’s intake of oral and I.V. 2. of the following conditions may require fluid restriction? Fever Chronic Obstructive Pulmonary Disease Renal Failure Dehydration Correct Answer: C. Which 1.V. In renal failure. Because of this. solutions or medications). the inflammation of a vein.V. of the following is a sign or symptom of a hemolytic reaction to blood transfusion? Hemoglobinuria Chest pain Urticaria Distended neck veins Correct Answer: A. or a localized allergic reaction to the needle or catheter. indicates a hemolytic reaction (incompatibility of the donor’s and recipient’s blood). 3. 3. Have the patient repeat the nurse’s instructions using her own words 3. Demonstrate the procedure to the patient and encourage to ask questions . The physician orders an IV solution of dextrose 5% in water at 100ml/hour. fluids may be necessary. Pain or discomfort at the IV insertion site 2. All of the following are common signs and symptoms of phlebitis except: 1. Chest pain and urticaria may be symptoms of impending anaphylaxis.8. 13 gtt/minute 3. 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute 9. Frank bleeding at the insertion site Correct Answer: D. Distended neck veins are an indication of hypervolemia 10. Signs and symptoms of phlebitis include pain or discomfort. Fever. 25 gtt/minute 4. What would the flow rate be if the drop factor is 15 gtt = 1 ml? 1. the kidney loses their ability to effectively eliminate wastes and fluids. 4. 2. A red streak exiting the IV insertion site 4. Edema and warmth at the IV insertion site 3. antibodies in the recipient’s plasma combine rapidly with donor RBC’s. the cells are hemolyzed in either circulatory or reticuloendothelial system. and dehydration are conditions for which fluids should be encouraged. Hemolysis occurs more rapidly in ABO incompatibilities than in Rh incompatibilities. The best way of determining whether a patient has learned to instill ear medication properly is for the nurse to: 1. 5 gtt/minute 2. edema and heat at the I. 50 gtt/minute Correct Answer: C. the abnormal presence of hemoglobin in the urine. insertion site. 2. In this reaction. can be caused by chemical irritants (I. Hemoglobinuria. chronic obstructive pulmonary disease.V. 4. Phlebitis. Sample Nursing Board Exam Review Questions 4 1. and a red streak going up the arm or leg from the I. mechanical irritants (the needle or catheter used during venipuncture or cannulation).
Idiosyncrasy 3. 2. it appears to be genetically determined. Coughing. 4. Allergy Correct Answer: D. The nurse explains to a patient that a cough: 1. Assess a vital signs every 15 minutes for 2 hours 4. however it can be voluntary. . Capsules. They are pharmaceutically manufactured in these forms for valid reasons. 3. An antitussive drug inhibits coughing. The other answers are appropriate nursing interventions for a patient who has undergone femoral arteriography. Ask the patient to demonstrate the procedure Correct Answer: D. The reaction can range from a rash or hives to anaphylactic shock. Return demonstration provides the most certain evidence for evaluating the effectiveness of patient teaching. Which 1. food. of the following types of medications can be administered via gastrostomy tube? Any oral medications Capsules whole contents are dissolve in water Enteric-coated tablets that are thoroughly dissolved in water Most tablets designed for oral use. 5. A patient has returned to his room after femoral arteriography. Splinting the abdomen supports the abdominal muscles when a patient coughs. as when a patient is taught to perform coughing exercises. and most extended duration or sustained release products should not be dissolved for use in a gastrostomy tube. Assess femoral. and altering them destroys their purpose. A patient who develops hives after receiving an antibiotic is exhibiting drug: 1. A drug-allergy is an adverse reaction resulting from an immunologic response following a previous sensitizing exposure to the drug. Is primarily a voluntary action 3. usually is involuntary.4. A hemoglobin and hematocrit count would be ordered by the physician if bleeding were suspected. The nurse should seek an alternate physician’s order when an ordered medication is inappropriate for delivery by tube. 4. Can be inhibited by “splinting” the abdomen Correct Answer: A. Order a hemoglobin and hematocrit count 1 hour after the arteriography Correct Answer: D. Synergism 4. or other substance. 3. Synergism. and pedal pulses every 15 minutes for 2 hours 2. is a drug interaction in which the sum of the drug’s combined effects is greater than that of their separate effects. Tolerance 2. popliteal. All of the following are appropriate nursing interventions except: 1. except for extended-duration compounds Correct Answer: D. Check the pressure dressing for sanguineous drainage 3. enteric-coated tablets. 6. Is a protective response to clear the respiratory tract of irritants 2. Tolerance to a drug means that the patient experiences a decreasing physiologic response to repeated administration of the drug in the same dosage. Idiosyncrasy is an individual’s unique hypersensitivity to a drug. a protective response that clears the respiratory tract of irritants. Is induced by the administration of an antitussive drug 4.
Attempts to cool the body result in further shivering. An infected patient has chills and begins shivering. she is prepared to provide bed side nursing with a high degree of knowledge and skill. Many medications and foods will discolor stool – for example. The National League of Nursing accredits educational programs in nursing and provides a testing service to evaluate student nursing competence but it does not certify nurses. increased metabloism. These certification (credentialing) demonstrates that the nurse has the knowledge and the ability to provide high quality nursing care in the area of her certification. An effect of medication 4. shivering results from the body’s attempt to increase heat production and the production of neutrophils and phagocytotic action through increased skeletal muscle tension and contractions. Constipation is characterized by small. Apply iced alcohol sponges 2. . Completed a master’s degree in the prescribed clinical area and is a registered professional nurse. A clinical nurse specialist must have completed a master’s degree in a clinical specialty and be a registered professional nurse. Received credentials from the Philippine Nurses’ Association 3. yielding light. Been certified by the National League for Nursing 2. A graduate of an associate degree program is not a clinical nurse specialist: however. and thus increased heat production. 8. Applying additional bed clothes helps to equalize the body temperature and stop the chills. Initial vasoconstriction may cause skin to feel cold to the touch. Upper GI bleeding 2. such as medical surgical nursing. Graduated from an associate degree program and is a registered professional nurse 4. Impending constipation 3. 10. The best nursing intervention is to: 1. Inhibit the growth of microorganisms Correct Answer: D. Change the urine’s concentration 4. 9. In an infected patient. hard masses.. Correct Answer: D. Provide increased ventilation Correct Answer: C. Decrease burning sensations 2. She must successfully complete the licensing examination to become a registered professional nurse. Clay colored stools indicate: 1.7. Upper GI bleeding results in black or tarry stool. Microorganisms usually do not grow in an acidic environment. beets turn stool red. Change the urine’s color 3. Provide additional bedclothes 4.. Bile obstruction Correct Answer: D. Bile colors the stool brown. Any inflammation or obstruction that impairs bile flow will affect the stool pigment. clay-colored stool. The American Nurses Association identifies requirements for certification and offers examinations for certification in many areas of nursing. A clinical nurse specialist is a nurse who has: 1. drugs containing iron turn stool black. The purpose of increasing urine acidity through dietary means is to: 1. Provide increased cool liquids 3.
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