MOCKBOARD PART 3 Answer Key

SUCCEED REVIEW CENTER
MOCK BOARD PART 3
1. A clinic nurse is providing instructions to a client with hypertension who will be taking captopril (Capoten). Which
statement by the client indicates a need for further instruction?
1. “I need to drink increased amounts of water.”
2. “I need to change positions slowly.”
3. “I need to avoid taking hot baths or showers.”
4. “I need to sit down and rest if dizziness or lightheadedness occurs.”
Correct Answer: 1
Rationale:
Captopril is an antihypertensive medication (angiotension-converting enzyme [ACE] inhibitor). Orthostatic hypotension
can occur in clients taking this medication. Clients are advised to avoid standing in one position for long periods; to
change positions slowly; and to avoid extreme warmth such as with baths, showers, or heat from the sun in warm
weather. The client should be instructed to monitor for signs of orthostatic hypotension, such as dizziness,
lightheadedness, weakness, and syncope. An increased intake of water could actually aggravate the hypertension. Test-
Taking Strategy:
Use the process of elimination, and note the strategic words need for further instruction. This phrasing indicates a
negative event query and directs you to select an incorrect statement. Note that the client has hypertension. Also focus
on the name of the medication and the suffix -pril. This suffix provides you with the clue that the medication is an ACE
inhibitor. Use knowledge regarding the effects of an antihypertensive to direct you to option 1. Review the client
teaching points related to captopril if you had difficulty with this question.
2. A nurse is providing instructions to a client with a diagnosis of hypertension regarding high-sodium items to be
avoided. The nurse instructs the client to avoid consuming:
1. Cantaloupe
2. Broccoli
3. Antacids
4. Bananas
Correct Answer: 3
Rationale:
The sodium level can increase with the use of several types of products, including toothpaste and mouthwash; over- the-
counter medications such as analgesics, antacids, laxatives, and sedatives; and softened water and mineral water.
Clients are instructed to read labels for sodium content. Water that is bottled, distilled, deionized, or demineralized may
be used for drinking and cooking. Fresh fruits and vegetables are low in sodium.
Test-Taking Strategy:
Note the strategic word avoid in the question. Use the process of elimination, noting that options 1, 2, and 4 are
comparable or alike in that they all identify fresh fruits and vegetables. If you had difficulty with this question, review
items that are low in sodium.
3. A nurse is preparing discharge instructions for a client with Raynaud’s disease. The nurse plans to tell the client to:
1. Stop smoking because it causes cutaneous vasospasm.
2. Always wear warm clothing even in warm climates to prevent vasoconstriction.
3. Use nail polish to protect the nail beds from injury.
4, Wear gloves for all activities involving use of both hands.
Correct Answer: 1
Rationale:
Raynaud’s disease is peripheral vascular disease characterized by abnormal vasoconstriction in the extremities. Smoking
cessation is one of the most important lifestyle changes that the client needs to make. The nurse should emphasize the
effects of tobacco on the blood vessels and the principles involved in stopping smoking. The nurse needs to provide
information to the client about smoking cessation programs available in the community. Options 2 and 3 are incorrect. It
is not necessary to wear gloves for all activities.
Use the process of elimination. Eliminate options 2 and 4 first because of the close-ended words always and all.
Regarding the remaining options, think about the physiology associated with Raynaud’s disease to direct you to option
1. Review client teaching points for Raynaud’s disease if you had difficulty with this question.
4. A nurse in the medical unit is reviewing the laboratory test results for a client who has been transferred from the
intensive care unit. The nurse notes that a cardiac troponin T level assay was performed while the client was in the
intensive care unit. The nurse determines that this test was performed to assist in diagnosing which of the following
conditions?
1. Myocardial infarction
2. Congestive heart failure
3. Ventricular tachycardia
4. Atrial fibrillation
Correct Answer: A
Rationale:
Cardiac troponin T or cardiac troponin I has been found to be a protein marker in the detection of myocardial infarction,
and assay for this protein is used in some institutions to aid in the diagnosis of a myocardial infarction. The test is not
used to diagnose congestive heart failure, ventricular tachycardia, or atrial fibrillation.
Specific knowledge regarding the cardiac troporlin test is needed to answer this question. Think about each condition
identified in the options and the method of diagnosing the condition to direct you to option 1. Review the purpose of
the troponin T level assay if you had difficulty with this question.
5. A nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the
client has developed atrial fibrillation and has a ventricular rate of 150 beats/mm. The nurse should next assess the
client for which of the following?
1. Flat neck veins
2. Complaints of nausea
3. Complaints of headache
4. Hypotension
Correct Answer: 4
Rationale:
The client with uncontrolled atrial fibrillation with a ventricular rate greater than 100 beats/mm is at risk for low cardiac
output due to loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension,
pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.
Use the process of elimination. Focus on the dual subjects: atrial fibrillation and a rapid ventricular rate. Eliminate option
1 first because flat neck veins are normal or indicate hypovolemia. Eliminate option 2 next because nausea and vomiting
would be associated with vagus nerve activity, which does not correlate with a tachycardic state. Regarding the
remaining options, recall that a falling cardiac output will result in hypotension. Review the effects of atnal fibrillation if
you had difficulty with this question.
6. A nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment
component would elicit specific information regarding the clients left-sided heart function?
1. Listening to lung sounds
2. Assessing for peripheral and sacral edema
3. Assessing for jugular vein distention
4. Monitoring for organomegaly
Correct Answer: 1
Rationale:
The client with heart failure may present with different symptoms, depending on whether the right or the left side of the
heart is failing. Peripheral and sacral edema, jugular vein distention, and organomegaly all are manifestations of
problems with right-sided heart function. Lung sounds constitute an accurate indicator of left-sided heart function.
Use the process of elimination and focus on the subject of the question: left-sided heart failure. Correlate left and lungs.
Options 2, 3, and 4 reflect right-sided heart failure. Review the signs of right- and left-sided heart failure if you had
difficulty with this question.
7. The clinic nurse is reviewing the assessment findings for a client who has been taking spironolactone (Aldactone) for
treatment of hypertension. Which of the following, if noted in the clients record, would indicate that the client is
experiencing a side effect related to the medication?
1. A potassium level of 3.2 mEq/L
2. A potassium level of 5.8 mEq/L
3. Client complaint of constipation
4. Client complaint of dry skin
Correct Answer: 2
Rationale:
Spironolactone is a potassium-sparing diuretic. Side effects include hyperkalemia, dehydration, hyponatremia, and
lethargy. Although the concern with most diuretics is hypokalemia, this medication is potassium sparing, which means
that the concern with this medication is hyperkalemia. Additional side effects include nausea, vomiting, cramping,
diarrhea, headache, ataxia, drowsiness, confusion, and fever.
Focus on the medication classification. Recalling that this medication is a potassium-sparing diuretic will direct you to
option 2. The potassium level noted in option 2 is elevated. Review the classification of spironolactone and its side
effects if you had difficulty with this question.
8. A nurse is reviewing the electrocardiogram (ECG) rhythm strip obtained on a client with a diagnosis of myocardial
infarction. The nurse notes that the PR interval is 0.20 second. The nurse determines that this is:
1. A normal finding
2. Indicative of atrial flutter
3. Indicative of impending reinfarction
4. Indicative of atrial fibrillation
Correct Answer: 1
Rationale:
The PR interval represents the time it takes for the cardiac impulse to spread from the atna to the ventricles. The normal
range for the PR interval is 0.12 to 0.20 second. Options 2, 3, and 4 are incorrect.
Cognitive Level: Understanding
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Assessment
Content Area: Adult Health: Cardiovascular
9. A nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein
thrombosis (DVT) of the right leg. The nurse develops the plan, expecting that the physician will most likely prescribe
which of the following?
1. Maintain the affected leg in a dependent position.
2. Apply cool packs to the affected leg for 20 minutes every 4 hours.
3. Maintain bedrest.
4. Administer an opioid analgesic every 4 hours around the clock.
Correct Answer: 3
Rationale:
Standard management for the client with DVT includes bedrest for 5 to 7 days, limb elevation, relief of discomfort with
warm moist heat, and analgesics as needed. Ambulation is contraindicated because such activity can cause the
thrombus to dislodge and travel to the lungs. Opioid analgesics are not required to relieve pain, and pain normally is
relieved with acetaminophen (Tylenol).
10. A client with a diagnosis of varicose veins is scheduled for treatment by sclerotherapy and asks the nurse to describe
the procedure. The appropriate nursing response is which of the following?
1. “It involves tying off the veins to prevent sluggishness of blood from occurring.”
2. “It involves tying off the veins so that circulation is redirected in another area.”
3. “It involves surgically removing the varicosity, so anesthesia will be required.”
4. “It involves injecting an agent into the vein to damage the vein wall and close it off.”
Correct Answer: 4
Rationale:
Sclerotherapy is the injection of a scLerosing agent into a varicosity. The agent damages the vessel and causes aseptic
thrombosis that results in vein closure. With no blood flow through the vessel, distention will not occur. The surgical
procedure for varicose veins is vein ligation and stripping. This procedure involves tying off the varicose vein and large
tributaries and then removing the vein with the use of a hook and wires applied through multiple small incisions in the
leg.
Use the process of elimination, focusing on the name of the treatment. Recalling that a vessel that is sclerosed is blocked
will assist in directing you to option 4. If you had difficulty with this question, review the sclerotherapy procedure.
11. A female client calls the nurse at the clinic and reports that ever since the vein ligation and stripping procedure was
performed, she has been experiencing a sensation as though the affected leg is falling asleep. Which response to the
client is appropriate?
1. “Keep the leg elevated as much as possible.
2. “Apply warm packs to the leg.”
3. “This normally occurs after surgery and will subside when the edema goes down.”
4. “Contact your physician right away to report this problem.’
Correct Answer: 4
Rationale:
A sensation of pins and needles or feeling as though the surgical limb is falling asleep may indicate temporary or
permanent nerve damage after surgery. The saphenous vein and the saphenous nerve run close together, and damage
to the nerve will produce paresthesias. Options 1, 2, and 3 are inaccurate responses.
Use the process of elimination, focusing on the client’s complaint. Knowing that the client’s complaint may indicate
nerve irritation or damage will assist in directing you to option 4. If you had difficulty with this question, review the
complications related to a vein ligation and stripping procedure.
12. A nurse is caring for a client who has been hospitalized with a diagnosis of angina pectoris. The client is receiving
oxygen via nasal cannula at 2 L/min. The client asks why the oxygen is necessary. The nurse accurately explains that:
1. Oxygen has a calming effect.
2. Oxygen will prevent the development of any thrombus.
3. Oxygen dilates the blood vessels so they can supply more nutrients to the heart muscle.
4. The pain of angina pectoris occurs because of a decreased oxygen supply to heart cells.
Correct Answer: 4
Rationale:
The pain associated with angina results from ischemia of myocardial cells. The pain often is precipitated by activity that
places more oxygen demand on heart muscle. Supplemental oxygen will help to meet the added demands on the heart
muscle. Oxygen does not dilate blood vessels or prevent thrombus formation and does not directly calm the client.
Focus on the subject of the question: the action of oxygen. Eliminate option 1 because it does not address the
physiological necessity of oxygen. Eliminate options 2 and 3 because oxygen does not prevent clot formation or cause
vessel dilation. Review the pathophysiology associated with angina if you had difficulty with this question.
13. A client with a diagnosis of angina pectoris is hospitalized for an angioplasty. The client returns to the nursing unit
after the procedure, and the nurse provides instructions to the client regarding home care measures. Which of the
following statements, if made by the client, indicates an understanding of the instructions?
1. “I am so relieved that I can eat anything that I want to now.”
2. “I need to cut down on cigarette smoking.”
3. “I am so relieved that my heart is repaired.”
4. “I need to adhere to my dietary restrictions.’
Correct Answer: 4
Rationale:
After angioplasty, the client needs to be instructed regarding the specific dietary restrictions that must be followed.
Making the recommended dietary and lifestyle changes will assist in preventing further atherosclerosis. Abrupt closure
of the artery can occur if the dietary and lifestyle recommendations are not followed. Cigarette smoking needs to be
stopped. An angioplasty does not repair the heart.
14. A nurse is caring for a client with a diagnosis of myocardial infarction (Ml) and is assisting the client in completing the
diet menu. Which of the following beverages would the nurse instruct the client to select from the menu?
1. Coffee
2. Tea
3. Lemonade
4. Cola
Correct Answer: 3
Rationale:
A client with a diagnosis of Ml should not consume caffeinated beverages. Caffeinated products can produce a
vasoconstrictive effect, leading to further cardiac ischemia. Coffee, tea, and cola all contain caffeine and need to be
avoided in the client with Ml.
15. A nurse is performing an admission assessment on a client with a diagnosis of angina pectoris who takes
nitroglycerin for chest pain at home. During the assessment the client complains of chest pain. The nurse immediately
asks the client which of the following questions?
1. “Are you having any nausea?”
2. “Where is the pain located?”
3. “Are you allergic to any medications?”
4. “Do you have your nitroglycerin with you?”
Correct Answer: 2
Rationale:
If a client complains of chest pain, the initial assessment question would be to ask the client about the pain intensity,
location, duration, and quality. Although options 1, 3, and 4 all may be components of the assessment, none of these
questions would be the initial assessment question with this client.
16. A nurse has provided dietary instructions to a client with coronary artery disease. Which statement by the client
indicates an understanding of the dietary instructions?
1. “I need to substitute eggs and whole milk for meat.”
2. “I should eliminate all cholesterol and fat from my diet.”
3. “I should use polyunsaturated oils in my diet.”
4. “I’ll need to become a strict vegetarian.”
Correct Answer: 3
Rationale:
The client with coronary artery disease should avoid foods high in saturated fat and cholesterol such as eggs, whole milk,
and red meat. These foods contribute to increases in low-density lipoproteins. The use of polyunsaturated oils is
recommended to control hypercholesterolemia. It is not necessary to eliminate all cholesterol and fat from the diet. It is
not necessary to become a strict vegetarian.
17. A client is admitted to the visiting nurse service for assessment and follow-up after being discharged from the
hospital with new-onset congestive heart failure (CHF). The nurse teaches the client about the dietary restrictions
required with CHF. Which statement by the client indicates that further teaching is needed?
1. “I’m going to have a ham and cheese sandwich and potato chips for lunch.”
2. “I’m going to weigh myself daily to be sure I don’t gain too much fluid.”
3. “I can have most fresh fruits and fresh vegetables.”
4. “I’m not supposed to eat cold cuts.”
Correct Answer: I
Rationale:
When a client has CHF, the goal is to reduce fluid accumulation. One way that this is accomplished is through sodium
reduction. Ham, cheese (and most cold cuts), and potato chips are high in sodium. Daily weighing is an appropriate
intervention to help the client monitor fluid overload. Most fresh fruits and vegetables are low in sodium.
18. A client has a nursing diagnosis of Activity intolerance related to underlying cardiovascular disease, as evidenced by
exertional fatigue and increased blood pressure. Which observation by the nurse best indicates client progress in
meeting goals for this nursing diagnosis?
1. Chooses a healthy diet that meets caloric needs
2. Sleeps without awakening throughout the night
3. Verbalizes the benefits of increasing activity
4. Ambulates 10 feet farther each day
Correct Answer: 4
Rationale:
Each of the options indicates a positive outcome on the part of the client. However, option 1 would most likely indicate
progress if the client had a nursing diagnosis of lmbalanced nutrition. Option 2 would be a satisfactory outcome for
Disturbed sleep pattern. Both options 3 and 4 relate to the nursing diagnosis of Activity intolerance. However, the
question asks about progress. Option 4 is more action-oriented and therefore is the better choice.
19. A client with coronary artery disease is scheduled to have a diagnostic exercise stress test. The nurse plans to include
which of the following instructions in client teaching about this procedure?

1. Avoid cigarettes for 30 minutes before the procedure.
2. Wear loose clothing with a shirt that buttons in front.
3. Eat breakfast just before the procedure.
4. Wear firm, rigid shoes, such as workboots.
Correct Answer: 2
Rationale:
The client should wear loose, comfortable clothing for the procedure. Electrocardiogram (ECG) lead placement is
enhanced if the client wears a shirt that buttons in the front. The client should wear rubber-soled, supportive shoes,
such as athletic training shoes. The client should receive nothing by mouth after bedtime or for a minimum of 2 hours
before the test. The client should avoid smoking, alcohol, and caffeine on the day of the test. Inadequate or incorrect
preparation can interfere with the test, with the potential for a false-positive result.
20. A client is scheduled for a cardiac catheterization to diagnose the extent of coronary artery disease. The nurse places
highest priority on telling the client to report which of the following sensations during the procedure?
1. Pressure at the insertion site
2. Urge to cough
3. Warm, flushed feeling
4. Chest pain
Correct Answer: 4
Rationale:
The client is taught to report chest pain or any unusual sensations immediately. The client is informed that a warm,
flushed feeling may accompany dye injection and is normal. The client also is told that he or she may be asked to cough
or breathe deeply from time to time during the procedure. Because a local anesthetic is used, the client is expected to
feel pressure at the insertion site.
21. A client with a history of angina pectoris tells the nurse that chest pain usually occurs after going up two flights of
stairs
or after walking four blocks. The nurse determines that the client is experiencing which of the following types of angina?
1. Stable
2. Unstable
3. Variant
4. Intractable
Correct Answer: 1
Rationale:
Stable angina is triggered by a predictable amount of effort or emotion. Unstable angina is triggered by an unpredictable
amount of exertion or emotion and may occur at night; the attacks increase in number, duration, and severity over time.
Variant angina is triggered by coronary artery spasm; the attacks are of longer duration than in classic angina and tend to
occur early in the day and at rest. Intractable angina is chronic and incapacitating and is refractory to medical therapy.
22. A client with a first-degree heart block has an electrocardiogram (ECG) taken during an episode of chest pain. The
nurse knows that which ECG finding indicates first-degree heart block?
1. Prolonged PR interval
2. Widened QRS complex
3. Tall, peaked T waves
4. Presence of Q waves
Correct Answer: 1
Rationale:
A prolonged PR interval indicates first-degree heart block. A widened ORS complex indicates a delay in intraventricular
conduction, such as bundle branch block. Tall, peaked T waves may indicate hyperkalemia. The development of Q waves
indicates myocardial necrosis. An ECG taken during a pain episode is intended to capture ischemic changes, which also
include ST-segment elevation or depression.
23. An ambulatory care nurse is working with a client who has been diagnosed with Prinzmetal’s (variant) angina. The
nurse plans to reinforce to the client that this type of angina:
1. Is most effectively managed by B-blocking agents
2. Generally is treated with calcium-channel—blocking agents
3. Has the same risk factors as stable and unstable angina
4. Can be controlled with a low-sodium, high-potassium diet
Correct Answer: 2
Rationale:
Prinzmetal’s angina results from spasm of the coronary vessels and is treated with calcium-channel blockers. The risk
factors are unknown, and this type of angina is relatively unresponsive to nitrates. 13-Blockers are contraindicated
because they may actually worsen the spasm. Diet therapy is not specifically indicated.
24. A nurse working in a long-term care facility is assessing a client who is experiencing chest pain. The nurse would
interpret that the pain is most likely due to myocardial infarction (Ml) on the basis of which of the following assessment
findings?
1. The client is not experiencing nausea or vomiting.
2. The client says the pain began while she was trying to open a stuck dresser drawer.
3. The pain has not been relieved by rest and three nitroglycerin tablets.
4. The client is not experiencing dyspnea.
Correct Answer: 3
Rationale:
The pain of angina may radiate to the left shoulder, arm, neck, or jaw. It often is precipitated by exertion or stress, is
accompanied by few associated symptoms, and is relieved by rest and nitroglycerin. The pain of Ml also may radiate to
the left arm, shoulder, jaw, and neck. It typically begins spontaneously, lasts longer than 30 minutes, and frequently is
accompanied by associated symptoms (such as nausea, vomiting, dyspnea, diaphoresis, or anxiety). The pain of Ml is not
relieved by rest and nitroglycerin and requires opioid analgesics, such as morphine sulfate, for relief.
25. A client has experienced an episode of pulmonary edema. The nurse determines that the client’s respiratory status is
improving after this episode if which of the following breath sounds are noted?
1. Crackles throughout the lung fields
2. Crackles in the bases
3. Wheezes
4. Rhonchi
Correct Answer: 2
Rationale:
Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pin kt
inged sputum. Auscultation of the lungs reveals crackles throughout the lung fields. As the client’s condition improves,
the amount of fluid in the alveoli decreases, which may be detected by crackles in the bases. (Clear lung sounds would
indicate full resolution of the episode.) Wheezes and rhonchi are not associated with pulmonary edema.
26. A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours
postoperatively, a nurse assesses for drainage and expects to note that it is:
1. Serous
2. Serosanguineous
3. Bloody
4. Bloody, with frequent small clots
27. A nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. The nurse is planning
to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which of the following nursing
interventions are required before plugging the tube?
1. Place the inner cannula into the tube.
2. Deflate the cuff on the tube.
3. Ensure that the client is able to swallow.
4. Ensure that the client is able to speak.
Correct Answer: 2
Rationale:
Plugging a tracheostomy tube is usually done by inserting the tracheostomy plug (decannulation stopper) into the
opening of the outer cannula. This closes off the tracheostomy, and airflow and respiration occur normally through the
nose and mouth. When plugging a cuffed tracheostomy tube, the cuff must be deflated. If it remains inflated, ventilation
cannot occur, and respiratory arrest could result. The ability to swallow or speak is unrelated to weaning and plugging
the tube.
28. A nurse is caring for a client who is on strict bedrest. The nurse develops a plan of care with goals related to the
prevention of deep vein thrombosis and pulmonary emboli. Which of the following nursing actions would be most
helpful to prevent these disorders from developing?
1. Applying a heating pad to the lower extremities
2. Encouraging active range-of-motion exercises
3. Placing a pillow under the knees
4. Restricting fluids
Correct Answer: 2
Rationale:
Clients at greatest risk for pulmonary emboli are immobilized clients. Basic preventive measures include early
ambulation, leg elevation, active leg exercises, elastic stockings, and intermittent pneumatic calf compression. Keeping
the client well hydrated is essential because dehydration predisposes to clotting. A pillow under the knees may cause
venous stasis. Heat should not be applied without a physician’s prescription.
29. A nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent
bubbling in the water seal chamber. Which of the following is the appropriate action?
1. Change the chest tube drainage system.
2. Document the findings.
3. Check for an air leak.
4. Notify the physician.
Correct Answer: 2
Rationale:
Bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the chamber.
Intermittent bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the
pleural space. Continuous bubbling during inspiration and expiration indicates that an air leak exists. If this occurs, it
must be corrected.
30. A nurse has assisted the physician and the anesthesiologist with placement of an endotracheal (ET) tube for a client
in respiratory distress. Which of the following is the initial nursing action to evaluate proper ET tube placement?
1. Ask the radiology department to obtain a stat portable radiograph at the client’s bedside.
2. Use an Ambu (resuscitation) bag to ventilate the client and assess for bilateral breath sounds.
3. Tape the ET tube in place, and note the centimeter marking at the lip line.
4. Attach the ET tube to the ventilator and determine whether the client is able to tolerate the tidal volume prescribed.
Correct Answer: 2
Rationale:
The nurse verifies the placement of an ET tube immediately by ventilating the client using an Ambu bag and by
auscultating for breath sounds bilaterally, which ensures ventilation of both lungs. After this initial assessment,
placement is checked radiographically. The nurse marks the ET tube at the point where it enters the nose or mouth for
ongoing monitoring of correct placement, but this will not determine initial adequate placement of the ET tube. Noting
the tidal volume and the client’s toleration of the tidal volume prescribed is not a measure of appropriate ET tube
placement.
31. A nurse is preparing to perform suctioning for a client with a tracheostomy tube and gathers the supplies needed for
the
procedure. Which of the following is the initial nursing action?
1. Set the suction pressure range at 150mm Hg.
2. Hyperoxygenate the client.
3. Place the catheter into the tracheostomy tube.
4. Apply suction on the catheter and insert it into the tracheostomy tube.
Correct Answer: 2
Rationale:
The nurse should hyperoxygenate the client both before and after suctioning. This would be the initial nursing action.
The safe suction range for an adult client is 80 to 120 mm Hg. When the nurse advances the catheter into the
tracheostomy tube, suction is not applied, because applying suction at that time will cause mucosal trauma and
aspiration of the client’s oxygen.
32. A nursing instructor is observing a nursing student suctioning a client through a tracheostomy tube. Which of the
following observations by the nursing instructor indicates an inappropriate action by the student?
1. Hyperventilating the client with 100% oxygen before suctioning
2. Applying suction intermittently during withdrawal of the catheter
3. Suctioning the client every hour
4. Applying suction only during withdrawal of the catheter
Correct Answer: 3
Rationale:
The client should be suctioned as needed. Unnecessary suctioning should be avoided because it can increase secretions
and cause mechanical trauma to the tissues. The client should be hyperoxygenated with 100% oxygen before suctioning.
Suction is not applied during insertion of the catheter; intermittent suction and a twirling motion of the catheter are
used during withdrawal.
33. A client is intubated with an endotracheal (ET) tube by the anesthesiologist. Which of the following is the
responsibility
of the nurse with regard to checking for ET tube placement immediately after tube insertion?
1. It is not the responsibility of the nurse to check for tube placement.
2. Arrange for a chest radiograph.
3. Auscultate the lungs for the presence of bilateral breath sounds.
4. Instill air into the ET tube and listen for its being forced into the lungs.
Correct Answer: 3
Rationale:
Immediately after an ET tube is inserted, tube placement is verified by both auscultation and chest radiography.
Auscultation of the lungs for bilateral breath sounds would be the immediate nursing action. The physician or
anesthesiologist is responsible for prescribing the chest radiograph. Option 4 is an inappropriate action.
34. A nurse is performing nasotracheal suctioning of a client. The nurse determines that the client is adequately
tolerating
the procedure if which of the following observations is made?
1. Secretions are becoming bloody.
2. Heart rate decreases from 78 to 54 beats per minute.
3. Coughing occurs with suctioning.
4. Skin color becomes cyanotic.
Correct Answer: 3
Rationale:
The nurse monitors for adverse effects of suctioning, which include cyanosis, excessively rapid or slow heart rate, and
sudden development of bloody secretions. If any of these signs is observed, the nurse immediately stops suctioning and
reports the adverse effect to the physician. Coughing is a normal response to suctioning for the client with an intact
cough reflex and does not indicate that the client cannot tolerate the procedure.
2. (D) Client need: physiological integrity; subcategory: physiological
adaptation; content area: med/surg
RATIONALE
(A) Inspiration is normally longer in vesicular areas. (B) Highpitched
sounds are normal in bronchial area. (C) Muffled sounds
are considered abnormal. (D) Inspiration and expiration are
equal normally in this area, and sounds are medium pitched.
36. A client with a tracheostomy tube who is on a ventilator is at risk for impaired gas exchange. The nurse should assess
for which of the following as the best indicator of adequate ongoing respiratory status?
1. Moderate amounts of tracheobronchial secretions
2. Small to moderate amounts of frank blood suctioned from the tube
3. Respiratory rate of 16 breaths per minute
4. Oxygen saturation of 90%
Correct Answer: 3
Rationale:
Impaired gas exchange could occur after tracheostomy because of excessive secretions, bleeding into the trachea,
restricted lung expansion because of immobility, or concurrent respiratory conditions. An oxygen saturation of 90% is
less than optimal. A respiratory rate of 16 breaths per minute is in the normal range.
37. A nurse is monitoring the respiratory status of a client after creation of a tracheostomy. The nurse understands that
oxygen saturation measurements obtained by pulse oximetry may be inaccurate if the client has which of the following
coexisting problems?
1. Hypotension
2. Fever
3. Respiratory failure
4. Epilepsy
Correct Answer: 1
Rationale:
Hypotension, shock, or the use of peripheral vasoconstricting medications may result in inaccurate pulse oximetry
readings as a result of impaired peripheral perfusion. Fever and epilepsy would not affect the accuracy of measurement.
Respiratory failure also would not affect the accuracy of measurement, although the readings may be abnormally low.
38. A nurse is monitoring the function of a client’s chest tube that is attached to a Pleur-Evac drainage system. The nurse
notes that the fluid in the water-seal chamber rises with inspiration and falls with expiration. The nurse determines that:
1. The client has residual pneumothorax.

2. The system is patent.
3. Suction should be added to the system.
4. There is a leak in the system.
Correct Answer: 2
Rationale:
When the chest tube is patent, the fluid in the water-seal chamber rises with inspiration and falls with expiration. This is
referred to as tidaling and indicates proper function of the system. Options 1, 3, and 4 are inaccurate interpretations.
39. A nurse is caring for a postoperative pneumonectomy client. Which of the following findings on nursing assessment
of the client is an adverse sign or symptom indicating pulmonary edema?
1. Respiratory rate of 20 breaths per minute
2. Pain with deep breathing
3. Lung crackles
4. Increased chest tube drainage
Correct Answer: 3
Rationale:
The client with pulmonary edema that developed after pneumonectomy demonstrates dyspnea, cough, frothy sputum,
crackles, and possibly cyanosis. A respiratory rate of 20 breaths per minute is within normal limits. Pain with deep
breathing is expected and is managed with analgesics. The client with pneumonectomy most likely will not have a chest
tube because the lung has been removed.
40. A clinic nurse is providing instructions to a client with a diagnosis of pharyngitis. The nurse instructs the client to:
1. Drink hot tea throughout the day.
2. Drink hot cocoa in place of coffee.
3. Avoid foods that are highly seasoned.
4. Restrict fluid intake to 1000 mL daily.
Correct Answer: 3
Rationale:
The client with pharyngitis should be instructed to consume cool clear fluids, ice chips, or ice pops to soothe the painful
throat. Citrus products should be avoided because they irritate the throat. Milk and milk products are avoided because
they tend to increase mucus production. Foods that are highly seasoned are irritating to the throat and should be
avoided. The client should be instructed to eat bland foods and drink 2000 to 3000 mL of fluid daily unless
contraindicated.
41. A client has had an arterial blood gas sample drawn from the radial artery, and the nurse is asked to hold pressure on
the site. The nurse should apply pressure for at least:

1. 1 minute
2. 2 minutes
3. 5 minutes
4. 10 minutes
Correct Answer: 3
Rationale:
After blood is drawn for arterial blood gas analysis, continuous pressure must be applied to the site. A radial artery site
requires at least 5 minutes of pressure, whereas a femoral artery site requires 10 minutes. A small pressure dressing
often is placed on the site after this time period. When the client is receiving anticoagulant therapy, application of
pressure for a longer period may be needed.
42. When a client suffers a complete pneumothorax. there is danger of a mediastinal shift. If such a shift occurs, what
potential effect should cause the nurse to be concerned?
1. Rupture of the pericardium
2. Infection of the subpleural lining
3. Decreased tilling of the right heart
4. Increased volume of the unaffected lung
Answer 3
Rationale 1. This complication might occur in severe chest trauma. not in mecliastinal
shift.
Rationale 2. Infection is not caused by a mediastinal shift.
Rationale 3. Pressure within the pleural cavity causes a shift of the heart and great vessels to the unaffected side. This
not only decreases the capacity of the unaffected lung but also impedes the tilling of the right side of the heart and leads
to a decreased cardiac output.
Rationale 4. The volume of the unaffected lung may decrease because of pressure from the shift.
43. What would be the priority goal established for a client with asthma who is being
discharged from the hospital? The client:
1. Is able to obtain pulse oximeter readings
2. Demonstrates use of a metered-dose inhaler
3. Knows the primary care providers office hours
4. Can identify the foods that may cause wheezing
Answer 2
Raonale 1. Pulse oximetry is rarely conducted in the home home management
usually includes self-monitoring of peak expiratory flow rate.
Rationale 2. Clients with asthma use metered-dose inhalers to administer medications prophylactically and!or during
times of an asthma attack: this is an important skill to have before discharge.
Rationale 3. Although this is important, it is not the priority: during a persistent asthma attack that does not respond to
planned interventions, the client should go to the emergency department of the local hospital or call 911 for assistance.
Rationale 4. Not all asthma is associated with food allergies.
44. A client is admitted for an exacerbation of emphysema. The client has a fever. chills, and difficulty breathing on
exertion. Based on the clients history and present status, what is a priority nursing action?
1. Checking for capillary refill
2. Encouraging increased fluid intake
3. Suctioning secretions from the airway
4.Administenng high concentration of 02
Answer 2
Rationale 1. Capillary refill relates to penpheral tissue perfusion.
Rationale 2. Fluids will replace fluid loss from fever and decrease viscosity of secretions.
Rationale 3. There are no data to suggest that secretions are blocking the airway:
there is no support that suctioning is needed. traditionally the reason given for this was clients with COPD become
desensitized to CO2 as a respiratory stimulus so that reduced 02 tevels act as the stimulus and high concentrations of °2
would actually depress respirations. The newer theory suggests that the hypoxic drive is valid for a small number the
majority of cases involve the Haldane effect: as hemoglobin molecules become more saturated with °2’ they are unable
to transport CO2 out of the body. leading to hypercapnia.
Rationale 4. High concentrations of 02 are generally not administered to clients with COPD
45. A client states that the physician said the tidal volume is slightly diminished and asks the nurse what this means.
What explanation should the nurse give the client? Tidal volume is the amount of air:
1. Exhaled forcibly after a normal expiration
2. Exhaled after there is a normal inspiration
3. Inspired forcibly above a normal inspiration
4. Trapped in the alveoli that cannot be exhaled
Answer 2
Rationale 1. This is the expiratory reserve volume (ERV).
Rationale 2. Tidal volume (TV) is defined as the amount of air exhaled after a normal inspiration.
Rationale 3. The volume of air that can be forcibly inspired over and above a normal inspiration is the inspiratory reserve
volume (IRV).
Rationale 4. This is the residual volume (RV).
46. What is the underlying reason the nurse must assess a client with emphysema for clinical indicators of hypoxia?
1. Pleural effusion
2. Infectious obstructions
3. Loss of aerating surface
4. Respiratory muscle paralysis
Answer 3
Rationale 1. Pleural effusion occurs when there is seepage of fluid into the intrapleural space. this does not occur with
emphysema.
Rationale 2. Infectious obstructions occur in conditions in which microorganisms invade lung tissue emphysema is not an
infectious disease.
Rationale 3. Destruction of the alveolar walls leads to diminished surface area for gaseous exchange and an increased
CO2 level in the blood.
Rationale 4. Muscle paralysis may occur in diseases affecting the neurologic system:
emphysema does not affect the neurologic system: therefore it is not a neurologic disease.
47. A client has an endotracheal tube and is receiving mechanical ventilation. The nurse identifies that periodic
suctioning may be necessary. The nurse follows a specific protocol when performing this procedure. After obtaining the
clients vital signs the nurse’s next intervention should be to:
1.Auscultate the lung sounds
2. Hyperoxygenate for 30 seconds
3. Suction for approximately 10 seconds
4. Rotate the catheter during its withdrawal
Answer 1
Rationale 1. The nurse should first assess the clients vital signs and lung sounds to
determine if suctioning is needed.
Rationale 2. Hyperoxygenation for 30 seconds before suctioning compensates for the removal of °2 during the
suctioning process, but it is done after auscultation of breath sounds.
Rationale 3. Suctioning occurs after the lung sounds have been auscultated. the client has been preoxygenated. and the
catheter is inserted into the endotracheal tube. Suctioning for less than 15 seconds is appropriate because suctioning for
longer than this irritates the mucosal lining of the respiratory tract as well as induces hypoxia.
Rationale 4. This is done near the end of the procedure when the catheter is rotated and removed.
48. A client is scheduled for a pulmonary function test. The nurse explains that during the test one of the instructions the
respiratory therapist will give the client is to breathe normally. What is being measuring when the client follows these
directions?
1. Tidal volume
2. Vital capacity
3. Expiratory reserve
4. lnspiratory reserve
Answer 1
Raonale 1. The tidal volume is the amount of air inhaled and exhaled while breathing
normally.
Rationale 2. This is air that can be forcibly expired after maximum inspiration.
Rationale 3. This is the maximum amount of air that can be expired after a normal expiration.
Rationale 4. This is the maximum amount of air that can be inspired after a normal inspiration.
49. A client with emphysema experiences a sudden episode of shortness of breath and is diagnosed with a spontaneous
pneumothorax. What likely cause of the spontaneous pneumothorax should the nurse’s response take into
consideration?
1. Pleural friction rub
2. Tracheoesophageal fistula
3. Rupture of a subpleural bleb
4. Puncture wound of the chest wall
Answer 3
Rationale 1. Pleural friction rub would result in pain on inspiration, not a
pneumothorax.
Rationale 2. A tracheoesophageal fistula would cause aspiration of food and saliva, resulting in respiratory distress.
Rationale 3. The etiology of a spontaneous pneumothorax is commonly the rupture of blebs on the lung surface. Blebs
are similar to blisters, but are filled with air. Rationale 4. The client had no history of trauma.
50. A client with asthma is being taught how to use a peak flow meter to monitor how well the asthma is being
controlled. What should the nurse instruct the client to do?
1. Perform the procedure once in the morning and once at night.
2. Move the trunk from an upright to a bending position while exhaling.
3. Inhale completely and then blow out as hard and as fast as possible through the mouthpiece.
4. Place the mouthpiece between the lips and in front of the teeth before starting the procedure.
Answer 3
Raonale 1. The peak flow measurement should be done daily in the morning before
the administration of medication or when experiencing dyspnea.
Rationale 2. The client should be standing or sitting straight.
Rationale 3. A peak flow meter measures the peak expiratory flow rate, the maximum flow of air that can be forcefully
exhaled in 1 second: this monitors the pulmonary status of a client with asthma.
Rationale 4. This would interfere with an accurate test: the mouthpiece should be in the mouth between the teeth with
the lips creating a seal around the mouthpiece.
51. When caring for a client with an ileostomy, the nurse should:
1. Teach the client to eat foods high in residue
2. Explain that drainage can be controlled with daily irrigations
3. Expect the stoma to start draining on the third postoperative day
4.Anticipate that any emotional stress can increase intestinal peRIstalsis
52. For which clinical indicator should the nurse monitor when caring for a client with
cholelithiasis and obstructive jaundice?
1. Yellow sclera
2. Pain on urination
3. Dark brown stool
4. Coffee-ground vomitus
53. A client asks, “Why do I have to have barium salts for the GI series and barium
enema?” Which is the best response by the nurse? “Barium salts:
1. Give off visible light and illuminate the alimentary tract.”
2. Provide fluorescence and thus illuminate the alimentary tract.”
3. Dye the alimentary tract and thus provide for color contrast.”
4. Absorb x-rays and thus give contrast to the soft tissues of the alimentary tract.”
Answer 4
Rationale 1. Barium has no light-emitting properties.
Rationale 2. Barium does not fluoresce.
Rationale 3. Barium does not have properties of a dye.
Rationale 4. Barium salts used in a GI series and barium enemas coat the inner lining of the GI tract and then absorb x-
rays passing through. They thus outline the surface features of the tract on a photographic plate
54. The nurse understands that the main reason why the risk for developing
respiratory tract infections increases after pancreatic surgery is the:
1. Length of time required for surgery
2. Proximity of the incision to the diaphragm
3. Lowered resistance caused by bile in the blood
4. Transfer of bacteria from the pancreas to the blood
Answer 2
Rationale 1. This is unrelated to the development of respiratory tract infections.
Rationale 2.An incision close to the diaphragm (as in surgery of the pancreas) causes a great deal of pain when the client
coughs and deep breathes These clients tend to take shallow breaths, leading to inadequate expansion of the lungs. the
accumulation of secretions, and infection.
Rationale 3. The elevation of serum bilirubin level in the blood does not affect the immune mechanisms.
Rationale 4. The need for pancreatic surgery generally is in response to an inflammatory, not an infectious, process.
55. The nurse is caring for a client with a diagnosis of acute pancreatitis and alcoholism. The nurse understands that an
acute attack of pancreatitis can be precipitated by heavy drinking because
1.Alcohol promotes the formation of calculi in the cystic duct
2. The pancreas is stimulated to secrete more insulin than it can immediately produce
3. The alcohol alters the composition of enzymes so they are capable of damaging the pancreas
4. Alcohol increases enzyme secretion and pancreatic duct pressure and causes backflow of enzymes into the pancreas
Answer 4
Rationale 1. Although blockage of the bile duct with calculi may precipitate pancreatitis. this is not associated with
alcohol.
Rationale 2. Alcohol does not deplete insulin stores the demand for insulin is unrelated to pancreatitis.
Rationale 3. Although the volume of secretions increases, the composition remains unchanged.
Rationale 4. Alcohol stimulates pancreatic enzyme secretion and an increase in pressure in the pancreatic duct. The
backflow of enzymes into the pancreatic interstitial spaces results in partial digestion and inflammation of the pancreatic
tissue.
56. How many inches should the nurse insert a catheter into the stoma when
performing a colostomy irrigation?
1.5 cm (2 inches)
2.8 cm (3 inches)
3. 15 cm (6 inches)
4. 20 cm (8 inches)
Answer 2
Rationale 1. This is inadequate, fluid may leak back around the catheter.
Rationale 2. This is far enough to direct the flow of solution into the bowel.
Rationale 3. This may cause trauma to the mucosa.
Rationale 4. This may cause trauma to the mucosa.
Client Need: Physiological Adaptation
57. A client is receiving a percutaneous endoscopic gastrostomy (PEG) tube feeding. When the nurse assesses the client,
which response indicates that the client is unable to tolerate a continuation of the feeding?
l.A passage of flatus
2. Epigastnc tenderness
3.A rise of formula in the tube
4. The rapid flow of the feeding
Answer 3
Rationale 1. Passage of flatus reflects intestinal motility, which does not pose a potential problem.
Rationale 2. Epigastric tenderness is not necessarily caused by a full stomach.
Rationale 3. A rise in the level of formula within the tube indicates a full stomach. Rationale 4. A rapid inflow is the result
of positioning the container too high or using a
feeding tube with too large a lumen.
58. A client is scheduled for ligation of hemorrhoids. Which diet should the nurse expect the physician to encourage the
client to ingest in preparation for this surgery?
1. Bland diet
2. Clear liquid diet
3. High-protein diet
4. Low-residue diet
Answer 4
Raonale 1. Bland diets are usually employed in the management of upper not lower,
Cl disturbances.
Rationale 2. Although a clear diet is low in residue. it does not meet normal nutritional needs.
Rationale 3. A high-protein diet is indicated postoperatively to promote healing.
Rationale 4. A low-residue diet limits stool formation.
59. Which explanation is most accurate when the nurse teaches a client about
intussusception of the bowel?
1. Kinking of the bowel onto itself
2.A band of connective tissue compressing the bowel
3. Telescoping of a proximal loop of bowel into a distal loop
4.A protrusion of an organ or part of an organ through the wall that contains it
Answer 3
Rationale 1. Volvulus is a twisting of the bowel onto itself.
Rationale 2. Adhesions are bands of scar tissue that can compress the bowel.
Rationale 3. lntussusception is the telescoping or prolapse of a segment of the bowel into the lumen of an immediately
connecting part.
Raonale 4. Hemiation describes protrusion of an organ through the wall that contains it.
60. A client is scheduled for a colonoscopy and the physician orders a tap water
enema. In which position should the nurse place the client?
1. Sims’ position
2. Back-lying position
3. Knee-chest position
4. Mid-Fowler’s position
Answer 1
Rabonale 1. To take advantage of the anatomic position of the sigmoid colon and the effect of gravity, the client should
be placed in a left Sims’ or left side-lying position for the enema.
Rationale 2. This position does not facilitate the flow of fluid into the sigmoid colon by gravity.
Rationale 3. This position does not facilitate the flow of fluid into the sigmoid colon by gravity.
Rabonale 4. This position does not facilitate the flow of fluid into the sigmoid colon by gravity.
61. A 93-year-old client with a history of diverticulitis is admitted with severe abdominal pain, anorexia. nausea,
vomiting for 24 hours, a markedly elevated temperature. and increased white blood cells. The nurse understands the
most likely reason for surgical intervention is that:
1. Surgery is usually indicated for a diagnosis of diverticulitis
2. The symptoms exhibited by the client on admission are life threatening
3. In some instances diverticulitis is difficult to differentiate from carcinoma except surgically
4. The clients age indicates immediate correction of the potentially fatal condition is needed
Answer 2
Rationale 1. Diverticulitis can in most cases be treated by diet, rest, and antibiotic therapy.
Rationale 2. The client’s status requires immediate intervention: to delay treatment may prove dangerous because
symptoms indicate possible perforation. Rationale 3. This is not true with the diagnostic techniques presently available.
Rationale 4. Age is not the factor: the symptoms indicate possible peritonitis.
62. An 18-year-old is admitted with an acute onset of right lower quadrant pain.
Appendicitis is suspected. For which clinical indicator should the nurse assess the client to determine if the pain is
secondary to appendicitis?
1. Urinary retention
2. Gastric hyperacidity
3. Rebound tenderness
4. Increased lower bowel motility
Answer 3
Rationale 1. Urinary retention does not cause acute lower right quadrant pain.
Rationale 2. Hyperacidity causes epigastric. not lower right quadrant. pain.
Rationale 3. Rebound tenderness is a classic subjective sign of appendicitis.
Rationale 4. There is generally decreased bowel motility distal to an inflamed appendix.
63. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) after extensive colon surgery. The nurse
concludes that the client understands teaching about the purpose of TPN when the client states, “TPN:
1. Provides short-term nutrition after surgery.”
2.Assists in providing supplemental nutrition.”
3. Provides total nutrition when GI function is questionable.”
4. Assists people who are unable to eat but have active GI function.”
Answer 3
Rationale 1. TPN is usually used in chronic or long-term therapy. not for short-term
therapy.
Rationale 2. TPN is used for total. not supplemental. nutrition.
Rationale 3. When GI absorption is inadequate, total parenteral nutrition (TPN) is
the nutritional therapy of choice because it provides needed nutrients.
Rationale 4. This is not the indication for TPN: a feeding tube would be used.
64. A nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which assessment
data would alert the nurse to this occurrence?
1. Firm, nontender mass palpable at the lower right costal margin
2. Severe, constant pain with rapid onset
3. Inability to pass flatus
4. Loss of anal sphincter control
Correct Answer: 3
Rationale:
An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most common form of nonmechanical
obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Option 1 is the description of the physical
finding of liver enlargement. The liver is usually enlarged in cases of cirrhosis or hepatitis. Although this client may have
an enlarged liver, an enlarged liver is not a sign of paralytic ileus or intestinal obstruction. Pain is associated with
paralytic ileus, but the pain usually manifests as a more constant generalized discomfort. Pain that is severe, constant,
and rapid in onset is more likely caused by strangulation of the bowel. Loss of sphincter control is not a sign of paralytic
ileus.
65. After performing an initial abdominal assessment on a client with a diagnosis of cholelithiasis, a nurse documents
that
the bowel sounds are normal. Which of the following descriptions best describes “normal bowel sounds”?
1. Waves of loud gurgles auscultated in all four quadrants
2. Very high-pitched loud rushes auscultated especially in one or two quadrants
3. Relatively high-pitched clicks or gurgles auscultated in all four quadrants
4. Low-pitched swishing auscultated in one or two quadrants
Correct Answer: 3
Rationale:
Although frequency and intensity of bowel sounds vary depending on the phase of digestion, normal bowel sounds are
relatively high-pitched clicks or gurgles. Loud gurgles (borborygmi) indicate hyperperistalsis. Bowel sounds are more
high-pitched and louder (hyperresonance) when the intestines are under tension, such as in intestinal obstruction. A
swishing or buzzing sound represents turbulent blood flow associated with a bruit. Bruits are not normal sounds.
66. A client is admitted to the hospital with a diagnosis of regional enteritis (Crohn’s disease). Which is the most likely
reason for the physician to order administration of parenteral vitamins to this client?
1. More rapid action results.
2. They are ineffective orally.
3. They decrease colon irritability.
4. Intestinal absorption may be inadequate.
Answer 4
Rationale 1.Although this is true, the risks associated with IV administration will
outweigh the benefits.
Rationale 2. Vitamins are effective orally unless disease of the Gl tract hampers
absorption
Rationale 3. IV vitamins do not decrease colonic irritability.
Rationale 4. Because the mucosa of the intestinal tract is damaged. its ability to absorb vitamins taken orally is greatly
impaired.
67. When an intestinal obstruction is suspected. a client has a nasogastric tube
inserted and attached to suction. The nurse should critically assess this client for:
1. Edema
2. Belching
3. Dehydration
4. Excessive salivation
Answer 3
Raonale 1. Based on the data provided, this symptom is not likely to occur.
Rationale 2. Based on the data provided, this symptom is not likely to occur.
Rationale 3. Dehydration is a danger because of fluid loss with GI suction.
Raonale 4. Based on the data provided, this symptom is not likely to occur.
68. A client has severe diarrhea and the physician orders intravenous therapy. sodium bicarbonate. and an antidiarrheal
medication. The nurse expects that the physician will probably order which most frequently ordered antidiarrheal drug?
1. Bisacodyl (Dulcolax)
2. Psyllium (Metamucil)
3. Docusate sodium (Colace)
4. Loperamide HCI (Imodium)
Answer 4
Rationale 1. This drug is a laxative, not an antidiarrfleal: it increases GI motility.
Rationale 2. This is not an antidiarrheal. but a bulk laxative that promotes an easier expulsion of feces.
Rationale 3. This drug corrects constipation, not diarrhea: water and fat are increased in the intestine, permitting easier
expulsion of feces.
Rationale 4. This drug is a piperidine derivative that acts directly on the intestinal muscles to decrease penstalsis.
69. After undergoing Billroth I gastric surgery, the client experiences fatigue and complains of numbness and tingling in
the
feet and difficulties with balance. On the basis of these symptoms, the nurse suspects which postoperative
complication?
1. Pernicious anemia
2. Bacterial meningitis
3. Stroke
4. Peripheral arterial disease
Correct Answer: 1
Rationale:
Billroth I surgery involves removing one half to two thirds of the stomach and reanastomosing the remaining segment of
the stomach to the duodenum. With the loss of this much of the stomach, development of pernicious anemia is not
uncommon. Pernicious anemia is a macrocytic anemia that most commonly is caused by the lack of intrinsic factor.
During a Billroth I procedure, a large portion of the parietal cells, which are responsible for producing intrinsic factor (a
necessary component for vitamin B., absorption), are removed. In this anemia, the red cell is larger than usual and hence
does not last as long in the circulation as normal red blood cells do, causing the client to have anemia with resultant
fatigue. Vitamin B., also is necessary for normal nerve function. Because of the lack of the necessary intrinsic factor,
persons with pernicious anemia also experience paresthesias, impaired gait, and impaired balance. 70. The nurse is
caring for a client with a peptic ulcer who has just had an esophagogastroduodenoscopy (EGD). Which
nursing diagnosis would be the priority?
1. Risk for aspiration related to poor gag reflex secondary to local anesthesia
2. Deficient knowledge of post-procedure care related to not having had an EGD before
3. Risk for Deficient fluid volume related to hemorrhage or perforation of the gastrointestinal tract
4. Impaired comfort (sore throat) related to passage of the endoscope through the pharyngeal region during EGD
Correct Answer: 1
Rationale:
EGD is a visual inspection of the esophagus, stomach, and duodenum using a fiberoptic endoscope. All the diagnoses
listed in this question are potentially appropriate for a client who just had an EGD. Looking at priorities of nursing
diagnoses, the nurse would first be concerned about the ABCs—airway, breathing, and circulation. After the procedure,
the client is recovering from the use of conscious sedation and the administration of a local anesthetic to the throat.
Therefore, the diagnosis of Risk for aspiration is most important at this point because of the potential for airway
problems.
Cognitive Level: Analyzing
Integrated Process: Nursing Process: Planning
Content Area: Adult Health: Gastrointestinal
Note the strategic word priority. Use the ABCs—airway, breathing, and circulation. This will direct you to option 1.
Review care of the client after an EGD if you had difficulty with this question.
Reference(s):
Pagana, K., & Pagana, T. (2009). Mosby’s diagnostic and laboratory test reference (9th ed., p. 407). St. Louis: Mosby.
hisevier items and denved items (c) 21.111 by Saunders, an impnnt hisevier, Inc. Some matenal was previously
published.
71. A nurse obtains an admission history for a client with suspected peptic ulcer disease (PUD). Which of the following
client factors documented by the nurse would increase the risk for PUD?
1. Recently retired from a job
2. Significant other has a gastnc ulcer
3. Takes ibuprofen (Motrin) for osteoarthritis
4. Occasionally drinks one cup of coffee in the morning
Correct Answer: 3
Rationale:
Risk factors for PUD include Helicobacterpylori infection, smoking (nicotine), chewing tobacco, corticosteroids, aspirin,
nonsteroidal anti-inflammatory drugs (NSAIDs), caffeine, alcohol, and stress. Ibuprofen is an NSAID, and when taken as
often as is typical for osteoarthritis, it will cause problems with the stomach. Certain medical conditions such as Crohns
disease, Zollinger-Ellison syndrome, and hepatic and biliary disease also can increase the risk for PUD by changing the
amount of gastric and biliary acids produced. Ulcer disease in a first-degree relative also is associated with increased risk
for an ulcer.
72. In performing a physical assessment of a client with a diagnosis of ulcerative colitis, the nurse would expect which of
the following findings?
1. Hypercalcemia
2. Fibrous stricture
3. Frothy, fatty stools
4. Decreased hemoglobin
Correct Answer: 4
Rationale:
Ulcerative colitis is an inflammatory disease of the large colon. The signs and symptoms of ulcerative colitis include
diarrhea with up to 10 to 20 liquid bloody stools per day, weight loss, anorexia, fatigue, increased white blood cell
count, increased erythrocyte sedimentation rate, dehydration, hyponatremia, and hypokalemia. Strictures and fistulas
are more commonly seen in Crohn’s disease than in ulcerative colitis. Clients with ulcerative colitis have bloody
diarrhea, not steatorrhea (fatty, frothy, foul-smelling stools). Because of the loss of blood, clients with ulcerative colitis
commonly have a decreased hemoglobin and hematocrit levels.
73. A nurse is performing an assessment on a client with acute pancreatitis who was admitted to the hospital. Which of
the following assessment questions would most specifically elicit information regarding the pain that is associated with
acute pancreatitis?
1. “Does the pain in your lower abdomen radiate to your groin?”
2. “Does the pain in your stomach radiate to the back?”
3. “Does the pain in your stomach radiate to your lower middle abdomen?”
4. “Does the pain in your lower abdomen radiate to the hip?”
Correct Answer: 2
Rationale:
The pain that is associated with acute pancreatitis is often severe and is located in the epigastric region and radiates to
the back. Options 1, 3, and 4 are incorrect because they are not specific for the pain experienced by the client with
pancreatitis.
74. The nurse is teaching a client with a permanent colostomy about self-care in preparation for discharge from the
hospital. Which should the nurse discuss with the client? The:
1. Need for special clothing
2. Periodic dilation of the stoma
3. Importance of limiting activity
4. Bland. low-residue diet regimen
Answer 2
Rationale 1. Clothing need not be special but should be nonconstncting.
Raonale 2. The stoma of a colostomy must be dilated with a lubricated, gloved finger to prevent strictures and
subsequent obstruction.
Rationale 3. Once healing has occurred, activity is not limited.
Rationale 4. Diet should be as close to normal for the individual as possible. gas- forming foods should be avoided.
75. A nurse is caring for a client after abdominal surgery and creation of a colostomy. The nurse is assessing the client for
a prolapsed stoma and would expect to note which of the following if this is present?
1. A sunken and hidden stoma
2. A stoma that is dusky or bluish
3. A narrow and flattened stoma
4. A protrusion of the bowel with an elongated, swollen appearance of the stoma
Correct Answer: 4
Rationale:
A prolapsed stoma is one in which the bowel protrudes, causing an elongated and swollen appearance to the stoma. A
retracted stoma is characterized by sinking of the stoma. lschemia of the stoma would be associated with a dusky or
bluish color. A stoma with a narrow opening is described as being stenosed.
Cognitive Level: Analyzing
Integrated Process: Nursing Process: Assessment
76. The nurse is caring for a client with an indwelling urinary catheter. What is the most
important action for the nurse to take when planning to irrigate the bladder?
1. Use sterile equipment.
2. Instill the fluid under high pressure.
3. Warm the solution to body temperature.
4. Aspirate immediately to ensure return flow.
Answer 1
Rationale 1. The bladder is a sterile body cavity: when introducing a solution/catheter.
surgical asepsis is required.
Rationale 2. Excessive pressure can traumatize the lining of the urinary tract.
Rationale 3. The solution is generally administered at room temperature.
Rationale 4. This is done if the fluid does not return by gravity: the negative pressure exerted during aspiration may
cause trauma.
77. A client diagnosed with chronic renal failure (CRF) is scheduled to begin hemodialysis. The nurse determines that
which of the following neurological and psychosocial manifestations, if exhibited by this client, is unrelated to the CRF?
1. Labile emotions
2. Withdrawal
3. Euphoria
4. Depression
Correct Answer: 3
Rationale:
The client with CRF often experiences a variety of psychosocial changes. These changes are related to uremia and to the
stress associated with living with a chronic disease that is life threatening. Clients with CRF may have labile emotions or
personality changes and may exhibit withdrawal, depression, or agitation. Delusions and psychosis also can occur.
Euphoria is not part of the clinical picture for the client in renal failure.
78. A client has chronic renal failure (CRF), but the condition does yet not require dialysis. Which of the following
comments to the nurse, if made by the client, needs further discussion?
1. “I will weigh myself on my bathroom scale every morning right after I have urinated.”
2. “I will reduce the sodium in my diet, and I can use salt substitutes to spice my food.”
3. “The amount of fluid I can have every day depends on the amount of urine I put out.”
4. “I should report a gain in weight, trouble with my breathing, or increased leg swelling.”
Correct Answer: 2
Rationale:
CRF is a condition in which the kidneys have progressive problems in their ability to clear nitrogenous waste products
and to control fluid and electrolyte balance within the body. Conservative treatment of CRF slows progression of the
disease and includes reducing the protein, sodium, potassium, and phosphorus in the diet; controlling the blood
pressure; and altering the fluid intake in relation to urine output. The daily weight is one of the most important
measurements to indicate fluid volume of the client. It is important to reduce the sodium in the diet, but salt substitutes
usually are potassium-based and should not be used by a client with kidney failure because of the risk of hyperkalemia.
The client should monitor for signs and symptoms of fluid overload, which could include an increase in weight, edema,
and fluid collection in the lungs.
79. For what should the nurse monitor when caring for a client who has hematuria?
1. Intractable diarrhea
2. Acetone in the urine
3. Symptoms of peritonitis
4. Gross blood in the urine
Answer 4
Rationale 1. This is unrelated to hematuria.
Rationale 2. This is unrelated to hematuna: it is associated with breakdown of adipose
tissue.
Rationale 3. This is unrelated to hematuria.
Rationale 4. Changes in the amount of blood in the urine may indicate progressive increases in kidney damage.
80. A nurse is giving general instructions to a client receiving hemodialysis. Which of the following statements would be
appropriate for the nurse to include?
1. “Several types of medications should be withheld on the day of dialysis until after the procedure.”
2. “Medications should be double-dosed on the morning of hemodialysis to prevent loss.”
3. “It is acceptable to exceed the fluid restriction on the day before hemodialysis.”
4. “It is acceptable to eat whatever you want on the day before hemodialysis.”
Correct Answer: 1
Rationale:
Many medications are dialyzable, which means that they are extracted from the bloodstream during dialysis. Therefore,
many medications may be withheld on the day of dialysis until after the procedure. It is not typical for medications to be
double-dosed, because there is no way to be certain how much of each medication is cleared by dialysis. Clients
receiving hemodialysis are not routinely taught that it is acceptable to disregard dietary and fluid restrictions. Cognitive
81. A client with chronic renal failure has been on dialysis for 3 years. The client is receiving the usual combination of
medications for the disease, including aluminum hydroxide as a phosphate-binding agent. The client now presents with
mental cloudiness, dementia, and complaints of bone pain. The nurse determines that these assessment data are
compatible with:
1. Phosphate overdose
2. Aluminum intoxication
3. Advancing uremia
4. Folic acid deficiency
Correct Answer: 2
Rationale:
Aluminum intoxication can occur when there is accumulation of aluminum, an ingredient in many phosphate-binding
antacids. It results in mental cloudiness, dementia, and bone pain from infiltration of the bone with aluminum. It can be
treated with aluminum-chelating agents, which make aluminum available to be dialyzed from the body. It can be
prevented by avoiding or limiting the use of phosphate-binding agents that contain aluminum. The data in the question
are not specifically associated with the other conditions noted in the options.
82. A client undergoing hemodialysis is at risk for bleeding from the heparin used during the hemodialysis treatment.
The
nurse assesses for this occurrence by periodically checking the results of which of the following laboratory tests?
1. Partial thromboplastin time (PU)
2. Prothrombin time (PT)
3. Thrombin time
4. Bleeding time
Correct Answer: 1
Rationale:
Heparin is the anticoagulant used most often during hemodialysis. The hemodialysis nurse monitors the extent of
anticoagulation by checking the PTT, which is the appropriate measure of heparin effect. The PT is one test used to
monitor the effect of warfarin (Coumadin) therapy. Thrombin and bleeding times are not used to measure the effect of
heparin therapy, although they are useful in the diagnosis of other clotting abnormalities.
83. A nurse is monitoring the fluid balance of an assigned client. The nurse determines that the client has proper fluid
balance if which of the following 24-hour intake and output totals is noted?
1. Intake 1500 mL, output 800 mL
Correct Answer: 4
Rationale:
For the client taking a normal diet, the normal fluid intake is approximately 1200 to 1800 mL of measurable fluids per
day. The client’s output in the same period should be about the same and does not include insensible losses, which are
extra. Insensible losses are offset by the fluid in solid foods, which also is not measured.
84. A nurse is caring for a client with acute renal failure (ARF). When performing an assessment, the nurse would expect
to
note which of the following breathing patterns?
1. Decreased respirations
2. Apnea
3. Cheyne-Stokes respirations
4. Kussmaul’s respirations
Correct Answer: 4
Rationale:
Clinical manifestations associated with ARF occur as a result of metabolic acidosis. The nurse would expect to note
Kussmaul’s respirations as a result of the metabolic acidosis because the bodily response is to exhale excess carbon
dioxide. The breathing patterns noted in options 1, 2, and 3 are not characteristic of ARF.
85. A nursing student is assigned to care for a client with a diagnosis of acute renal failure (ARF), diuretic phase. The
nursing instructor asks the student about the primary goal of the treatment plan for this client. Which of the following
goals, if stated by the nursing student, would indicate an adequate understanding of the treatment plan for this client?
1. Prevent loss of electrolytes.
2. Reduce the urine specific gravity.
3. Promote the excretion of wastes.
4. Prevent fluid overload.
Correct Answer: 1
Rationale:
In the diuretic phase, fluids and electrolytes are lost in the urine. As a result, the plan of care focuses on fluid and
electrolyte replacement and monitoring. Options 2, 3, and 4 are not the primary concerns in this phase of renal failure.
86. A client with chronic renal failure is about to begin hemodialysis therapy. The client asks the nurse about the
frequency
and scheduling of hemodialysis treatments. The nurse’s response is based on an understanding that the typical
schedule is:
1. 5 hours of treatment 2 days per week
2. 3 to 4 hours of treatment 3 days per week
3. 2 to 3 hours of treatment 5 days per week
4. 2 hours of treatment 6 days per week
Correct Answer: 2
Rationale:
The typical schedule for hemodialysis is 3 to 4 hours of treatment 3 days per week. Individual adjustments are made
according to variables such as the size of the client, type of dialyzer, rate of blood flow, personal client preferences, and
other factors.
87. A client is about to begin hemodialysis. Which of the following measures should the nurse avoid in the care of the
client?
1. Giving the client a mask to wear during connection to the machine
2. Wearing full protective clothing such as goggles, mask, gloves, and apron
3. Covering the connection site with a bath blanket to enhance extremity warmth
4. Using sterile technique for needle insertion
Correct Answer: 3
Rationale:
Infection is a major concern with hemodialysis. For that reason, the use of sterile technique and the application of a face
mask for both nurse and client are extremely important. It also is imperative that standard precautions be followed,
which includes the use of goggles, mask, gloves, and an apron. The connection site should not be covered; it should be
visible so that the nurse can assess for bleeding, ischemia, and infection at the site during the hemodialysis procedure.
88. A nurse is assessing the renal function of a client at risk for renal failure. After noting the amount of urine output and
urine characteristics, the nurse proceeds to assess which of the following as the best indirect indicator of renal status?
1. Jugular vein distention
2. Level of consciousness
3. Apical heart rate
4. Blood pressure
Correct Answer: 4
Rationale:
The kidneys normally receive 20% to 25% of the cardiac output, even under conditions of rest. For kidney function to be
optimal, adequate renal perfusion is necessary. Perfusion can best be estimated by the blood pressure, which is an
indirect reflection of the adequacy of cardiac output. The heart rate affects the cardiac output but can be altered by
factors unrelated to kidney function. Jugular vein distention and level of consciousness are unrelated items.
89. The home care nurse is preparing to visit a client who has undergone renal transplantation. The nurse develops a
plan of care that includes monitoring the client for signs of acute graft rejection. The nurse documents in the plan to
assess the client for which signs of acute graft rejection?
1. Hypotension, graft tenderness, and hypothermia
2. Hypertension, polyuria, and thirst
3. Fever, hypotension, and polyuria
4. Fever, hypertension, and graft tenderness
Correct Answer: 4
Rationale:
Acute rejection usually occurs within the first 3 months after transplantation, although it can occur for up to 2 years
after transplantation. The client exhibits fever, hypertension, malaise, and graft tenderness. Treatment with
corticosteroids, and possibly also with monoclonal antibodies and antilymphocyte agents, is begun immediately.
90. A nurse is planning a teaching session with a client who has chronic renal failure (CRF) about managing the condition
between dialysis treatments. The nurse plans to include the instruction that weight gain between dialysis treatments
should be ideally no more than:
1.0.5 to 1.0 kg
2.1 to 1.5 kg
3. 2 to 4 kg
4. 5 to 6 kg
Correct Answer: 2
Rationale:
Limiting weight gain to 1 to 1 .5 kg between dialysis treatments helps prevent the hypotension that occurs with the
removal of large volumes of fluid during dialysis. The nurse instructs the client in how to manage daily fluid allotment to
assist the client in staying within a low fluid intake range to prevent excess weight gain. Options 1, 3, and 4 are incorrect.
Cognitive Level: Applying

Integrated Process: Teaching and Learning
Content Area: Adult Health: Renal
91. When caring for a client with a diagnosis of benign prostatic hyperplasia. it is
important for the nurse to understand that it:
1. Is a congenital abnormality
2. usually becomes malignant
3. Predisposes to hydronephrosis
4. Causes an elevated acid phosphatase level
Answer 3
Rationale 1. BPH develops over the client’s life span: it is not congenital.
Rationale 2. It is uncommon for BPH to become malignant.
Rationale 3. Inability to empty the bladder. as a result of pressure exerted by the enlarging prostate on the urethra,
causes a backup of urine into the ureters and finally the kidneys (hyd roneph rosis).
Rationale 4. This level is elevated in prostatic carcinoma.
92. The nurse is caring for a client with chronic kidney failure. Which adaptation
should the nurse expect?
1. Polyuria
2. Hypotension
3. Muscle twitching
4. Respiratory acidosis
Answer 3
Rationale 1. Extensive nephron damage causes oliguna. not polyuna.
Rationale 2. Hypotension does not occur: the BP is within the expected range or elevated as a result of increased total
body fluid.
Rationale 3. This adaptation results from excess nitrogenous wastes.
Rationale 4. Metabolic, not respiratory. acidosis occurs because of the kidneys’ inability to excrete hydrogen and
regulate sodium and bicarbonate levels.
93. The pathology report states that a client’s urinary calculus is composed of uric
acid. Which should the nurse instruct the client to avoid?
1. Eggs
2. Fruit
3. Meat extracts
4. Raw vegetables
Answer 3
Raonale1.Thi5 is not high in purine and need not be avoided.
Rabonale 2. This is not high in purine and need not be avoided.
Rationale 3. Uric acid stones are controlled by a low-purine diet: foods high in purine. such as organ meats and meat
extracts, should be avoided.
Rationale 4. This is not high in purine and need not be avoided.
94. A client with acute kidney failure becomes confused and irritable. The nurse understands that the most likely cause
of this behavior is:
1. Hyperkalemia
2. Hypernatremia
3.An elevated BUN
4.Alimited fluid intake
Answer 3
Rationale 1. Hyperkalemia is associated with muscle weakness, irritability, nausea. and diarrhea
Rationale 2. Hypernatremia is associated with firm tissue turgor. oliguria. and agitation.
Rationale 3M elevated blood urea nitrogen level, indicating uremia, is toxic to the CNS and causes mental cloudiness and
confusion and can result in a loss of consciousness.
Rationale 4. Dehydration can cause fatigue, dry skin and mucous membranes, along with rapid pulse and respiratory
rates.
95. The nurse is caring for clients with renal calculi. Which is the most important nursing action?
1. Limit fluid intake at night.
2. Strain the urine at each voiding.
3. Record the client’s blood pressure.
4. Administer analgesics every 3 hours.
Answer 2
Raonale 1. Fluids should be encouraged to promote dilute urine and facilitate passage of the calculi.
Rationale 2. Urine is strained to determine whether any calculi or calcium gravel has been passed.
Raonale 3. Blood pressure assessment is of no particular importance to the patient with kidney stones.
Rationale 4. Administration of analgesics is based on the physicians order.
Client Need: Reduction of Risk Potential
Cognitive Level: Application
Integrated Process/Nursing Process: Assessment/Analysis
Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.
96. The nurse understands which pnnciple is associated with the reabsorption of water
from glomerular filtrate in the kidney tubules?
1. Osmosis
2. Diffusion
3. Active dialysis
4. Active transport
Answer 1
RaonaIe 1. Osmosis is the diffusion of water through a selectively permeable membrane. Such membranes include
cellular membranes and capillary walls. Osmosis occurs in the kidney tubules and in all capillary beds.
Rabonale 2. Diffusion is the process by which particulate matter in a fluid moves from an area of greater concentration
to an area of lesser concentration.
Rationale 3. Dialysis is the diffusion of small molecules, other than water, down their concentration gradients through a
selectively permeable membrane.
Raonale 4. Active transport is the movement of molecules against a concentration gradient and requires energy input:
osmosis and diffusion are passive processes.
97. The nurse is caring for a client with a diagnosis of cancer of the prostate Which
serum level should be monitored to follow the course of the disease?
1. Creatinine
2. Blood urea nitrogen
3. Nonprotein nitrogen
4. Prostate-spec inc antigen
Answer 4
Raonale 1. Elevated creatinine levels may be caused by impaired renal function as a result of blockage by an enlarged
prostate but do not indicate that metastasis has occurred.
Rabonale 2. Elevated BUN levels may be caused by impaired renal function as a result of blockage by an enlarged
prostate but do not indicate that metastasis has occurred.
Rationale 3. Nonprotein nitrogen refers to waste products from metabolism of protein and includes urea. creatinine. uric
acid, and ammonia.
Rationale 4. The PSA is an indication of cancer of the prostate: the higher the level. the greater the tumor burden.
98. The nurse understands that metabolic acidosis develops in kidney failure as a result of:
1. Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate
2. Depressed respiratory rate by metabolic wastes, causing carbon dioxide retention
3. Inability of the renal tubules to reabsorb water to dilute the acid contents of blood
4. Impaired glomerular filtration, causing retention of sodium and metabolic waste products
Answer 1
Rabonale 1. Bicarbonate buffering is limited, hydrogen ions accumulate. and acidosis results.
Rationale 2. The rate of respirations increases in metabolic acidosis to compensate for a low pH.
Rationale 3. The fluid balance does not significantly alter the pH.
Rationale 4. The retention of sodium ions is related to fluid retention and edema rather than to acidosis.
99. The nurse is caring for a client with an external shunt used for hemodialysis. The nurse understands that the most
serious complication associated with
hemoclialysis is:
1. Septicemia
2. Clot formation
3. Exsanguination
4. Sclerosis of vessels
Answer 3
Rationale 1.Although a potential complication, this does not pose the same
immediate threat to life as does exsanguination.
Rationale 2. Although a potential complication, this does not pose the same
immediate threat to life as does exsanguination.
Rationale 3. Because an external shunt provides circulatory access to a major artery and vein, special safety precautions
must be taken to prevent disconnection of the cannula. Disconnection can cause unimpeded excessive blood loss and
death. Clamps should be carried at all times by the client and the client should know how to use them in preparation for
this emergency.
Rationale 4. Although a potential complication, this does not pose the same immediate threat to life as does
exsanguination.
100. A client with acute kidney failure is to receive a very low-protein diet. The nurse understands that this diet is based
on the principle that:
l.A high-protein intake ensures an adequate daily supply of amino acids to compensate for losses
2. Essential and nonessential amino acids are necessary in the diet to supply materials for tissue protein synthesis
3. This supplies only essential amino acids, reducing the amount of metabolic waste products. thus decreasing stress on
the kidneys
4. Urea nitrogen cannot be used to synthesize amino acids in the body. so the nitrogen for amino acid synthesis must
come from the dietary protein
Answer 3
Rationale I. In kidney failure the kidneys are unable to eliminate the waste products
of a high-protein diet.
Rationale 2. The body is able to synthesize the nonessential amino acids.
Rationale 3. The amount of protein permitted in the diet (usually below 50 9) depends on the extent of kidney function:
excess protein causes an increase in urea concentration, which should be avoided: adequate calories are provided to
prevent tissue catabolism that also results in an increase in metabolic waste products.
Rationale 4. Urea is a waste product of protein metabolism: the body is able to synthesize the nonessential amino acids.

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SUCCEED REVIEW CENTER

MOCK BOARD PART 3

which of the following instructions in client teaching about this procedure?

1. The client has residual pneumothorax.

the site. The nurse should apply pressure for at least:

Cognitive Level: Applying

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