School of human ecology

Emergency

. A patient arrives at the emergency department complaining of mid-sternal chest pain.

Which of the following nursing action should take priority?

A. A complete history with emphasis on preceding events.

B. An electrocardiogram.
C. Careful assessment of vital signs.
D. Chest exam with auscultation.

2. A patient has been hospitalized with pneumonia and is about to be discharged. A nurse
provides discharge instructions to a patient and his family. Which misunderstanding by the
family indicates the need for more detailed information?

A. The patient may resume normal home activities as tolerated but should avoid physical exertion and
get adequate rest.
B. The patient should resume a normal diet with emphasis on nutritious, healthy foods.
C. The patient may discontinue the prescribed course of oral antibiotics once the symptoms have
completely resolved.
D. The patient should continue use of the incentive spirometer to keep airways open and free of
secretions.

3. A nurse is caring for an elderly Vietnamese patient in the terminal stages of lung cancer.
Many family members are in the room around the clock performing unusual rituals and
bringing ethnic foods. Which of the following actions should the nurse take?

A. Restrict visiting hours and ask the family to limit visitors to two at a time.
B. Notify visitors with a sign on the door that the patient is limited to clear fluids only with no solid
food allowed.
C. If possible, keep the other bed in the room unassigned to provide privacy and comfort to the
family.
D. Contact the physician to report the unusual rituals and activities.

4. The charge nurse on the cardiac unit is planning assignments for the day. Which of the
following is the most appropriate assignment for the float nurse that has been reassigned
from labor and delivery?

A. A one-week postoperative coronary bypass patient, who is being evaluated for placement of a
pacemaker prior to discharge.
B. A suspected myocardial infarction patient on telemetry, just admitted from the Emergency
Department and scheduled for an angiogram.
C. A patient with unstable angina being closely monitored for pain and medication titration.
D. A post-operative valve replacement patient who was recently admitted to the unit because all
surgical beds were filled.

5. A newly diagnosed 8-year-old child with type I diabetes mellitus and his mother are
receiving diabetes education prior to discharge. The physician has prescribed Glucagon for
emergency use. The mother asks the purpose of this medication. Which of the following
statements by the nurse is correct?

A. Glucagon enhances the effect of insulin in case the blood sugar remains high one hour after
injection.
B. Glucagon treats hypoglycemia resulting from insulin overdose.
C. Glucagon treats lipoatrophy from insulin injections.
D. Glucagon prolongs the effect of insulin, allowing fewer injections.

6. A patient on the cardiac telemetry unit unexpectedly goes into ventricular fibrillation.
The advanced cardiac life support team prepares to defibrillate. Which of the following
choices indicates the correct placement of the conductive gel pads?

A. The left clavicle and right lower sternum.

B. Right of midline below the bottom rib and the left shoulder.
C. The upper and lower halves of the sternum.
D. The right side of the sternum just below the clavicle and left of the precordium.

7. The nurse performs an initial abdominal assessment on a patient newly admitted for
abdominal pain. The nurse hears what she describes as "clicks and gurgles in all four
quadrants" as well as "swishing or buzzing sound heard in one or two quadrants." Which of
the following statements is correct?

A. The frequency and intensity of bowel sounds varies depending on the phase of digestion.
B. In the presence of intestinal obstruction, bowel sounds will be louder and higher pitched.
C. A swishing or buzzing sound may represent the turbulent blood flow of a bruit and is not normal.
D. All of the above.

8. A patient arrives in the emergency department and reports splashing concentrated

household cleaner in his eye. Which of the following nursing actions is a priority?

A. Irrigate the eye repeatedly with normal saline solution.

B. Place fluorescein drops in the eye.
C. Patch the eye.
D. Test visual acuity.

9. A nurse is caring for a patient who has had hip replacement. The nurse should be most
concerned about which of the following findings?

A. Complaints of pain during repositioning.

B. Scant bloody discharge on the surgical dressing.
C. Complaints of pain following physical therapy.
D. Temperature of 101.8 F (38.7 C).

10. A child is admitted to the hospital with an uncontrolled seizure disorder. The admitting
physician writes orders for actions to be taken in the event of a seizure. Which of the
following actions would NOT be included?

A. Notify the physician.

B. Restrain the patient's limbs.
C. Position the patient on his/her side with the head flexed forward.
D. Administer rectal diazepam.

11. Emergency department triage is an important nursing function. A nurse working the
evening shift is presented with four patients at the same time. Which of the following
patients should be assigned the highest priority?

A. A patient with low-grade fever, headache, and myalgias for the past 72 hours.
B. A patient who is unable to bear weight on the left foot, with swelling and bruising following a
running accident.
C. A patient with abdominal and chest pain following a large, spicy meal.
D. A child with a one-inch bleeding laceration on the chin but otherwise well after falling while jumping
on his bed.
12. A patient is admitted to the hospital with a calcium level of 6.0 mg/dL. Which of the
following symptoms would you NOT expect to see in this patient?

A. Numbness in hands and feet.

B. Muscle cramping.
C. Hypoactive bowel sounds.
D. Positive Chvostek's sign.

13. A nurse cares for a patient who has a nasogastric tube attached to low suction because
of a suspected bowel obstruction. Which of the following arterial blood gas results might be
expected in this patient?

A. pH 7.52, PCO2 54 mm Hg.

B. pH 7.42, PCO2 40 mm Hg.
C. pH 7.25, PCO2 25 mm Hg.
D. pH 7.38, PCO2 36 mm Hg.

14. A patient is admitted to the hospital for routine elective surgery. Included in the list of
current medications is Coumadin (warfarin) at a high dose. Concerned about the possible
effects of the drug, particularly in a patient scheduled for surgery, the nurse anticipates
which of the following actions?

A. Draw a blood sample for prothrombin (PT) and international normalized ratio (INR) level.
B. Administer vitamin K.
C. Draw a blood sample for type and crossmatch and request blood from the blood bank.
D. Cancel the surgery after the patient reports stopping the Coumadin one week previously.

15. The follow lab results are received for a patient. Which of the following results are
abnormal? Note: More than one answer may be correct.

A. Hemoglobin 10.4 g/dL.

B. Total cholesterol 340 mg/dL.
C. Total serum protein 7.0 g/dL.
D. Glycosylated hemoglobin A1C 5.4%.

16. A nurse is performing routine assessment of an IV site in a patient receiving both IV

fluids and medications through the line. Which of the following would indicate the need for
discontinuation of the IV line as the next nursing action?

A. The patient complains of pain on movement.

B. The area proximal to the insertion site is reddened, warm, and painful.
C. The IV solution is infusing too slowly, particularly when the limb is elevated.
D. A hematoma is visible in the area of the IV insertion site.

17. A hospitalized patient has received transfusions of 2 units of blood over the past few
hours. A nurse enters the room to find the patient sitting up in bed, dyspneic and
uncomfortable. On assessment, crackles are heard in the bases of both lungs, probably
indicating that the patient is experiencing a complication of transfusion. Which of the
following complications is most likely the cause of the patient's symptoms?

A. Febrile non-hemolytic reaction.

B. Allergic transfusion reaction.
C. Acute hemolytic reaction.
D. Fluid overload.

18. A patient in labor and delivery has just received an amniotomy. Which of the following
is correct? Note: More than one answer may be correct.
A. Frequent checks for cervical dilation will be needed after the procedure.
B. Contractions may rapidly become stronger and closer together after the procedure.
C. The FHR (fetal heart rate) will be followed closely after the procedure due to the possibility of cord
compression.
D. The procedure is usually painless and is followed by a gush of amniotic fluid.

19. A nurse is counseling the mother of a newborn infant with hyperbilirubinemia. Which of
the following instructions by the nurse is NOT correct?

A. Continue to breastfeed frequently, at least every 2-4 hours.

B. Follow up with the infant's physician within 72 hours of discharge for a recheck of the serum
bilirubin and exam.
C. Watch for signs of dehydration, including decreased urinary output and changes in skin turgor.
D. Keep the baby quiet and swaddled, and place the bassinet in a dimly lit area.

20. A nurse is giving discharge instructions to the parents of a healthy newborn. Which of
the following instructions should the nurse provide regarding car safety and the trip home
from the hospital?

A. The infant should be restrained in an infant car seat, properly secured in the back seat in a rear-
facing position.
B. The infant should be restrained in an infant car seat, properly secured in the front passenger seat.
C. The infant should be restrained in an infant car seat facing forward or rearward in the back seat.
D. For the trip home from the hospital, the parent may sit in the back seat and hold the newborn.

Answer Key

1. Answer: C

The priority nursing action for a patient arriving at the ED in distress is always assessment of vital
signs. This indicates the extent of physical compromise and provides a baseline by which to plan
further assessment and treatment. A thorough medical history, including onset of symptoms, will be
necessary and it is likely that an electrocardiogram will be performed as well, but these are not the
first priority. Similarly, chest exam with auscultation may offer useful information after vital signs are
assessed.

2. Answer: C

It is always critical that patients being discharged from the hospital take prescribed medications as
instructed. In the case of antibiotics, a full course must be completed even after symptoms have
resolved to prevent incomplete eradication of the organism and recurrence of infection. The patient
should resume normal activities as tolerated, as well as a nutritious diet. Continued use of the
incentive spirometer after discharge will speed recovery and improve lung function.

3. Answer: C

When a family member is dying, it is most helpful for nursing staff to provide a culturally sensitive
environment to the degree possible within the hospital routine. In the Vietnamese culture, it is
important that the dying be surrounded by loved ones and not left alone. Traditional rituals and foods
are thought to ease the transition to the next life. When possible, allowing the family privacy for this
traditional behavior is best for them and the patient. Answers A, B, and D are incorrect because they
create unnecessary conflict with the patient and family.

4. Answer: A

The charge nurse planning assignments must consider the skills of the staff and the needs of the
patients. The labor and delivery nurse who is not experienced with the needs of cardiac patients
should be assigned to those with the least acute needs. The patient who is one-week post-operative
and nearing discharge is likely to require routine care. A new patient admitted with suspected MI and
scheduled for angiography would require continuous assessment as well as coordination of care that is
best carried out by experienced staff. The unstable patient requires staff that can immediately identify
symptoms and respond appropriately. A post-operative patient also requires close monitoring and
cardiac experience.

5. Answer: B

Glucagon is given to treat insulin overdose in an unresponsive patient. Following Glucagon

administration, the patient should respond within 15-20 minutes at which time oral carbohydrates
should be given. Glucagon reverses rather than enhances or prolongs the effects of insulin.
Lipoatrophy refers to the effect of repeated insulin injections on subcutaneous fat.

6. Answer: D

One gel pad should be placed to the right of the sternum, just below the clavicle and the other just left
of the precordium, as indicated by the anatomic location of the heart. To defibrillate, the paddles are
placed over the pads. Options A, B, and C are not consistent with the position of the heart and are
therefore incorrect responses.

7. Answer: D

All of the statements are true. The gurgles and clicks described in the question represent normal
bowel sounds, which vary with the phase of digestion. Intestinal obstruction causes the sounds to
intensify as the normal flow is blocked by the obstruction. The swishing and buzzing sound of
turbulent blood flow may be heard in the abdomen in the presence of abdominal aortic aneurism, for
example, and should always be considered abnormal.

8. Answer: A

Emergency treatment following a chemical splash to the eye includes immediate irrigation with normal
saline. The irrigation should be continued for at least 10 minutes. Fluorescein drops are used to check
for scratches on the cornea due to their fluorescent properties and are not part of the initial care of a
chemical splash, nor is patching the eye. Following irrigation, visual acuity will be assessed.

9. Answer: D

Post-surgical nursing assessment after hip replacement should be principally concerned with the risk
of neurovascular complications and the development of infection. A temperature of 101.8 F (38.7 C)
postoperatively is higher than the low grade that is to be expected and should raise concern. Some
pain during repositioning and following physical therapy is to be expected and can be managed with
analgesics. A small amount of bloody drainage on the surgical dressing is a result of normal healing.

10. Answer: B

During a witnessed seizure, nursing actions should focus on securing the patient's safely and curtailing
the seizure. Restraining the limbs is not indicated because strong muscle contractions could cause
injury. A side-lying position with head flexed forward allows for drainage of secretions and prevents
the tongue from falling back, blocking the airway. Rectal diazepam may be a treatment ordered by the
physician, who should be notified of the seizure.

11. Answer: C

Emergency triage involves quick patient assessment to prioritize the need for further evaluation and
care. Patients with trauma, chest pain, respiratory distress, or acute neurological changes are always
classified number one priority. Though the patient with chest pain presented in the question recently
ate a spicy meal and may be suffering from heartburn, he also may be having an acute myocardial
infarction and require urgent attention. The patient with fever, headache and muscle aches (classic flu
symptoms) should be classified as non-urgent. The patient with the foot injury may have sustained a
sprain or fracture, and the limb should be x-rayed as soon as is practical, but the damage is unlikely
to worsen if there is a delay. The child's chin laceration may need to be sutured but is also non-
urgent.

12. Answer: C

Normal serum calcium is 8.5 - 10 mg/dL. The patient is hypocalcemic. Increased gastric motility,
resulting in hyperactive (not hypoactive) bowel sounds, abdominal cramping and diarrhea is an
indication of hypocalcemia. Numbness in hands and feet and muscle cramps are also signs of
hypocalcemia. Positive Chvostek's sign refers to the sustained twitching of facial muscles following
tapping in the area of the cheekbone and is a hallmark of hypocalcemia.

13. Answer: A

A patient on nasogastric suction is at risk of metabolic alkalosis as a result of loss of hydrochloric acid
in gastric fluid. Of the answers given, only answer A (pH 7.52, PCO2 54 mm Hg) represents alkalosis.
Answer B is a normal blood gas. Answer C represents respiratory acidosis. Answer D is borderline
normal with slightly low PCO2.

14. Answer: A

The effect of Coumadin is to inhibit clotting. The next step is to check the PT and INR to determine the
patient's anticoagulation status and risk of bleeding. Vitamin K is an antidote to Coumadin and may be
used in a patient who is at imminent risk of dangerous bleeding. Preparation for transfusion, as
described in option C, is only indicated in the case of significant blood loss. If lab results indicate an
anticoagulation level that would place the patient at risk of excessive bleeding, the surgeon may
choose to delay surgery and discontinue the medication.

15. Answer: A and B

Normal hemoglobin in adults is 12 - 16 g/dL. Total cholesterol levels of 200 mg/dL or below are
considered normal. Total serum protein of 7.0-g/dL and glycosylated hemoglobin A1c of 5.4% are
both normal levels.

16. Answer: B

An IV site that is red, warm, painful and swollen indicates that phlebitis has developed and the line
should be discontinued and restarted at another site. Pain on movement should be managed by
maneuvers such as splinting the limb with an IV board or gently shifting the position of the catheter
before making a decision to remove the line. An IV line that is running slowly may simply need
flushing or repositioning. A hematoma at the site is likely a result of minor bleeding at the time of
insertion and does not require discontinuation of the line.

17. Answer: D

Fluid overload occurs when then the fluid volume infused over a short period is too great for the
vascular system, causing fluid leak into the lungs. Symptoms include dyspnea, rapid respirations, and
discomfort as in the patient described. Febrile non-hemolytic reaction results in fever. Symptoms of
allergic transfusion reaction would include flushing, itching, and a generalized rash. Acute hemolytic
reaction may occur when a patient receives blood that is incompatible with his blood type. It is the
most serious adverse transfusion reaction and can cause shock and death.

18. Answer: B, C, and D

Uterine contractions typically become stronger and occur more closely together following amniotomy.
The FHR is assessed immediately after the procedure and followed closely to detect changes that may
indicate cord compression. The procedure itself is painless and results in the quick expulsion of
amniotic fluid. Following amniotomy, cervical checks are minimized because of the risk of infection

19. Answer: D

An infant discharged home with hyperbilirubinemia (newborn jaundice) should be placed in a sunny
rather than dimly lit area with skin exposed to help process the bilirubin. Frequent feedings will help to
metabolize the bilirubin. A recheck of the serum bilirubin and a physical exam within 72 hours will
confirm that the level is falling and the infant is thriving and is well hydrated. Signs of dehydration,
including decreased urine output and skin changes, indicate inadequate fluid intake and will worsen
the hyperbilirubinemia.

20. Answer: A

All infants under 1 year of age weighing less than 20 lbs. should be placed in a rear-facing infant car
seat secured properly in the back seat. Infant car seats should never be placed in the front passenger
seat. Infants should always be placed in an approved car seat during travel, even on that first ride
home from the hospital.
1. After the lungs, the kidneys work to maintain body pH. 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.

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3. 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.

4. 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.

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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.

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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
tests are done while the client is on the drug.

18. 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. Artificial nails
b. Vasodilation
c. Hypothermia
d. Movement of the head

Answer: c

Rationale: Hypothermia or fever may lead to an inaccurate reading. Artificial nails may
distort a reading if a finger probe is used. Vasoconstriction can cause an inaccurate
reading of oxygen saturation. Arterial saturations have a close correlation with the
reading from the pulse oximeter as long as the arterial saturation is above 70 percent.

19. While on a camping trip, a friend sustains a snake bite from a poisonous
snake. The most effective initial intervention would be to

a. Place a restrictive band above the snake bite

b. Elevate the bite area above the level of the heart
c. Position the client in a supine position
d. 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. Elevation
of the limb or immobilization would not be effective interventions.

20. There is a physician's order to irrigate a client's bladder. Which one of the
following nursing measures will ensure patency?
a. Use a solution of sterile water for the irrigation
b. Apply a small amount of pressure to push the mucus out of the catheter tip if the
tube is not patent
c. Carefully insert about 100 mL of aqueous Zephiran into the bladder, allow it to
remain for 10 hour, and then siphon it out
d. Irrigate with 20mL's of normal saline to establish patency

Answer: d

Rationale: Normal saline is the fluid of choice for irrigation. It is never advisable to force
fluids into a tubing to check for patency. Sterile water and aqueous Zephiran will affect
the pH of the bladder as well as cause irritation.

21. A female client has orders for an oral cholecystogram. Prior to the test, the
nursing intervention would be to

a. Provide a high fat diet for dinner, then NPO

b. Explain that diarrhea may result from the dye tablets
c. Administer the dye tablets following a regular diet for dinner
d. Administer enemas until clear

Answer: b

Rationale: Diarrhea is a very common response to the dye tablets. A dinner of tea and
toast is usually given to the client. Each dye tablet is given at 5 minute intervals,
usually with 1 glass of water following each tablet. The number of tablets prescribed will
vary, because it is based on the weight of the client.

22. The physician has just completed a liver biopsy. Immediately following the
procedure, the nurse will position the client

a. On his right side to promote hemostasis

b. In Fowler's position to facilitate ventilation
c. Supine to maintain blood pressure
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, thus promoting hemostasis and preventing hemorrhage. The other
positions will not be effective in achieving these goals.

23. When a client has peptic ulcer disease, the nurse would expect a priority
intervention to be

a. Assisting in inserting a Miller-Abbott tube

b. Assisting in inserting an arterial pressure line
c. Inserting a nasogastric tube
d. 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. A Miller-Abbott tube is a weighted,
mercury-filled ballooned tube used to resolve bowel obstructions. There is no evidence
of shock or fluid overload in the client; therefore, an arterial line is not appropriate at
this time and an IV is optional.

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25. In preparation for discharge of a client with arterial insufficiency and

Raynaud's disease, client teaching instructions should include

a. Walking several times each day as a part of an exercise routine

b. Keeping the heat up so that the environment is warm
c. Wearing TED hose during the day
d. Using hydrotherapy for increasing oxygenation

Answer: b

Rationale: The client's instructions should include keeping the environment warm to
prevent vasoconstriction. Wearing gloves, warm clothes, and socks will also be useful in
preventing vasoconstriction, but TED hose would not be therapeutic. Walking will most
likely increase pain.

26. When a client asks the nurse why the physician says he "thinks" he has
tuberculosis, the nurse explains to him that diagnosis of tuberculosis can take
several weeks to confirm. Which of the following statements supports this
answer?

a. A positive reaction to a tuberculosis skin test indicates that the client has active
tuberculosis, even if one negative sputum is obtained
b. A positive sputum culture takes at least 3 weeks, due to the slow reproduction of the
bacillus
c. Because small lesions are hard to detect on chest x-rays, x-rays usually need to be
repeated during several consecutive weeks
d. 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. Usually even
very small lesions can be seen on x-rays due to the natural contrast of the air in the
lungs; therefore, chest x-rays do not need to be repeated frequently (c). Clients may
have positive smears but negative cultures if they have been on medication (d). A
positive skin test indicates the person only has been infected with tuberculosis but may
not necessarily have active disease (a).
27. The nurse is counseling a client with the diagnosis of glaucoma. She
explains that if left untreated, this condition leads to

a. Blindness
b. Myopia
c. Retrolental fibroplasia
d. Uveitis

Answer: a

Rationale: The increase in intraocular pressure causes atrophy of the retinal ganglion
cells and the optic nerve, and leads eventually to blindness.

28. A nursing assessment for initial signs of hypoglycemia will include

a. Pallor, blurred vision, weakness, behavioral changes

b. Frequent urination, flushed face, pleural friction rub
c. Abdominal pain, diminished deep tendon reflexes, double vision
d. Weakness, lassitude, irregular pulse, dilated pupils

Answer: a

Rationale: Weakness, fainting, blurred vision, pallor and perspiration are all common
symptoms when there is too much insulin or too little food - hypoglycemia. The signs
and symptoms in answers (b) and (c) are indicative of hyperglycemia.

29. The physician has ordered a 24-hour urine specimen. After explaining the
procedure to the client, the nurse collects the first specimen. This specimen is
then

a. Discarded, then the collection begins

b. Saved as part of the 24-hour collection
c. Tested, then discarded
d. 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. After the first discarded specimen, urine
is collected for 24 hours.

30. Following an accident, a client is admitted with a head injury and

concurrent cervical spine injury. The physician will use Crutchfield tongs. The
purpose of these tongs is to

a. Hypoextend the vertebral column

b. Hyperextend the vertebral column
c. Decompress the spinal nerves
d. 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. 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; only the head
of the bed can be elevated.

31. The most appropriate nursing intervention for a client requiring a finger
probe pulse oximeter is to

a. Apply the sensor probe over a finger and cover lightly with gauze to prevent skin
breakdown
b. Set alarms on the oximeter to at least 100 percent
c. Identify if the client has had a recent diagnostic test using intravenous dye
d. Remove the sensor between oxygen saturation readings

Answer: c

Rationale: Clients may experience inaccurate readings if dye has been used for a
diagnostic test. Dyes use colors that tint the blood which leads to inaccurate readings.

32. A client being treated for esophageal varices has a Sengstaken-Blakemore

tube inserted to control the bleeding. The most important assessment is for
the nurse to

a. Check that a hemostat is at the bedside

b. Monitor IV fluids for the shift
c. Regularly assess respiratory status
d. Check that the balloon is deflated on a regular basis

Answer: c

Rationale: The respiratory system can become occluded if the balloon slips and moves
up the esophagus, putting pressure on the trachea. This would result in respiratory
distress and should be assessed frequently. Scissors should be kept at the bedside to
cut the tube if distress occurs. This is a safety intervention.

33. A 55-year-old client with sever epigastric pain due to acute pancreatitis
has been admitted to the hospital. The client's activity at this time should be

a. Ambulation as desired
b. Bedrest in supine position
c. Up ad lib and right side-lying position in bed
d. Bedrest in Fowler's position

Answer: d
Rationale: The pain of pancreatitis is made worse by walking and supine positioning.
The client is more comfortable sitting up and leaning forward.

34. Of the following blood gas values, the one the nurse would expect to see in
the client with acute renal failure is

a. pH 7.49, HCO3 24, PCO2 46

b. pH 7.49, HCO3 14, PCO2 30
c. pH 7.26, HCO3 24, PCO2 46
d. pH 7.26, HCO3 14, 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. Normal values are pH 7.35 to 7.45;
HCO3 23 to 27 mEg; and PCO2 35 to 45 mmHg.

35. A client in acute renal failure receives an IV infusion of 10% dextrose in

water with 20 units of regular insulin. The nurse understands that the
rationale for this therapy is to

a. Correct the hyperglycemia that occurs with acute renal failure

b. Facilitate the intracellular movement of potassium
c. Provide calories to prevent tissue catabolism and azotemia
d. 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. An exchange resin
may also be employed.

This type of infusion is often administered before cardiac surgery to stabilize irritable
cells and prevent arrhythmias; in this case KC1 is also added to the infusion.

36. Skip

37. Skip

38. A client has had a cystectomy and ureteroileostomy (ileal conduit). The
nurse observes this client for complications in the postoperative period. Which
of the following symptoms indicates an unexpected outcome and requires
priority care?

a. Edema of the stoma

b. Mucus in the drainage appliance
c. Redness of the stoma
d. 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. The proximal and distal ileal borders can
be resumed. Feces should not be draining from the conduit. Edema and a red color of
the stoma are expected outcomes in the immediate postoperative period, as is mucus
from the stoma.

39. A nursing care plan for a client with a suprapubic cystostomy would
include

a. Placing a urinal bag around the tube insertion to collect the urine
b. Clamping the tube and allowing the client to void through the urinary meatus before
removing the tube
c. Catheter irrigations every 4 hours to prevent formation of
urinary stones
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. Irrigations are not recommended,
as they increase the chances of the client developing a urinary tract infection. Any time
a client has an indwelling catheter in place, fluids should be encouraged (unless
contraindicated) to prevent stone formation.

40. For a client who has ataxia, which of the following tests would be
performed to assess the ability to ambulate?

a. Kernig's
b. Romberg's
c. Riley-Day's
d. 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. Kernig's sign, a reflex
contraction, is pain in the hamstring muscle when attempting to extend the leg after
flexing the thigh.

41. A client admitted to a surgical unit for possible bleeding in the cerebrum
has vital signs taken every hour to monitor to neurological status. Which of
the following neurological checks will give the nurse the best information
about the extent of bleeding?

a. Pupillary checks
b. Spinal tap
c. Deep tendon reflexes
d. Evaluation of extrapyramidal motor system

Answer: a

Rationale: Pupillary checks reflect function of the third cranial nerve, which stretches as
it becomes displaced by blood, tumor, etc.

42. Assessing for immediate postoperative complications, the nurse knows

that a complication likely to occur following unresolved atelectasis is

a. Hemorrhage
b. Infection
c. Pneumonia
d. Pulmonary embolism

Answer: c

Rationale: Pneumonia is a major complication of unresolved atelectasis and must be

treated along with vigorous treatment for atelectasis. Hemorrhage and infection are not
related to this condition. Pulmonary embolism could result from deep vein thrombosis.

43. A young client is in the hospital with his left leg in Buck's traction. The
team leader asks the nurse to place a footplate on the affected side at the
bottom of the bed. The purpose of this action is to

a. Anchor the traction

b. Prevent footdrop
c. Keep the client from sliding down in bed
d. Prevent pressure areas on the foot

Answer: b

Rationale: The purpose of the footplate is to prevent footdrop while the client is
immobilized in traction. This will not anchor the traction, keep the client from sliding
down in bed, or prevent pressure areas.