Professional Documents
Culture Documents
confused and very short of breath. He complains of pain to his chest. The nurse also notes
petechial hemorrhages on his legs and stomach. The nurse suspects that this clients.
Rationale: B
Because involvement of the long bone with shortness of breath involving respiration and
petechia this occur within 24 to 48 which not mention. What make (A) wrong because it is
2. The nurse is the first professional to arrive at the scene of a multi vehicle accident. Mr. R. was
riding a motorcycle. Upon impact, he fell off the bike and it fell back on his legs. Priority care
Rationale: B
In the presence of multiple trauma, maintenance of a patent airway must always be the priority
in the sequence of care delivery. Assessing blood loss would be the second priority of care.
Obtaining vital signs would be the next action. Organizing lay people on the scene would be a
later action.
3. A client involved in a motor vehicle accidents is brought to the emergency department with
head and chest injuries. The client is unresponsive and is unable to give informed consent for
surgery. Which of the following actions is most appropriate for the nurse to take?
c. Prepare the client for surgery and omit the form since the client cannot consent.
Rationale: C
Informed consent for adults is not needed when delay of treatment to obtain consent would be
harmful or lethal to the client or when the client waives the right to informed consent. In this
situation, the first circumstance applies, and the nurse should prepare the client for surgery.
Option A is incorrect; these two individuals do not sign the consent form. Options B and D are
4. What is the most important aspect to include when developing a home care plan for a client
Rationale: ATo maintain quality of life, the plan for care must emphasize preserving function. Proper
body
positioning and posture and active and passive range of motion exercises important
5. An adult client sustained a fractured tibia three hours ago. A long leg cast was applied. Now
the client is complaining of increasing pain. The pain is more intense with passive flexion of
the toes. The nurse suspects the client is developing compartment syndrome. Which initial
b. Administer the ordered narcotic IV, then reassess the client’s pain in 15 minutes.
c. Raise the casted leg above the heart, apply ice and notify the physician.
d. Raise the casted leg to the level of the heart, notify the physician, and prepare to split
the cast.
Rationale: D
To decrease the pressure within the compartment, raise the affected extremity only to the level
of the heart and remove any constructive dressing or cast. If this does not work to decrease the
Option B – Pain from compartment syndrome does not respond well to pain medicine
Option C – Placing the extremely above the level of the heart increases compartment pressure
and should be avoided.
6. Mrs. Susan has a fractured right hip with 5 lb of Buck’s traction. The bed that Mrs. F. is in is
broken. How should the nurse best direct the team to move Mrs. F. to the new bed?
a. Slowly lift the traction to release the weight, support the right leg, and lift Mrs. F. to
b. Slowly lift the 5 lb weight from the traction set up, and apply 10 lb of manual traction
c. It is not safe to move Mrs. F. with Buck’s traction. Support her position changes with
d. Decrease the weight of traction over a two hour period; then discontinue the traction
Rationale: A
5-8 lbs of traction is applied temporarily to provide immobilization prior to surgery. Buck’s
traction should be removed every eight hours to assess the skin under the traction device.
Option B - it is not necessary to maintain manual traction, especially at twice the weight, to
Option C - it is safe to move persons with Buck’s traction and would be uncomfortable to use
Option D - Once the weight of traction has been established as effective, the weight should be
7. A nurse is training a client for a swing-to gait. What is the most specific direction you can give
to your client?
a. “Move both crutches forward, then lift and swing your body past the crutches.”
b. “Place the two crutches forward, immediately follow your weak leg in lined to them, them
c. “Look down at your feet before moving the crutches to ensure you won’t fall, then raise
your head as you sways away.”d. “Move both crutches forward, then lift and swing your body in
conjunction with
crutches.”
Rationale: D
This is the procedure for using the swing-to gait. Clients are instructed to look straight ahead
when walking with crutches. Looking down can lead to falls and uneven gait. Option A is swingthrough.
Option B is 3-point gait.
Reference: Smith, Sandra. Review for NCLEX-RN. 10th ed., 2002. p. 311.
8. On the second postoperative day after the hip surgery for a fractured left hip, you are going to
help your client ambulate. The best thing that you can do is:
a. Allow minimal amount of weight on the hips when getting him up.
b. Let the client get up by having him flex the hips for about degrees to maintain proper
bodily contour.
d. Let the client dangle first his legs before moving up.
Rationale: C
Postoperatively hip replacement clients may get up the first day, but need to use a walker for
balance. They should not bear any weight on the affected side, dangle or sit in a chair, flexing
Reference: Smith, Sandra. Review for NCLEX-RN. 10th ed., 2002. p. 51.
9. A nursing student is problematic about her upcoming NCLEX exam, she tells you “If only my
skull can move! I think I can get an extra enlargement of my ideas too.” The skull is
a. Syndesmosis c. Synarthrosis
b. Amphiarthrosis d. Diarthrosis
Rationale : C
Functional classification depends on the degree of movement the joint allows. A diarthrosis,
such as the knee, moves freely. A synarthrosis can’t move like the pelvis and skull.
Amphiarthrosis can move only slightly like the coccyx and sacrum. A syndesmosis like the
10. Which among the following could be the best health teaching to a client who had sprained
b. “Try to exercise the site a little to prevent loss of function and gangrene formation.”
c. “Place your toes and ankle in lined with your hips to prevent much blood loss.”
Rationale: D
Treatment of a sprained muscle includes resting the affected leg and applying an elastic or
compression bandage to a sprained muscle to control swelling. Elevating the legs and applying
ice area also included. Option D is just the reword ICE! (RICE: rest, ice, compress, elevate)
Reference: Bates, Rita. Straight A’s in Anatomy and Physiology. 2007. p. 121.
11. After change-of-shift report, which patient should the nurse assist first?a. A client with fracture
complaining that the cast is tight
Rationale: A
The patient with the tight cast is at risk for circulation impairment and peripheral nerve damage.
While all of the other patients’ concerns are important and the nurse will want to see them as
12. A client with Paget’s disease is admitted in your unit. After thorough assessment, which
Rationale: C
Platybasia (basilar skull invagination) causes brain stem manifestations that threaten life.
Patients with Paget’s disease are usually short and often have bowing of the long bones that
results in asymmetric knees or elbow deformities. Their skull is typically soft, thick, and
enlarged.
13. A 1year-old boy is admitted to the hospital with a fractured femur. Which of the following
Rationale: A
The finger foods appeal to a 1-year-old and offer appropriate nutrition as well. A fractured femur
Option B, this may be a nutritious meal, but offers little variety in texture, and the child cannot
Option C, it is best to avoid fried foods when possible. Foods should be broiled, poached, or
Option D, solids should be introduced to the child at around six months of age.
Reference: Hoefler, Patricia. The Complete Q&A Book for the NCLEX/CAT-RN. 1994. p. 65.
14. Which of the following assessment findings would a nurse expect in a client with gouty
arthritis?
Rationale: A
Hyperuricemia and pruritus are associated with gouty arthritis. Osteomyelitis causes localized
bone pain, tenderness, heat and swelling at affected area, high fever, increased WBC count and
ESR and positive blood culture results. Petechiae over the chest and abnormal ABG results
suggest fat embolism.Reference: Huttel, Ray. Lippincott’s Review Series: Medical Surgical Nursing. 3rd
ed. 2001. p.
433.
15. A 16-year-old client is admitted for scoliosis repair with a Harrington Rod insertion. The
Nurse should not fail in giving this information to the client before the postoperative care:
Rationale: D
These clients must be monitored closely for the first 48-72 hours for respiratory problems. Bowel
and urinary problems need to be assessed along with neurological problems in the extremities.
Option A, incorrect because the client may have a nasogastric tube to low suction. Option C,
incorrect because the client will have a catheter. Option B, is not appropriate for the situation.
16. Client Morazella wrathfully goes to you for some advices. She yells to you, “What’s the fact
Rationale: A
The proportion of body water varies inversely with the body’s fat content because fat contains
no water. Therefore, an obese person has a lower percentage of water than a lean person. Most
women have a lower percentage of water than men because their bodies normally have a
Reference: Bates, Rita. Straight A’s in Anatomy and Physiology. 2007. p. 341.
17. The nurse made her diagnosis for a client who is having a shock, Fluid Volume Deficit
related to decreased plasma volume. Which of the following supports her diagnosis?
Rationale: D
Normally, check veins are distended when the client is in the supine position. These veins flatten
as the client moves to a sitting position. The other three responses are characteristics of Fluid
Volume Excess.
Rationale: A
SIADH causes a relative sodium deficit due to excessive retention of water.Reference: LaCharity, Linda.
Prioritization, Delegation, and Assignment. 2006. p. 24.
19. Which of the following would the nurse suspect if the client’s ECG waveform is tall-tented T
waves?
a. Hyperkalemia c. Hypokalemia
b. Hypercalcemia d. Hypocalcemia
Rationale: A
The ECG pattern typically associated with hyperkalemia reveals tall-tented T waves, a
prolonged PR interval and QRS duration, absent P waves, and ST depression. The ECG
associated with hypocalcemia typically shows a prolonged QT interval. With hypokalemia, the
ECG reveals a flattened T wave, prominent U wave, depressed ST segment, and prolonged PR
interval.
Reference: Huttel, Ray. Lippincott’s Review Series: Medical Surgical Nursing. 3rd ed., 2001. p.
66.
c. Hyperreflexia
Rationale: C
Soft tissue calcification and hyperreflexia are indicative of hypermagnesemia. Increased RR and
depth are associated with metabolic acidosis. Hypermagnesemia is manifested by hot, flushed
skin and diaphoresis. Muscle pain and acute rhabdomyolysis are indicative of
hypophosphatemia.
Reference: Huttel, Ray. Lippincott’s Review Series: Medical Surgical Nursing. 3rd ed., 2001. p.
66.
21. Foods high in potassium should be avoided in which of the following anomalies?
Rationale: A
Clients with renal disease are predisposed to hyperkalemia and should avoid foods high in
potassium. Clients receiving diuretics, with ileostomies, or with metabolic alkalosis may be
Reference: Huttel, Ray. Lippincott’s Review Series: Medical Surgical Nursing. 3rd ed. 2001. p.
65.
22. When assessing a client in the oliguric-anuric stage of acute renal failure, the nurse notices
a respiratory rate of 28, and the client complains of nausea, a dull headache, and general
The nurse should look for the client’s latest potassium level, since these symptoms indicate
Option D, the physician will want a complete assessment before being notified, and will require
Reference: Hoefler, Patricia. The Complete Q&A Book for the NCLEX/CAT-RN. 1994. p. 159.
23. ICF as opposed to ECF has higher concentration of which of the following electrolyes?
Rationale: A
ICF has higher concentrations of magnesium, potassium, protein, phosphate, and sulfate, and
Reference: Bates, Rita. Straight A’s in Anatomy and Physiology. 2007. p. 341.
24. A client, admitted with aspirin intoxication, has the following results: pH=7.50, PaCO2=32,
HCO3=24. This client’s blood gas values indicate which of the following acid-base
disturbances?
Rationale: A
This is common due hyperventilation, which causes blowing off CO2 and hence a decrease in
plasma carbonic acid content. This should be uncompensated because the bicarbonate is
normal.
Reference: Hoefler, Patricia. The Complete Q&A Book for the NCLEX/CAT-RN. 1994. p. 159.
25. The laboratory technician just handed to you the electrolyte profile. It is known that the major
Rationale: C
Major cations (positively charged) include Na, potassium, calcium, and magnesium. Major
Reference: Bates, Rita. Straight A’s in Anatomy and Physiology. 2007. p. 341.
26. Twelve hours post lumbar laminectomy a client complains of discomfort and the inability to
Rationale: B
After surgery, urinary retention may occur for may occur for many reasons: anesthesia
depresses the micturition reflex arch, voluntary micturition is impeded when the bladder is
distended, or the supine position reduces the ability to relax the perineal muscles and external
sphincter. If the bladder is distended and conservative measures have not induced voiding, an
Rationale : D
The glomerular filtration rate is decreased dramatically in the elderly because of changes in the
renal tubles. The person loses the ability to concentrate urine as aging occurs. Microscopic
outcome of aging.
28. The nurse would expect to find an improvement in which of the blood values as a result of
dialysis treatment?
Rationale: A
erythropoietin by the kidney and is not affected by hemodialysis. Hyperkalemia and high base
29. There is a physician’s order to irrigate a client’s bladder. Which one of the following nursing
measures will ensure patency?
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
Rationale: D
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
30. Nurse Joyce is putting a retention catheter for a male client. She is confused where to tape
the catheter. You are helping her if you suggested her to tape it where?
Rationale: D
The catheter should be taped on the lower abdomen or upper thigh to prevent a penoscrotal
Reference: Smith, Sandra. Review for NCLEX-RN. 10th ed., 2002. p. 291.
31. Grandpa Daddy is ordered by the physician to take Finasteride (Proscar) for the treatment of
benign prostatic hyperthrophy (BPH). Which statement if made by him will you give him a
a. “I’m glad that this medication can have its effect within 6 months.”b. “I should maintain proper
hygiene because I know I will be catheterized for months.”
c. “Grandma will have some lonely nights, but I know I can express my love in some other
ways.”
d. “This drug does not give the guarantee that surgery will be another thing to be done.”
Rationale: C
not work for all clients. Some clients, therefore, will need surgery to relieve the obstructive
symptoms of BPH. One of the side effects of the drug is decreased libido.
Reference: Smith, Sandra. Review for NCLEX-RN. 10th ed., 2002. p. 293.
32. Mrs. Hilary arrived in the emergency room because she made an overheated argument with
Obaman regarding the issue about sex change. Your blood pressure reading is 220/150.
Upon further assessments done by the primary physician, he decided to give her a loop
a. This medication acts on the loop of Henle to control the flow of water and electrolytes.
c. Water is removed from the filtrate and returned to the interstitial fluid.
d. Solutes are reabsorbed from the glomerular filtrate back into the blood.
Rationale: A
Sodium and chloride are removed to maintain osmolality by ascending tubule of loop of Henle
Reference: Bates, Rita. Straight A’s in Anatomy and Physiology. 2007. p. 324.
33. A client put his call light on and tells the nurse that she has to urinate. The client has had a
Foley catheter in place since her surgery 3 days ago. What is the most appropriate nursing
action?
a. Checking the catheter and tubing for kinks, note also for the urine output in the drainage
bag.
b. Explain to him that the urge to void is a common occurrence for clients who have urinary
catheters.
d. Remind the client that she has a Foley catheter in place and does not need to go to the
bathroom.
Rationale: A
Checking the equipment is the best nursing action, since data will be obtained which will assist
the nurse with problem solving. This is a nursing process question, and assessment is always
Option B - The urge to void usually occurs upon initial insertion of the Foley catheter, not 2 days
afterwards. There are several possible reasons for the client having urgency, and the nurse
must attempt to discover the cause in order to meet the client’s needs.
Option C - a new catheter might be necessary to meet the client’s needs, but the nurse must
assess the situation further to determine the cause of the client’s urge to void.
Option D - although a Foley catheter is in place, it may not be patent, which can result in
distention of the bladder and cause the patient to feel the urge to void. This action does not
meet the client’s needs.Reference: Hoefler, Patricia. The Complete Q&A Book for the NCLEX/CAT-RN.
1994. p. 54.
34. Which among the following statements made by the client would be the cause of his
impotence problem?
Rationale: C
Impotence may result from psychogenic and organic causes. Endocrine conditions such as
diabetes, pituitary tumors, and hypogonadism are possible organic causes of impotence.
Options A & D are the result or effects of this impotence. Option B, are signs and symptoms of
BPH.
Reference: Huttel, Ray. Lippincott’s Review Series: Medical Surgical Nursing. 3rd ed. 2001. p.
279.
35. A three-way bladder irrigation is used after TURP to prevent which of the following
inconsistencies?
Rationale: A
After TURP, 3-way bladder irrigation provides continuous normal saline in the bladder to prevent
hemorrhaging. Typically, the urine output should be light pink. Infection, urinary retention, and
thrombosis are complications after the TURP, but bladder irrigation cannot prevent them.
Reference: Huttel, Ray. Lippincott’s Review Series: Medical Surgical Nursing. 3rd ed. 2001. p.
278.
36. A common management for a client having chronic renal failure is which of the following?
a. Weighing the client before each meal and drinking 500 ml of fluid about 5 times each
day.
b. Subtracting 500 ml to the previous day’s urine and limiting intake of coffee.
c. Adding 500 ml to the previous day’s urine and dividing that amount over the next 24
hours.
d. Maintain the intake of fluid in the morning rather than the afternoon to prevent nighttime
bladder distention.
Rationale: C
Insensible losses (500 ml) plus urine output determines intake in the renal failure. Fluid intake
should be divided over a 24-hour period. Drinking 500 ml of fluid 5X each day far exceeds the
recommended allotment.
Reference: Huttel, Ray. Lippincott’s Review Series: Medical Surgical Nursing. 3rd ed. 2001. p.
488.
37. A nurse is caring for clients having a common theme of knowledge deficit related to the
needs for teaching to prevent pyelonephritis. This concept is not commonly related to which
of the following?
d. A woman who has been treated for urinary tract infection and retention.Rationale: C
Kidney infections are caused by immobility, reflux, stasis and debilitation. Women are more
Reference: Huttel, Ray. Lippincott’s Review Series: Medical Surgical Nursing. 3rd ed. 2001. p.
488.
38. A client has an order for a sterile urine specimen to be obtained. What is the best nursing
a. Clamp the drainage tube, when fresh urine collects, open the tubing and drain in into a
sterile container.
b. Disconnect the tubing between the catheter and the drainage bag and drain urine into
sterile container.
c. Disconnect the drain at the bottom of the drainage bag and drain urine into a sterile
container.
d. Use sterile syringe and needle to obtain urine from the porthole.
Rationale: D
This represents the appropriate process in collecting a sterile urine specimen. The other options
39. A client has lower flank pain due to possible renal calculi. On completion of an ultrasound of
the kidney and ureters, the priority nursing intervention should be:
Rationale: A
With complaint of flank pain and the possibility of renal calculi, straining urine is appropriate.
Option B, would not be done, as a client with possible renal calculi needs to increase fluids to
promote the flushing out of the stone. Option C, is unnecessary. Option D, is not as high a
40. During peritoneal dialysis, the nurse notes that the outflow is less than the inflow. What
Rationale: B
The outflow should always be greater than the inflow. After the dwell time the dialysate should
be diffusing out the extra fluid and waste products. By changing a client’s position you can affect
the drainage. If after changing the client’s position there is not an increased amount of drainage,
the doctor should be notified (Option A). Sometimes problems with outflow are related to a full
colon. Peritoneal catheters are surgically placed and are usually not irrigated (options C&D).
41. The nurse finds her client who has myxedema having some crackles in the right lower lung
lobe, decreased breath sound and a respiratory rate of 11/min. The client does not appear
to be dyspneic. The best nursing action that you can institute upon seeing this condition is:
a. Initiate postural drainage.b. Increase turning in bed and some deep breathing exercises.
Rationale: B
Clients with myexedema often experience a decreased respiratory rate and chest excursion, so
they require extra care to prevent atelectasis. Encouraging moving, turning, and coughing
exercises will open the alveoli, thus decreasing the risk of atelectasis. Postural drainage and
increase fluid intake will not prevent atelectasis because the treatment does not expand the
alveoli.
Reference: Smith, Sandra. Review for NCLEX-RN. 10th ed., 2002. p. 363.
42. Client Nenita has a hyperparathyroidism. When her papa comes she yells for some comfort.
Nenita loves to be thrown in the air. Upon seeing this, you think of giving him this teaching
that Nenita’s extremities, especially the arms, should be held with care because of
b. It can suppress her energy stores and depletes her calcium and phosphate bone
deposits.
Rationale: C
The parathyroid glands regulate calcium in the body. Excessive activity results in calcium
leaving the bones and teeth to enter the bloodstream. This makes the bones more brittle and
susceptible to fracture.
Reference: Smith, Sandra. Review for NCLEX-RN. 10th ed., 2002. p. 362.
43. After several sessions of health teaching about proper care of the bodily systems in the
community hospital, you try asking one client for what is the possible cause of myxedema.
You and the group of patients will clap your hands when she says:
b. “Give me another day to confirm this, but as I remember it, it is caused by decreased
Rationale: C
metabolism, hand and facial swelling, and coarse, edematous skin. Too much FSH leadsto
characterized by fatigue, weakness, and adiposity of the face, neck, and trunk.
Reference: Bates, Rita. Straight A’s in Anatomy and Physiology. 2007. p. 364.
44. A client is a type I diabetes mellitus client. He is scheduled for a gall bladder X-ray in the
outpatient department. He was given medication to take as a preparation for this test. Which
of the following nursing actions is most important when preparing the client for this test?
a. Give the client directions to the Outpatient Department and the parking lot.
b. Tell the client to take his insulin and eat breakfast before leaving home.
c. Explain to the client that he should not take his insulin before the X-ray.d. Explain the procedure to
the client, and ask if he has any question.
Rationale: C
IF the client takes his insulin before the test but remains PO as required for procedure,
hypoglycemia may result and potentially life-threatening. Maintaining the glucose level is a
physiological need which should receive highest priority based on Maslow’s Hierarchy of Needs.
Option B, the client should not eat breakfast. The test for which he is scheduled requires that he
remain NPO. It is also very important that the client not take his insulin, because taking his
Option A, the client should be given directions to the outpatient department and information
about whereto park. However, this is not the most important nursing action in preparing him for
the test.
Option D, any client scheduled for a test should be given an explanation and opportunity to ask
questions.
Reference: Hoefler, Patricia. The Complete Q&A Book for the NCLEX/CAT-RN. 1994. p. 60.
45. Which among the following would be included in the fluid management for the client
Rationale: C
SIADH involves the oversecretion of ADH, resulting in excessive water conservation. Fluid
management involves fluid restriction, because the client already has an excess amount of fluid
in the body. Rapid administration of IVF, IFI, and dextrose would exacerbate the client’s
waterintoxicated state.
Reference: Huttel, Ray. Lippincott’s Review Series: Medical Surgical Nursing. 3rd ed. 2001. p.
246.
46. A client is manifesting some addisonian crisis. Which of the following are common with this
disorder?
Rationale: A
The signs and symptoms of an addisonian (adrenal) crisis are the clinical manifestations of
shock such as hypotension, rapid respirations, and pallor. Polyuria, polydipsia, and polyphagia
are signs and symptoms of DM. Tremors, tachycardia and headache are associated with
hypoglycemia. A positive Chvostek sign, photophobia and numbness are signs and symptoms
of hypoparathyroidism.
Reference: Huttel, Ray. Lippincott’s Review Series: Medical Surgical Nursing. 3rd ed. 2001. p.
247.
47. A nurse is caring for a diabetic client. The client has been managed by giving regular and
NPH insulin in the morning and evening. The result of the blood glucose-monitoring test is
hyperglycemic before the morning meal. Which of the following doses of insulin would the
Rationale: A
The NPH insulin taken at supper exerts its greatest effect during the night. The peak action of
regular insulin occurs at 2-4 hours, so neither the morning nor evening dose could affect
breakfast-time blood glucose level. The morning dose of NPH dissipates long before breakfast
Reference: Huttel, Ray. Lippincott’s Review Series: Medical Surgical Nursing. 3rd ed. 2001. p.
247.
48. The physician prescribes regular insulin, 5 units subcutaneous. Regular insulin begins to
exert an effect:
Answer: B
Rationale: Calcitonin promotes calcium absorption in the bone decreasing serum calcium levels.
50. When the nurse tested an unconscious client for noxious stimuli, the client responded with
b. Rigid extension of the upper and lower extremities and hyperextension of the neck
c. Complete flaccidity of both upper and lower extremities and hyperextension of the neck
d. Flexion of the upper extremities, extension of the lower extremities, and plantar flexion
Rationale: D
Decorticate rigidity or posturing is best described as an abnormal flexor response in the arm
with extension and plantar flexion in the lower extremities. Decerebrate rigidity involves rigid
extension of the arms and legs with plantar flexion. Flexion of the upper and lower extremities
51. Which of the following reduces cerebral edema by constricting cerebral veins?
Rationale: B
Mannitol is an osmotic diuretic. While the actions of both drugs will reduce cerebral edema,
neither constricts cerebral veins. Ventriculostomy is a surgical procedure where a catheter is placed into
a cerebral ventricle to drain excess cerebrospinal fluid.
52. The nurse is caring for an adult client who was admitted unconcious. The initial assessment
utilized the Glasgow Coma Scale. The nurse knows that the Glasgow Coma Scale is a
systemic neurological assessment tool that evaluates all of the following EXCEPT
Rationale: C
The Glasgow Coma Scale is a practical scale that independently evaluates three features: eye
opening, motor response, and verbal performance. It does not evaluate pupillary reaction.
53. An adult’s Glasgow Coma Scale score is indicative of coma. Her score is:
Rationale: C
Without even thinking about it the answer must be #3 due to the fact that the lowest score
The score obtained with this scale is used to the assess Coma and impaired consciousness
# Moderate is 9 to 12 points
54. An adult has the medical diagnosis of increased intracranial pressure and is being cared for
on the neurology unit. The nursing care plan includes elevating the head of the bed and
positioning the client’s head in proper alignment. The nurse recognizes that these actions
Rationale: C
It has been demonstrated that positioning the client with the head elevated to 30 degrees
decreases ICP. Gravity aids in venous drainage from the head. Pronounced angulation of the
neck can obstruct venous return. Pain, airway problems, and a Valvalsa maneuver will all
increase ICP and will not directly benefit from proper head alignment.
55. An elderly woman reports that she has been using more salt on her food than she used to.
This is because:
Rationale: A
The taste buds begin to atrophy at age 40 and insensitivity to taste qualities occurs after 60.
Studies related to diminished taste indicate that there are changes in the salt threshold for some
elderly individuals. People lose the ability to compensate for fluid losses as they age. Extra
sodium is not needed for renal function. Confusion can cause a wide variety of behaviors but
56. 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
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
Rationale: B
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.
57. 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 Pa CO2 is less
than 45 mmHg. Evaluating this ABG panel, the nurse would conclude that:
Hypoxic states may cause cerebral edema. Hypoxia also causes cerebral vasodilatation
58. A client is admitted following an automobile accident in which he sustained a contusion. The
Rationale: D
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,
59. Mrs. Cuneta is an 80-year-old client admitted to your nursing unit with a diagnosis of
weakness, status post fall. The admission face sheet indicates that she is widowed and
lives alone. As you work through your nursing admission assessment, which of the
c. Ask Mrs. T about her ability to shop and cook for herself.
Rationale: BMrs. Cuneta’s reason for admission is weakness and a fall. Priority concerns in assessment
would be to identify any intrinsic or extrinsic factors that lead to her fall. Her interest in reading,
although it be important in determining possible activities to incorporate into her care plan while
60. You are the emergency nurse on duty when a young man is brought in after an auto
accident with massive head injuries. You know that if he is judged to be brain dead, organ
donation is suggested. Which of the following statement is true about organ donation?
a. The family of a donor is not changed for the cost of organ donation
b. Organ donation disfigures the donor and potentially alters the funeral arrangements
c. The family is not asked for organ donation when a client has massive head inujuries
d. The donor’s name and personal information is given to the organ recipient to facilitate
Rationale: A
The family or donor's estate is not charged for organ donation. Organ donation does not
disfigure the donor. Funeral arrangements, such as open caskets, do not have to be altered
because of donation. Often families of clients with massive head injuries who become brain
dead are given the opportunity to donate organs because the other organs are still functional.
The donor's information is confidential and not communicated to the recipient under normal
circumstances.
61. 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
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
Rationale: B
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.
62. 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
Rationale: C
Hypoxic states may cause cerebral edema. Hypoxia also causes cerebral vasodilatation
63. A client is admitted following an automobile accident in which he sustained a contusion. The nurse
knows that the significance of a contusion is
Rationale: D
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,
64. The nurse is counseling a client with the diagnosis of glaucoma. She explains that if left
Rationale: A
The increase in intraocular pressure causes atrophy of the retinal ganglion cells and the optic
65. A nurse is caring for a burn client who has sustained thoracic burns and smoke inhalation
and is risk for impaired gas exchange. The nurse avoids which action in caring for this
client?
b. maintaining the client in a supine position with the head of the bed elevated
Rationale: A
Aggressive pulmonary measures are used to prevent respiratory complications in the client who
has impaired gas exchange as a result of a burn injury. These include turning and repositioning,
positioning for comfort, using humidified oxygen, providing incentive spirometry, and suctioning
the client on an as needed basis. The nurse would avoid maintaining the client in one position.
66. A client sustains a burn injury to the entire right arm, entire right leg, and anterior thorax.
According to the rule of nine’s the nurse determines that what body percent was injured?
Rationale: A
According to the Rule of Nine’s, the right arm is equal to 9% and the left arm is equal to 9%. The
right leg is equal to 18% and the left leg is equal to 18%. The anterior thorax is equal to 18%
and the posterior thorax is equal to 18%. The head is equal to 9% and the perineum is 1%. If
the anterior thorax (18%), entire right leg (18%), and entire right arm (9%) were burned,
67. A nurse assesses a burn injury and determines that the client sustained a full-thickness
Rationale: CIn a full-thickness fourth-degree burn injury, charring is visible. Extremity movement is
limited
weeping surface would be noted in a partial-thickness second-degree burn injury. A dry wound
68. A client is brought to the emergency room following a burn injury. In assessment the nurse
notes that the client’s eyebrow and nasal hairs are singed. The nurse would identify this type
of burn as:
Rationale: A
Exposure to or contact with flames, hot liquids, or hot objects causes thermal burns. Thermal
burns are those sustained in residential fires, explosive accidents, scald injuries, or ignition of
clothing or liquids. If the nurse notes facial burns or singed eyebrow or nasal hairs, the victim
likely experienced the burn in an enclosed smoke filled space such as in a residential fire.
Electrical burns are caused by heat that is generated by the electrical energy as it passes
through the body. Radiation burns are caused by exposure to a radioactive source. Chemical
burns are caused by tissue contact with strong acids, alkalis, or organic compounds.
69. A nurse assesses the carbon monoxide level of a client following a burn injury and notes
that the level is 8%. Based on this level, which finding would the nurse expect to note during
Rationale: D
Clinical manifestations of carbon monoxide poisoning are related to the levels of carbon
monoxide saturation. A level between 5 to 10% would cause impaired visual acuity; 11 to 20%
flushing and headache; 21 to 30% nausea and impaired dexterity; 31 to 40% vomiting,
dizziness, and syncope; 41 to 50% tachypnea and tachycardia; and greater than 50% coma and
death.
70. A nurse assesses the client’s burn injury and determines that the client sustained a partial-
thickness superficial burn. Based on this determination, which finding did the nurse note?
Rationale: A
A partial-thickness superficial burn appears wet, shiny, and weeping, or may contain blisters.
The wound blanches with pressure, is painful, and very sensitive to touch or air currents.
Charring would occur in a deep full-thickness burn. Decreased or absence of wound sensation
71. A nurse assesses the client’s burn injury and determines that the client sustained a partial-
thickness deep burn. Based on this determination, which finding did the nurse note?
Rationale: B
A partial-thickness deep burn appears dry and may be red or white in appearance. No blanching
occurs and thrombosed vessels may be visible. Decreased wound sensation will be present.
Blisters and a wet shiny weeping surface occur in partial-thickness superficial burns. Charring would
occur in deep full-thickness burns. Total absence of wound sensation would occur in deep
full-thickness burns.
72. On assessment of a child, the nurse notes the presence of white patches on the child’s
tongue and determines that they may be indicative of candidiasis (thrush). The nurse
Rationale: A
Candidiasis, a fungal infection, adheres firmly to the tongue and/or mucous membranes of the
mouth and throat. Bleeding may occur after the trauma of trying to remove the patches. A red
circle on the skin may be associated with other disorders such as Lyme disease but is not seen
in candidiasis. Candidiasis can occur on the oral mucous membranes as well as on the tongue.
73. On assessment, a nurse notes a flat brown circular nevi on the skin of a client that
measures less than one centimeter. The client asks, "Is this cancer?" The nurse makes
Rationale: A
A flat brown circular nevi is a description of a classic benign mole. Therefore option 1 is correct.
If the color changes or varies, if the size is greater than 1 cm, or if the mole was raised or itchy,
it should be considered suspicious. The description in the question indicates that the lesions are
Rationale: A
The data identified in the question suggest the possibility of malignant melanoma; therefore,
moles with these characteristics should be considered suspicious. Options b, c, and d are
incorrect.
75. A client is diagnosed with herpes zoster (shingles). Which pharmacological therapy would
Rationale: C
The goals of treatment for herpes zoster are to relieve pain, to prevent infection and scarring,
and to reduce the possibility of postherpetic neuralgia. Oral analgesics are prescribed to reduce
the incidence of persistent pain. The lesions may also be injected with corticosteroids. Acyclovir,
if started early, may reduce the severity of herpes zoster. Options a and b identify antibiotics thatare not
normally prescribed for this condition. Option d is a nonsteroidal antiinflammatory
medication.