Nursing Practice Iv

NURSING PRACTICE IV
CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS PART B
1. A client is hospitalized for treatment of a fractured femur. Suddenly, he becomes pale,
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.
a. Is having an acute anxiety attack c. May have a wound infection
b. May have a fat embolism d. Is having a myocardial infarction
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
psychosocial and (C, D) it didn’t answer the question.
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
for Mr. R. should be directed toward:
a. assessing blood loss c. obtaining vital signs
b. monitoring respiratory status d. organizing lay people on the scene
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?
a. Have the physician and anesthesiologist sign the consent form.
b. Witness the consent form along with another nurse.
c. Prepare the client for surgery and omit the form since the client cannot consent.
d. Request that the nursing supervisor witness the consent form.
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
incorrect because there is no client signature to witness.
4. What is the most important aspect to include when developing a home care plan for a client
with severe arthritis?
a. Maintaining and preserving function c. Supporting coping with limitations
b. Anticipating side effects of therapy d. Ensuring compliance with medications
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
interventions for maintaining function of affected joints.
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
action should the nurse take?
a. Prepare for emergency fasciotomy.
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
pressure, a fasciotomy may be necessary
Option A - Fasciotomy is performed if compartment pressure cannot be relieved
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
the new bed
b. Slowly lift the 5 lb weight from the traction set up, and apply 10 lb of manual traction
during the move
c. It is not safe to move Mrs. F. with Buck’s traction. Support her position changes with
pillows until traction is no longer needed.
d. Decrease the weight of traction over a two hour period; then discontinue the traction
and move Mrs. F. into the new bed.
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.
Skeletal traction should not be released unless there is a life-threatening emergency.
Option B - it is not necessary to maintain manual traction, especially at twice the weight, to
move a person in Buck’s traction.
Option C - it is safe to move persons with Buck’s traction and would be uncomfortable to use
pillow support for position changes.
Option D - Once the weight of traction has been established as effective, the weight should be
maintained until it is no longer needed.
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
lift swing your other leg.”
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.
c. Use a walker for balance when getting up the client.
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
their hips. Positions with 60-90 degree flexion should be avoided.
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
functionally classified as what type of joint?
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
tibiofibular or radioulnar joint, is a type of amphiarthrosis with intervening connective tissue
forming an interosseous membrane or ligament.

Reference: Bates, Rita. Straight A’s in Anatomy and Physiology. 2007. p. 96.
10. Which among the following could be the best health teaching to a client who had sprained
her ankle and the toes?
a. “Place a lukewarm compress to the site.”
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.”
d. “You can try frozen water to the affected areas.”
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)
11. After change-of-shift report, which patient should the nurse assist first?a. A client with fracture
complaining that the cast is tight
b. A client with right leg amputation complaining of phantom pain
c. A client with hyperthyroidism who tells you that he feels depressed
d. A client with carpal tunnel syndrome complaining of pain
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
soon as possible, none of their concerns is urgent.
Reference: LaCharity, Linda. Prioritization, Delegation, and Assignment. 2006. p. 62.
12. A client with Paget’s disease is admitted in your unit. After thorough assessment, which
finding indicates that the physician should be notified?
a. The patient is 4’11” and weighs 110 pounds.
b. The patient’s skull is soft and larger than normal.
c. The base of the patient’s skull is invaginated.
d. The patient has bowing legs
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
lunches would be the most appropriate?
a. String beans b. Strained beans c. French fries d. Infant formula
Rationale: A
The finger foods appeal to a 1-year-old and offer appropriate nutrition as well. A fractured femur
does not require a special diet.
Option B, this may be a nutritious meal, but offers little variety in texture, and the child cannot
easily feed herself.
Option C, it is best to avoid fried foods when possible. Foods should be broiled, poached, or
baked rather than fried.
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?
a. Pruritus and increased calcium in the blood
b. Positive blood culture results and increased ESR
c. Abnormal ABG results and petechiae in the chest
d. Bone pain and increased WBC
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:
a. Take a soft diet
b. Elevate legs 5 times every 2 hours
c. Get off and on the bedpan by lifting hips
d. Take 10 deep breaths every 2 hours
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.
Reference: Manning, Loretta. NCLEX-RN 101: How to Pass! 1993. p. 28.
16. Client Morazella wrathfully goes to you for some advices. She yells to you, “What’s the fact
about being obese?!”
a. “Obese people have a lower percentage of water than lean people.”
b. “Obese people have a higher percentage of water than lean people.”
c. “Girls have a higher percentage of water than boys.”
d. “You are not obese, you are sexy! We are sexy”
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
higher percentage of body fat. (Option D is the best answer nyahaha!)
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?
a. Shallow respirations with some bubbling crackling sounds.
b. Some pitting edema found in the ankles.

c. Bounding post-tibial pulses
d. Flattened neck veins, which are obvious upon lying in.
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.
18. If a client had a diagnosis of Syndrome of Inappropriate Anti-diuretic Hormone (SIADH),
which of the following electrolyte should a nurse watchful for?
a. Decreased sodium c. Increased potassium
b. Increased sodium d. Decreased potassium
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
An ECG waveform showing a shortened QT interval and bradycardia suggests hypercalcemia.
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.
20. Which of the following clinical manifestations signifies hyperphosphatemia?
a. Increased respiratory rate

b. Diaphoresis, flushed skin
c. Hyperreflexia
d. Rhabdomyolysis and muscle pain
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?
a. Renal disease c. Ileostomy
b. Colostomy d. Metabolic alkalosis
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
hypokalemic and should be encouraged to eat foods high in potassium.
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
malaise. The priority nursing action should be?
a. Provide oxygen at 2 L by nasal cannula.
b. Administer analgesic and antiemetic as ordered.
c. Check the chart for her latest electrolyte values.
d. Notify the physicianRationale: C
The nurse should look for the client’s latest potassium level, since these symptoms indicate
hyperkalemia, which can lead to death.
Option A, the client is not in respiratory distress.

Option B, this is not a priority since the client is exhibiting symptoms of an increased potassium
level, which can lead to death.
Option D, the physician will want a complete assessment before being notified, and will require
the nurse to relate the potassium level.
23. ICF as opposed to ECF has higher concentration of which of the following electrolyes?
a. Magnesium and potassium c. Calcium and potassium
b. Sodium and calcium d. Chloride and potassium
Rationale: A
ICF has higher concentrations of magnesium, potassium, protein, phosphate, and sulfate, and
lower concentrations of sodium, calcium, chloride and bicarbonate.
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?
a. Respiratory Alkalosis c. Respiratory Alkalosis, compensated
b. Metabolic Alkalosis d. Metabolic Alkalosis, uncompensated
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.
25. The laboratory technician just handed to you the electrolyte profile. It is known that the major
cation of the body is
a. Bicarbonate b. Phosphate c. Magnesium d. Choride
Rationale: C
Major cations (positively charged) include Na, potassium, calcium, and magnesium. Major
anions (negatively charged) include chloride, bicarbonate and phosphate.
26. Twelve hours post lumbar laminectomy a client complains of discomfort and the inability to
void. Which is the best action for the nurse to take?
a. Assist the client to the bathroom
b. Palpate for fullness of the bladder
c. Apply manual pressure to the bladder as the client attempts to void
d. Insert an indwelling catheter
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
order for catheterization should be obtained.
27. A normal sign of aging in the renal system is:
a. incontinence c. microscopic hematuria
b. concentrated urine d. a decreased glomerular filtration rate
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
hematuria is a symptom of pathology, not normal aging. Incontinence is not an expected
outcome of aging.
28. 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 c. Hypocalcemia
b. Low hemoglobin welve d. Hypokalemia
Rationale: A
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.
29. 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
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
well as cause irritation.
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?
a. On the inner thigh c. Under the thigh
b. On the navel area d. On the upper thigh
Rationale: D
The catheter should be taped on the lower abdomen or upper thigh to prevent a penoscrotal
angle that can cause a fistula development.
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
two thumbs up?
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
Finasteride is an androgen inhibitor that may promote a reductionof prostatic hypertrophy,

thereby improving bladder emptying. It may take 6-12 months to become effective and it does
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.
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
diuretic. What is the purpose of this medication?
a. This medication acts on the loop of Henle to control the flow of water and electrolytes.
b. Hydrogen ions and potassium are secreted and reabsorbed
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
Option B refers to the function of nephron’s distal tubule.
Option C, refers to descending tubule of the loop of Henle.
Option D, refers to proximal tubule..
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.
c. Replace the Foley catheter with a new catheter.
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
the first nursing action in this type of question.
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?
a. “I have never had an intimate sexual relationship for 2 years now.”
b. “I have urinary frequency and dribbling.”
c. “I have had diabetes for the last 5 years.”
d. “I don’t buy Men’s magazine anymore.”
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.
279.
35. A three-way bladder irrigation is used after TURP to prevent which of the following
inconsistencies?
a. Hemorrhage b. Urinary retention c. Infection d. Clot formation
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.
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.
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?
a. A bedridden grandmother, with an indwelling catheter.
b. A toddler with a history of vesicourethral reflux.
c. A 28-year-old, sexually active man.
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
prone to UTI. The other options are more prone to UTI.
488.
38. A client has an order for a sterile urine specimen to be obtained. What is the best nursing
action in obtaining specimen from the retention collector?
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
open a closed system which allows bacteria to be introduced.
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:
a. Straining urine c. Administer a laxative
b. Restricting fluids d. Obtaining vital signs
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
priority since this is not an invasive procedure.
40. During peritoneal dialysis, the nurse notes that the outflow is less than the inflow. What
should the nurse do?
a. Notify the physician c. Reposition the dialysis catheter
b. Change the client’s position d. Irrigate the catheter with 30 ml of saline
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.
c. Maintain enough rest and sleep.
d. Increase fluid intake
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.
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
a. Edema causes tissue to seepage easily and may tore easily.
b. It can suppress her energy stores and depletes her calcium and phosphate bone
deposits.
c. Decreased calcium bone deposits can lead to fractures.
d. Hypercalcemia leads to bone resorption.
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.
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:
a. “It is caused by overproduction of FSH.”
b. “Give me another day to confirm this, but as I remember it, it is caused by decreased
secretion of adrenocorticotropin hormone”
c. “It is caused by too little TSH.”
d. “It is caused by too much secretion of adrenocorticotropin.”
Rationale: C
Hyposecretion of TSH causes myxedema, which is characterized by slow speech, slow
metabolism, hand and facial swelling, and coarse, edematous skin. Too much FSH leadsto
precocious puberty. Hyposecretion of adrenocorticotropin hormone results in Addison’s disease,
which is marked by hypotension, anorexia, increased skin pigmentation, hypoglycemia, nausea
and hypotension. Hypersecretion of adrenocorticotropin results in Cushing’s disease, which is
characterized by fatigue, weakness, and adiposity of the face, neck, and trunk.
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
insulin without eating breakfast may cause a potentially life-threatening hypoglycemia.
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.
45. Which among the following would be included in the fluid management for the client
diagnosed with SIADH?
a. Increased fluid intake c. Fluid restriction
b. D10W as ordered d. NSS and IVF as ordered
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.
246.
46. A client is manifesting some addisonian crisis. Which of the following are common with this
disorder?
a. Rapid respirations, pallor and hypotension
b. Chvostek sign, numbness
c. Tremors, heached, increased heart rate
d. Increased urine output, increase fang
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.
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
nurse suspect to be the cause?
a. Evening dose of NPH insulin
b. Morning dose of regular insulinc. Evening dose of regular insulin
d. Morning dose of NPH insulin
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
the next morning.
247.
48. The physician prescribes regular insulin, 5 units subcutaneous. Regular insulin begins to
exert an effect:
a. In 10-20 minutes c. In 60 – 120 minutes
b. In 30-60 minutes d. In 40-100 minutes
Answer: B
Rationale: The onset for regular insulin is 30-60 minutes.
Reference: Exam Cram, 1st Edition 2006. Pearson Education Ltd.
49. The result of the stimulation of calcitonin is which of the following?
a. High serum calcium level

b. Low serum calcium level
c. High sodium level
d. Low sodium level
Rationale: Calcitonin promotes calcium absorption in the bone decreasing serum calcium levels.
Reference: Mastering Fundamentals of Nursing, 2004. Josie Udan, RN.
50. When the nurse tested an unconscious client for noxious stimuli, the client responded with
decorticate rigidity or posturing. This is best described as:
a. Flexion of the upper and lower extremities into a fetal-like position
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
into a fetal-like position is a complication of bed rest.
51. Which of the following reduces cerebral edema by constricting cerebral veins?
a. Dexamethasone (Decadron) c. Mannitol (Osmitrol)
b. Mechanical hyperventilation d. Ventriculostomy
Rationale: B
Mechanical hyperventilation to reduce CO2 levels to 25 mmHg produces cerebral
vasoconstriction and thereby decreases ICP. Dexamethasone is an anti-inflammatory agent.
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
a. Eye opening c. Pupillary reaction

b. Motor response d. Verbal performance
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:
a. Zero b. Two c. Six d. Ten
Rationale: C
Without even thinking about it the answer must be #3 due to the fact that the lowest score
possible is a 3 and the top being a 15.
The score obtained with this scale is used to the assess Coma and impaired consciousness
# Mild is 13 through 15 points
# Moderate is 9 to 12 points
# Severe 3 through 8 points
# Patients with score less than 8 are in Coma
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
are effective because they act by
a. making it easier for the client to breathe c. promoting venous drainage
b. preventing a Valsalva maneuver d. reducing pain
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:
a. Her taste buds are dulled
b. She is confused because of her advancing age

c. Sodium is needed to ensure adequate renal function
d. Her body is attempting to compensate for lost fluids
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
most elderly individuals do not experience confusion.
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
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
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:
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

Rationale: C
Hypoxic states may cause cerebral edema. Hypoxia also causes cerebral vasodilatation
particularly in response to a decrease in the PaO2 below 60 mmHg.
58. 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 c. Amnesia will occur
b. Loss of consciousness may be transient d. Laceration of the brain may occur
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,
retrograde amnesia, and is generally reversible.
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
following would be the least priority concern?
a. Ask Mrs. T about the details of her fall.
b. Does Mrs. T like to read?
c. Ask Mrs. T about her ability to shop and cook for herself.
d. What medications has she been taking?
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
in the hospital, is a lesser priority.

Nursing Practice Iv

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Nursing Practice Iv

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NURSING PRACTICE IV

CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS PART B

1. A client is hospitalized for treatment of a fractured femur. Suddenly, he becomes pale,

a. Is having an acute anxiety attack c. May have a wound infection

b. May have a fat embolism d. Is having a myocardial infarction

psychosocial and (C, D) it didn’t answer the question.

for Mr. R. should be directed toward:

a. assessing blood loss c. obtaining vital signs

b. monitoring respiratory status d. organizing lay people on the scene

a. Have the physician and anesthesiologist sign the consent form.

b. Witness the consent form along with another nurse.

d. Request that the nursing supervisor witness the consent form.

incorrect because there is no client signature to witness.

with severe arthritis?

a. Maintaining and preserving function c. Supporting coping with limitations

b. Anticipating side effects of therapy d. Ensuring compliance with medications

interventions for maintaining function of affected joints.

action should the nurse take?

a. Prepare for emergency fasciotomy.

pressure, a fasciotomy may be necessary

Option A - Fasciotomy is performed if compartment pressure cannot be relieved

the new bed

during the move

pillows until traction is no longer needed.

and move Mrs. F. into the new bed.

Skeletal traction should not be released unless there is a life-threatening emergency.

move a person in Buck’s traction.

pillow support for position changes.

maintained until it is no longer needed.

lift swing your other leg.”

c. Use a walker for balance when getting up the client.

their hips. Positions with 60-90 degree flexion should be avoided.

functionally classified as what type of joint?

tibiofibular or radioulnar joint, is a type of amphiarthrosis with intervening connective tissue

forming an interosseous membrane or ligament.

her ankle and the toes?

a. “Place a lukewarm compress to the site.”

d. “You can try frozen water to the affected areas.”

b. A client with right leg amputation complaining of phantom pain

c. A client with hyperthyroidism who tells you that he feels depressed

d. A client with carpal tunnel syndrome complaining of pain

soon as possible, none of their concerns is urgent.

Reference: LaCharity, Linda. Prioritization, Delegation, and Assignment. 2006. p. 62.

finding indicates that the physician should be notified?

a. The patient is 4’11” and weighs 110 pounds.

b. The patient’s skull is soft and larger than normal.

c. The base of the patient’s skull is invaginated.

d. The patient has bowing legs

Reference: LaCharity, Linda. Prioritization, Delegation, and Assignment. 2006. p. 62.

lunches would be the most appropriate?

a. String beans b. Strained beans c. French fries d. Infant formula

does not require a special diet.

easily feed herself.

baked rather than fried.

a. Pruritus and increased calcium in the blood

b. Positive blood culture results and increased ESR

c. Abnormal ABG results and petechiae in the chest

d. Bone pain and increased WBC

a. Take a soft diet

b. Elevate legs 5 times every 2 hours

c. Get off and on the bedpan by lifting hips

d. Take 10 deep breaths every 2 hours

Reference: Manning, Loretta. NCLEX-RN 101: How to Pass! 1993. p. 28.

about being obese?!”

a. “Obese people have a lower percentage of water than lean people.”