Airway - Obstruction and Asthma

Airway – Obstruction and
Asthma
1. An elderly client with pneumonia may appear with which of the following symptoms first?
A. Altered mental status and dehydration
B. fever and chills
C. Hemoptysis and dyspnea
D. Pleuretic chest pain and cough
Ans-1. 1. Fever, chills, hemoptysis, dyspnea, cough, and pleuric chest pain are the common
symptoms of pneumonia, but elderly clients may first appear with only an altered mental status
and dehydration due to a blunted immune response.
2. Which of the following pathophysiological mechanisms that occurs in the lung
parenchyma allows pneumonia to develop?
1. Atelectasis
2. Bronchiectasis
3. Effusion
4. Inflammation
Ans-2. 4. the most common feature of all types of pneumonia is an inflammatory pulmonary
response to the offending organism or agent. Atelectasis and bronchiectasis indicate a collapse of
a portion of the airway that doesn’t occur with pneumonia. An effusion is an accumulation of
excess pleural fluid in the pleural space, which may be a secondary response to pneumonia.
3. A 7-year-old client is brought to the E.R. He’s tachypneic and afebrile and has a
respiratory rate of 36 breaths/minute and a nonproductive cough. He recently had a cold.
From his history, the client may have which of the following?
1. Acute asthma
2. Bronchial pneumonia
3. Chronic obstructive pulmonary disease (COPD)
4. Emphysema
Ans-3. 1. Based on the client’s history and symptoms, acute asthma is the most likely diagnosis.
He’s unlikely to have bronchial pneumonia without a productive cough and fever and he’s too
young to have developed COPD or emphysema.
4. Which of the following assessment findings would help confirm a diagnosis of asthma in a
client suspected of having the disorder?
1. Circumoral cyanosis
2. Increased forced expiratory volume
3. Inspiratory and expiratory wheezing
4. Normal breath sounds
Ans-4. 3. Inspiratory and expiratory wheezes are typical findings in asthma. Circumoral cyanosis
may be present in extreme cases of respiratory distress. The nurse would expect the client to
have a decreased forced expiratory volume because asthma is an obstructive pulmonary disease.
Breath sounds will be “tight” sounding or markedly decreased; they won’t be normal.
5. Which of the following types of asthma involves an acute asthma attack brought on by an
upper respiratory infection?
1. Emotional
2. Extrinsic
3. Intrinsic
4. Mediated
Ans-5. 1. Intrinsic asthma doesn’t have an easily identifiable allergen and can be triggered by the
common cold. Asthma caused be emotional reasons is considered to be in the extrinsic category.
Extrinsic asthma is caused by dust, molds, and pets; easily identifiable allergens. Mediated
asthma doesn’t exist.
6. A client with acute asthma showing inspiratory and expiratory wheezes and a decreased
expiratory volume should be treated with which of the following classes of medication right
away?
1. Beta-adrenergic blockers
2. Bronchodilators
3. Inhaled steroids
4. Oral steroids
Ans-6. 2. Bronchodilators are the first line of treatment for asthma because bronchoconstriction
is the cause of reduced airflow. Beta-adrenergic blockers aren’t used to treat asthma and can
cause bronchoconstriction. Inhaled or oral steroids may be given to reduce the inflammation but
aren’t used for emergency relief.
7. A 19-year-old comes into the emergency department with acute asthma. His respiratory rate
is 44 breaths/minute, and he appears to be in acute respiratory distress. Which of the following
actions should be taken first?
1. Take a full medication history

2. Give a bronchodilator by nebulizer
3. Apply a cardiac monitor to the client
4. Provide emotional support to the client.
Ans-7. 2. The client is having an acute asthma attack and needs to increase oxygen delivery to
the lung and body. Nebulized bronchodilators open airways and increase the amount of oxygen
delivered. First resolve the acute phase of the attack ad how to prevent attacks in the future. It
may not be necessary to place the client on a cardiac monitor because he’s only 19-years-old,
unless he has a past medical history of cardiac problems.
8. A 58-year-old client with a 40-year history of smoking one to two packs of cigarettes a day
has a chronic cough producing thick sputum, peripheral edema, and cyanotic nail beds. Based
on this information, he most likely has which of the following conditions?
1. Adult respiratory distress syndrome (ARDS)

2. Asthma
3. Chronic obstructive bronchitis
4. Emphysema
Ans-8. 3. Because of his extensive smoking history and symptoms, the client most likely has
chronic obstructive bronchitis. Clients with ARDS have acute symptoms of and typically need
large amounts of oxygen. Clients with asthma and emphysema tend not to have a chronic cough
or peripheral edema.
9. The term “blue bloater” refers to which of the following conditions?
1. Adult respiratory distress syndrome (ARDS)

2. Asthma
4. Emphysema
Ans-9. 3. Clients with chronic obstructive bronchitis appear bloated; they have large barrel
chests and peripheral edema, cyanotic nail beds and, at times, circumoral cyanosis. Clients with
ARDS are acutely short of breath and frequently need intubation for mechanical ventilation and
large amounts of oxygen. Clients with asthma don’t exhibit characteristics of chronic disease,
and clients with emphysema appear pink and cachectic (a state of ill health, malnutrition, and
wasting).
10. The term “pink puffer” refers to the client with which of the following conditions?
1. ARDS
2. Asthma
4. Emphysema
Ans-10. 4. Because of the large amount of energy it takes to breathe, clients with emphysema are
usually cachectic. They’re pink and usually breathe through pursed lips, hence the term “puffer”.
Clients with ARDS are usually acutely short of breath. Clients with asthma don’t have any
particular characteristics, and clients with chronic obstructive bronchitis are bloated and cyanotic
in appearance.
11. A 66-year-old client has marked dyspnea at rest, is thin, and uses accessory muscles to
breathe. He’s tachypneic, with a prolonged expiratory phase. He has no cough. He leans
forward with his arms braced on his knees to support his chest and shoulders for breathing.
This client has symptoms of which of the following respiratory disorders?
1. ARDS
2. Asthma
4. Emphysema
Ans-11. 4. These are classic signs and symptoms of a client with emphysema. Clients with
ARDS are acutely short of breath and require emergency care; those with asthma are also acutely
short of breath during an attack and appear very frightened. Clients with chronic obstructive
bronchitis are bloated and cyanotic in appearance.
12. Its highly recommended that clients with asthma, chronic bronchitis, and emphysema
have Pneumovax and flu vaccinations for which of the following reasons?
1. All clients are recommended to have these vaccines

2. These vaccines produce bronchodilation and improve oxygenation.
3. These vaccines help reduce the tachypnea these clients experience.
4. Respiratory infections can cause severe hypoxia and possibly death in these clients.
Ans-12. 4. it’s highly recommended that clients with respiratory disorders be given vaccines to
protect against respiratory infection. Infections can cause these clients to need intubation and
mechanical ventilation, and it may be difficult to wean these clients from the ventilator. The
vaccines have no effect on bronchodilation or respiratory care.
13. Exercise has which of the following effects on clients with asthma, chronic bronchitis,
and emphysema?
1. It enhances cardiovascular fitness.

2. It improves respiratory muscle strength.
3. It reduces the number of acute attacks.
4. It worsens respiratory function and is discouraged.
Ans-13. 1. Exercise can improve cardiovascular fitness and help the client tolerate periods of
hypoxia better, perhaps reducing the risk of heart attack. Most exercise has little effect on
respiratory muscle strength, and these clients can’t tolerate the type of exercise necessary to do
this. Exercise won’t reduce the number of acute attacks. In some instances, exercise may be
contraindicated, and the client should check with his physician before starting any exercise
program.
14. Clients with chronic obstructive bronchitis are given diuretic therapy. Which of the
following reasons best explains why?
1. Reducing fluid volume reduces oxygen demand.

2. Reducing fluid volume improves clients’ mobility.
3. Restricting fluid volume reduces sputum production.
4. Reducing fluid volume improves respiratory function.
Ans-14. 1. Reducing fluid volume reduces the workload of the heart, which reduces oxygen
demand and, in turn, reduces the respiratory rate. It may also reduce edema and improve mobility
a little, but exercise tolerance will still be harder to clear airways. Reducing fluid volume won’t
improve respiratory function, but may improve oxygenation.
15. A 69-year-old client appears thin and cachectic. He’s short of breath at rest and his
dyspnea increases with the slightest exertion. His breath sounds are diminished even with deep
inspiration. These signs and symptoms fit which of the following conditions?
1. ARDS
2. Asthma
4. Emphysema
Ans-15. 4. In emphysema, the wall integrity of the individual air sacs is damaged, reducing the
surface area available for gas exchange. Very little air movement occurs in the lungs because of
bronchiole collapse, as well. In ARDS, the client’s condition is more acute and typically requires
mechanical ventilation. In asthma and bronchitis, wheezing is prevalent.
16. A client with emphysema should receive only 1 to 3 L/minute of oxygen, if needed, or he
may lose his hypoxic drive. Which of the following statements is correct about hypoxic drive?
1. The client doesn’t notice he needs to breathe.

2. The client breathes only when his oxygen levels climb above a certain point.
3. The client breathes only when his oxygen levels dip below a certain point.
4. The client breathes only when his carbon dioxide level dips below a certain point.
Ans-16. 3. Clients with emphysema breathe when their oxygen levels drop to a certain level; this
is known as the hypoxic drive. They don’t take a breath when their levels of carbon dioxide are
higher than normal, as do those with healthy respiratory physiology. If too much oxygen is
given, the client has little stimulus to take another breath. In the meantime, his carbon dioxide
levels continue to climb, and the client will pass out, leading to a respiratory arrest.
17. Teaching for a client with chronic obstructive pulmonary disease (COPD) should include
which of the following topics?
1. How to have his wife learn to listen to his lungs with a stethoscope from Wal-Mart.
2. How to increase his oxygen therapy.
3. How to treat respiratory infections without going to the physician.
4. How to recognize the signs of an impending respiratory infection.
Ans-17. 4. Respiratory infection in clients with a respiratory disorder can be fatal. It’s important
that the client understands how to recognize the signs and symptoms of an impending respiratory
infection. It isn’t appropriate for the wife to listen to his lung sounds, besides, you can’t purchase
stethoscopes from Wal-Mart. If the client has signs and symptoms of an infection, he should
contact his physician at once.
18. Which of the following respiratory disorders is most common in the first 24 to 48 hours
after surgery?
1. Atelectasis
2. Bronchitis
3. Pneumonia
4. Pneumothorax
Ans-18. 1. Atelectasis develops when there’s interference with the normal negative pressure that
promotes lung expansion. Clients in the postoperative phase often splint their breathing because
of pain and positioning, which causes hypoxia. It’s uncommon for any of the other respiratory
disorders to develop.
19. Which of the following measures can reduce or prevent the incidence of atelectasis in a
post-operative client?
1. Chest physiotherapy
2. Mechanical ventilation
3. Reducing oxygen requirements
4. Use of an incentive spirometer
Ans-19. 4. Using an incentive spirometer requires the client to take deep breaths and promotes
lung expansion. Chest physiotherapy helps mobilize secretions but won’t prevent atelectasis.
Reducing oxygen requirements or placing someone on mechanical ventilation doesn’t affect the
development of atelectasis.
20. Emergency treatment of a client in status asthmaticus includes which of the following
medications?
1. Inhaled beta-adrenergic agents

2. Inhaled corticosteroids
3. I.V. beta-adrenergic agents
4. Oral corticosteroids
Ans-20. 1. Inhaled beta-adrenergic agents help promote bronchodilation, which improves

oxygenation. I.V. beta-adrenergic agents can be used but have to be monitored because of their
greater systemic effects. They’re typically used when the inhaled beta-adrenergic agents don’t
work. Corticosteroids are slow-acting, so their use won’t reduce hypoxia in the acute phase.
21. Which of the following treatment goals is best for the client with status asthmaticus?
1. Avoiding intubation
2. Determining the cause of the attack
3. Improving exercise tolerance
4. Reducing secretions
Ans-21. 1. Inhaled beta-adrenergic agents, I.V. corticosteroids, and supplemental oxygen are
used to reduce bronchospasm, improve oxygenation, and avoid intubation. Determining the
trigger for the client’s attack and improving exercise tolerance are later goals. Typically,
secretions aren’t a problem in status asthmaticus.
22. Dani was given dilaudid for pain. She’s sleeping and her respiratory rate is 4
breaths/minute. If action isn’t taken quickly, she might have which of the following reactions?
1. Asthma attack
2. Respiratory arrest
3. Be pissed about receiving Narcan
4. Wake up on her own
Ans-22. 2. Narcotics can cause respiratory arrest if given in large quantities. Its unlikely Dani
will have an asthma attack or wake up on her own. She may be pissed for a minute, but then
she’d be grateful for saving her butt.
23. Which of the following additional assessment data should immediately be gathered to
determine the status of a client with a respiratory rate of 4 breaths/minute?
1. Arterial blood gas (ABG) and breath sounds

2. Level of consciousness and a pulse oximetry value.
3. Breath sounds and reflexes
4. Pulse oximetry value and heart sounds
Ans-23. 2. First, the nurse should attempt to rouse the client because this should increase the
client’s respiratory rate. If available, a spot pulse oximetry check should be done and breath
sounds should be checked. The physician should be notified immediately if of the findings. He’ll
probably order ABG analysis to determine specific carbon dioxide and oxygen levels, which will
indicate the effectiveness of ventilation. Reflexes and heart sounds will be part of the more
extensive examination done after these initial actions are completed.
24. A client is in danger of respiratory arrest following the administration of a narcotic

analgesic. An arterial blood gas value is obtained. The nurse would expect to PaCO2 to be which
of the following values?
1. 15 mm Hg
2. 30 mm Hg
3. 40 mm Hg
4. 80 mm Hg
Ans-24. 4. A client about to go into respiratory arrest will have inefficient ventilation and will be
retaining carbon dioxide. The value expected would be around 80 mm Hg. All other values are
lower than expected.
25. A client has started a new drug for hypertension. Thirty minutes after he takes the drug,
he develops chest tightness and becomes short of breath and tachypneic. He has a decreased
level of consciousness. These signs indicate which of the following conditions?
1. Asthma attack
2. Pulmonary embolism
3. respiratory failure
4. Rheumatoid arthritis
Ans-25. 3. The client was reacting to the drug with respiratory signs of impending anaphylaxis,
which could lead to eventual respiratory failure. Although the signs are also related to an asthma
attack or a pulmonary embolism, consider the new drug first. Rheumatoid arthritis doesn’t
manifest these signs.
26. Emergency treatment for a client with impending anaphylaxis secondary to

hypersensitivity to a drug should include which of the following actions first?
1. Administering oxygen
2. Inserting an I.V. catheter
3. Obtaining a complete blood count (CBC)
4. Taking vital signs
Ans-26. 1. Giving oxygen would be the best first action in this case. Vital signs then should be
checked and the physician immediately notified. If the client doesn’t already have an I.V.
catheter, one may be inserted now if anaphylactic shock is developing. Obtaining a CBC
wouldn’t help the emergency situation.
27. Following the initial care of a client with asthma and impending anaphylaxis from
hypersensitivity to a drug, the nurse should take which of the following steps next?
1. Administer beta-adrenergic blockers

2. Administer bronchodilators
3. Obtain serum electrolyte levels
4. Have the client lie flat in the bed.
Ans-27. 2. Bronchodilators would help open the client’s airway and improve his oxygenation
status. Beta-adrenergic blockers aren’t indicated in the management of asthma because they may
cause bronchospasm. Obtaining laboratory values wouldn’t be done on an emergency basis, and
having the client lie flat in bed could worsen his ability to breathe.
28. A client’s ABG results are as follows: pH: 7.16; PaCO2 80 mm Hg; PaO2 46 mm Hg; HCO3–
24 mEq/L; SaO2 81%. This ABG result represents which of the following conditions?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis
Ans-28. 3. You all should know this. Practice some problems if you got this wrong.
29. A nurse plans care for a client with chronic obstructive pulmonary disease, knowing that
the client is most likely to experience what type of acid-base imbalance?
Ans-29. 1. Respiratory acidosis is most often due to hypoventilation. Chronic respiratory

acidosis is most commonly caused by COPD. In end-stage disease, pathological changes lead to
airway collapse, air trapping, and disturbance of ventilation-perfusion relationships.
30. A nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate
a pH of 7.50 and a PCO2 of 30 mm Hg. The nurse has determined that the client is experiencing
respiratory alkalosis. Which laboratory value would most likely be noted in this condition?
1. Sodium level of 145 mEq/L

2. Potassium level of 3.0 mEq/L
3. Magnesium level of 2.0 mg/L
4. Phosphorus level of 4.0 mg/dl
Ans-30. 2. Clinical manifestations of respiratory alkalosis include headache, tachypnea,

paresthesias, tetany, vertigo, convulsions, hypokalemia, and hypocalcemia. Options 1, 3, and 4
identify normal laboratory values. Option 2 identifies the presence of hypokalemia.
31. A nurse reviews the arterial blood gas results of a patient and notes the following: pH
7.45; PCO2 30 mm Hg; and bicarbonate concentration of 22 mEq/L. The nurse analyzes these
results as indicating:
1. Metabolic acidosis, compensated.

2. Metabolic alkalosis, uncompensated.
3. Respiratory alkalosis, compensated.
4. Respiratory acidosis, compensated.
Ans-31. 3. The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite (see-saw) will
be seen between the pH and the PCO2. In this situation, the pH is at the high end of the normal
value and the PCO2 is low. In an alkalotic condition, the pH is up. Therefore, the values identified
in the question indicate a respiratory alkalosis. Compensation occurs when the pH returns to a
normal value. Because the pH is in the normal range at the high end, compensation has occurred.
32. A client is scheduled for blood to be drawn from the radial artery for an ABG
determination. Before the blood is drawn, an Allen’s test is performed to determine the
adequacy of the:
1. Popliteal circulation
2. Ulnar circulation
3. Femoral circulation
4. Carotid circulation
Ans-32. 2. Before radial puncture for obtaining an ABG, you should perform an Allen’s test to
determine adequate ulnar circulation. Failure to determine the presence of adequate collateral
circulation could result in severe ischemic injury o the hand if damage to the radial artery occurs
with arterial puncture.

33. A nurse is caring for a client with a nasogastric tube that is attached to low suction. The
nurse monitors the client, knowing that the client is at risk for which acid-base disorder?
Ans-33. 4. Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as
a result of the loss of hydrochloric acid.

34. A nurse is caring for a client with an ileostomy understands that the client is most at risk
for developing which acid-base disorder?

Ans-34. 3. Intestinal secretions are high in bicarbonate and may be lost through enteric drainage
tubes or an ileostomy or with diarrhea (remember, diarrhea is coming out of the base). These
conditions result in metabolic acidosis.
35. A nurse is caring for a client with diabetic ketoacidosis and documents that the client is
experiencing Kussmaul’s respirations. Based on this documentation, which of the following
did the nurse observe?
1. Respirations that are abnormally deep, regular, and increased in rate.

2. Respirations that are regular but abnormally slow.
3. Respirations that are labored and increased in depth and rate
4. Respirations that cease for several seconds.
Ans-35. 1. Kussmaul’s respirations are abnormally deep, regular, and increased in rate.

36. A nurse understands that the excessive use of oral antacids containing bicarbonate can
result in which acid-base disturbance?
Ans-36. 4. Increases in base components occur as a result of oral or parenteral intake of

bicarbonates, carbonates, acetates, citrates, or lactates. Excessive use of oral antacids containing
bicarbonate can cause metabolic alkalosis.
37. A nurse is caring for a client with renal failure. Blood gas results indicate a pH of 7.30; a
PCO2 of 32 mm Hg, and a bicarbonate concentration of 20 mEq/L. The nurse has determined
that the client is experiencing metabolic acidosis. Which of the following laboratory values
would the nurse expect to note?
1. Sodium level of 145 mEq/L

2. Magnesium level of 2.0 mg/dL
3. Potassium level of 5.2 mEq/L
4. Phosphorus level of 4.0 mg/dL

Ans-37. 3. Clinical manifestations of metabolic acidosis include hyperpnea with Kussmaul’s

respirations; headache; N/V, and diarrhea; fruity-smelling breath resulting from improper fat
metabolism; CNS depression, including mental dullness, drowsiness, stupor, and coma;
twitching, and coma. Hyperkalemia will occur.
38. A nurse is preparing to obtain an arterial blood gas specimen from a client and plans to
perform the Allen’s test on the client. Number in order of priority the steps for performing the
Allen’s test (#1 is first step).
1. Ask the client to open and close the hand repeatedly.

2. Apply pressure over the ulnar and radial arteries.
3. Assess the color of the extremity distal to the pressure point
4. Release pressure from the ulnar artery
5. Explain the procedure to the client.

Ans-38. 5, 2, 1, 4, and then 3.
39. A nurse is preparing to obtain a sputum specimen from a client. Which of the following
nursing actions will facilitate obtaining the specimen?
1. Limiting fluids
2. Having the client take 3 deep breaths.
3. Asking the client to spit into the collection container.
4. Asking the client to obtain the specimen after eating.
Ans-39. 2. To obtain a sputum specimen, the client should rinse the mouth to prevent
contamination, breathe deeply, and then cough unto a sputum specimen container. The client
should be encouraged to cough and not spit so as to obtain sputum. Sputum can be thinned by
fluids or by a respiratory treatment such as inhalation of nebulized saline or water. The optimal
time to obtain a specimen is on arising in the morning.
40. A nurse is caring for a client after a bronchoscopy and biopsy. Which of the following
signs if noted in the client should be reported immediately to the physician?
1. Blood-streaked sputum
2. Dry cough
3. Hematuria
4. Bronchospasm
Ans-40. 4. If a biopsy was performed during a bronchoscopy, blood streaked sputum is expected
for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client
should be assessed for signs of complications, which would include cyanosis, dyspnea,
stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is
unrelated to this procedure.
41. A nurse is suctioning fluids from a client via a tracheostomy tube. When suctioning, the
nurse must limit the suctioning to a maximum of:
1. 5 seconds
2. 10 seconds
3. 30 seconds
4. 1 minute
Ans-41. 2. Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker
cells within the heart. A vasovagal response may occur causing bradycardia. The nurse must
preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds.
42. A nurse is suctioning fluids from a client through an endotracheal tube. During the
suctioning procedure, the nurse notes on the monitor that the heart rate decreases. Which of
the following is the most appropriate nursing intervention?
1. Continue to suction
2. Ensure that the suction is limited to 15 seconds
3. Stop the procedure and reoxyenate the client
4. Notify the physician immediately.
Ans-42. 3. During suctioning, the nurse should monitor the client closely for side effects,
including hypoxemia, cardiac irregularities such as a decrease in HR resulting from vagal
stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If side effects develop,
especially cardiac irregularities, this procedure is stopped and the client is reoxygenated.
43. An unconscious client is admitted to an emergency room. Arterial blood gas

measurements reveal a pH of 7.30, a low bicarbonate level, a normal carbon dioxide level, and
a normal oxygen level. An elevated potassium level is also present. These results indicate the
presence of:
3. Combined respiratory and metabolic acidosis
4. overcompensated respiratory acidosis
Ans-43. 1. In an acidotic condition the pH would be low, indicating the acidosis. In addition, a
low bicarbonate level along with the pH would indicate a metabolic state.
44. A nurse is caring for a client hospitalized with acute exacerbation of COPD. Which of the
following would the nurse expect to note on assessment of this client?
1. Increased oxygen saturation with exercise

2. Hypocapnia
3. A hyperinflated chest on x-ray film
4. A widened diaphragm noted on chest x-ray film
Ans-44. 3. Clinical manifestations of COPD include hypoxemia, hypercapnia, dyspnea on

exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of
respiration. Chest x-ray films reveal a hyperinflated chest and a flattened diaphragm is the
disease is advanced.
45. An oxygenated delivery system is prescribed for a client with COPD to deliver a precise
oxygen concentration. Which of the following types of oxygen delivery systems would the
nurse anticipate to be prescribed?
1. Venturi mask
2. Aerosol mask
3. Face tent
4. Tracheostomy collar
Ans-45. 1. The venture mask delivers the most accurate oxygen concentration. The Venturi
mask is the best oxygen delivery system for the client with chronic airflow limitation because it
delivers a precise oxygen concentration. The face tent, the aerosol mask, and the tracheostomy
collar are also high-flow oxygen delivery systems but most often are used to administer high
humidity.
46. Theophylline (Theo-Dur) tablets are prescribed for a client with chronic airflow
limitation, and the nurse instructs the client about the medication. Which statement by the
client indicates a need for further teaching?
1. “I will take the medication on an empty stomach.”
2. “I will take the medication with food.”
3. “I will continue to take the medication even if I am feeling better.”
4. “Periodic blood levels will need to be obtained.”
Ans-46. 1. Theo-Dur is a bronchodilator. The medication should be administered with food such
as milk and crackers to prevent GI irritation.
47. A nurse is caring for a client with emphysema. The client is receiving oxygen. The nurse
assesses the oxygen flow rate to ensure that it does not exceed
1. 1 L/min
2. 2 L/min
3. 6 L/min
4. 10 L/min
Ans-47. 2. one to 3 L/min of oxygen by nasal cannula may be required to raise to PaO2 to 60 to
80 mm Hg. However, oxygen is used cautiously and should not exceed 2 L/min. Because of the
long-standing hypercapnia, the respiratory drive is triggered by low oxygen levels rather than
increased carbon dioxide levels, as is the case in normal respiratory system.
48. The nurse reviews the ABG values of a client. The results indicate respiratory acidosis.
Which of the following values would indicate that this acid-base imbalance exists?
1. pH of 7.48
2. PCO2 of 32 mm Hg
3. pH of 7.30
4. HCO3– of 20 mEq/L
Ans-48. 3.
49. A nurse instructs a client to use the pursed lip method of breathing. The client asks the
nurse about the purpose of this type of breathing. The nurse responds, knowing that the
primary purpose of pursed lip breathing is:
1. Promote oxygen intake

2. Strengthen the diaphragm
3. Strengthen the intercostal muscles
4. Promote carbon dioxide elimination

Ans-49. 4. Pursed lip breathing facilitates maximum expiration for clients with obstructive lung
disease. This type of breathing allows better expiration by increasing airway pressure that keeps
air passages open during exhalation.
50. A nurse reviews the ABG values and notes a pH of 7.50, a PCO2 of 30 mm Hg, and an
HCO3 of 25 mEq/L. The nurse interprets these values as indicating:
1. Respiratory acidosis uncompensated

2. Respiratory alkalosis uncompensated
3. Metabolic acidosis uncompensated
4. Metabolic acidosis partially compensated.
Ans-50. 2. In respiratory alkalosis the pH will be higher than normal and the PCO2 will be low.
51. Aminophylline (theophylline) is prescribed for a client with acute bronchitis. A nurse
administers the medication, knowing that the primary action of this medication is to:
1. Promote expectoration
2. Suppress the cough
3. Relax smooth muscles of the bronchial airway
4. Prevent infection
Ans-51. 3. Aminophylline is a bronchodilator that directly relaxes the smooth muscles of the
bronchial airway.
52. A client is receiving isoetharine hydrochloride (Bronkosol) via a nebulizer. The nurse
monitors the client for which side effect of this medication?
1. Constipation
2. Diarrhea
3. Bradycardia
4. Tachycardia
Ans-52. 4. Side effects that can occur from a beta 2 agonist include tremors, nausea,
nervousness, palpitations, tachycardia, peripheral vasodilation, and dryness of the mouth or
throat.
53. A nurse teaches a client about the use of a respiratory inhaler. Which action by the client
indicated a need for further teaching?
1. Removes the cap and shakes the inhaler well before use.
2. Presses the canister down with finger as he breathes in.
3. Inhales the mist and quickly exhales.
4. Waits 1 to 2 minutes between puffs if more than one puff has been prescribed.
Ans-53. 3. The client should be instructed to hold his or her breath at least 10 to 15 seconds
before exhaling the mist.
54. A female client is scheduled to have a chest radiograph. Which of the following questions
is of most importance to the nurse assessing this client?
1. “Is there any possibility that you could be pregnant?”

2. “Are you wearing any metal chains or jewelry?”
3. “Can you hold your breath easily?”
4. “Are you able to hold your arms above your head?”

Ans-54. 1. the most important item to ask about is the client’s pregnancy status because
pregnant women should not be exposed to radiation. Clients are also asked to remove any chains
or metal objects that could interfere with obtaining an adequate film. A chest radiograph most
often is done at full inspiration, which gives optimal lung expansion. If a lateral view of the chest
is ordered, the client is asked to raise the arms above the head. Most films are done in posterior-
anterior view.
55. A client has just returned to a nursing unit following bronchoscopy. A nurse would
implement which of the following nursing interventions for this client?
1. Encouraging additional fluids for the next 24 hours

2. Ensuring the return of the gag reflex before offering foods or fluids
3. Administering atropine intravenously
4. Administering small doses of midazolam (Versed).
Ans-55. 2. After bronchoscopy, the nurse keeps the client on NPO status until the gag reflex
returns because the preoperative sedation and the local anesthesia impair swallowing and the
protective laryngeal reflexes for a number of hours. Additional fluids is unnecessary because no
contrast dye is used that would need to be flushed from the system. Atropine and Versed would
be administered before the procedure, not after.
56. A client has an order to have radial ABG drawn. Before drawing the sample, a nurse
occludes the:
1. Brachial and radial arteries, and then releases them and observes the circulation of the hand.
2. Radial and ulnar arteries, releases one, evaluates the color of the hand, and repeats the
process with the other artery.
3. Radial artery and observes for color changes in the affected hand.
4. Ulnar artery and observes for color changes in the affected hand.
Ans-56. 2. Before drawing an ABG, the nurse assesses the collateral circulation to the hand with
Allen’s test. This involves compressing the radial and ulnar arteries and asking the client to close
and open the fist. This should cause the hand to become pale. The nurse then releases pressure on
one artery and observes whether circulation is restored quickly. The nurse repeats the process,
releasing the other artery. The blood sample may be taken safely if collateral circulation is
adequate.
57. A nurse is assessing a client with chronic airflow limitation and notes that the client has a
“barrel chest.” The nurse interprets that this client has which of the following forms of
chronic airflow limitation?

2. Emphysema
3. Bronchial asthma
4. Bronchial asthma and bronchitis
Ans-57. 2. The client with emphysema has hyperinflation of the alveoli and flattening of the
diaphragm. These lead to increased anteroposterior diameter, which is referred to as “barrel
chest.” The client also has dyspnea with prolonged expiration and has hyperresonant lungs to
percussion.
58. A client has been taking benzonatate (Tessalin Perles) as prescribed. A nurse concludes
that the medication is having the intended effect if the client experiences:
1. Decreased anxiety level

2. Increased comfort level
3. Reduction of N/V
4. Decreased frequency and intensity of cough
Ans-58. 4. Benzonatate is a locally acting antitussive the effectiveness of which is measured by

the degree to which it decreases the intensity and frequency of cough without eliminating the
cough reflex
59. Which of the following would be an expected outcome for a client recovering from an
upper respiratory tract infection? The client will:
1. Maintain a fluid intake of 800ml every 24 hours.

2. Experience chills only once a day
3. Cough productively without chest discomfort.
4. Experience less nasal obstruction and discharge.
Ans-59. 4. A client recovering from an URI should report decreasing or no nasal discharge and
obstruction. Daily fluid intake should be increase to more than 1 L every 24 hours to liquefy
secretions. The temperature should be below 100*F (37.8*C) with no chills or diaphoresis. A
productive cough with chest pain indicated pulmonary infection, not an URI
60. Which of the following individuals would the nurse consider to have the highest priority
for receiving an influenza vaccination?
1. A 60-year-old man with a hiatal hernia

2. A 36-year-old woman with 3 children
3. A 50-year-old woman caring for a spouse with cancer
4. a 60-year-old woman with osteoarthritis
Ans-60. 3. Individuals who are household members or home care providers for high-risk
individuals are high-priority targeted groups for immunization against influenza to prevent
transmission to those who have a decreased capacity to deal with the disease. The wife who is
caring for a husband with cancer has the highest priority of the clients described.
61. A client with allergic rhinitis asks the nurse what he should do to decrease his symptoms.
Which of the following instructions would be appropriate for the nurse to give the client?
1. “Use your nasal decongestant spray regularly to help clear your nasal passages.”
2. “Ask the doctor for antibiotics. Antibiotics will help decrease the secretion.”
3. “It is important to increase your activity. A daily brisk walk will help promote drainage.”
4. “Keep a diary if when your symptoms occur. This can help you identify what precipitates
your attacks.”
Ans-61. 4. It is important for clients with allergic rhinitis to determine the precipitating factors
so that they can be avoided. Keeping a diary can help identify these triggers. Nasal decongestant
sprays should not be used regularly because they can cause a rebound effect. Antibiotics are not
appropriate. Increasing activity will not control the client’s symptoms; in fact, walking outdoors
may increase them if the client is allergic to pollen.
62. An elderly client has been ill with the flu, experiencing headache, fever, and chills. After 3
days, she develops a cough productive of yellow sputum. The nurse auscultates her lungs and
hears diffuse crackles. How would the nurse best interpret these assessment findings?
1. It is likely that the client is developing a secondary bacterial pneumonia.

2. The assessment findings are consistent with influenza and are to be expected.
3. The client is getting dehydrated and needs to increase her fluid intake to decrease secretions.
4. The client has not been taking her decongestants and bronchodilators as prescribed.
Ans-62. 1. Pneumonia is the most common complication of influenza, especially in the elderly.
The development of a purulent cough and crackles may be indicative of a bacterial infection are
not consistent with a diagnosis of influenza. These findings are not indicative of dehydration.
Decongestants and bronchodilators are not typically prescribed for the flu.
63. Guaifenesin 300 mg four times daily has been ordered as an expectorant. The dosage
strength of the liquid is 200mg/5ml. How many mL should the nurse administer each dose?
1. 5.0 ml
2. 7.5 ml
3. 9.5 ml
4. 10 ml
Ans-63. 2.
64. Pseudoephedrine (Sudafed) has been ordered as a nasal decongestant. Which of the
following is a possible side effect of this drug?
1. Constipation
2. Bradycardia
3. Diplopia
4. Restlessness
Ans-64. 4. Side effects of pseudoephedrine are experienced primarily in the cardiovascular

system and through sympathetic effects on the CNS. The most common CNS effects include
restlessness, dizziness, tension, anxiety, insomnia, and weakness. Common cardiovascular side
effects include tachycardia, hypertension, palpitations, and arrhythmias. Constipation and
diplopia are not side effects of pseudoephedrine. Tachycardia, not bradycardia, is a side effect of
pseudoephedrine.
65. A client with COPD reports steady weight loss and being “too tired from just breathing to
eat.” Which of the following nursing diagnoses would be most appropriate when planning
nutritional interventions for this client?
1. Altered nutrition: Less than body requirements related to fatigue.

2. Activity intolerance related to dyspnea.
3. Weight loss related to COPD.
4. Ineffective breathing pattern related to alveolar hypoventilation.
Ans-65. 1. The client’s problem is altered nutrition—specifically, less than required. The cause,
as stated by the client, is the fatigue associated with the disease process. Activity intolerance is a
likely diagnosis but is not related to the client’s nutritional problems. Weight loss is not a nursing
diagnosis. Ineffective breathing pattern may be a problem, but this diagnosis does not
specifically address the problem of weight loss described by the client.
66. When developing a discharge plan to manage the care of a client with COPD, the nurse
should anticipate that the client will do which of the following?
1. Develop infections easily

2. Maintain current status
3. Require less supplemental oxygen
4. Show permanent improvement.
Ans-66. 1. A client with COPD is at high risk for development of respiratory infections. COPD
is a slowly progressive; therefore, maintaining current status and establishing a goal that the
client will require less supplemental oxygen are unrealistic expectations. Treatment may slow
progression of the disease, but permanent improvement is highly unlikely
67. Which of the following outcomes would be appropriate for a client with COPD who has
been discharged to home? The client:
1. Promises to do pursed lip breathing at home.

2. States actions to reduce pain.
3. States that he will use oxygen via a nasal cannula at 5 L/minute.
4. Agrees to call the physician if dyspnea on exertion increases.
Ans-67. 4. Increasing dyspnea on exertion indicates that the client may be experiencing
complications of COPD, and therefore the physician should be notified. Extracting promises
from clients is not an outcome criterion. Pain is not a common symptom of COPD. Clients with
COPD use low-flow oxygen supplementation (1 to 2 L/minute) to avoid suppressing the
respiratory drive, which, for these clients, is stimulated by hypoxia.
68. Which of the following physical assessment findings would the nurse expect to find in a
client with advanced COPD?
1. Increased anteroposterior chest diameter
2. Underdeveloped neck muscles
3. Collapsed neck veins
4. Increased chest excursions with respiration
Ans-68. 1. Increased anteroposterior chest diameter is characteristic of advanced COPD. Air is

trapped in the overextended alveoli, and the ribs are fixed in an inspiratory position. The result is
the typical barrel-chested appearance. Overly developed, not underdeveloped, neck muscles are
associated with COPD because of their increased use in the work of breathing. Distended, not
collapsed, neck veins are associated with COPD as a symptom of the heart failure that the client
may experience secondary to the increased workload on the heart to pump into pulmonary
vasculature. Diminished, not increased, chest excursion is associated with COPD.
69. Which of the following is the primary reason to teach pursed-lip breathing to clients with
emphysema?
1. To promote oxygen intake

2. To strengthen the diaphragm
3. To strengthen the intercostal muscles
4. To promote carbon dioxide elimination
Ans-69. 4. Pursed lip breathing prolongs exhalation and prevents air trapping in the alveoli,
thereby promoting carbon dioxide elimination. By prolonged exhalation and helping the client
relax, pursed-lip breathing helps the client learn to control the rate and depth of respiration.
Pursed-lip breathing does not promote the intake of oxygen, strengthen the diaphragm, or
strengthen intercostal muscles.
70. Which of the following is a priority goal for the client with COPD?
1. Maintaining functional ability

2. Minimizing chest pain
3. Increasing carbon dioxide levels in the blood
4. Treating infectious agents
Ans-70. 1. A priority goal for the client with COPD is to manage the s/s of the disease process
so as to maintain the client’s functional ability. Chest pain is not a typical sign of COPD. The
carbon dioxide concentration in the blood is increased to an abnormal level in clients with
COPD; it would not be a goal to increase the level further. Preventing infection would be a goal
of care for the client with COPD.

71. A client’s arterial blood gas levels are as follows: pH 7.31; PaO2 80 mm Hg, PaCO2 65 mm
Hg; HCO3– 36 mEq/L. Which of the following signs or symptoms would the nurse expect?
1. Cyanosis
2. Flushed skin
3. Irritability
4. Anxiety
Ans-71. 2. The high PaCO2 level causes flushing due to vasodilation. The client also becomes
drowsy and lethargic because carbon dioxide has a depressant effect on the CNS. Cyanosis is a
late sign of hypoxia. Irritability and anxiety are not common with a PaCO2 level of 65 mm Hg but
are associated with hypoxia.
72. When teaching a client with COPD to conserve energy, the nurse should teach the client
to lift objects:
1. While inhaling through an open mouth.

2. While exhaling through pursed lips
3. After exhaling but before inhaling.
4. While taking a deep breath and holding it.
Ans-72. 2. Exhaling requires less energy than inhaling. Therefore, lifting while exhaling saves
energy and reduced perceived dyspnea. Pursing the lips prolongs exhalation and provides the
client with more control over breathing. Lifting after exhalation but before inhaling is similar to
lifting with the breath held. This should not be recommended because it is similar to the Valsalva
maneuver, which can stimulate cardiac dysrhythmias.
73. The nurse teaches a client with COPD to assess for s/s of right-sided heart failure. Which
of the following s/s would be included in the teaching plan?
1. Clubbing of nail beds

2. Hypertension
3. Peripheral edema
4. Increased appetite
Ans-73. 3. Right-sided heart failure is a complication of COPD that occurs because of

pulmonary hypertension. Signs and symptoms of right-sided heart failure include peripheral
edema, jugular venous distention, hepatomegaly, and weight gain due to increased fluid volume.
Clubbing of nail beds is associated with conditions of chronic hypoxia. Hypertension is
associated with left-sided heart failure. Clients with heart failure have decreased appetites.
74. The nurse assesses the respiratory status of a client who is experiencing an exacerbation
of COPD secondary to an upper respiratory tract infection. Which of the following findings
would be expected?
1. Normal breath sounds

2. Prolonged inspiration
3. Normal chest movement
4. Coarse crackles and rhonchi
Ans-74. 4. Exacerbations of COPD are frequently caused by respiratory infections. Coarse

crackles and rhonchi would be auscultated as air moves through airways obstructed with
secretions. In COPD, breath sounds are diminished because of an enlarged anteroposterior
diameter of the chest. Expiration, not inspiration, becomes prolonged. Chest movement is
decreased as lungs become over distended.
75. Which of the following ABG abnormalities should the nurse anticipate in a client with
advanced COPD?
1. Increased PaCO2
2. Increased PaO2
3. Increased pH.
4. Increased oxygen saturation
Ans-75. 1. As COPD progresses, the client typically develops increased PaCO2 levels and
decreased PaO2 levels. This results in decreased pH and decreased oxygen saturation. These
changes are the result of air trapping and hypoventilation.
76. Which of the following diets would be most appropriate for a client with COPD?
1. Low fat, low cholesterol

2. Bland, soft diet
3. Low-Sodium diet
4. High calorie, high-protein diet
Ans-76. 4. The client should eat high-calorie, high-protein meals to maintain nutritional status
and prevent weight loss that results from the increased work of breathing. The client should be
encouraged to eat small, frequent meals. A low-fat, low-cholesterol diet is indicated for clients
with coronary artery disease. The client with COPD does not necessarily need to follow a
sodium-restricted diet, unless otherwise medically indicated.
77. The nurse is planning to teach a client with COPD how to cough effectively. Which of the
following instructions should be included?
1. Take a deep abdominal breath, bend forward, and cough 3 to 4 times on exhalation.
2. Lie flat on back, splint the thorax, take two deep breaths and cough.
3. Take several rapid, shallow breaths and then cough forcefully.
4. Assume a side-lying position, extend the arm over the head, and alternate deep breathing
with coughing.
Ans-77. 1. The goal of effective coughing is to conserve energy, facilitate removal of secretions,
and minimize airway collapse. The client should assume a sitting position with feet on the floor
if possible. The client should bend forward slightly and, using pursed-lip breathing, exhale. After
resuming an upright position, the client should use abdominal breathing to slowly and deeply
inhale. After repeating this process 3 or 4 times, the client should take a deep abdominal breath,
bend forward and cough 3 or 4 times upon exhalation (“huff” cough). Lying flat does not
enhance lung expansion; sitting upright promotes full expansion of the thorax. Shallow breathing
does not facilitate removal of secretions, and forceful coughing promotes collapse of airways. A
side-lying position does not allow for adequate chest expansion to promote deep breathing.
78. A 34-year-old woman with a history of asthma is admitted to the emergency department.
The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/minute, nasal
flaring, and use of accessory muscles. Auscultation of the lung fields reveals greatly
diminished breath sounds. Based on these findings, what action should the nurse take to
initiate care of the client?
1. Initiate oxygen therapy and reassess the client in 10 minutes.

2. Draw blood for an ABG analysis and send the client for a chest x-ray.
3. Encourage the client to relax and breathe slowly through the mouth
4. Administer bronchodilators
Ans-78. 4. In an acute asthma attack, diminished or absent breath sounds can be an ominous
sign of indicating lack of air movement in the lungs and impending respiratory failure. The client
requires immediate intervention with inhaled bronchodilators, intravenous corticosteroids, and
possibly intravenous theophylline. Administering oxygen and reassessing the client 10 minutes
later would delay needed medical intervention, as would drawing an ABG and obtaining a chest
x-ray. It would be futile to encourage the client to relax and breathe slowly without providing
necessary pharmacologic intervention.
79. The nurse would anticipate which of the following ABG results in a client experiencing a
prolonged, severe asthma attack?
1. Decreased PaCO2, increased PaO2, and decreased pH.

2. Increased PaCO2, decreased PaO2, and decreased pH.
3. Increased PaCO2, increased PaO2, and increased pH.
4. Decreased PaCO2, decreased PaO2, and increased pH.
Ans-79. 2. As the severe asthma attack worsens, the client becomes fatigued and alveolar
hypotension develops. This leads to carbon dioxide retention and hypoxemia. The client
develops respiratory acidosis. Therefore, the PaCO2 level increase, the PaO2 level decreases, and the
pH decreases, indicating acidosis.
80. A client with acute asthma is prescribed short-term corticosteroid therapy. What is the
rationale for the use of steroids in clients with asthma?
1. Corticosteroids promote bronchodilation

2. Corticosteroids act as an expectorant
3. Corticosteroids have an anti-inflammatory effect
4. Corticosteroids prevent development of respiratory infections.
Ans-80. 3. Corticosteroids have an anti-inflammatory effect and act to decrease edema in the
bronchial airways and decrease mucus secretion. Corticosteroids do not have a bronchodilator
effect, act as expectorants, or prevent respiratory infections.
81. The nurse is teaching the client how to use a metered dose inhaler (MDI) to administer a
Corticosteroid drug. Which of the following client actions indicates that he us using the MDI
correctly? Select all that apply.
1. The inhaler is held upright.

2. Head is tilted down while inhaling the medication
3. Client waits 5 minutes between puffs.
4. Mouth is rinsed with water following administration
5. Client lies supine for 15 minutes following administration.
Ans-81. 1 and 4.
82. A client is prescribed metaproterenol (Alupent) via a metered dose inhaler (MDI), two
puffs every 4 hours. The nurse instructs the client to report side effects. Which of the following
are potential side effects of metaproterenol?
1. Irregular heartbeat
2. Constipation
3. Petal edema
4. Decreased heart rate.
Ans-82. 1. Irregular heart rates should be reported promptly to the care provider. Metaproterenol
may cause irregular heartbeat, tachycardia, or anginal pain because of its adrenergic effect on the
beta-adrenergic receptors in the heart. It is not recommended for use in clients with known
cardiac disorders. Metaproterenol does not cause constipation, petal edema, or bradycardia.
83. A client has been taking flunisolide (Aerobid), two inhalations a day, for treatment of
asthma. He tells the nurse that he has painful, white patches in his mouth. Which response by
the nurse would be the most appropriate?
1. “This is an anticipated side-effect of your medication. It should go away in a couple of

weeks.”
2. “You are using your inhaler too much and it has irritated your mouth.”
3. “You have developed a fungal infection from your medication. It will need to be treated with
an antibiotic.”
4. “Be sure to brush your teeth and floss daily. Good oral hygiene will treat this problem.”
Ans-83. 3. Use of oral inhalant corticosteroids, such as flunisolide, can lead to the development
of oral thrush, a fungal infection. Once developed, thrush must be treated by antibiotic therapy; it
will not resolve on its own. Fungal infections can develop even without overuse of the
Corticosteroid inhaler. Although good oral hygiene can help prevent development of a fungal
infection, it cannot be used alone to treat the problem.
84. Which of the following health promotion activities should the nurse include in the
discharge teaching plan for a client with asthma?
1. Incorporate physical exercise as tolerated into the treatment plan.

2. Monitor peak flow numbers after meals and at bedtime.
3. Eliminate stressors in the work and home environment
4. Use sedatives to ensure uninterrupted sleep at night.
Ans-84. 1. Physical exercise is beneficial and should be incorporated as tolerated into the
client’s schedule. Peak flow numbers should be monitored daily, usually in the morning (before
taking medication). Peak flow does not need to be monitored after each meal. Stressors in the
client’s life should be modified but cannot be totally eliminated. Although adequate sleep is
important, it is not recommended that sedatives be routinely taken to induce sleep.
85. The client with asthma should be taught that which of the following is one of the most
common precipitating factors of an acute asthma attack?
1. Occupational exposure to toxins

2. Viral respiratory infections
3. Exposure to cigarette smoke
4. Exercising in cold temperatures
Ans-85. 2. The most common precipitator of asthma attacks is viral respiratory infection. Clients
with asthma should avoid people who have the flu or a cold and should get yearly flu
vaccinations. Environmental exposure to toxins or heavy particulate matter can trigger asthma
attacks; however, far fewer asthmatics are exposed to such toxins than are exposed to viruses.
Cigarette smoke can also trigger asthma attacks, but to a lesser extent than viral respiratory
infections. Some asthmatic attacks are triggered by exercising in cold weather.
86. A female client comes into the emergency room complaining of SOB and pain in the lung
area. She states that she started taking birth control pills 3 weeks ago and that she smokes.
Her VS are: 140/80, P 110, R 40. The physician orders ABG’s, results are as follows: pH:
7.50; PaCO2 29 mm Hg; PaO2 60 mm Hg; HCO3– 24 mEq/L; SaO2 86%. Considering these
results, the first intervention is to:
1. Begin mechanical ventilation

2. Place the client on oxygen
3. Give the client sodium bicarbonate
4. Monitor for pulmonary embolism.

Ans-86. 2. The pH (7.50) reflects alkalosis, and the low PaCO2 indicated the lungs are involved.
The client should immediately be placed on oxygen via mask so that the SaO2 is brought up to
95%. Encourage slow, regular breathing to decrease the amount of CO2 she is losing. This client
may have pulmonary embolism, so she should be monitored for this condition (4), but it is not
the first intervention. Sodium bicarbonate (3) would be given to reverse acidosis; mechanical
ventilation (1) may be ordered for acute respiratory acidosis.
87. Basilar crackles are present in a client’s lungs on auscultation. The nurse knows that
these are discrete, noncontinuous sounds that are:
1. Caused by the sudden opening of alveoli

2. Usually more prominent during expiration
3. Produced by airflow across passages narrowed by secretions
4. Found primarily in the pleura.
Ans-87. 1. Basilar crackles are usually heard during inspiration and are caused by sudden
opening of the alveoli.
88. A cyanotic client with an unknown diagnosis is admitted to the E.R. In relation to oxygen,
the first nursing action would be to:
1. Wait until the client’s lab work is done.

2. Not administer oxygen unless ordered by the physician.
3. Administer oxygen at 2 L flow per minute.
4. Administer oxygen at 10 L flow per minute and check the client’s nail beds.
Ans-88. 3. Administer oxygen at 2 L/minute and no more, for if the client if emphysemic and
receives too high a level of oxygen, he will develop CO2 narcosis and the respiratory system will
cease to function.
89. Immediately following a thoeacentesis, which clinical manifestations indicate that a

complication has occurred and the physician should be notified?
1. Serosanguineous drainage from the puncture site

2. Increased temperature and blood pressure
3. Increased pulse and pallor
4. Hypotension and hypothermia
Ans-89. 3. Increased pulse and pallor are symptoms associated with shock. A compromised
venous return may occur if there is a mediastinal shift as a result of excessive fluid removal.
Usually no more than 1 L of fluid is removed at one time to prevent this from occurring.
90. If a client continues to hypoventilate, the nurse will continually assess for a complication
of:
Ans-90. 1. Respiratory acidosis represents an increase in the acid component, carbon dioxide,
and an increase in the hydrogen ion concentration (decreased pH) of the arterial blood.
91. A client is admitted to the hospital with acute bronchitis. While taking the client’s VS, the
nurse notices he has an irregular pulse. The nurse understands that cardiac arrhythmias in
chronic respiratory distress are usually the result of:
2. A build-up of carbon dioxide
3. A build-up of oxygen without adequate expelling of carbon dioxide.
4. An acute respiratory infection.
Ans-91. 2. The arrhythmias are caused by a build-up of carbon dioxide and not enough oxygen
so that the heart is in a constant state of hypoxia
92. Auscultation of a client’s lungs reveals crackles in the left posterior base. The nursing
intervention is to:
1. Repeat auscultation after asking the client to deep breathe and cough.
2. Instruct the client to limit fluid intake to less than 2000 ml/day.
3. Inspect the client’s ankles and sacrum for the presence of edema
4. Place the client on bed rest in a semi-Fowlers position.
Ans-92. 1. Although crackles often indicate fluid in the alveoli, they may also be related to
hypoventilation and will clear after a deep breath or a cough. It is, therefore, premature to impose
fluid (2) or activity (4) restrictions (which Margaret would totally do if Dani weren’t there to
smack her). Inspection for edema (3) would be appropriate after reauscultation.
93. The most reliable index to determine the respiratory status of a client is to:
1. Observe the chest rising and falling

2. Observe the skin and mucous membrane color.
3. Listen and feel the air movement.
4. Determine the presence of a femoral pulse.
Ans-93. 3. To check for breathing, the nurse places her ear and cheek next to the client’s mouth
and nose to listen and feel for air movement. The chest rising and falling (1) is not conclusive of
a patent airway. Observing skin color (2) is not an accurate assessment of respiratory status, nor
is checking the femoral pulse.
94. A client with COPD has developed secondary polycythemia. Which nursing diagnosis
would be included in the plan of care because of the polycythemia?
1. Fluid volume deficit related to blood loss.

2. Impaired tissue perfusion related to thrombosis
3. Activity intolerance related to dyspnea
4. Risk for infection related to suppressed immune response.
Ans-94. 2. Chronic hypoxia associated with COPD may stimulate excessive RBC production
(polycythemia). This results in increased blood viscosity and the risk of thrombosis. The other
nursing diagnoses are not applicable in this situation.
95. The physician has scheduled a client for a left pneumonectomy. The position that will
most likely be ordered postoperatively for his is the:
1. Unoperative side or back
2. Operative side or back
3. Back only
4. Back or either side.
Ans-95. 2. Positioning the client on the operative side facilitates the accumulation of
serisanguineous fluid. The fluid forms a solid mass, which prevents the remaining lung from
being drawn into the space.
96. Assessing a client who has developed atelectasis postoperatively, the nurse will most likely
find:
1. A flushed face
2. Dyspnea and pain
3. Decreased temperature
4. Severe cough and no pain.

Ans-96. 2. Atelectasis is a collapse of the alveoli due to obstruction or hypoventilation. Clients

become short of breath, have a high temperature, and usually experience severe pain but do not
have a severe cough (4). The shortness of breath is a result of decreased oxygen-carbon dioxide
exchange at the alveolar level.
97. A fifty-year-old client has a tracheostomy and requires tracheal suctioning. The first
intervention in completing this procedure would be to:
1. Change the tracheostomy dressing

2. Provide humidity with a trach mask
3. Apply oral or nasal suction
4. Deflate the tracheal cuff
Ans-97. 3. Before deflating the tracheal cuff (4), the nurse will apply oral or nasal suction to the
airway to prevent secretions from falling into the lung. Dressing change (1) and humidity (2) do
not relate to suctioning.
98. A client states that the physician said the tidal volume is slightly diminished and asks the
nurse what this means. The nurse explains that the tidal volume is the amount of air:
1. Exhaled forcibly after a normal expiration

2. Exhaled after there is a normal inspiration
3. Trapped in the alveoli that cannot be exhaled
4. Forcibly inspired over and above a normal respiration.
Ans-98. 2. Tidal volume (TV) is defined as the amount of air exhaled after a normal inspiration.
99. An acceleration in oxygen dissociation from hemoglobin, and thus oxygen delivery to the
tissues, is caused by:
1. A decreasing oxygen pressure in the blood

2. An increasing carbon dioxide pressure in the blood
3. A decreasing oxygen pressure and/or an increasing carbon dioxide pressure in the blood.
4. An increasing oxygen pressure and/or a decreasing carbon dioxide pressure in the blood.
Ans-99. 3. The lower the PO2 and the higher the PCO2, the more rapidly oxygen dissociated from
the oxy-hemoglobin molecule.
Airway – Pneumonia and T
Clients with chronic illnesses are more likely to get pneumonia when which of the following
situations is present?
1. Dehydration
2. Group living
3. Malnutrition
4. Severe periodontal disease
Ans-1. 2. Clients with chronic illnesses generally have poor immune systems. Often, residing in
group living situations increases the chance of disease transmission.
2. Which of the following pathophysiological mechanisms that occurs in the lung
parenchyma allows pneumonia to develop?
1. Atelectasis
2. Bronchiectasis
3. Effusion
4. Inflammation
Ans-2. 4. The common feature of all type of pneumonia is an inflammatory pulmonary response
to the offending organism or agent. Atelectasis and bronchiectasis indicate a collapse of a portion
of the airway that doesn’t occur in pneumonia. An effusion is an accumulation of excess pleural
fluid in the pleural space, which may be a secondary response to pneumonia.
3. Which of the following organisms most commonly causes community-acquired

pneumonia in adults?
1. Haemiphilus influenza
2. Klebsiella pneumonia
3. Steptococcus pneumonia
4. Staphylococcus aureus
Ans-3. 3. Pneumococcal or streptococcal pneumonia, caused by streptococcus pneumonia, is the

most common cause of community-acquired pneumonia. H. influenza is the most common cause
of infection in children. Klebsiella species is the most common gram-negative organism found in
the hospital setting. Staphylococcus aureus is the most common cause of hospital-acquired
pneumonia.
4. An elderly client with pneumonia may appear with which of the following symptoms first?
1. Altered mental status and dehydration

2. Fever and chills
3. Hemoptysis and dyspnea
4. Pleuritic chest pain and cough
Ans-4. 1. Fever, chills, hemoptysis, dyspnea, cough, and pleuritic chest pain are common
symptoms of pneumonia, but elderly clients may first appear with only an altered mental status
and dehydration due to a blunted immune response.
5. When auscultating the chest of a client with pneumonia, the nurse would expect to hear
which of the following sounds over areas of consolidation?
1. Bronchial
2. Bronchovestibular
3. Tubular
4. Vesicular
Ans-5. 1. Chest auscultation reveals bronchial breath sounds over areas of consolidation.
Bronchiovesicular are normal over mid-lobe lung regions, tubular sounds are commonly heard
over large airways, and vesicular breath sounds are commonly heard in the bases of the lung
fields.
6. A diagnosis of pneumonia is typically achieved by which of the following diagnostic tests?
1. ABG analysis
2. Chest x-ray
3. Blood cultures
4. sputum culture and sensitivity
Ans-6. 4. Sputum C & S is the best way to identify the organism causing the pneumonia. Chest
x-ray will show the area of lung consolidation. ABG analysis will determine the extent of
hypoxia present due to the pneumonia, and blood cultures will help determine if the infection is
systemic.
7. A client with pneumonia develops dyspnea with a respiratory rate of 32 breaths/minute
and difficulty expelling his secretions. The nurse auscultates his lung fields and hears
bronchial sounds in the left lower lobe. The nurse determines that the client requires which of
the following treatments first?
1. Antibiotics
2. Bed rest
3. Oxygen
4. Nutritional intake
Ans-7. 3. The client is having difficulty breathing and is probably becoming hypoxic. As an
emergency measure, the nurse can provide oxygen without waiting for a physician’s order.
Antibiotics may be warranted, but this isn’t a nursing decision. The client should be maintained
on bed rest if he is dyspneic to minimize his oxygen demands, but providing additional will deal
more immediately with his problem. The client will need nutritional support, but while dyspneic,
he may be unable to spare the energy needed to eat and at the same time maintain adequate
oxygenation.
8. A client has been treated with antibiotic therapy for right lower-lobe pneumonia for 10
days and will be discharged today. Which of the following physical findings would lead the
nurse to believe it is appropriate to discharge this client?
1. Continued dyspnea
2. Fever of 102*F
3. Respiratory rate of 32 breaths/minute
4. Vesicular breath sounds in right base
Ans-8. 4. If the client still has pneumonia, the breath sounds in the right base will be bronchial,
not the normal vesicular breath sounds. If the client still has dyspnea, fever, and increased
respiratory rate, he should be examined by the physician before discharge because he may have
another source of infection or still have pneumonia.
9. The right forearm of a client who had a purified protein derivative (PPD) test for
tuberculosis is reddened and raised about 3mm where the test was given. This PPD would be
read as having which of the following results?
1. Indeterminate
2. Needs to be redone
3. Negative
4. Positive
Ans-9. 3. This test would be classed as negative. A 5mm raised area would be a positive result if
a client was HIV+ or had recent close contact with someone diagnosed with TB. Indeterminate
isn’t a term used to describe results of a PPD test. If the PPD is reddened and raised 10mm or
more, it’s considered positive according to the CDC.
10. A client with primary TB infection can expect to develop which of the following
conditions?
1. Active TB within 2 weeks

2. Active TB within 1 month
3. A fever that requires hospitalization
4. A positive skin test
Ans-10. 4. A primary TB infection occurs when the bacillus has successfully invaded the entire
body after entering through the lungs. At this point, the bacilli are walled off and skin tests read
positive. However, all but infants and immunosuppressed people will remain asymptomatic. The
general population has a 10% risk of developing active TB over their lifetime, in many cases
because of a break in the body’s immune defenses. The active stage shows the classic symptoms
of TB: fever, hemoptysis, and night sweats.
11. A client was infected with TB 10 years ago but never developed the disease. He’s now
being treated for cancer. The client begins to develop signs of TB. This is known as which of
the following types of infection?
1. Active infection
2. Primary infection
3. Superinfection
4. Tertiary infection
Ans-11. 1. Some people carry dormant TB infections that may develop into active disease. In
addition, primary sites of infection containing TB bacilli may remain inactive for years and then
activate when the client’s resistance is lowered, as when a client is being treated for cancer.
There’s no such thing as tertiary infection, and superinfection doesn’t apply in this case.
12. A client has active TB. Which of the following symptoms will he exhibit?
1. Chest and lower back pain

2. Chills, fever, night sweats, and hemoptysis
3. Fever of more than 104*F and nausea
4. Headache and photophobia
Ans-12. 2. Typical signs and symptoms are chills, fever, night sweats, and hemoptysis. Chest
pain may be present from coughing, but isn’t usual. Clients with TB typically have low-grade
fevers, not higher than 102*F. Nausea, headache, and photophobia aren’t usual TB symptoms.
13. Which of the following diagnostic tests is definitive for TB?
1. Chest x-ray
2. Mantoux test
3. Sputum culture
4. Tuberculin test
Ans-13. 3. The sputum culture for Mycobacterium tuberculosis is the only method of confirming
the diagnosis. Lesions in the lung may not be big enough to be seen on x-ray. Skin tests may be
falsely positive or falsely negative.
Ans-14. 3. If the lesions are large enough, the chest x-ray will show their presence in the lungs.
Sputum culture confirms the diagnosis. There can be false-positive and false-negative skin test
results. A chest x-ray can’t determine if this is a primary or secondary infection.
14. A client with a positive Monteux test result will be sent for a chest x-ray. For which of the
following reasons is this done?
1. To confirm the diagnosis

2. To determine if a repeat skin test is needed
3. To determine the extent of the lesions
4. To determine if this is a primary or secondary infection
Ans-14. 3. If the lesions are large enough, the chest x-ray will show their presence in the lungs.
Sputum culture confirms the diagnosis. There can be false-positive and false-negative skin test
results. A chest x-ray can’t determine if this is a primary or secondary infection.
15. A chest x-ray should a client’s lungs to be clear. His Monteux test is positive, with a 10mm
if induration. His previous test was negative. These test results are possible because:
1. He had TB in the past and no longer has it
2. He was successfully treated for TB, but skin tests always stay positive.
3. He’s a “seroconverter”, meaning the TB has gotten to his bloodstream.
4. He’s a “tuberculin converter,” which means he has been infected with TB since his last skin
test.
Ans-15. 4. A tuberculin converter’s skin test will be positive, meaning he has been exposed to
an infected with TB and now has a cell-mediated immune response to the skin test. The client’s
blood and x-ray results may stay negative. It doesn’t mean the infection has advanced to the
active stage. Because his x-ray is negative, he should be monitored every 6 months to see if he
develops changes in his x-ray or pulmonary examination. Being a seroconverter doesn’t mean
the TB has gotten into his bloodstream; it means it can be detected by a blood test.
16. A client with a positive skin test for TB isn’t showing signs of active disease. To help
prevent the development of active TB, the client should be treated with isonaizid, 300mg daily,
for how long?
1. 10 to 14 days
2. 2 to 4 weeks
3. 3 to 6 months
4. 9 to 12 months
Ans-16. 4. Because of the increased incidence of resistant strains of TB, the disease must be
treated for up to 24 months in some cases, but treatment typically lasts for 9-12 months. Isoaizid
is the most common medication used for the treatment of TB, but other antibiotics are added to
the regimen to obtain the best results.
17. A client with a productive cough, chills, and night sweats is suspected of having active TB.
The physician should take which of the following actions?
1. Admit him to the hospital in respiratory isolation

2. Prescribe isoniazid and tell him to go home and rest
3. Give a tuberculin test and tell him to come back in 48 hours and have it read.
4. Give a prescription for isoniazid, 300mg daily for 2 weeks, and send him home.
Ans-17. 1. The client is showing s/s of active TB and, because of the productive cough, is highly
contagious. He should be admitted to the hospital, placed in respiratory isolation, and three
sputum cultures should be obtained to confirm the diagnosis. He would most likely be given
isoniazid and two or three other antitubercular antibiotics until the diagnosis is confirmed, then
isolation and treatment would continue if the cultures were positive for TB. After 7 to 10 days,
three more consecutive sputum cultures will be obtained. If they’re negative, he would be
considered non-contagious and may be sent home, although he’ll continue to take the
antitubercular drugs for 9 to 12 months.
18. A client is diagnosed with active TB and started on triple antibiotic therapy. What signs
and symptoms would the client show if therapy is inadequate?
1. Decreased shortness of breath

2. Improved chest x-ray
3. Nonproductive cough
4. Positive acid-fast bacilli in a sputum sample after 2 months of treatment.
Ans-18. 4. Continuing to have acid-fast bacilli in the sputum after 2 months indicated continued
infection.
19. A client diagnosed with active TB would be hospitalized primarily for which of the
following reasons?
1. To evaluate his condition

2. To determine his compliance
3. to prevent spread of the disease
4. To determine the need for antibiotic therapy.
Ans-19. 3. The client with active TB is highly contagious until three consecutive sputum
cultures are negative, so he’s put in respiratory isolation in the hospital.
20. A high level of oxygen exerts which of the following effects on the lung?
1. Improves oxygen uptake

2. Increases carbon dioxide levels
3. Stabilizes carbon dioxide levels
4. Reduces amount of functional alveolar surface area
Ans-20. 4. Oxygen toxicity causes direct pulmonary trauma, reducing the amount of alveolar
surface area available for gaseous exchange, which results in increased carbon dioxide levels and
decreased oxygen uptake.
21. A 24-year-old client comes into the clinic complaining of right-sided chest pain and
shortness of breath. He reports that it started suddenly. The assessment should include which
of the following interventions?
1. Auscultation of breath sounds

2. Chest x-ray
3. Echocardiogram
4. Electrocardiogram (ECG)
Ans-21. 1. Because the client is short of breath, listening to breath sounds is a good idea. He
may need a chest x-ray and an ECG, but a physician must order these tests. Unless a cardiac
source for the client’s pain is identified, he won’t need an echocardiogram.
22. A client with shortness of breath has decreased to absent breath sounds on the right side,
from the apex to the base. Which of the following conditions would best explain this?
1. Acute asthma
2. Chronic bronchitis
3. Pneumonia
4. Spontaneous pneumothorax
Ans-22. 4. A spontaneous pneumothorax occurs when the client’s lung collapses, causing an
acute decrease in the amount of functional lung used in oxygenation. The sudden collapse was
the cause of his chest pain and shortness of breath. An asthma attack would show wheezing
breath sounds, and bronchitis would have rhonchi. Pneumonia would have bronchial breath
sounds over the area of consolidation.
23. Which of the following treatments would the nurse expect for a client with a spontaneous
pneumothorax?
1. Antibiotics
2. Bronchodilators
3. Chest tube placement
4. Hyperbaric chamber
Ans-23. 3. The only way to re-expand the lung is to place a chest tube on the right side so the air
in the pleural space can be removed and the lung re-expanded.
24. Which of the following methods is the best way to confirm the diagnosis of a
pneumothorax?
1. Auscultate breath sounds

2. Have the client use an incentive spirometer
3. Take a chest x-ray
4. stick a needle in the area of decreased breath sounds
Ans-24. 3. A chest x-ray will show the area of collapsed lung if pneumothorax is present as well
as the volume of air in the pleural space. Listening to breath sounds won’t confirm a diagnosis.
An IS is used to encourage deep breathing. A needle thoracotomy is done only in an emergency
and only by someone trained to do it.
25. A pulse oximetry gives what type of information about the client?
1. Amount of carbon dioxide in the blood

2. Amount of oxygen in the blood
3. Percentage of hemoglobin carrying oxygen
4. Respiratory rate
Ans-25. 3. The pulse oximeter determines the percentage of hemoglobin carrying oxygen. This
doesn’t ensure that the oxygen being carried through the bloodstream is actually being taken up
by the tissue.
26. What effect does hemoglobin amount have on oxygenation status?
1. No effect
2. More hemoglobin reduces the client’s respiratory rate
3. Low hemoglobin levels cause reduces oxygen-carrying capacity
4. Low hemoglobin levels cause increased oxygen-carrying capacity.
Ans-26. 3. Hemoglobin carries oxygen to all tissues in the body. If the hemoglobin level is low,
the amount of oxygen-carrying capacity is also low. More hemoglobin will increase oxygen-
carrying capacity and thus increase the total amount of oxygen available in the blood. If the
client has been tachypneic during exertion, or even at rest, because oxygen demand is higher
than the available oxygen content, then an increase in hemoglobin may decrease the respiratory
rate to normal levels.0
27. Which of the following statements best explains how opening up collapsed alveoli
improves oxygenation?
1. Alveoli need oxygen to live

2. Alveoli have no effect on oxygenation
3. Collapsed alveoli increase oxygen demand
4. Gaseous exchange occurs in the alveolar membrane.
Ans-27. 4. Gaseous exchange occurs in the alveolar membrane, so if the alveoli collapse, no
exchange occurs, Collapsed alveoli receive oxygen, as well as other nutrients, from the
bloodstream. Collapsed alveoli have no effect on oxygen demand, though by decreasing the
surface area available for gas exchange, they decrease oxygenation of the blood.
28. Continuous positive airway pressure (CPAP) can be provided through an oxygen mask to
improve oxygenation in hypoxic patients by which of the following methods?
1. The mask provides 100% oxygen to the client.

2. The mask provides continuous air that the client can breathe.
3. The mask provides pressurized oxygen so the client can breathe more easily.
4. The mask provides pressurized at the end of expiration to open collapsed alveoli.
Ans-28. 3. The mask provides pressurized oxygen continuously through both inspiration and
expiration. The mask can be set to deliver any amount of oxygen needed. By providing the client
with pressurized oxygen, the client has less resistance to overcome in taking his next breath,
making it easier to breathe. Pressurized oxygen delivered at the end of expiration is positive end-
expiratory pressure (PEEP), not continuous positive airway pressure.
29. Which of the following best describes pleural effusion?
1. The collapse of alveoli

2. The collapse of bronchiole
3. The fluid in the alveolar space
4. The accumulation of fluid between the linings of the pleural space.
Ans-29. 4. The pleural fluid normally seeps continually into the pleural space from the
capillaries lining the parietal pleura and is reabsorbed by the visceral pleural capillaries and
lymphatics. Any condition that interferes with either the secretion or drainage of this fluid will
lead to a pleural effusion.
30. If a pleural effusion develops, which of the following actions best describes how the fluid
can be removed from the pleural space and proper lung status restored?
1. Inserting a chest tube

2. Performing thoracentesis
3. Performing paracentesis
4. Allowing the pleural effusion to drain by itself.
Ans-30. 2. Performing thoracentesis is used to remove excess pleural fluid. The fluid is then
analyzed to determine if it’s transudative or exudative. Transudates are substances that have
passed through a membrane and usually occur in low protein states. Exudates are substances that
have escaped from blood vessels. They contain an accumulation of cells and have a high specific
gravity and a high lactate dehydrogenase level. Exudates usually occur in response to a
malignancy, infection, or inflammatory process. A chest tube is rarely necessary because the
amount of fluid typically isn’t large enough to warrant such a measure. Pleural effusions can’t
drain by themselves.
31. A comatose client needs a nasopharyngeal airway for suctioning. After the airway is
inserted, he gags and coughs. Which action should the nurse take?
1. Remove the airway and insert a shorter one.

2. Reposition the airway.
3. Leave the airway in place until the client gets used to it.
4. Remove the airway and attempt suctioning without it.
Ans-31. 1. If a client gags or coughs after nasopharyngeal airway placement, the tube may be
too long. The nurse should remove it and insert a shorter one. Simply repositioning the airway
won’t solve the problem. The client won’t get used to the tube because it’s the wrong size.
Suctioning without a nasopharyngeal airway causes trauma to the natural airway.
32. An 87-year-old client requires long term ventilator therapy. He has a tracheostomy in
place and requires frequent suctioning. Which of the following techniques is correct?
1. Using intermittent suction while advancing the catheter.

2. Using continuous suction while withdrawing the catheter.
3. Using intermittent suction while withdrawing the catheter.
4. Using continuous suction while advancing the catheter.
Ans-32. Intermittent suction should be applied during catheter withdrawal. To prevent hypoxia,
suctioning shouldn’t last more than 10-seconds at a time. Suction shouldn’t be applied while the
catheter is being advanced.
33. A client’s ABG analysis reveals a pH of 7.18, PaCO2 of 72 mm Hg, PaO2 of 77 mm Hg, and
HCO3– of 24 mEq/L. What do these values indicate?
Ans-33. 4.
34. A police officer brings in a homeless client to the ER. A chest x-ray suggests he has TB.
The physician orders an intradermal injection of 5 tuberculin units/0.1 ml of tuberculin
purified derivative. Which needle is appropriate for this injection?
1. 5/8” to ½” 25G to 27G needle.

2. 1” to 3” 20G to 25G needle.
3. ½” to 3/8” 26 or 27G needle.
4. 1” 20G needle.
Ans-34. 3. Intradermal injections like those used in TN skin tests are administered in small
volumes (usually 0.5 ml or less) into the outer skin layers to produce a local effect. A TB syringe
with a ½” to 3/8” 26G or 27G needle should be inserted about 1/8” below the epidermis.
35. A 76-year old client is admitted for elective knee surgery. Physical examination reveals
shallow respirations but no signs of respiratory distress. Which of the following is a normal
physiologic change related to aging?
1. Increased elastic recoil of the lungs

2. Increased number of functional capillaries in the alveoli
3. Decreased residual volume
4. Decreased vital capacity.
Ans-35. 4. Reduction in VC is a normal physiologic change in the older adult. Other normal
physiologic changes include decreased elastic recoil of the lungs, fewer functional capillaries in
the alveoli, and an increase is residual volume.
36. A 79-year-old client is admitted with pneumonia. Which nursing diagnosis should take
priority?
1. Acute pain related to lung expansion secondary to lung infection

2. Risk for imbalanced fluid volume related to increased insensible fluid losses secondary to
fever.
3. Anxiety related to dyspnea and chest pain.
4. Ineffective airway clearance related to retained secretions.
Ans-36. 4. Pneumonia is an acute infection of the lung parenchyma. The inflammatory reaction
may cause an outpouring of exudate into the alveolar spaces, leading to an ineffective airway
clearance related to retained secretions.
37. A community health nurse is conducting an educational session with community members
regarding TB. The nurse tells the group that one of the first symptoms associated with TB is:
1. A bloody, productive cough

2. A cough with the expectoration of mucoid sputum
3. Chest pain
4. Dyspnea
Ans-37. 2. One of the first pulmonary symptoms includes a slight cough with the expectoration
of mucoid sputum.
38. A nurse evaluates the blood theophylline level of a client receiving aminophylline
(theophylline) by intravenous infusion. The nurse would determine that a therapeutic blood
level exists if which of the following were noted in the laboratory report?
1. 5 mcg/mL
2. 15 mcg/mL
3. 25 mcg/mL
4. 30 mcg/mL
Ans-38. 2. The therapeutic theophylline blood level range from 10-20 mcg/mL.
39. Isoniazid (INH) and rifampin (Rifadin) have been prescribed for a client with TB. A nurse
reviews the medical record of the client. Which of the following, if noted in the client’s history,
would require physician notification?
1. Heart disease
2. Allergy to penicillin
3. Hepatitis B
4. Rheumatic fever
Ans-39. 3. Isoniazid and rafampin are contraindicated in clients with acute liver disease or a
history of hepatic injury.
40. A client is experiencing confusion and tremors is admitted to a nursing unit. An initial
ABG report indicates that the PaCO2 level is 72 mm Hg, whereas the PaO2 level is 64 mm Hg. A
nurse interprets that the client is most likely experiencing:
1. Carbon monoxide poisoning

2. Carbon dioxide narcosis
Ans-40. 2. Carbon dioxide narcosis is a condition that results from extreme hypercapnia, with
carbon dioxide levels in excess of 70 mm Hg. The client experiences symptoms such as
confusion and tremors, which may progress to convulsions and possible coma.
41. A client who is HIV+ has had a PPD skin test. The nurse notes a 7-mm area of induration
at the site of the skin test. The nurse interprets the results as:
1. Positive
2. Negative
3. Inconclusive
4. The need for repeat testing.
Ans-41. 1. The client with HIV+ status is considered to have positive results on PPD skin test
with an area greater than 5-mm of induration. The client with HIV is immunosuppressed, making
a smaller area of induration positive for this type of client.
42. A nurse is caring for a client diagnosed with TB. Which assessment, if made by the nurse,
would not be consistent with the usual clinical presentation of TB and may indicate the
development of a concurrent problem?
1. Nonproductive or productive cough

2. Anorexia and weight loss
3. Chills and night sweats
4. High-grade fever
Ans-42. 4. The client with TB usually experiences cough (non-productive or productive),
fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats
(which may occur at night), and a low-grade fever.
43. A nurse is teaching a client with TB about dietary elements that should be increased in the
diet. The nurse suggests that the client increase intake of:
1. Meats and citrus fruits

2. Grains and broccoli
3. Eggs and spinach
4. Potatoes and fish
Ans-43. 1. The nurse teaches the client with TB to increase intake of protein, iron, and vitamin
C.
44. Which of the following would be priority assessment data to gather from a client who has
been diagnosed with pneumonia? Select all that apply.
1. Auscultation of breath sounds

2. Auscultation of bowel sounds
3. Presence of chest pain.
4. Presence of peripheral edema
5. Color of nail beds
Ans-44. 1, 3, 5. A respiratory assessment, which includes auscultating breath sounds and

assessing the color of the nail beds, is a priority for clients with pneumonia. Assessing for the
presence of chest pain is also an important respiratory assessment as chest pain can interfere with
the client’s ability to breathe deeply. Auscultating bowel sounds and assessing for peripheral
edema may be appropriate assessments, but these are not priority assessments for the patient with
pneumonia.
45. A client with pneumonia has a temperature of 102.6*F (39.2*C), is diaphoretic, and has a
productive cough. The nurse should include which of the following measures in the plan of
care?
1. Position changes q4h

2. Nasotracheal suctioning to clear secretions
3. Frequent linen changes
4. Frequent offering of a bedpan.
Ans-45. 3. Frequent linen changes are appropriate for this client because of diaphoresis.
Diaphoresis produces general discomfort. The client should be kept dry to promote comfort.
Position changes need to be done every 2 hours. Nasotracheal suctioning is not indicated with the
client’s productive cough. Frequent offering of a bedpan is not indicated by the data provided in
this scenario.
46. The cyanosis that accompanies bacterial pneumonia is primarily caused by which of the
following?
1. Decreased cardiac output

2. Pleural effusion
3. Inadequate peripheral circulation
4. Decreased oxygenation of the blood.
Ans-46. 4. A client with pneumonia has less lung surface available for the diffusion of gases
because of the inflammatory pulmonary response that creates lung exudate and results in reduced
oxygenation of the blood. The client becomes cyanotic because blood is not adequately
oxygenated in the lungs before it enters the peripheral circulation.
47. Which of the following mental status changes may occur when a client with pneumonia is
first experiencing hypoxia?
1. Coma
2. Apathy
3. Irritability
4. Depression
Ans-47. 3. Clients who are experiencing hypoxia characteristically exhibit irritability,

restlessness, or anxiety as initial mental status changes. As the hypoxia becomes more
pronounced, the client may become confused and combative. Coma is a late clinical
manifestation of hypoxia. Apathy and depression are not symptoms of hypoxia.
48. A client with pneumonia has a temperature ranging between 101* and 102*F and periods
of diaphoresis. Based on this information, which of the following nursing interventions would
be a priority?
1. Maintain complete bed rest

2. Administer oxygen therapy
3. Provide frequent linen changes.
4. Provide fluid intake of 3 L/day
Ans-48. 4. A fluid intake of at least 3 L/day should be provided to replace any fluid loss
occurring as a result the fever and diaphoresis; this is a high-priority intervention.
49. Which of the following would be an appropriate expected outcome for an elderly client
recovering from bacterial pneumonia?
1. A respiratory rate of 25 to 30 breaths per minute

2. The ability to perform ADL’s without dyspnea
3. A maximum loss of 5 to 10 pounds of body weight
4. Chest pain that is minimized by splinting the ribcage.
Ans-49. 2. An expected outcome for a client recovering from pneumonia would be the ability to
perform ADL’s without experiencing dyspnea. A respiratory rate of 25 to 30 breaths/minute
indicates the client is experiencing tachypnea, which would not be expected on recovery. A
weight loss of 5-10 pounds is undesirable; the expected outcome would be to maintain normal
weight. A client who is recovering from pneumonia should experience decreased or no chest
pain.
50. Which of the following symptoms is common in clients with TB?
1. Weight loss
3. Dyspnea on exertion
4. Mental status changes
Ans-50. 1. TB typically produces anorexia and weight loss. Other signs and symptoms may
include fatigue, low-grade fever, and night sweats.
51. The nurse obtains a sputum specimen from a client with suspected TB for laboratory
study. Which of the following laboratory techniques is most commonly used to identify
tubercle bacilli in sputum?
1. Acid-fast staining
2. Sensitivity testing
3. Agglutination testing
4. Dark-field illumination
Ans-51. 1. The most commonly used technique to identify tubercle bacilli is acid-fast staining.
The bacilli have a waxy surface, which makes them difficult to stain in the lab. However, once
they are stained, the stain is resistant to removal, even with acids. Therefore, tubercle bacilli are
often called acid-fast bacilli.
52. Which of the following antituberculus drugs can cause damage to the eighth cranial
nerve?
1. Streptomycin
2. Isoniazid
3. Para-aminosalicylic acid
4. Ethambutol hydrochloride
Ans-52. 1. Streptomycin is an aminoglycoside, and eight cranial nerve damage (ototoxicity) is a

common side effect from aminoglycosides.
53. The client experiencing eighth cranial nerve damage will most likely report which of the
following symptoms?
1. Vertigo
2. Facial paralysis
3. Impaired vision
4. Difficulty swallowing
Ans-53. 1. The eighth cranial nerve is the vestibulocochlear nerve, which is responsible for
hearing and equilibrium. Streptomycin can damage this nerve.
54. Which of the following family members exposed to TB would be at highest risk for
contracting the disease?
1. 45-year-old mother
2. 17-year-old daughter
3. 8-year-old son
4. 76-year-old grandmother
Ans-54. 4. Elderly persons are believed to be at higher risk for contracting TB because of
decreased immunocompetence. Other high-risk populations in the US include the urban poor,
AIDS, and minority groups.
55. The nurse is teaching a client who has been diagnosed with TB how to avoid spreading
the disease to family members. Which statement(s) by the client indicate(s) that he has
understood the nurses’ instructions? Select all that apply.
1. “I will need to dispose of my old clothing when I return home.”

2. “I should always cover my mouth and nose when sneezing.”
3. “It is important that I isolate myself from family when possible.”
4. “I should use paper tissues to cough in and dispose of them properly.”
5. “I can use regular plate and utensils whenever I eat.”
Ans-55. 2, 4, 5.
56. A client has a positive reaction to the PPD test. The nurse correctly interprets this reaction
to mean that the client has:
1. Active TB
2. Had contact with Mycobacterium tuberculosis
3. Developed a resistance to tubercle bacilli
4. Developed passive immunity to TB.
Ans-56. 2. A positive PPD test indicates that the client has been exposed to tubercle bacilli.
Exposure does not necessarily mean that active disease exists.
57. INH treatment is associated with the development of peripheral neuropathies. Which of
the following interventions would the nurse teach the client to help prevent this complication?
1. Adhere to a low cholesterol diet

2. Supplement the diet with pyridoxine (vitamin B6)
3. Get extra rest
4. Avoid excessive sun exposure.
Ans-57. 2. INH competes with the available vitamin B6 in the body and leaves the client at risk
for development of neuropathies related to vitamin deficiency. Supplemental vitamin B6 is
routinely prescribed.
58. The nurse should include which of the following instructions when developing a teaching
plan for clients receiving INH and rifampin for treatment for TB?
1. Take the medication with antacids

2. Double the dosage if a drug dose is forgotten
3. Increase intake of dairy products
4. Limit alcohol intake
Ans-58. 4. INH and rifampin are hepatoxic drugs. Clients should be warned to limit intake of
alcohol during drug therapy. Both drugs should be taken on an empty stomach. If antacids are
needed for GI distress, they should be taken 1 hour before or 2 hours after these drugs are
administered. Clients should not double the dosage of these drugs because of their potential
toxicity. Clients taking INH should avoid foods that are rich in tyramine, such as cheese and
dairy products, or they may develop hypertension.
59. The public health nurse is providing follow-up care to a client with TB who does not
regularly take his medication. Which nursing action would be most appropriate for this client?
1. Ask the client’s spouse to supervise the daily administration of the medications.
2. Visit the clinic weekly to ask him whether he is taking his medications regularly.
3. Notify the physician of the client’s non-compliance and request a different prescription.
4. Remind the client that TB can be fatal if not taken properly.
Ans-59. 1. Directly observed therapy (DOT) can be implemented with clients who are not
compliant with drug therapy. In DOT, a responsible person, who may be a family member or a
health care provider, observes the client taking the medication. Visiting the client, changing the
prescription, or threatening the client will not ensure compliance if the client will not or cannot
follow the prescribed treatment.
Blood Disorders
1. The nurse is preparing to teach a client with microcytic hypochromic anemia about the
diet to follow after discharge. Which of the following foods should be included in the diet?
A. Eggs
B. Lettuce
C. Citrus fruits
D. Cheese
Ans-1. 1. One of the microcytic, hypochromic anemia’s is iron-deficiency amenia. A rich source
of iron is needed in the diet, and eggs are high in iron. Other foods high in iron include organ and
muscle (dark) meats; shellfish, shrimp, and tuna; enriched, whole-grain, and fortified cereals and
breads; legumes, nuts, dried fruits, and beans; oatmeal; and sweet potatoes. Dark green leafy
vegetables and citrus fruits are good sources of vitamin C. Cheese is a good source of calcium.
2. The nurse would instruct the client to eat which of the following foods to obtain the best
supply of vitamin B12?
1. Whole grains
2. Green leafy vegetables
3. Meats and dairy products
4. Broccoli and Brussels sprouts
Ans-2. 3. Good sources of vitamin B12 include meats and dairy products. Whole grains are a
good source of thiamine. Green leafy vegetables are good sources of niacin, folate, and
carotenoids (precursors of vitamin A). Broccoli and Brussels sprouts are good sources of
ascorbic acid (vitamin C).
3. The nurse has just admitted a 35-year-old female client who has a serum B12
concentration of 800 pg/ml. Which of the following laboratory findings would cue the nurse to
focus the client history on specific drug or alcohol abuse?
1. Total bilirubin, 0.3 mg/dL

2. Serum creatinine, 0.5 mg/dL
3. Hemoglobin, 16 g/dL
4. Folate, 1.5 ng/mL
Ans-3. 4. The normal range of folic acid is 1.8 to 9 ng/mL, and the normal range of vitamin B12
is 200 to 900 pg/mL. A low folic acid level in the presence of a normal vitamin B12 level is
indicative of a primary folic acid-deficiency anemia. Factors that affect the absorption of folic
acid are drugs such as methotrexate, oral contraceptives, antiseizure drugs, and alcohol. The total
bilirubin, serum creatinine, and hemoglobin values are within normal limits.
4. The nurse understands that the client with pernicious anemia will have which
distinguishing laboratory findings?
1. Schilling’s test, elevated

2. Intrinsic factor, absent.
3. Sedimentation rate, 16 mm/hour
4. RBCs 5.0 million
Ans-4. 2. The defining characteristic of pernicious anemia, a megaloblastic anemia, is lack of the
intrinsic factor, which results from atrophy of the stomach wall. Without the intrinsic factor,
vitamin B12 cannot be absorbed in the small intestines, and folic acid needs vitamin B12 for
DNA synthesis of RBCs. The gastric analysis was done to determine the primary cause of the
anemia. An elevated excretion of the injected radioactive vitamin B12, which is protocol for the
first and second stage of the Schilling test, indicates that the client has the intrinsic factor and can
absorb vitamin B12 into the intestinal tract. A sedimentation rate of 16 mm/hour is normal for
both men and women and is a nonspecific test to detect the presence of inflammation. It is not
specific to anemias. An RBC value of 5.0 million is a normal value for both men and women and
does not indicate anemia.
5. The nurse devises a teaching plan for the patient with aplastic anemia. Which of the
following is the most important concept to teach for health maintenance?
1. Eat animal protein and dark leafy vegetables each day

2. Avoid exposure to others with acute infection
3. Practice yoga and meditation to decrease stress and anxiety
4. Get 8 hours of sleep at night and take naps during the day
Ans-5. 2. Clients with aplastic anemia are severely immunocompromised and at risk for infection
and possible death related to bone marrow suppression and pancytopenia. Strict aseptic
technique and reverse isolation are important measures to prevent infection. Although diet,
reduced stress, and rest are valued in supporting health, the potentially fatal consequence of an
acute infection places it as a priority for teaching the client about health maintenance. Animal
meat and dark green leafy vegetables, good sources of vitamin B12 and folic acid, should be
included in the daily diet. Yoga and meditation are good complimentary therapies to reduce
stress. Eight hours of rest and naps are good for spacing and pacing activity and rest.
6. A client comes into the health clinic 3 years after undergoing a resection of the terminal
ileum complaining of weakness, shortness of breath, and a sore tongue. Which client
statement indicates a need for intervention and client teaching?
1. “I have been drinking plenty of fluids.”

2. “I have been gargling with warm salt water for my sore tongue.”
3. “I have 3 to 4 loose stools per day.”
4. “I take a vitamin B12 tablet every day.”
Ans-6. 4. Vitamin B12 combines with intrinsic factor in the stomach and is then carried to the
ileum, where it is absorbed in the bloodstream. In this situation, vitamin B12 cannot be absorbed
regardless of the amount of oral intake of sources of vitamin B12 such as animal protein or
vitamin B12 tablets. Vitamin B12 need to be injected every month, because the ileum has been
surgically removed. Replacement of fluids and electrolytes is important when the client has
continuous multiple loose stools on a daily basis. Warm salt water is used to soothe sore mucous
membranes. Crohn’s disease and small bowel resection may cause several loose stools a day.
7. A vegetarian client was referred to a dietician for nutritional counseling for anemia.
Which client outcome indicates that the client does not understand nutritional counseling?
The client:
1. Adds dried fruit to cereal and baked goods

2. Cooks tomato-based foods in iron pots
3. Drinks coffee or tea with meals
4. Adds vitamin C to all meals
Ans-7. 3. Coffee and tea increase gastrointestinal mobility and inhibit the absorption of nonheme
iron. Clients are instructed to add dried fruits to dishes at every meal because dried fruits are a
nonheme or no animal iron source. Cooking in iron cookware, especially acid-based foods such
as tomatoes, adds iron to the diet. Clients are instructed to add a rich supply of vitamin C to
every meal because the absorption of iron is increased when food with vitamin C or ascorbic acid
is consumed.
8. A client was admitted with iron deficiency anemia and blood-streaked emesis. Which
question is most appropriate for the nurse to ask in determining the extent of the client’s
activity intolerance?
1. “What activities were you able to do 6 months ago compared with the present?”
2. “How long have you had this problem?”
3. “Have you been able to keep up with all your usual activities?”
4. “Are you more tired now than you used to be?”
1. Ans-8. 1. It is difficult to determine activity intolerance without objectively comparing

activities from one time frame to another. Because iron deficiency anemia can occur
gradually and individual endurance varies, the nurse can best assess the client’s activity
tolerance by asking 0 client to compare activities 6 months ago and at the present.
Asking a client how long a problem has existed is a very open-ended question that
allows for too much subjectivity for any definition of the client’s activity tolerance. Also,
the client may not even identify that a “problem” exists. Asking the client whether he is
staying abreast of usual activities addresses whether the tasks were completed, not the
tolerance of the client while the tasks were being completed or the resulting condition of
the client after the tasks were completed. Asking the client if he is more tired now than
usual does not address his activity tolerance. Tiredness is a subjective evaluation and
again can be distorted by factors such as the gradual onset of the anemia or the
endurance of the individual.
9. The primary purpose of the Schilling test is to measure the client’s ability to:
1. Store vitamin B12

2. Digest vitamin B12
3. Absorb vitamin B12
4. Produce vitamin B12
Ans-9. 3. Pernicious anemia is caused by the body’s inability to absorb vitamin B12. This results
in a lack of intrinsic factor in the gastric juices. Schilling’s test helps diagnose pernicious anemia
by determining the client’s ability to absorb vitamin B12.
10. The nurse implements which of the following for the client who is starting a Schilling
test?
1. Administering methylcellulose (Citrucel)

2. Starting a 24- to 48 hour urine specimen collection
3. Maintaining NPO status
4. Starting a 72 hour stool specimen collection
Ans-10. 2. Urinary vitamin B12 levels are measured after the ingestion of radioactive vitamin
B12. A 24-to 48- hour urine specimen is collected after administration of an oral dose of
radioactively tagged vitamin B12 and an injection of nonradioactive vitamin B12. In a healthy state
of absorption, excess vitamin B12 is excreted in the urine; in a malabsorption state or when the
intrinsic factor is missing, vitamin B12 is excreted in the feces. Citrucel is a bulk-forming agent.
Laxatives interfere with the absorption of vitamin B12. The client is NPO 8 to 12 hours before the
test but is not NPO during the test. A stool collection is not part of the Schilling test. If stool
contaminates the urine collection, the results will be altered.
11. A client with pernicious anemia asks why she must take vitamin B12 injections for the rest
of her life. What is the nurse’s best response?
1. “The reason for your vitamin deficiency is an inability to absorb the vitamin because the
stomach is not producing sufficient acid.”
2. “The reason for your vitamin deficiency is an inability to absorb the vitamin because the
stomach is not producing sufficient intrinsic factor.”
3. “The reason for your vitamin deficiency is an excessive excretion of the vitamin because of
kidney dysfunction.”
4. “The reason for your vitamin deficiency is an increased requirement for the vitamin because
of rapid red blood cell production.”
Ans-11. 2. Most clients with pernicious anemia have deficient production of intrinsic factor in
the stomach. Intrinsic factor attaches to the vitamin in the stomach and forms a complex that
allows the vitamin to be absorbed in the small intestine. The stomach is producing enough acid,
there is not an excessive excretion of the vitamin, and there is not a rapid production of RBCs in
this condition.
12. The nurse is assessing a client’s activity intolerance by having the client walk on a
treadmill for 5 minutes. Which of the following indicates an abnormal response?
1. Pulse rate increased by 20 bpm immediately after the activity

2. Respiratory rate decreased by 5 breaths/minute
3. Diastolic blood pressure increased by 7 mm Hg
4. Pulse rate within 6 bpm of resting phase after 3 minutes of rest.
Ans-12. 2. The normal physiologic response to activity is an increased metabolic rate over the
resting basal rate. The decrease in respiratory rate indicates that the client is not strong enough to
complete the mechanical cycle of respiration needed for gas exchange. The post activity pulse is
expected to increase immediately after activity but by no more than 50 bpm if it is strenuous
activity. The diastolic blood pressure is expected to rise but by no more than 15 mm Hg. The
pulse returns to within 6 bpm of the resting pulse after 3 minutes of rest.
13. When comparing the hematocrit levels of a post-op client, the nurse notes that the
hematocrit decreased from 36% to 34% on the third day even though the RBC and
hemoglobin values remained stable at 4.5 million and 11.9 g/dL, respectively. Which nursing
intervention is most appropriate?
1. Check the dressing and drains for frank bleeding
2. Call the physician
3. Continue to monitor vital signs
4. Start oxygen at 2L/min per NC
Ans-13. 3. The nurse should continue to monitor the client, because this value reflects a normal
physiologic response. The physician does not need to be called, and oxygen does not need to be
started based on these laboratory findings. Immediately after surgery, the client’s hematocrit
reflects a falsely high value related to the body’s compensatory response to the stress of sudden
loss of fluids and blood. Activation of the intrinsic pathway and the renin-angiotensin cycle via
antidiuretic hormone produces vasoconstriction and retention of fluid for the first 1 to 2 day post-
op. By the second to third day, this response decreases and the client’s hematocrit level is more
reflective of the amount of RBCs in the plasma. Fresh bleeding is a less likely occurrence on the
third post-op day but is not impossible; however, the nurse would have expected to see a
decrease in the RBC and hemoglobin values accompanying the hematocrit.
14. A client is to receive epoetin (Epogen) injections. What laboratory value should the nurse
assess before giving the injection?
1. Hematocrit
2. Partial thromboplastin time
3. Hemoglobin concentration
4. Prothrombin time
Ans-14. 1. Epogen is a recombinant DNA form of erythropoietin, which stimulates the

production of RBCs and therefore causes the hematocrit to rise. The elevation in hematocrit
causes an elevation in blood pressure; therefore, the blood pressure is a vital sign that should be
checked. The PTT, hemoglobin level, and PT are not monitored for this drug.
15. A client states that she is afraid of receiving vitamin B12 injections because of the potential
toxic reactions. What is the nurse’s best response to relieve these fears?
1. “Vitamin B12 will cause ringing in the eats before a toxic level is reached.”
2. “Vitamin B12 may cause a very mild skin rash initially.”
3. “Vitamin B12 may cause mild nausea but nothing toxic.”
4. “Vitamin B12 is generally free of toxicity because it is water soluble.”
Ans-15. 4. Vitamin B12 is a water-soluble vitamin. When water-soluble vitamins are taken in
excess of the body’s needs, they are filtered through the kidneys and excreted. Vitamin B12is
considered to be nontoxic. Adverse reactions that have occurred are believed to be related to
impurities or to the preservative in B12 preparations. Ringing in the ears, skin rash, and nausea
are not considered to be related to vitamin B12 administration.
16. A client with microcytic anemia is having trouble selecting food items from the hospital
menu. Which food is best for the nurse to suggest for satisfying the client’s nutritional needs
and personal preferences?
1. Egg yolks
2. Brown rice
3. Vegetables
4. Tea
Ans-16. 2. Brown rice is a source of iron from plant sources (nonheme iron). Other sources of
nonheme iron are whole-grain cereals and breads, dark green vegetables, legumes, nuts, dried
fruits (apricots, raisins, and dates), oatmeal, and sweet potatoes. Egg yolks have iron but it is not
as well absorbed as iron from other sources. Vegetables are a good source of vitamins that may
facilitate iron absorption. Tea contains tannin, which combines with nonheme iron, preventing its
absorption.
17. A client with macrocytic anemia has a burn on her foot and states that she had been
watching television while lying on a heating pad. What is the nurse’s first response?
1. Assess for potential abuse

2. Check for diminished sensations
3. Document the findings
4. Clean and dress the area
Ans-17. 2. Macrocytic anemias can result from deficiencies in vitamin B12 or ascorbic acid. Only
vitamin B12 deficiency causes diminished sensations of peripheral nerve endings. The nurse
should assess for peripheral neuropathy and instruct the client in self-care activities for her
diminished sensation to heat and pain. The burn could be related to abuse, but this conclusion
would require more supporting data. The findings should be documented, but the nurse would
want to address the client’s sensations first. The decision of how to treat the burn should be
determined by the physician.
18. Which of the following nursing assessments is a late symptom of polycythemia vera?
1. Headache
2. Dizziness
3. Pruritus
4. Shortness of breath
Ans-18. 3. Pruritus is a late symptom that results from abnormal histamine metabolism.
Headache and dizziness are early symptoms from engorged veins. Shortness of breath is an early
symptom from congested mucous membrane and ineffective gas exchange.
19. The nurse is teaching a client with polycythemia Vera about potential complications from
this disease. Which manifestations would the nurse include in the client’s teaching plan?
Select all that apply.
1. Hearing loss
2. Visual disturbance
3. Headache
4. Orthopnea
5. Gout
6. Weight loss
Ans-19. 2, 3, 4, 5. Polycythemia Vera, a condition in which too many RBCs are produced in the
blood serum, can lead to an increase in the hematocrit and hypervolemia, hyperviscosity, and
hypertension. Subsequently, the client can experience dizziness, tinnitus, visual disturbances,
headaches, or a feeling of fullness in the head. The client may also experience cardiovascular
symptoms such as heart failure (shortness of breath and orthopnea) and increased clotting time or
symptoms of an increased uric acid level such as painful swollen joints (usually the big toe).
Hearing loss and weight loss are not manifestations associated with polycythemia vera.
20. When a client is diagnosed with aplastic anemia, the nurse monitors for changes in which
of the following physiological functions?
1. Bleeding tendencies
2. Intake and output
3. Peripheral sensation
4. Bowel function
Ans-20. 1. Aplastic anemia decreases the bone marrow production of RBCs, WBCs, and
platelets. The client is at risk for bruising and bleeding tendencies. A change in the intake and
output is important, but assessment for the potential for bleeding takes priority. Change in the
peripheral nervous system is a priority problem specific to clients with vitamin B12 deficiency.
Change in bowel function is not associated with aplastic anemia.
21. Which of the following blood components is decreased in anemia?
1. Erythrocytes
2. Granulocytes
3. Leukocytes
4. Platelets
Ans-21. 1. Anemia is defined as a decreased number of erythrocytes (red blood cells).

Leukopenia is a decreased number of leukocytes (white blood cells). Thrombocytopenia is a
decreased number of platelets. Lastly, granulocytopenia is a decreased number of granulocytes (a
type of white blood cells).
22. A client with anemia may be tired due to a tissue deficiency of which of the following
substances?
1. Carbon dioxide
2. Factor VIII
3. Oxygen
4. T-cell antibodies
Ans-22. 3. Anemia stems from a decreased number of red blood cells and the resulting
deficiency in oxygen and body tissues. Clotting factors, such as factor VIII, relate to the body’s
ability to form blood clots and aren’t related to anemia, not is carbon dioxide of T antibodies.
23. Which of the following cells is the precursor to the red blood cell (RBC)?
1. B cell
2. Macrophage
3. Stem cell
4. T cell
Ans-23. 3. The precursor to the RBC is the stem cell. B cells, macrophages, and T cells and
lymphocytes, not RBC precursors.
24. Which of the following symptoms is expected with hemoglobin of 10 g/dl?
1. None
2. Pallor
3. Palpitations
Ans-24. 1. Mild anemia usually has no clinical signs. Palpitations, SOB, and pallor are all
associated with severe anemia.
25. Which of the following diagnostic findings are most likely for a client with aplastic
anemia?
1. Decreased production of T-helper cells

2. Decreased levels of white blood cells, red blood cells, and platelets
3. Increased levels of WBCs, RBCs, and platelets
4. Reed-Sternberg cells and lymph node enlargement
Ans-25. 2. In aplastic anemia, the most likely diagnostic findings are decreased levels of all the
cellular elements of the blood (pancytopenia). T-helper cell production doesn’t decrease in
aplastic anemia. Reed-Sternberg cells and lymph node enlargement occur with Hodgkin’s
disease.
26. A client with iron deficiency anemia is scheduled for discharge. Which instruction about
prescribed ferrous gluconate therapy should the nurse include in the teaching plan?
1. “Take the medication with an antacid.”

2. “Take the medication with a glass of milk.”
3. “Take the medication with cereal.”
4. “Take the medication on an empty stomach.”
Ans-26. 4. Preferably, ferrous gluconate should be taken on an empty stomach. Ferrous

gluconae should not be taken with antacids, milk, or whole-grain cereals because these foods
reduce iron absorption.
27. Which of the following disorders results from a deficiency of factor VIII?
1. Sickle cell disease

2. Christmas disease
3. Hemophilia A
4. Hemophilia B
Ans-27. 3. Hemophilia A results from a deficiency of factor VIII. Sickle cell disease is caused
by a defective hemoglobin molecule. Christmas disease, also called hemophilia B, results in a
factor IX deficiency.
28. The nurse explains to the parents of a 1-year-old child admitted to the hospital in a sickle
cell crisis that the local tissue damage the child has on admission is caused by which of the
following?
1. Autoimmune reaction complicated by hypoxia

2. Lack of oxygen in the red blood cells
3. Obstruction to circulation
4. Elevated serum bilirubin concentration.
Ans-28. 3. Characteristic sickle cells tend to cause “log jams” in capillaries. This results in poor
circulation to local tissues, leading to ischemia and necrosis. The basic defect in sickle cell
disease is an abnormality in the structure of RBCs. The erythrocytes are sickle-shaped, rough in
texture, and rigid. Sickle cell disease is an inherited disease, not an autoimmune reaction.
Elevated serum bilirubin concentrations are associated with jaundice, not sickle cell disease.
29. The mothers asks the nurse why her child’s hemoglobin was normal at birth but now the
child has S hemoglobin. Which of the following responses by the nurse is most appropriate?
1. “The placenta bars passage of the hemoglobin S from the mother to the fetus.”
2. “The red bone marrow does not begin to produce hemoglobin S until several months after
birth.”
3. “Antibodies transmitted from you to the fetus provide the newborn with temporary
immunity.”
4. “The newborn has a high concentration of fetal hemoglobin in the blood for some time after
birth.”
Ans-29. 4. Sickle cell disease is an inherited disease that is present at birth. However, 60% to
80% of a newborns hemoglobin is fetal hemoglobin, which has a structure different from that of
hemoglobin S or hemoglobin A. Sickle cell symptoms usually occur about 4 months after birth,
when hemoglobin S begins to replace the fetal hemoglobin. The gene for sickle cell disease is
transmitted at the time of conception, not passed through the placenta. Some hemoglobin S is
produced by the fetus near term. The fetus produces all its own hemoglobin from the earliest
production in the first trimester. Passive immunity conferred by maternal antibodies is not related
to sickle cell disease, but this transmission of antibodies is important to protect the infant from
various infections during early infancy.
30. Which of the following would the nurse identify as the priority nursing diagnosis during a
toddler’s vasoocclusive sickle cell crisis?
1. Ineffective coping related to the presence of a life-threatening disease

2. Decreased cardiac output related to abnormal hemoglobin formation
3. Pain related to tissue anoxia
4. Excess fluid volume related to infection.
Ans-30. 3. For the child in a sickle cell crisis, pain is the priority nursing diagnosis because the
sickled cells clump and obstruct the blood vessels, leading to occlusive and subsequent tissue
ischemia. Although ineffective coping may be important, it is not the priority. Decreased cardiac
output is not a problem with this type of vasoocclusive crisis. Typically, a sickle cell crisis can
be precipitated by a fluid volume deficit or dehydration.
31. A mother asks the nurse if her child’s iron deficiency anemia is related to the child’s
frequent infections. The nurse responds based on the understanding of which of the
following?
1. Little is known about iron-deficiency anemia and its relationship to infection in children.
2. Children with iron deficiency anemia are more susceptible to infection than are other
children.
3. Children with iron-deficiency anemia are less susceptible to infection than are other children.
4. Children with iron-deficient anemia are equally as susceptible to infection as are other
children.
Ans-31. 2. Children with iron-deficiency anemia are more susceptible to infection because of
marked decreases in bone marrow functioning with microcytosis.
32. Which statements by the mother of a toddler would lead the nurse to suspect that the child
has iron-deficiency anemia? Select all that apply.
1. “He drinks over 3 cups of milk per day.”

2. “I can’t keep enough apple juice in the house; he must drink over 10 ounces per day.”
3. “He refuses to eat more than 2 different kinds of vegetables.”
4. “He doesn’t like meat, but he will eat small amounts of it.”
5. “He sleeps 12 hours every night and take a 2-hour nap.”
Ans-32. 1, 2. Toddlers should have between 2 and 3 cups of milk per day and 8 ounces of juice
per day. If they have more than that, then they are probably not eating enough other foods,
including iron-rich foods that have the needed nutrients.
33. Which of the following foods would the nurse encourage the mother to offer to her child
with iron deficiency anemia?
1. Rice cereal, whole milk, and yellow vegetables

2. Potato, peas, and chicken
3. Macaroni, cheese, and ham
4. Pudding, green vegetables, and rice
Ans-33. 2. Potato, peas, chicken, green vegetables, and rice cereal contain significant amounts
of iron and therefore would be recommended. Milk and yellow vegetables are not good iron
sources. Rice by itself also is not a good source of iron.
34. The physician has ordered several laboratory tests to help diagnose an infant’s bleeding
disorder. Which of the following tests, if abnormal, would the nurse interpret as most likely to
indicate hemophilia?
1. Bleeding time
2. Tourniquet test
3. Clot retraction test
4. Partial thromboplastin time (PTT)
Ans-34. 4. PTT measures the activity of thromboplastin, which is dependent on intrinsic clotting
factors. In hemophilia, the intrinsic clotting factor VIII (antihemiphilic factor) is deficient,
resulting in a prolonged PTT. Bleeding time reflects platelet function; the tourniquet test
measures vasoconstriction and platelet function; and the clot retraction test measures capillary
fragility. All of these are unaffected in people with hemophilia.
35. Which of the following assessments in a child with hemophilia would lead the nurse to
suspect early hemarthrosis?p
1. Child’s reluctance to move a body part

2. Cool, pale, clammy extremity
3. Ecchymosis formation around a joint
4. Instability of a long bone in passive movement
Ans-35. 1. Bleeding into the joints in the child with hemophilia leads to pain and tenderness,
resulting in restricted movement. Therefore, an early sign of hemarthrosis would be the child’s
reluctance to move a body part. If the bleeding into the joint continues, the area becomes hot,
swollen, and immobile—not cool, pale, and clammy. Ecchymosis formation around a joint
would be difficult to assess. Instability of a long bone on passive movement is not associated
with joint hemarthrosis.
36. Because of the risks associated with administration of factor VIII concentrate, the nurse
would teach the client’s family to recognize and report which of the following?
1. Yellowing of the skin

2. Constipation
3. Abdominal distention
4. Puffiness around the eyes
Ans-36. 1. Because factor VIII concentrate is derived from large pools of human plasma, the
risk of hepatitis is always present. Clinical manifestations of hepatitis include yellowing of the
skin, mucous membranes, and sclera. Use of factor VIII concentrate is not associated with
constipation, abdominal distention, or puffiness around the eyes.
37. A child suspected of having sickle cell disease is seen in a clinic, and laboratory studies
are performed. A nurse checks the lab results, knowing that which of the following would be
increased in this disease?
1. Platelet count
2. Hematocrit level
3. Reticulocyte count
4. Hemoglobin level
Ans-37. 3. A diagnosis is established based on a complete blood count, examination for sickled
red blood cells in the peripheral smear, and hemoglobin electrophoresis. Laboratory studies will
show decreased hemoglobin and hematocrit levels and a decreased platelet count, and increased
reticulocyte count, and the presence of nucleated red blood cells. Increased reticulocyte counts
occur in children with sickle cell disease because the life span of their sickled red blood cells is
shortened.
38. A clinic nurse instructs the mother of a child with sickle cell disease about the
precipitating factors related to pain crisis. Which of the following, if identified by the mother
as a precipitating factor, indicates the need for further instructions?
1. Infection
2. Trauma
3. Fluid overload
4. Stress
Ans-38. 3. Pain crisis may be precipitated by infection, dehydration, hypoxia, trauma, or

physical or emotional stress. The mother of a child with sickle cell disease should encourage
fluid intake of 1 ½ to 2 times the daily requirement to prevent dehydration.
39. Laboratory studies are performed for a child suspected of having iron deficiency anemia.
The nurse reviews the laboratory results, knowing that which of the following results would
indicate this type of anemia?
1. An elevated hemoglobin level

2. A decreased reticulocyte count
3. An elevated RBC count
4. Red blood cells that are microcytic and hypochromic
Ans-39. 4. The results of a CBC in children with iron deficiency anemia will show decreased
hemoglobin levels and microcytic and hypochromic red blood cells. The red blood cell count is
decreased. The reticulocyte count is usually normal or slightly elevated.
40. A pediatric nurse health educator provides a teaching session to the nursing staff
regarding hemophilia. Which of the following information regarding this disorder would the
nurse plan to include in the discussion?
1. Hemophilia is a Y linked hereditary disorder

2. Males inherit hemophilia from their fathers
3. Females inherit hemophilia from their mothers
4. Hemophilia A results from a deficiency of factor VIII
Ans-40. 4. Males inherit hemophilia from their mothers, and females inherit the carrier status
from their fathers. Hemophilia is inherited in a recessive manner via a genetic defect on the X-
chromosome. Hemophilia A results from a deficiency of factor VIII. Hemophilia B (Christmas
disease) is a deficiency of factor IX.
Cancer
1. Which of the following conditions is not a complication of Hodgkin’s disease?
1. Anemia
2. Infection
3. Myocardial Infarction
4. Nausea
Ans-1. 3. Complications of Hodgkin’s are pancytopenia, nausea, and infection. Cardiac

involvement usually doesn’t occur.
2. Which of the following laboratory values is expected for a client just diagnosed with
chronic lymphocytic leukemia?
1. Elevated sedimentation rate

2. Uncontrolled proliferation of granulocytes
3. Thrombocytopenia and increased lymphocytes
4. Elevated aspartate aminotransferase and alanine aminotransferase levels.
Ans-2. 3. Chronic lymphocytic leukemia shows a proliferation of small abnormal mature B

lymphocytes and decreased antibody response. Thrombocytopenia also is often present.
Uncontrolled proliferation of granulocytes occurs in myelogenous leukemia.
3. At the time of diagnosis of Hodgkin’s lymphoma, which of the following areas is often
involved?
1. Back
2. Chest
3. Groin
4. Neck
Ans-3. 4. At the time of diagnosis, a painless cervical lesion is often present. The back, chest,
and groin areas aren’t involved.
4. According to a standard staging classification of Hodgkin’s disease, which of the

following criteria reflects stage II?
1. Involvement of extra lymphatic organs or tissues

2. Involvement of single lymph node region or structure
3. Involvement of two or more lymph node regions or structures.
4. Involvement of lymph node regions or structures on both sides of the diaphragm.
Ans-4. 3. Stage II involves two or more lymph node regions. Stage I only involves one lymph
node region; stage III involves nodes on both sides of the diaphragm; and stage IV involves extra
lymphatic organs or tissues.
5. Which of the following statements is correct about the rate of cell growth in relation to
chemotherapy?
1. Faster growing cells are less susceptible to chemotherapy.

2. Non-dividing cells are more susceptible to chemotherapy
3. Faster growing cells are more susceptible to chemotherapy
4. Slower growing cells are more susceptible to chemotherapy.
Ans-5. 3. The faster the cell grows, the more susceptible it is to chemotherapy and radiation
therapy. Slow-growing and non-dividing cells are less susceptible to chemotherapy. Repeated
cycles of chemotherapy are used to destroy nondividing cells as they begin active cell division.
6. Which of the following foods should a client with leukemia avoid?
1. White bread
2. Carrot sticks
3. Stewed apples
4. Medium rare steak
Ans-6. 2. A low-bacteria diet would be indicated with excludes raw fruits and vegetables.
7. A client with leukemia has neutropenia. Which of the following functions must be
frequently assessed?
1. Blood pressure
2. Bowel sounds
3. Heart sounds
4. Breath sounds
Ans-7. 4. Pneumonia, both viral and fungal, is a common cause of death in clients with
neutropenia, so frequent assessment of respiratory rate and breath sounds is required. Although
assessing blood pressure, bowel sounds, and heart sounds is important, it won’t help detect
pneumonia.
8. Which of the following clients is most at risk for developing multiple myeloma?
1. A 20-year-old Asian woman
2. A 30-year-old White man
3. A 50-year-old Hispanic woman
4. A 60-year-old Black man
Ans-8. 4. Multiple myeloma is more common in middle-aged and older clients (the median age
at diagnosis is 60 years) and is twice as common in Blacks as Whites. It occurs most often in
Black men.
9. Which of the following substances has abnormal values early in the course of multiple
myeloma (MM)?
1. Immunoglobulins
2. Platelets
3. Red blood cells
4. White blood cells
Ans-9. 1. MM is characterized by malignant plasma cells that produce an increased amount of

immunoglobin that isn’t functional. As more malignant plasma cells are produced, there’s less
space in the bone marrow for RBC production. In late stages, platelets and WBC’s are reduced as
the bone marrow is infiltrated by malignant plasma cells.
10. For which of the following conditions is a client with multiple myeloma (MM) monitored?
1. Hypercalcemia
2. Hyperkalemia
3. Hypernatremia
4. Hypermagnesemia
Ans-10. 1. Calcium is released when the bone is destroyed. This causes an increase in serum
calcium levels. MM doesn’t affect potassium, sodium, or magnesium levels.
11. Giving instructions for breast self-examination is particularly important for clients with
which of the following medical problems?
1. Cervical dysplasia
2. A dermoid cyst
3. Endometrial polyps
4. Ovarian cancer
Ans-11. 4. Clients with ovarian cancer are at increased risk for breast cancer. Breast self-
examination supports early detection and treatment and is very important.
12. During a routine physical examination, a firm mass is palpated in the right breast of a 35-
year-old woman. Which of the following findings or client history would suggest cancer of the
breast as opposed to fibrocystic disease?
1. History of early menarche

2. Cyclic changes in mass size
3. History of an ovulatory cycles
4. Increased vascularity of the breast
Ans-12. 4. Increase in breast size or vascularity is consistent with cancer of the breast. Early
menarche as well as late menopause or a history of an ovulatory cycles are associated with
fibrocystic disease. Masses associated with fibrocystic disease of the breast are firm, most often
located in the upper outer quadrant of the breast, and increase in size prior to menstruation. They
may be bilateral in a mirror image and are typically well demarcated and freely moveable.
13. The client with which of the following types of lung cancer has the best prognosis?
1. Adenocarcinoma
2. Oat cell
3. Squamous cell
4. Small cell
Ans-13. 3. Squamous cell carcinoma is a slow-growing, rarely metastasizing type of cancer.

Adenocarcinoma is the next best lung cancer to have in terms of prognosis. Oat cell and small
cell carcinoma are the same. Small cell carcinoma grows rapidly and is quick to metastasize.
14. Warning signs and symptoms of lung cancer include persistent cough, bloody sputum,
dyspnea, and which of the other following symptoms?
1. Dizziness
2. Generalized weakness
3. Hypotension
4. Recurrent pleural effusion
Ans-14. 4. Recurring episodes of pleural effusions can be caused by the tumor and should be
investigated. Dizziness, generalized weakness, and hypotension aren’t typically considered
warning signals, but may occur in advanced stages of cancer.
15. A centrally located tumor would produce which of the following symptoms?
1. Coughing
2. Hemoptysis
3. Pleuritic pain
4. Shoulder pain
Ans-15. 1. Centrally located pulmonary tumors are found in the upper airway (vocal cords) and
usually obstruct airflow, producing such symptoms as coughing, wheezing, and stridor. Small
cell tumors tend to be located in the lower airways and often cause hemoptysis. As the tumor
invades the pleural space, it may cause pleuritic pain. Pancoast tumors that occur in the apices
may cause shoulder pain.
16. Which of the following interventions is the key to increasing the survival rates of clients
with lung cancer?
1. Early bronchoscopy
2. Early detection
3. High-dose chemotherapy
4. Smoking cessation
Ans-16. 2. Early detection of cancer when the cells may be premalignant and potentially curable
would be most beneficial. However, a tumor must be 1 cm in diameter before it’s detectable on a
chest x-ray, so this is difficult. A bronchoscopy may help identify cell type but may not increase
survival rate. High-dose chemotherapy has minimal effect on long-term survival. Smoking
cessation won’t reverse the process but may help prevent further decompensation.
17. A client has been diagnosed with lung cancer and requires a wedge resection. How much
of the lung is removed?
1. One entire lung

2. A lobe of the lung
3. A small, localized area near the surface of the lung.
4. A segment of the lung, including a bronchiole and its alveoli.
Ans-17. 3. A small area of tissue close to the surface of the lung is removed in a wedge
resection. An entire lung is removed in a pneumonectomy. A segment of the lung is removed in a
segmental resection and a lobe is removed in a lobectomy.
18. When a client has a lobectomy, what fills the space where the lobe was?
1. The space stays empty.

2. The surgeon fills the space with gel
3. The lung space fills up with serous fluid
4. The remaining lobe or lobes overexpand to fill the space.
Ans-18. 4. The remaining lobe or lobes over expand slightly to fill the space previously
occupied by the removed tissue. The diaphragm is carried higher on the operative side to further
reduce the empty space. The space can’t remain “empty” because truly empty would imply a
vacuum, which would interfere with the intrathoracic pressure changes that allow breathing. The
surgeon doesn’t use a gel to fill the space. Serous fluid overproduction would compress the
remaining lobes, diminish their function and possibly, cause a mediastinal shift.
19. Which of the following is the primary goal for surgical resection of lung cancer?
1. To remove the tumor and all surrounding tissue.

2. To remove the tumor and as little surrounding tissue as possible.
3. To remove all of the tumor and any collapsed alveoli in the same region.
4. To remove as much as the tumor as possible, without removing any alveoli.
Ans-19. 2. The goal of surgical resection is to remove the lung tissue that has a tumor in it while
saving as much surrounding tissue as possible. It may be necessary to remove alveoli and
bronchioles, but care is taken to make sure only what’s absolutely necessary is removed.
20. If the client with lung cancer also has preexisting pulmonary disease, which of the
following statements best describes how the extent of that can be performed?
1. It doesn’t affect it.

2. It may require a whole lung to be removed.
3. The entire tumor may not be able to be removed
4. It may prevent surgery if the client can’t tolerate lung tissue removal.
Ans-20. 4. If the client’s preexisting pulmonary disease is restrictive and advanced, it may be
impossible to remove the tumor, and the client may have to be treated with chemotherapy and
radiation.
21. The client with a benign lung tumor is treated in which of the following ways?
1. The tumor is treated with radiation only.

2. The tumor is treated with chemotherapy only.
3. The tumor is left alone unless symptoms are present.
4. The tumor is removed, involving the least possible amount of tissue.
Ans-21. 4. The tumor is removed to prevent further compression of the lung tissue as the tumor
grows, which could lead to respiratory decompensation. If for some reason it can’t be removed,
then radiation or chemotherapy may be used to try to shrink the tumor.
22. In the client with terminal lung cancer, the focus of nursing care is on which of the
following nursing interventions?
1. Provide emotional support

2. Provide nutritional support
3. Provide pain control
4. Prepare the client’s will
Ans-22. 3. The client with terminal lung cancer may have extreme pleuritic pain and should be
treated to reduce his discomfort. Preparing the client and his family for the impending death and
providing emotional support is also important but shouldn’t be the primary focus until the pain is
under control. Nutritional support may be provided, but as the terminal phase advances, the
client’s nutritional needs greatly decrease. Nursing care doesn’t focus on helping the client
prepare the will.
23. What are the three most important prognostic factors in determining long-term survival
for children with acute leukemia?
1. Histologic type of disease, initial platelet count, and type of treatment

2. Type of treatment and client’s sex
3. Histologic type of disease, initial WBC count, and client’s age at diagnosis
4. Progression of illness, WBC at the time of diagnosis, and client’s age at the time of
diagnosis.
Ans-23. 3. The factor whose prognostic value is considered to be of greatest significance in

determining the long-range outcome is the histologic type of leukemia. Children with a normal
or low WBC count appear to have a much better prognosis than those with a high WBC count.
Children diagnosed between ages 2 and 10 have consistently demonstrated a better prognosis
because age 2 or after 10.
24. Which of the following complications are three main consequences of leukemia?
1. Bone deformities, spherocytosis, and infection.

2. Anemia, infection, and bleeding tendencies
3. Lymphocytopoesis, growth delays, and hirsutism
4. Polycythemia, decreased clotting time, and infection.
Ans-24. 2. The three main consequences of leukemia are anemia, caused by decreased
erythrocyte production; infection secondary to neutropenia; and bleeding tendencies, from
decreased platelet production. Bone deformities don’t occur with leukemia although bones may
become painful because of the proliferation of cells in the bone marrow. Spherocytosis refers to
erythrocytes taking on a spheroid shape and isn’t a feature in leukemia. Mature cells aren’t
produced in adequate numbers. Hirsutism and growth delay can be a result of large doses of
steroids but isn’t common in leukemia. Anemia, not polycythemia, occurs. Clotting times would
be prolonged.
25. A child is seen in the pediatrician’s office for complaints of bone and joint pain. Which of
the following other assessment findings may suggest leukemia?
1. Abdominal pain
2. Increased activity level
4. Petechiae
Ans-25. 4. The most frequent signs and symptoms of leukemia are a result of infiltration of the
bone marrow. These include fever, pallor, fatigue, anorexia, and petechiae, along with bone and
joint pain. Increased appetite can occur but it usually isn’t a presenting symptom. Abdominal
pain may be caused by areas of inflammation from normal flora within the GI tract or any
number of other causes.
26. Which of the following assessment findings in a client with leukemia would indicate that
the cancer has invaded the brain?
1. Headache and vomiting.

2. Restlessness and tachycardia
3. Hypervigilant and anxious behavior
4. Increased heart rate and decreased blood pressure.
Ans-26. 1. The usual effect of leukemic infiltration of the brain is increased intracranial
pressure. The proliferation of cells interferes with the flow of cerebrospinal fluid in the
subarachnoid space and at the base of the brain. The increased fluid pressure causes dilation of
the ventricles, which creates symptoms of severe headache, vomiting, irritability, lethargy,
increased blood pressure, decreased heart rate, and eventually, coma. Often children with a
variety of illnesses are hypervigilant and anxious when hospitalized.
27. Which of the following types of leukemia carries the best prognosis?
1. Acute lymphoblastic leukemia

2. Acute myelogenous leukemia
3. Basophilic leukemia
4. Eosinophilia leukemia
Ans-27. 1. Acute lymphoblastic leukemia, which accounts for more than 80% of all childhood
cases, carries the best prognosis. Acute myelogenous leukemia, with several subtypes, accounts
for most of the other leukemias affecting children. Basophilic and eosinophillic leukemia are
named for the specific cells involved. These are much rarer and carry a poorer prognosis.
28. Which of the following is the reason to perform a spinal tap on a client newly diagnosed
with leukemia?
1. To rule out meningitis

2. To decrease intracranial pressure
3. To aid in classification of the leukemia
4. To assess for central nervous system infiltration
Ans-28. 4. A spinal tap is performed to assess for central nervous system infiltration. It wouldn’t
be done to decrease ICP nor does it aid in the classification of the leukemia. Spinal taps can
result in brain stem herniation in cases of ICP. A spinal tap can be done to rule out meningitis but
this isn’t the indication for the test on a leukemic client.
29. Which of the following tests in performed on a client with leukemia before initiation of
therapy to evaluate the child’s ability to metabolize chemotherapeutic agents?
1. Lumbar puncture
2. Liver function studies
3. Complete blood count (CBC)
4. Peripheral blood smear
Ans-29. 2. Liver and kidney function studies are done before initiation of chemotherapy to
evaluate the child’s ability to metabolize the chemotherapeutic agents. A CBC is performed to
assess for anemia and white blood cell count. A peripheral blood smear is done to assess the
maturity and morphology of red blood cells. A lumbar puncture is performed to assess for central
nervous system infiltration.
30. Which of the following immunizations should not be given to a 4-month-old sibling of a
client with leukemia?
1. Diphtheria and tetanus and pertussis (DPT) vaccine.

2. Hepatitis B vaccine
3. Haemophilus influenza type b vaccines (Hib)
4. Oral poliovirus vaccine (OPV)
Ans-30. 4. OPV is a live attenuated virus excreted in the stool. The excreted virus can be
communicated to the immunosuppressed child, resulting in an overwhelming infection.
Inactivated polio vaccine would be indicated because it isn’t a live virus and wouldn’t pose the
threat of infection. DTP, Hib, and hepatitis B vaccines can be given accordingly to the
recommended schedule.
31. Which of the following medications usually is given to a client with leukemia as
prophylaxis against P. carinii pneumonia?
1. Bactrim
2. Oral nystatin suspension
3. Prednisone
4. Vincristine (Oncovin)
Ans-31. 1. The most frequent cause of death from leukemia is overwhelming infection. P.
carinii infection is lethal to a child with leukemia. As prophylaxis against P. cariniipneumonia,
continuous low doses of co-trimoxazole (Bactrim) are frequently prescribed. Oral nystatin
suspension would be indicated for the treatment of thrush. Prednisone isn’t an antibiotic and
increases susceptibility to infection. Vincristine is an antineoplastic agent.
32. In which of the following diseases would bone marrow transplantation not be indicated in
a newly diagnosed client?
1. Acute lymphocytic leukemia

2. Chronic myeloid leukemia
3. Severe aplastic anemia
4. Severe combined immunodeficiency
Ans-32. 1. For the first episode of acute lymphocytic anemia, conventional therapy is superior to
bone marrow transplantation. In severe combined immunodeficiency and in severe aplastic
anemia, bone marrow transplantation has been employed to replace abnormal stem cells with
healthy cells from the donor’s marrow. In myeloid leukemia, bone marrow transplantation is
done after chemotherapy to infuse healthy marrow and to replace marrow stem cells ablated
during chemotherapy.
33. Which of the following treatment measures should be implemented for a child with
leukemia who has been exposed to the chickenpox?
1. No treatment is indicated.
2. Acyclovir (Zovirax) should be started on exposure
3. Varicella-zoster immune globin (VZIG) should be given with the evidence of disease
4. VZIG should be given within 72 hours of exposure.
Ans-33. 4. Varicella is a lethal organism to a child with leukemia. VZIG, given within 72 hours,
may favorably alter the course of the disease. Giving the vaccine at the onset of symptoms
wouldn’t likely decrease the severity of the illness. Acyclovir may be given if the child develops
the disease but not if the child has been exposed.
34. Nausea and vomiting are common adverse effects of radiation and chemotherapy. When
should a nurse administer antiemetics?
1. 30 minutes before the initiation of therapy.

2. With the administration of therapy.
3. Immediately after nausea begins.
4. When therapy is completed.
Ans-34. 1. Antiemetics are most beneficial when given before the onset of nausea and vomiting.
To calculate the optimum time for administration, the first dose is given 30 minutes to 1 hour
before nausea is expected, and then every 2, 4, or 6 hours for approximately 24 hours after
chemotherapy. If the antiemetic was given with the medication or after the medication, it could
lose its maximum effectiveness when needed.
35. Parents of pediatric clients who undergo irradiation involving the central nervous system
should be warned about postirradiation somnolence. When does this neurologic syndrome
usually occur?
1. Immediately
2. Within 1 to 2 weeks
3. Within 5 to 8 weeks
4. Within 3 to 6 months
Ans-35. 3. Postirradiation somnolence may develop 5 to 8 weeks after CNS irradiation and may
last 3 to 15 days. It’s characterized by somnolence with or without fever, anorexia, nausea, and
vomiting. Although the syndrome isn’t thought to be clinically significant, parents should be
prepared to expect such symptoms and encourage the child needed rest.
36. The nurse is instructing the client to perform a testicular self-examination. The nurse tells
the client:
1. To examine the testicles while lying down.

2. The best time for the examination is after a shower
3. To gently feel the testicle with one finger to feel for a growth
4. That testicular examination should be done at least every 6 months.
Ans-36. 2. The testicular-self-examination is recommended monthly after a warm shower or

bath when the scrotal skin is relaxed. The client should stand to examine the testicles. Using both
hands, with the fingers under the scrotum and the thumbs on top, the client should gently roll the
testicles, feeling for any lumps.
37. The community nurse is conducting a health promotion program at a local school and is
discussing the risk factors associated with cancer. Which of the following, if identified by the
client as a risk factor, indicates a need for further instructions?
1. Viral factors
2. Stress
3. Low-fat and high-fiber diets
4. Exposure to radiation
Ans-37. 3. Viruses may be one of multiple agents acting to initiate carcinogenesis and have been
associated with several types of cancer. Increased stress has been associated with causing the
growth and proliferation of cancer cells. Two forms of radiation, ultraviolet and ionizing, can
lead to cancer. A diet high in fat may be a factor in the development of breast, colon, and
prostate cancers. High-fiber diets may reduce the risk of colon cancer.
38. The client with cancer is receiving chemotherapy and develops thrombocytopenia. The
nurse identifies which intervention as the highest priority in the nursing plan of care?
1. Ambulation three times a day
2. Monitoring temperature
3. Monitoring the platelet count
4. Monitoring for pathological factors
Ans-38. 3. Thrombocytopenia indicates a decrease in the number of platelets in the circulating

blood. A major concern is monitoring for and preventing bleeding. Option 2 relates to
monitoring for infection particularly if leukopenia is present. Options 1 and 4, although
important in the plan of care are not related directly to thrombocytopenia.
39. A client is diagnosed with multiple myeloma. The client asks the nurse about the
diagnosis. The nurse bases the response on which of the following descriptions of this
disorder?
1. Malignant exacerbation in the number of leukocytes.

2. Altered red blood cell production.
3. Altered production of lymph nodes
4. Malignant proliferation of plasma cells and tumors within the bone.

39. A client is diagnosed with multiple myeloma. The client asks the nurse about the
diagnosis. The nurse bases the response on which of the following descriptions of this
disorder?
1. Malignant exacerbation in the number of leukocytes.

2. Altered red blood cell production.
3. Altered production of lymph nodes
4. Malignant proliferation of plasma cells and tumors within the bone.

Ans-39. 4. Multiple myeloma is a B cell neoplastic condition characterized by abnormal

malignant proliferation of plasma cells and the accumulation of mature plasma cells in the bone
marrow. Option 1 describes the leukemic process. Options 2 and 3 are not characteristics of
multiple myeloma.
40. The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma.
Which of the following would the nurse expect to note specifically in this disorder?
1. Decreased number of plasma cells in the bone marrow.

2. Increased WBC’s
3. Increased calcium levels
4. Decreased blood urea nitrogen
Ans-40. 3. Findings indicative of multiple myeloma are an increased number of plasma cells in
the bone marrow, anemia, hypercalcemia caused by the release of calcium from the deteriorating
bone tissue, and an elevated blood urea nitrogen level. An increased white blood cell count may
or may not be present and is not related specifically to multiple myeloma.
41. The nurse is developing a plan of care for the client with multiple myeloma. The nurse
includes which priority intervention in the plan of care?
1. Coughing and deep breathing

2. Encouraging fluids
3. Monitoring red blood cell count
4. Providing frequent oral care
Ans-41. 2. Hypercalcemia caused by bone destruction is a priority concern in the client with
multiple myeloma. The nurse should administer fluids in adequate amounts to maintain and
output of 1.5 to 2 L a day. Clients require about 3 L of fluid pre day. The fluid is needed not only
to dilute the calcium overload but also to prevent protein from precipitating in renal tubules.
Options 1, 3, and 4 may be components in the plan of care but are not the priority in this client.
42. The oncology nurse specialist provides an educational session to nursing staff regarding
the characteristics of Hodgkin’s disease. The nurse determines that further education is
needed if a nursing staff member states that which of the following is characteristic of the
disease?
1. Presence of Reed-Sternberg cells

2. Involvement of lymph nodes, spleen, and liver
3. Occurs most often in the older client
4. Prognosis depends on the stage of the disease
Ans-42. 3. Hodgkin’s disease is a disorder of young adults. Options 1, 2, and 4 are
characteristics of this disease.
43. The nurse is reviewing the laboratory results of a client receiving chemotherapy. The
platelet count is 10,000 cells/mm. Based on this laboratory value, the priority nursing
assessment is which of the following?
1. Assess level of consciousness

2. Assess temperature
3. Assess bowel sounds
4. Assess skin turgor
Ans-43. 1. A high risk of hemorrhage exists when the platelet count is fewer than 20,000. Fatal
central nervous system hemorrhage or massive gastrointestinal hemorrhage can occur when the
platelet count is fewer than 10,000. The client should be assessed for changes in levels of
consciousness, which may be an early indication of an intracranial hemorrhage. Option 2 is a
priority nursing assessment when the white blood cell count is low and the client is at risk for an
infection.
44. The nurse is caring for a client following a modified radical mastectomy. Which
assessment finding would indicate that the client is experiencing a complication related to this
surgery?
1. Sanguineous drainage in the Jackson-Pratt drain

2. Pain at the incisional site
3. Complaints of decreased sensation near the operative site
4. Arm edema on the operative side
Ans-44. 4. Arm edema on the operative side (lymphedema) is a complication following

mastectomy and can occur immediately postoperatively or may occur months or even years after
surgery. The other options are expected occurrences.
45. A nurse is providing education in a community setting about general measures to avoid
excessive sun exposure. Which of the following recommendations is appropriate?
1. Apply sunscreen only after going in the water.
2. Avoid peak exposure hours from 9am to 1pm
3. Wear loosely woven clothing for added ventilation
4. Apply sunscreen with a sun protection factor (SPF) of 15 or more before sun exposure.
Ans-45. 4. A sunscreen with a SPF of 15 or higher should be worn on all sun-exposed skin
surfaces. It should be applied before sun exposure and reapplied after being in the water. Peak
sun exposure usually occurs between 10am to 2pm, tightly woven clothing, protective hats, and
sunglasses are recommended to decrease sun exposure. Suntanning parlors should be avoided.
46. Which of the following nursing interventions would be most helpful in making the
respiratory effort of a client with metastatic lung cancer more efficient?
1. Teaching the client diaphragmatic breathing techniques

2. Administering cough suppressants as ordered
3. Teaching and encouraging pursed-lip breathing
4. Placing the client in a low semi-Fowlers position
Ans-46. 3. For clients with obstructive versus restrictive disorders, extending exhalation through
pursed-lip breathing will make the respiratory effort more efficient. The usual position of choice
for this client is the upright position, leaning slightly forward to allow greater lung expansion.
Teaching diaphragmatic breathing techniques will be more helpful to the client with a restrictive
disorder. Administering cough suppressants will not help respiratory effort. A low semi-Fowlers
position does not encourage lung expansion. Lung expansion is enhanced in the upright position.
47. The nurse is teaching a 17-year old client and the client’s family about what to expect
with high-dose chemotherapy and the effects of neutropenia. What should the nurse teach as
the most reliable early indicator of infection in a neutropenic client?
1. Fever
2. Chills
3. Tachycardia
4. Dyspnea
Ans-47. 1. Fever is an early sign requiring clinical intervention to identify potential causes.
Chills and dyspnea may or may not be observed. Tachycardia can be an indicator in a variety of
clinical situations when associated with infection; it usually occurs in response to an elevated
temperature or change in cardiac function.
48. A 58-year-old man is going to have chemotherapy for lung cancer. He asks the nurse how
the chemotherapeutic drugs will work. The most accurate explanation the nurse can give is
which of the following?
1. “Chemotherapy affects all rapidly dividing cells.”

2. “The molecular structure of the DNA is altered.”
3. “Cancer cells are susceptible to drug toxins.”
4. “Chemotherapy encourages cancer cells to divide.”
Ans-48. 1. There are many mechanisms of action for chemotherapeutic agents, but most affect
the rapidly dividing cells—both cancerous and noncancerous. Cancer cells are characterized by
rapid cell division. Chemotherapy slows cell division. Not all chemotherapeutic agents affect
molecular structure. All cells are susceptible to drug toxins, but not all chemotherapeutic agents
are toxins.
49. When caring for a client with a central venous line, which of the following nursing
actions should be implemented in the plan of care for chemotherapy administration? Select all
that apply.
1. Verify patency of the line by the presence of a blood return at regular intervals.
2. Inspect the insertion site for swelling, erythema, or drainage.
3. Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not
present.
4. If unable to aspirate blood, reposition the client and encourage the client to cough.
5. Contact the health care provider about verifying placement if the status is questionable.
Ans-49. 1, 2, 4, 5. A major concern with intravenous administration of cytotoxic agents is vessel

irritation or extravasation. The Oncology Nursing Society and hospital guidelines require
frequent evaluation of blood return when administering vesicant or nonvesicant chemotherapy
due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In
addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing
or aspirating blood may indicate the line is against the vessel wall or may indicate the line has
occlusion. Having the client cough or move position may change the status of the line if it is
temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study
to verify placement if the status is questionable and may require a declotting regimen.
50. A client with stomach cancer is admitted to the oncology unit after vomiting for 3 days.
Physical assessment findings include irregular pulse, muscle twitching, and complaints of
prickling sensations in the fingers and hands. Laboratory results include a potassium level of
2.9 mEq/L, a pH of 7.46, and a bicarbonate level of 29 mEq/L. The client is experiencing:
Ans-50. 3. The client is experiencing metabolic alkalosis caused by loss of hydrogen and
chloride ions from excessive vomiting. This is shown by a pH of 7.46 and elevated bicarbonate
level of 29 mEq/L.
51. A 32-year-old woman meets with the nurse on her first office visit since undergoing a left
mastectomy. When asked how she is doing, the woman states her appetite is still not good, she
is not getting much sleep because she doesn’t go to bed until her husband is asleep, and she is
really anxious to get back to work. Which of the following nursing interventions should the
nurse explore to support the client’s current needs?
1. Call the physician to discuss allowing the client to return to work earlier.
2. Suggest that the client learn relaxation techniques to help with her insomnia
3. Perform a nutritional assessment to assess for anorexia
4. Ask open-ended questions about sexuality issues related to her mastectomy
Ans-51. 4. The content of the client’s comments suggests that she is avoiding intimacy with her
husband by waiting until he is asleep before going to bed. Addressing sexuality issues is
appropriate for a client who has undergone a mastectomy. Rushing her return to work may
debilitate her and add to her exhaustion. Suggesting that she learn relaxation techniques to help
her with her insomnia is appropriate; however, the nurse must first address the psychosocial and
sexual issues that are contributing to her sleeping difficulties. A nutritional assessment may be
useful, but there is no indication that she has anorexia.
52. One of the most serious blood coagulation complications for individuals with cancer and
for those undergoing cancer treatments is disseminated intravascular coagulation (DIC). The
most common cause of this bleeding disorder is:
1. Underlying liver disease

2. Brain metastasis
3. Intravenous heparin therapy
4. Sepsis
Ans-52. 4. Bacterial endotoxins released from gram-negative bacteria activate the Hageman
factor or coagulation factor XII. This factor inhibits coagulation via the intrinsic pathway of
homeostasis, as well as stimulating fibrinolysis. Liver disease can cause multiple bleeding
abnormalities resulting in chronic, subclinic DIC; however, sepsis is the most common cause.
53. A pneumonectomy is a surgical procedure sometimes indicated for treatment of non-

small-cell lung cancer. A pneumonectomy involves removal of:
1. An entire lung field

2. A small, wedge-shaped lung surface
3. One lobe of a lung
4. One or more segments of a lung lobe
Ans-53. 1. A pneumonectomy is the removal of an entire lung field. A wedge resection refers to
removal of a wedge-shaped section of lung tissue. A lobectomy is the removal of one lobe.
Removal of one or more segments of a lung lobe is called a partial lobectomy.
54. A 36-year-old man with lymphoma presents with signs of impending septic shock 9 days
after chemotherapy. The nurse could expect which of the following to be present?
1. Flushing, decreased oxygen saturation, mild hypotension

2. Low-grade fever, chills, tachycardia
3. Elevated temperature, oliguria, hypotension
4. High-grade fever, normal blood pressure, increased respirations

Ans-54. 2. Nine days after chemotherapy, one would expect the client to be
immunocompromised. The clinical signs of shock reflect changes in cardiac function, vascular
resistance, cellular metabolism, and capillary permeability. Low-grade fever, tachycardia, and
flushing may be early signs of shock. The client with impending signs of septic shock may not
have decreased oxygen saturation levels. Oliguria and hypotension are late signs of shock. Urine
output can be initially normal or increased.
55. Which of the following represents the most appropriate nursing intervention for a client
with pruritis caused by cancer or the treatments?
1. Administration of antihistamines
2. Steroids
3. Silk sheets
4. Medicated cool baths
Ans-55. 4. Nursing interventions to decrease the discomfort of pruritus include those that
prevent vasodilation, decrease anxiety, and maintain skin integrity and hydration. Medicated
baths with salicyclic acid or colloidal oatmeal can be soothing as a temporary relief. The use of
antihistamines or topical steroids depends on the cause of pruritus, and these agents should be
used with caution. Using silk sheets is not a practical intervention for the hospitalized client with
pruritis.
56. A 56-year-old woman is currently receiving radiation therapy to the chest wall for
recurrent breast cancer. She calls her health care provider to report that she has pain while
swallowing and burning and tightness in her chest. Which of the following complications of
radiation therapy is most likely responsible for her symptoms?
1. Hiatal hernia
2. Stomatitis
3. Radiation enteritis
4. Esophagitis
Ans-56. 4. Difficulty in swallowing, pain, and tightness in the chest are signs of esophagitis,
which is a common complication of radiation therapy of the chest wall.
Cardiac – MI and HF
1) Which of the following actions is the first priority of care for a client exhibiting signs
and symptoms of coronary artery disease?
1. Decrease anxiety
2. Enhance myocardial oxygenation
3. Administer sublingual nitroglycerin
4. Educate the client about his symptoms
Ans-1. 2. Enhancing myocardial oxygenation is always the first priority when a client exhibits
signs or symptoms of cardiac compromise. Without adequate oxygenation, the myocardium
suffers damage. Sublingual nitroglycerin is administered to treat acute angina, but administration
isn’t the first priority. Although educating the client and decreasing anxiety are important in care
delivery, neither are priorities when a client is compromised.
2) Medical treatment of coronary artery disease includes which of the following
procedures?
1. Cardiac catherization
2. Coronary artery bypass surgery
3. Oral medication therapy
4. Percutaneous transluminal coronary angioplasty
Ans-2. 3. Oral medication administration is a noninvasive, medical treatment for coronary artery
disease. Cardiac catherization isn’t a treatment, but a diagnostic tool. Coronary artery bypass
surgery and percutaneous transluminal coronary angioplasty are invasive, surgical treatments.
3) Which of the following is the most common symptom of myocardial infarction (MI)?
1. Chest pain
2. Dyspnea
3. Edema
4. Palpitations
Ans-3. 1. The most common symptom of an MI is chest pain, resulting from deprivation of
oxygen to the heart. Dyspnea is the second most common symptom, related to an increase in the
metabolic needs of the body during an MI. Edema is a later sign of heart failure, often seen after
an MI. Palpitations may result from reduced cardiac output, producing arrhythmias.
4) Which of the following symptoms is the most likely origin of pain the client described as
knifelike chest pain that increases in intensity with inspiration?
1. Cardiac
2. Gastrointestinal
3. Musculoskeletal
4. Pulmonary
Ans-4. 4. Pulmonary pain is generally described by these symptoms. Musculoskeletal pain only
increases with movement. Cardiac and GI pains don’t change with respiration.
5) Which of the following blood tests is most indicative of cardiac damage?
1. Lactate dehydrogenase
3. Troponin I
4. Creatine kinase (CK)
Ans-5. 3. Troponin I levels rise rapidly and are detectable within 1 hour of myocardial injury.
Troponin I levels aren’t detectable in people without cardiac injury. Lactate dehydrogenase
(LDH) is present in almost all body tissues and not specific to heart muscle. LDH isoenzymes
are useful in diagnosing cardiac injury. CBC is obtained to review blood counts, and a complete
chemistry is obtained to review electrolytes. Because CK levels may rise with skeletal muscle
injury, CK isoenzymes are required to detect cardiac injury.
6) What is the primary reason for administering morphine to a client with an MI?
1. To sedate the client

2. To decrease the client’s pain
3. To decrease the client’s anxiety
4. To decrease oxygen demand on the client’s heart
Ans-6. 4. Morphine is administered because it decreases myocardial oxygen demand. Morphine
will also decrease pain and anxiety while causing sedation, but it isn’t primarily given for those
reasons.
7) Which of the following conditions is most commonly responsible for myocardial
infarction?
1. Aneurysm
2. Heart failure
3. Coronary artery thrombosis
4. Renal failure
Ans-7. 3. Coronary artery thrombosis causes an inclusion of the artery, leading to myocardial
death. An aneurysm is an out pouching of a vessel and doesn’t cause an MI. Renal failure can be
associated with MI but isn’t a direct cause. Heart failure is usually a result from an MI.
8) Which of the following complications is indicated by a third heart sound (S3)?
1. Ventricular dilation
2. Systemic hypertension
3. Aortic valve malfunction
4. Increased atrial contractions
Ans-8. 1. Rapid filling of the ventricle causes vasodilation that is auscultated as S3. Increased
atrial contraction or systemic hypertension can result in a fourth heart sound. Aortic valve
malfunction is heard as a murmur.
9) After an anterior wall myocardial infarction, which of the following problems is
indicated by auscultation of crackles in the lungs?
1. Left-sided heart failure

2. Pulmonic valve malfunction
3. Right-sided heart failure
4. Tricuspid valve malfunction
Ans-9. 1. The left ventricle is responsible for most of the cardiac output. An anterior wall MI
may result in a decrease in left ventricular function. When the left ventricle doesn’t function
properly, resulting in left-sided heart failure, fluid accumulates in the interstitial and alveolar
spaces in the lungs and causes crackles. Pulmonic and tricuspid valve malfunction causes right
sided heart failure.
10) What is the first intervention for a client experiencing MI?
1. Administer morphine
2. Administer oxygen
4. Obtain an ECG
Ans-10. 2. Administering supplemental oxygen to the client is the first priority of care. The
myocardium is deprived of oxygen during an infarction, so additional oxygen is administered to
assist in oxygenation and prevent further damage. Morphine and nitro are also used to treat MI,
but they’re more commonly administered after the oxygen. An ECG is the most common
diagnostic tool used to evaluate MI.
11) Which of the following classes of medications protects the ischemic myocardium by
blocking catecholamines and sympathetic nerve stimulation?
2. Calcium channel blockers
3. Narcotics
4. Nitrates
Ans-11. 1. Beta-adrenergic blockers work by blocking beta receptors in the myocardium,

reducing the response to catecholamines and sympathetic nerve stimulation. They protect the
myocardium, helping to reduce the risk of another infarction by decreasing myocardial oxygen
demand. Calcium channel blockers reduce the workload of the heart by decreasing the heart rate.
Narcotics reduce myocardial oxygen demand, promote vasodilation, and decrease anxiety.
Nitrates reduce myocardial oxygen consumption by decreasing left ventricular end-diastolic
pressure (preload) and systemic vascular resistance (afterload).
12) What is the most common complication of an MI?
1. Cardiogenic shock
2. Heart failure
3. arrhythmias
4. Pericarditis
Ans-12. 3. Arrhythmias, caused by oxygen deprivation to the myocardium, are the most common
complication of an MI. Cardiogenic shock, another complication of an MI, is defined as the end
stage of left ventricular dysfunction. This condition occurs in approximately 15% of clients with
MI. Because the pumping function of the heart is compromised by an MI, heart failure is the
second most common complication. Pericarditis most commonly results from a bacterial or viral
infection but may occur after the MI.
13) With which of the following disorders is jugular vein distention most prominent?
1. Abdominal aortic aneurysm

2. Heart failure
3. MI
4. Pneumothorax
Ans-13. 2. Elevated venous pressure, exhibited as jugular vein distention, indicates a failure of
the heart to pump. JVD isn’t a symptom of abdominal aortic aneurysm or pneumothorax. An MI,
if severe enough, can progress to heart failure, however, in and of itself, an MI doesn’t cause
JVD.
14) Toxicity from which of the following medications may cause a client to see a green-
yellow halo around lights?
1. Digoxin
2. Furosemide (Lasix)
3. Metoprolol (Lopressor)
4. Enalapril (Vasotec)
Ans-14.1. One of the most common signs of digoxin toxicity is the visual disturbance known as
the “green-yellow halo sign.” The other medications aren’t associated with such an effect.
15) Which of the following symptoms is most commonly associated with left-sided heart
failure?
1. Crackles
2. Arrhythmias
3. Hepatic engorgement
4. Hypotension
Ans-15. 1. Crackles in the lungs are a classic sign of left-sided heart failure. These sounds are
caused by fluid backing up into the pulmonary system. Arrhythmias can be associated with both
right- and left-sided heart failure. Left-sided heart failure causes hypertension secondary to an
increased workload on the system.
16) In which of the following disorders would the nurse expect to assess sacral edema in a
bedridden client?
1. Diabetes
2. Pulmonary emboli
3. Renal failure
Ans-16. 4. The most accurate area on the body to assess dependent edema in a bed-ridden client
is the sacral area. Sacral, or dependent, edema is secondary to right-sided heart failure.
17) Which of the following symptoms might a client with right-sided heart failure exhibit?
1. Adequate urine output

2. Polyuria
3. Oliguria
4. Polydipsia
Ans-17. 3. Inadequate deactivation of aldosterone by the liver after right-sided heart failure leads
to fluid retention, which causes oliguria.
18) Which of the following classes of medications maximizes cardiac performance in clients
with heart failure by increasing ventricular contractibility?
3. Diuretics
4. Inotropic agents
Ans-18. 4. Inotropic agents are administered to increase the force of the heart’s contractions,
thereby increasing ventricular contractility and ultimately increasing cardiac output.
19) Stimulation of the sympathetic nervous system produces which of the following
responses?
1. Bradycardia
2. Tachycardia
3. Hypotension
4. Decreased myocardial contractility
Ans-19. 2. Stimulation of the sympathetic nervous system causes tachycardia and increased
contractility. The other symptoms listed are related to the parasympathetic nervous system,
which is responsible for slowing the heart rate.
20) Which of the following conditions is most closely associated with weight gain, nausea,
and a decrease in urine output?
1. Angina pectoris
2. Cardiomyopathy
3. Left-sided heart failure
Ans-20. 4. Weight gain, nausea, and a decrease in urine output are secondary effects of right-
sided heart failure. Cardiomyopathy is usually identified as a symptom of left-sided heart failure.
Left-sided heart failure causes primarily pulmonary symptoms rather than systemic ones. Angina
pectoris doesn’t cause weight gain, nausea, or a decrease in urine output.
21) Which of the following heart muscle diseases is unrelated to other cardiovascular
disease?
1. Cardiomyopathy
2. Coronary artery disease
3. Myocardial infarction
4. Pericardial effusion
Ans-21. 1. Cardiomyopathy isn’t usually related to an underlying heart disease such as

atherosclerosis. The etiology in most cases is unknown. CAD and MI are directly related to
atherosclerosis. Pericardial effusion is the escape of fluid into the pericardial sac, a condition
associated with Pericarditis and advanced heart failure.
22) Which of the following types of cardiomyopathy can be associated with childbirth?
1. Dilated
2. Hypertrophic
3. Myocarditis
4. Restrictive
Ans-22. 1. Although the cause isn’t entirely known, cardiac dilation and heart failure may
develop during the last month of pregnancy or the first few months after birth. The condition
may result from a preexisting cardiomyopathy not apparent prior to pregnancy. Hypertrophic
cardiomyopathy is an abnormal symmetry of the ventricles that has an unknown etiology but a
strong familial tendency. Myocarditis isn’t specifically associated with childbirth. Restrictive
cardiomyopathy indicates constrictive pericarditis; the underlying cause is usually myocardial.
23) Septal involvement occurs in which type of cardiomyopathy?
1. Congestive
2. Dilated
3. Hypertrophic
4. Restrictive
Ans-23. 3. In hypertrophic cardiomyopathy, hypertrophy of the ventricular septum—not the

ventricle chambers—is apparent. This abnormality isn’t seen in other types of cardiomyopathy.
24) Which of the following recurring conditions most commonly occurs in clients with
cardiomyopathy?
1. Heart failure
2. Diabetes
3. MI
4. Pericardial effusion
Ans-24. 1. Because the structure and function of the heart muscle is affected, heart failure most
commonly occurs in clients with cardiomyopathy. MI results from prolonged myocardial
ischemia due to reduced blood flow through one of the coronary arteries. Pericardial effusion is
most predominant in clients with pericarditis.
25) Dyspnea, cough, expectoration, weakness, and edema are classic signs and symptoms of
which of the following conditions?
1. Pericarditis
2. Hypertension
3. MI
4. Heart failure
Ans-25. 4. These are the classic signs of failure. Pericarditis is exhibited by a feeling of fullness
in the chest and auscultation of a pericardial friction rub. Hypertension is usually exhibited by
headaches, visual disturbances, and a flushed face. MI causes heart failure but isn’t related to
these symptoms.
26) In which of the following types of cardiomyopathy does cardiac output remain normal?
1. Dilated
2. Hypertrophic
3. Obliterative
4. Restrictive
Ans-26. 2. Cardiac output isn’t affected by hypertrophic cardiomyopathy because the size of the
ventricle remains relatively unchanged. All of the rest decrease cardiac output.
27) Which of the following cardiac conditions does a fourth heart sound (S4) indicate?
1. Dilated aorta
2. Normally functioning heart
3. Decreased myocardial contractility
4. Failure of the ventricle to eject all of the blood during systole
Ans-27. 4. An S4 occurs as a result of increased resistance to ventricular filling after atrial

contraction. The increased resistance is related to decreased compliance of the ventricle. A
dilated aorta doesn’t cause an extra heart sound, though it does cause a murmur. Decreased
myocardial contractility is heard as a third heart sound. An S4 isn’t heard in a normally
functioning heart.
28) Which of the following classes of drugs is most widely used in the treatment of
cardiomyopathy?
1. Antihypertensive
4. Nitrates
Ans-28. 2. By decreasing the heart rate and contractility, beta-blockers improve myocardial
filling and cardiac output, which are primary goals in the treatment of cardiomyopathy.
Antihypertensive aren’t usually indicated because they would decrease cardiac output in clients
who are already hypotensive. Calcium channel blockers are sometimes used for the same reasons
as beta-blockers; however, they aren’t as effective as beta-blockers and cause increased
hypotension. Nitrates aren’t used because of their dilating effects, which would further
compromise the myocardium.
29) If medical treatments fail, which of the following invasive procedures is necessary for
treating cardiomyopathy?
2. Coronary artery bypass graft (CABG)
3. Heart transplantation
4. Intra-aortic balloon pump (IABP)
Ans-29. 3. The only definitive treatment for cardiomyopathy that can’t be controlled medically is
a heart transplant because the damage to the heart muscle is irreversible.
30) Which of the following conditions is associated with a predictable level of pain that
occurs as a result of physical or emotional stress?
1. Anxiety
2. Stable angina
3. Unstable angina
4. Variant angina
Ans-30. 2. The pain of stable angina is predictable in nature, builds gradually, and quickly
reaches maximum intensity. Unstable angina doesn’t always need a trigger, is more intense, and
lasts longer than stable angina. Variant angina usually occurs at rest—not as a result of exercise
or stress.
31) Which of the following types of angina is most closely related with an impending MI?
1. Angina decubitus
2. Chronic stable angina
3. Nocturnal angina
4. Unstable angina
Ans-31. 4. Unstable angina progressively increases in frequency, intensity, and duration and is
related to an increased risk of MI within 3 to 18 months.
32) Which of the following conditions is the predominant cause of angina?
1. Increased preload
2. Decreased afterload
3. Coronary artery spasm
4. Inadequate oxygen supply to the myocardium
Ans-32. 4. Inadequate oxygen supply to the myocardium is responsible for the pain
accompanying angina. Increased preload would be responsible for right-sided heart failure.
Decreased afterload causes increased cardiac output. Coronary artery spasm is responsible for
variant angina.
33) Which of the following tests is used most often to diagnose angina?
1. Chest x-ray
2. Echocardiogram
4. 12-lead electrocardiogram (ECG)
Ans-33. 4. The 12-lead ECG will indicate ischemia, showing T-wave inversion. In addition, with
variant angina, the ECG shows ST-segment elevation. A chest x-ray will show heart enlargement
or signs of heart failure, but isn’t used to diagnose angina.
34) Which of the following results is the primary treatment goal for angina?
1. Reversal of ischemia
2. Reversal of infarction
3. Reduction of stress and anxiety
4. Reduction of associated risk factors
Ans-34. 1. Reversal of the ischemia is the primary goal, achieved by reducing oxygen
consumption and increasing oxygen supply. An infarction is permanent and can’t be reversed.
35) Which of the following interventions should be the first priority when treating a client
experiencing chest pain while walking?
1. Sit the client down

2. Get the client back to bed
3. Obtain an ECG
Ans-35. 1. The initial priority is to decrease the oxygen consumption; this would be achieved by
sitting the client down. An ECG can be obtained after the client is sitting down. After the ECGm
sublingual nitro would be administered. When the client’s condition is stabilized, he can be
returned to bed.
36) Myocardial oxygen consumption increases as which of the following parameters

increase?
1. Preload, afterload, and cerebral blood flow

2. Preload, afterload, and renal blood flow
3. Preload, afterload, contractility, and heart rate.
4. Preload, afterload, cerebral blood flow, and heart rate.
Ans-36. 3. Myocardial oxygen consumption increases as preload, afterload, renal contractility,

and heart rate increase. Cerebral blood flow doesn’t directly affect myocardial oxygen
consumption.
37) Which of the following positions would best aid breathing for a client with acute
pulmonary edema?
1. Lying flat in bed

2. Left side-lying
3. In high Fowler’s position
4. In semi-Fowler’s position
Ans-37. 3. A high Fowler’s position promotes ventilation and facilitates breathing by reducing
venous return. Lying flat and side-lying positions worsen the breathing and increase workload of
the heart. Semi-Fowler’s position won’t reduce the workload of the heart as well as the Fowler’s
position will.
38) Which of the following blood gas abnormalities is initially most suggestive of pulmonary
edema?
1. Anoxia
2. Hypercapnia
3. Hyperoxygenation
4. Hypocapnia
Ans-38. 4. In an attempt to compensate for increased work of breathing due to hyperventilation,

carbon dioxide decreases, causing hypocapnea. If the condition persists, CO2 retention occurs and
hypercapnia results.
39) Which of the following is a compensatory response to decreased cardiac output?
1. Decreased BP
2. Alteration in LOC
3. Decreased BP and diuresis
4. Increased BP and fluid retention
Ans-39. 4. The body compensates for a decrease in cardiac output with a rise in BP, due to the
stimulation of the sympathetic NS and an increase in blood volume as the kidneys retain sodium
and water. Blood pressure doesn’t initially drop in response to the compensatory mechanism of
the body. Alteration in LOC will occur only if the decreased cardiac output persists.
40) Which of the following actions is the appropriate initial response to a client coughing up
pink, frothy sputum?
1. Call for help

3. Start an I.V. line
4. Suction the client
Ans-40. 1. Production of pink, frothy sputum is a classic sign of acute pulmonary edema.
Because the client is at high risk for decompensation, the nurse should call for help but not leave
the room. The other three interventions would immediately follow.
41) Which of the following terms describes the force against which the ventricle must expel
blood?
1. Afterload
2. Cardiac output
3. Overload
4. Preload
Ans-41. 1. Afterload refers to the resistance normally maintained by the aortic and pulmonic
valves, the condition and tone of the aorta, and the resistance offered by the systemic and
pulmonary arterioles. Cardiac output is the amount of blood expelled by the heart per minute.
Overload refers to an abundance of circulating volume. Preload is the volume of blood in the
ventricle at the end of diastole.
42) Acute pulmonary edema caused by heart failure is usually a result of damage to which of
the following areas of the heart?
1. Left atrium
2. Right atrium
3. Left ventricle
4. Right ventricle
Ans-42. 3. The left ventricle is responsible for the majority of force for the cardiac output. If the
left ventricle is damaged, the output decreases and fluid accumulates in the interstitial and
alveolar spaces, causing pulmonary edema. Damage to the left atrium would contribute to heart
failure but wouldn’t affect cardiac output or, therefore, the onset of pulmonary edema. If the
right atrium and right ventricle were damaged, right-sided heart failure would result.
43) An 18-year-old client who recently had an URI is admitted with suspected rheumatic
fever. Which assessment findings confirm this diagnosis?
1. Erythema marginatum, subcutaneous nodules, and fever

2. Tachycardia, finger clubbing, and a load S3
3. Dyspnea, cough, and palpitations
4. Dyspnea, fatigue, and syncope
Ans-43. 1. Diagnosis of rheumatic fever requires that the client have either two major Jones
criteria or one minor criterion plus evidence of a previous streptococcal infection. Major criteria
include carditis, polyarthritis, Sydenham’s chorea, subcutaneous nodules, and erythema
maginatum (transient, nonprurtic macules on the trunk or inner aspects of the upper arms or
thighs). Minor criteria include fever, arthralgia, elevated levels of acute phase reactants, and a
prolonged PR-interval on ECG.
44) A client admitted with angina complains of severe chest pain and suddenly becomes
unresponsive. After establishing unresponsiveness, which of the following actions should the
nurse take first?
1. Activate the resuscitation team

2. Open the client’s airway
3. Check for breathing
4. Check for signs of circulation
Ans-44. 1. Immediately after establishing unresponsiveness, the nurse should activate the
resuscitation team. The next step is to open the airway using the head-tilt, chin-lift maneuver and
check for breathing (looking, listening, and feeling for no more than 10-seconds). If the client
isn’t breathing, give two slow breaths using a bag mask or pocket mask. Next, check for signs of
circulation by palpating the carotid pulse.
45) A 55-year-old client is admitted with an acute inferior-wall myocardial infarction. During
the admission interview, he says he stopped taking his metoprolol (Lopressor) 5 days ago
because he was feeling better. Which of the following nursing diagnoses takes priority for this
client?
1. Anxiety
2. Ineffective tissue perfusion; cardiopulmonary
3. Acute pain
4. Ineffective therapeutic regimen management
Ans-45. 2. MI results from prolonged myocardial ischemia caused by reduced blood flow
through the coronary arteries. Therefore, the priority nursing diagnosis for this client
is Ineffective tissue perfusion (cardiopulmonary). Anxiety, acute pain, and ineffective therapeutic
regimen management are appropriate but don’t take priority.
46) A client comes into the E.R. with acute shortness of breath and a cough that produces
pink, frothy sputum. Admission assessment reveals crackles and wheezes, a BP of 85/46, a HR
of 122 BPM, and a respiratory rate of 38 breaths/minute. The client’s medical history included
DM, HTN, and heart failure. Which of the following disorders should the nurse suspect?
1. Pulmonary edema
2. Pneumothorax
3. Cardiac tamponade
4. Pulmonary embolus
Ans-46. 1. SOB, tachypnea, low BP, tachycardia, crackles, and a cough producing pink, frothy
sputum are late signs of pulmonary edema.
47) The nurse coming on duty receives the report from the nurse going off duty. Which of the
following clients should the on-duty nurse assess first?
1. The 58-year-old client who was admitted 2 days ago with heart failure, BP of 126/76, and a
respiratory rate of 21 breaths a minute.
2. The 88-year-old client with end-stage right-sided heart failure, BP of 78/50, and a DNR
order.
3. The 62-year-old client who was admitted one day ago with thrombophlebitis and receiving
IV heparin.
4. A 76-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is
receiving IV diltiazem (Cardizem).
Ans-47. 4. The client with A-fib has the greatest potential to become unstable and is on IV
medication that requires close monitoring. After assessing this client, the nurse should assess the
client with thrombophlebitis who is receiving a heparin infusion, and then go to the 58-year-old
client admitted 2-days ago with heart failure (her s/s are resolving and don’t require immediate
attention). The lowest priority is the 89-year-old with end stage right-sided heart failure, who
requires time consuming supportive measures.
48) When developing a teaching plan for a client with endocarditis, which of the following
points is most essential for the nurse to include?
1. “Report fever, anorexia, and night sweats to the physician.”

2. “Take prophylactic antibiotics after dental work and invasive procedures.”
3. “Include potassium rich foods in your diet.”
4. “Monitor your pulse regularly.”
Ans-48. 1. The most essential teaching point is to report signs of relapse, such as fever, anorexia,
and night sweats, to the physician. To prevent further endocarditis episodes, prophylactic
antibiotics are taken before and sometimes after dental work, childbirth, or GU, GI, or
gynecologic procedures. A potassium-rich diet and daily pulse monitoring aren’t necessary for a
client with endocarditis.
49) A nurse is conducting a health history with a client with a primary diagnosis of heart
failure. Which of the following disorders reported by the client is unlikely to play a role in
exacerbating the heart failure?
1. Recent URI
2. Nutritional anemia
3. Peptic ulcer disease
4. A-Fib
Ans-49. 3. Heart failure is precipitated or exacerbated by physical or emotional stress,

dysrhythmias, infections, anemia, thyroid disorders, pregnancy, Paget’s disease, nutritional
deficiencies (thiamine, alcoholism), pulmonary disease, and hypervolemia.
50) A nurse is preparing for the admission of a client with heart failure who is being sent
directly to the hospital from the physician’s office. The nurse would plan on having which of
the following medications readily available for use?
1. Diltiazem (Cardizem)
2. Digoxin (Lanoxin)
3. Propranolol (Inderal)
4. Metoprolol (Lopressor)
Ans-50. 2. Digoxin exerts a positive inotropic effect on the heart while slowing the overall rate
through a variety of mechanisms. Digoxin is the medication of choice to treat heart failure.
Diltiazem (calcium channel blocker) and propranolol and metoprolol (beta blockers) have a
negative inotropic effect and would worsen the failing heart.
51) A nurse caring for a client in one room is told by another nurse that a second client has
developed severe pulmonary edema. On entering the 2nd client’s room, the nurse would expect
the client to be:
1. Slightly anxious
2. Mildly anxious
3. Moderately anxious
4. Extremely anxious
Ans-51. 4. Pulmonary edema causes the client to be extremely agitated and anxious. The client
may complain of a sense of drowning, suffocation, or smothering.
52) A client with pulmonary edema has been on diuretic therapy. The client has an order for
additional furosemide (Lasix) in the amount of 40 mg IV push. Knowing that the client also
will be started on Digoxin (Lanoxin), a nurse checks the client’s most recent:
1. Digoxin level
2. Sodium level
3. Potassium level
4. Creatinine level
Ans-52. 3. The serum potassium level is measured in the client receiving digoxin and
furosemide. Heightened digitalis effect leading to digoxin toxicity can occur in the client with
hypokalemia. Hypokalemia also predisposes the client to ventricular dysrhythmias.
53) A client who had cardiac surgery 24 hours ago has a urine output averaging 19 ml/hr for
2 hours. The client received a single bolus of 500 ml of IV fluid. Urine output for the
subsequent hour was 25 ml. Daily laboratory results indicate the blood urea nitrogen is 45
mg/dL and the serum creatinine is 2.2 mg/dL. A nurse interprets the client is at risk for:
1. Hypovolemia
2. UTI
3. Glomerulonephritis
4. Acute renal failure
Ans-53. 4. The client who undergoes cardiac surgery is at risk for renal injury from poor
perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal insult is
signaled by decreased urine output, and increased BUN and creatinine levels. The client may
need medications such as dopamine (Intropin) to increase renal perfusion and possibly could
need peritoneal dialysis or hemodialysis.
54) A nurse is preparing to ambulate a client on the 3rd day after cardiac surgery. The nurse
would plan to do which of the following to enable the client to best tolerate the ambulation?
1. Encourage the client to cough and deep breathe

2. Premedicate the client with an analgesic
3. Provide the client with a walker
4. Remove telemetry equipment because it weighs down the hospital gown.
Ans-54. 2. The nurse should encourage regular use of pain medication for the first 48 to 72 hours
after cardiac surgery because analgesia will promote rest, decrease myocardial oxygen
consumption resulting from pain, and allow better participation in activities such as coughing,
deep breathing, and ambulation. Options 1 and 3 will not help in tolerating ambulation. Removal
of telemetry equipment is contraindicated unless prescribed.
55) A client’s electrocardiogram strip shows atrial and ventricular rates of 80 complexes per
minute. The PR interval is 0.14 second, and the QRS complex measures 0.08 second. The
nurse interprets this rhythm is:
1. Normal sinus rhythm

2. Sinus bradycardia
3. Sinus tachycardia
4. Sinus dysrhythmia
Ans-55. 1.
56) A client has frequent bursts of ventricular tachycardia on the cardiac monitor. A nurse is
most concerned with this dysrhythmia because:
1. It is uncomfortable for the client, giving a sense of impending doom.

2. It produces a high cardiac output that quickly leads to cerebral and myocardial ischemia.
3. It is almost impossible to convert to a normal sinus rhythm.
4. It can develop into ventricular fibrillation at any time.
Ans-56. 4. Ventricular tachycardia is a life-threatening dysrhythmia that results from an irritable

ectopic focus that takes over as the pacemaker for the heart. The low cardiac output that results
can lead quickly to cerebral and myocardial ischemia. Client’s frequently experience a feeling of
impending death. Ventricular tachycardia is treated with antidysrhythmic medications or
magnesium sulfate, cardioversion (client awake), or defibrillation (loss of consciousness),
Ventricular tachycardia can deteriorate into ventricular defibrillation at any time.
57) A home care nurse is making a routine visit to a client receiving digoxin (Lanoxin) in the
treatment of heart failure. The nurse would particularly assess the client for:
1. Thrombocytopenia and weight gain
2. Anorexia, nausea, and visual disturbances
3. Diarrhea and hypotension
4. Fatigue and muscle twitching
Ans-57. 2. The first signs and symptoms of digoxin toxicity in adults include abdominal pain,
N/V, visual disturbances (blurred, yellow, or green vision, halos around lights), bradycardia, and
other dysrhythmias.
58) A client with angina complains that the angina pain is prolonged and severe and occurs
at the same time each day, most often in the morning, on further assessment a nurse notes that
the pain occurs in the absence of precipitating factors. This type of anginal pain is best
described as:
1. Stable angina
2. Unstable angina
3. Variant angina
4. Nonanginal pain
Ans-58. 3. Stable angina is induced by exercise and is relieved by rest or nitroglycerin tablets.
Unstable angina occurs at lower and lower levels of activity and rest, is less predictable, and is
often a precursor of myocardial infarction. Variant angina, or Prinzmetal’s angina, is prolonged
and severe and occurs at the same time each day, most often in the morning.
59) The physician orders continuous intravenous nitroglycerin infusion for the client with
MI. Essential nursing actions include which of the following?
1. Obtaining an infusion pump for the medication

2. Monitoring BP q4h
3. Monitoring urine output hourly
4. Obtaining serum potassium levels daily
Ans-59. 1. IV nitro infusion requires an infusion pump for precise control of the medication. BP
monitoring would be done with a continuous system, and more frequently than every 4 hours.
Hourly urine outputs are not always required. Obtaining serum potassium levels is not associated
with nitroglycerin infusion.
60) Aspirin is administered to the client experiencing an MI because of it’s:
1. Antipyretic action
2. Antithrombotic action
3. Antiplatelet action
4. Analgesic action
Ans-60. 2. Aspirin does have antipyretic, antiplatelet, and analgesic actions, but the primary
reason ASA is administered to the client experiencing an MI is its antithrombotic action.
61) Which of the following is an expected outcome for a client on the second day of
hospitalization after an MI?
1. Has severe chest pain

2. Can identify risks factors for MI
3. Agrees to participate in a cardiac rehabilitation walking program
4. Can perform personal self-care activities without pain
Ans-61. 4. By day 2 of hospitalization after an MI, clients are expected to be able to perform
personal care without chest pain. Day 2 hospitalization may be too soon for clients to be able to
identify risk factors for MI or begin a walking program; however, the client may be sitting up in
a chair as part of the cardiac rehabilitation program. Severe chest pain should not be present.
62) Which of the following reflects the principle on which a client’s diet will most likely be
based during the acute phase of MI?
1. Liquids as ordered
2. Small, easily digested meals
3. Three regular meals per day
4. NPO
Ans-62. 2. Recommended dietary principles in the acute phase of MI include avoiding large
meals because small, easily digested foods are better digested foods are better tolerated. Fluids
are given according to the client’s needs, and sodium restrictions may be prescribed, especially
for clients with manifestations of heart failure. Cholesterol restrictions may be ordered as well.
Clients are not prescribed a diet of liquids only or NPO unless their condition is very unstable.
63) An older, sedentary adult may not respond to emotional or physical stress as well as a
younger individual because of:
1. Left ventricular atrophy

2. Irregular heartbeats
3. peripheral vascular occlusion
4. Pacemaker placement
Ans-63. 1. In older adults who are less active and do not exercise the heart muscle, atrophy can
result. Disuse or deconditioning can lead to abnormal changes in the myocardium of the older
adult. As a result, under sudden emotional or physical stress, the left ventricle is less able to
respond to the increased demands on the myocardial muscle.
64) Which of the following nursing diagnoses would be appropriate for a client with heart
failure? Select all that apply.
1. Ineffective tissue perfusion related to decreased peripheral blood flow secondary to

decreased cardiac output.
2. Activity intolerance related to increased cardiac output.
3. Decreased cardiac output related to structural and functional changes.
4. Impaired gas exchange related to decreased sympathetic nervous system activity.
Ans-64. 1 and 3. HF is a result of structural and functional abnormalities of the heart tissue
muscle. The heart muscle becomes weak and does not adequately pump the blood out of the
chambers. As a result, blood pools in the left ventricle and backs up into the left atrium, and
eventually into the lungs. Therefore, greater amounts of blood remain in the ventricle after
contraction thereby decreasing cardiac output. In addition, this pooling leads to thrombus
formation and ineffective tissue perfusion because of the decrease in blood flow to the other
organs and tissues of the body. Typically, these clients have an ejection fraction of less than 50%
and poorly tolerate activity. Activity intolerance is related to a decrease, not increase, in cardiac
output. Gas exchange is impaired. However, the decrease in cardiac output triggers
compensatory mechanisms, such as an increase in sympathetic nervous system activity.
65) Which of the following would be a priority nursing diagnosis for the client with heart
failure and pulmonary edema?
1. Risk for infection related to stasis of alveolar secretions

2. Impaired skin integrity related to pressure
3. Activity intolerance related to pump failure
4. Constipation related to immobility
Ans-65. 3. Activity intolerance is a primary problem for clients with heart failure and pulmonary
edema. The decreased cardiac output associated with heart failure leads to reduced oxygen and
fatigue. Clients frequently complain of dyspnea and fatigue. The client could be at risk for
infection related to stasis of secretions or impaired skin integrity related to pressure. However,
these are not the priority nursing diagnoses for the client with HF and pulmonary edema, nor is
constipation related to immobility.
66) Captopril may be administered to a client with HF because it acts as a:
1. Vasopressor
2. Volume expander
3. Vasodilator
4. Potassium-sparing diuretic
Ans-66. 3. ACE inhibitors have become the vasodilators of choice in the client with mild to
severe HF. Vasodilator drugs are the only class of drugs clearly shown to improve survival in
overt heart failure.
67) Furosemide is administered intravenously to a client with HF. How soon after
administration should the nurse begin to see evidence of the drugs desired effect?
1. 5 to 10 minutes
2. 30 to 60 minutes
3. 2 to 4 hours
4. 6 to 8 hours
Ans-67. 1. After IV injection of furosemide, diuresis normally begins in about 5 minutes and
reaches its peak within about 30 minutes. Medication effects last 2 to 4 hours.
68) Which of the following foods should the nurse teach a client with heart failure to avoid
or limit when following a 2-gram sodium diet?
1. Apples
2. Tomato juice
3. Whole wheat bread
4. Beef tenderloin
Ans-68. 2. Canned foods and juices, such as tomato juice, are typically high in sodium and
should be avoided in a sodium-restricted diet. BRING ON THE STEAK!
69) The nurse finds the apical pulse below the 5th intercostal space. The nurse suspects:
1. Left atrial enlargement
2. Left ventricular enlargement
3. Right atrial enlargement
4. Right ventricular enlargement
Ans-69. 2. A normal apical impulse is found under over the apex of the heart and is typically
located and auscultated in the left fifth intercostal space in the midclavicular line. An apical
impulse located or auscultated below the fifth intercostal space or lateral to the midclavicular line
may indicate left ventricular enlargement.
Cardiac dysrhythmias
1. A nurse is assessing an electrocardiogram rhythm strip. The P waves and QRS complexes
are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The
overall heart rate is 64 beats per minute. The nurse assesses the cardiac rhythm as:
A. Normal sinus rhythm
B. Sinus bradycardia
C. Sick sinus syndrome
D. First-degree heart block.
Ans-1. 1. Measurements are normal, measuring 0.12 to 0.20 second and 0.4 to 0.10 second,
respectively.
2 A nurse notices frequent artifact on the ECG monitor for a client whose leads are
connected by cable to a console at the bedside. The nurse examines the client to determine the
cause. Which of the following items is unlikely to be responsible for the artifact?
1. Frequent movement of the client

2. Tightly secured cable connections
3. Leads applied over hairy areas
4. Leads applied to the limbs
Ans-2. 2. Motion artifact, or “noise,” can be caused by frequent client movement, electrode
placement on limbs, and insufficient adhesion to the skin, such as placing electrodes over hairy
areas of the skin. Electrode placement over bony prominences also should be avoided. Signal
interference can also occur with electrode removal and cable disconnection.
3. A nurse is watching the cardiac monitor and notices that the rhythm suddenly changes.
There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but
over 100. The nurse determines that the client is experiencing:
1. Premature ventricular contractions

2. Ventricular tachycardia
3. Ventricular fibrillation
Ans-3. 2. Ventricular tachycardia is characterized by the absence of P waves, wide QRS

complexes (usually greater than 0.14 second), and a rate between 100 and 250 impulses per
minute. The rhythm is usually regular.
4. A nurse is viewing the cardiac monitor in a client’s room and notes that the client has
just gone into ventricular tachycardia. The client is awake and alert and has good skin color.
The nurse would prepare to do which of the following?
1. Immediately defibrillate
2. Prepare for pacemaker insertion
3. Administer amiodarone (Cordarone) intravenously
4. Administer epinephrine (Adrenaline) intravenously
Ans-4. 3. First-line treatment of ventricular tachycardia in a client who is hemodynamically
stable is the use of anti-dysrhythmics such as amiodarone (Cordarone), lidocaine (Xylocaine),
and procainamide (Pronestyl). Cardioversion also may be needed to correct the rhythm
(cardioversion is recommended for stable ventricular tachycardia). Defibrillation is used with
pulseless ventricular tachycardia. Epinephrine would stimulate and already excitable ventricle
and is contraindicated.
5. A nurse is caring for a client with unstable ventricular tachycardia. The nurse instructs
the client to do which of the following, if prescribed, during an episode of ventricular
tachycardia?
1. Breathe deeply, regularly, and easily.

2. Inhale deeply and cough forcefully every 1 to 3 seconds.
3. Lie down flat in bed
4. Remove any metal jewelry
Ans-5. 2. Cough cardiopulmonary resuscitation (CPR) sometimes is used in the client with
unstable ventricular tachycardia. The nurse tells the client to use cough CPR, if prescribed, by
inhaling deeply and coughing forcefully every 1 to 3 seconds. Cough CPR may terminate the
dysrhythmia or sustain the cerebral and coronary circulation for a short time until other measures
can be implemented.
6. A client is having frequent premature ventricular contractions. A nurse would place
priority on assessment of which of the following items?
1. Blood pressure and peripheral perfusion

2. Sensation of palpitations
3. Causative factors such as caffeine
4. Precipitating factors such as infection
Ans-6. 1. Premature ventricular contractions can cause hemodynamic compromise. The

shortened ventricular filling time with the ectopic beats leads to decreased stroke volume and, if
frequent enough, to decreased cardiac output. The client may be asymptomatic or may feel
palpations. PVCs can be caused by cardiac disorders or by any number of physiological
stressors, such as infection, illness, surgery, or trauma, and by the intake of caffeine, alcohol, or
nicotine.
7. A client has developed atrial fibrillation, which a ventricular rate of 150 beats per minute.
A nurse assesses the client for:
1. Hypotension and dizziness

2. Nausea and vomiting
3. Hypertension and headache
4. Flat neck veins
Ans-7. 1. The client with uncontrolled atrial fibrillation with a ventricular rate more than 150
beats a minute is at risk for low cardiac output because of 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.
8. A nurse is watching the cardiac monitor, and a client’s rhythm suddenly changes. There
are no P waves; instead there are wavy lines. The QRS complexes measure 0.08 second, but
they are irregular, with a rate of 120 beats a minute. The nurse interprets this rhythm as:
2. Atrial fibrillation
Ans-8. 2. Atrial fibrillation is characterized by a loss of P waves; an undulating, wavy baseline;

QRS duration that is often within normal limits; and an irregular ventricular rate, which can
range from 60 to 100 beats per minute (when controlled with medications) to 100 to 160 beats
per minute (when uncontrolled).
9. A client with rapid rate atrial fibrillation asks a nurse why the physician is going to
perform carotid massage. The nurse responds that this procedure may stimulate the:
1. Vagus nerve to slow the heart rate

2. Vagus nerve to increase the heart rate; overdriving the rhythm.
3. Diaphragmic nerve to slow the heart rate
4. Diaphragmic nerve to overdrive the rhythm
Ans-9. 1. Carotid sinus massage is one of the maneuvers used for vagal stimulation to decrease a
rapid heart rate and possibly terminate a tachydysrhythmia. The others include inducing the gag
reflex and asking the client to strain or bear down. Medication therapy often is needed as an
adjunct to keep the rate down or maintain the normal rhythm.
10. A nurse notes that a client with sinus rhythm has a premature ventricular contraction
that falls on the T wave of the preceding beat. The client’s rhythm suddenly changes to one
with no P waves or definable QRS complexes. Instead there are coarse wavy lines of varying
amplitude. The nurse assesses this rhythm to be:
3. Atrial fibrillation
4. Asystole
Ans-10. 2. Ventricular fibrillation is characterized by irregular, chaotic undulations of varying

amplitudes. Ventricular fibrillation has no measurable rate and no visible P waves or QRS
complexes and results from electrical chaos in the ventricles.
11. While caring for a client who has sustained an MI, the nurse notes eight PVCs in one
minute on the cardiac monitor. The client is receiving an IV infusion of D5W and oxygen at 2
L/minute. The nurse’s first course of action should be to:
1. Increase the IV infusion rate

2. Notify the physician promptly
3. Increase the oxygen concentration
4. Administer a prescribed analgesic
Ans-11. 2. PVCs are often a precursor of life-threatening dysrhythmias, including ventricular

tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if
PVCs occur at a rate greater than 5 or 6 per minute in the post MI client, the physician should be
notified immediately. More than 6 PVCs per minute is considered serious and usually calls for
decreasing ventricular irritability by administering medications such as lidocaine. Increasing the
IV infusion rate would not decrease the number of PVCs. Increasing the oxygen concentration
should not be the nurse’s first course of action; rather, the nurse should notify the physician
promptly. Administering a prescribed analgesic would not decrease ventricular irritability.
12. The adaptations of a client with complete heart block would most likely include:
1. Nausea and vertigo

2. Flushing and slurred speech
3. Cephalalgia and blurred vision
4. Syncope and low ventricular rate
Ans-12. 4. In complete atrioventricular block, the ventricles take over the pacemaker function in
the heart but at a much slower rate than that of the SA node. As a result there is decreased
cerebral circulation, causing syncope.
13. A client with a bundle branch block is on a cardiac monitor. The nurse should expect to
observe:
1. Sagging ST segments
2. Absence of P wave configurations
3. Inverted T waves following each QRS complex
4. Widening of QRS complexes to 0.12 second or greater.
Ans-13. 4. Bundle branch block interferes with the conduction of impulses from the AV node to
the ventricle supplied by the affected bundle. Conduction through the ventricles is delayed, as
evidenced by a widened QRS complex.
14. When ventricular fibrillation occurs in a CCU, the first person reaching the client
should:
2. Defibrillate the client
3. Initiate CPR
4. Administer sodium bicarbonate intravenously
Ans-14. 2. Ventricular fibrillation is a death-producing dysrhythmia and, once identified, must be
terminated immediately by precordial shock (defibrillation). This is usually a standing
physician’s order in a CCU.
15. What criteria should the nurse use to determine normal sinus rhythm for a client on a
cardiac monitor? Check all that apply.
1. The RR intervals are relatively consistent

2. One P wave precedes each QRS complex
3. Four to eight complexes occur in a 6 second strip
4. The ST segment is higher than the PR interval
5. The QRS complex ranges from 0.12 to 0.20 second.
Ans-15. 1, 2. The consistency of the RR interval indicates regular rhythm. A normal P wave
before each complex indicates the impulse originated in the SA node. The number of complexes
in a 6 second strip is multiplied by 10 to approximate the heart rate; normal sinus rhythm is 60 to
100. Elevation of the ST segment is a sign of cardiac ischemia and is unrelated to the rhythm.
The QRS duration should be less than 0.12 second; the PR interval should be 0.12 to 0.20
second.
16. When auscultating the apical pulse of a client who has atrial fibrillation, the nurse
would expect to hear a rhythm that is characterized by:
1. The presence of occasional coupled beats

2. Long pauses in an otherwise regular rhythm
3. A continuous and totally unpredictable irregularity
4. Slow but strong and regular beats
Ans-16. 3. In atrial fibrillation, multiple ectopic foci stimulate the atria to contract. The AV node
is unable to transmit all of these impulses to the ventricles, resulting in a pattern of highly
irregular ventricular contractions.
Cardiac Surgical Patient
1. Atherosclerosis impedes coronary blood flow by which of the following mechanisms?

A. Plaques obstruct the vein
B. Plaques obstruct the artery
C. Blood clots form outside the vessel wall
D. Hardened vessels dilate to allow blood to flow through
Ans-1. 2. Arteries, not veins, supply the coronary arteries with oxygen and other nutrients.
Atherosclerosis is a direct result of plaque formation in the artery. Hardened vessels can’t
dilate properly and, therefore, constrict blood flow.
2. A paradoxical pulse occurs in a client who had a coronary artery bypass graft (CABG)
surgery 2 days ago. Which of the following surgical complications should the nurse
suspect?
A. Left-sided heart failure
B. Aortic regurgitation
C. Complete heart block
D. Pericardial tamponade
Ans-2. 4. A paradoxical pulse (a palpable decrease in pulse amplitude on quiet inspiration)

signals pericardial tamponade, a complication of CABG surgery. Left-sided heart failure can
cause pulsus alternans (pulse amplitude alternation from beat to beat, with a regular rhythm).
Aortic regurgitation may cause bisferious pulse (an increased arterial pulse with a double systolic
peak). Complete heart block may cause a bounding pulse (a strong pulse with increased pulse
pressure).
3. After cardiac surgery, a client’s blood pressure measures 126/80. The nurse determines
that the mean arterial pressure (MAP) is which of the following?
A. 46 mm Hg
B. 80 mm Hg
C. 95 mm Hg
D. 90 mm Hg
Ans-3. 3. Check with Dani if you have issues with this problem.
4. A woman with severe mitral stenosis and mitral regurgitation has a pulmonary artery
catheter inserted. The physician orders pulmonary artery pressure monitoring, including
pulmonary capillary wedge pressures. The purpose of this is to help assess the:
A. Degree of coronary artery stenosis

B. Peripheral arterial pressure
C. Pressure from fluid within the left ventricle
D. Oxygen and carbon dioxide concentration is the blood
Ans-4. 3. The pulmonary artery pressures are used to assess the heart’s ability to receive and
pump blood. The pulmonary capillary wedge pressure reflects the left ventricle end-diastolic
pressure and guides the physician in determining fluid management for the client. The degree of
coronary artery stenosis is assessed during a cardiac catherization. The peripheral arterial
pressure is assessed with an arterial line.
5. For a client who excretes excessive amounts of calcium during the postoperative period
after open heart surgery, which of the following measures should the nurse institute to
help prevent complications associated with excessive calcium excretion?
A. Ensure a liberal fluid intake

B. Provide an alkaline-ash diet
C. Prevent constipation
D. Enrich the client’s diet with dairy products
Ans-5. 1. In an immobilized client, calcium leaves the bone and concentrates in the ECF fluid.
When a large amount of calcium passes through the kidneys, calcium can precipitate and form
calculi. Nursing interventions that help prevent calculi include ensuring a liberal fluid intake
(unless contraindicated). A diet rich in acid should be provided to keep the urine acidic, which
increases the solubility of calcium. Preventing constipation is not associated with excessive
calcium excretion. Limiting foods rich in calcium, such as dairy products, will help on
preventing renal calculi.
6. A nurse is assessing the neurovascular of a client who has returned to the surgical nursing
unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and
the nurse notes redness and edema. The pedal pulse is palpable and unchanged from
admission. The nurse interprets that the neurovascular status is:
A. Normal because of increased blood flow through the leg

B. Slightly deteriorating and should be monitored for another hour
C. Moderately impaired, and the surgeon should be called
D. Adequate from an arterial approach, but venous complications are arising.
Ans-6. 1. An expected outcome of surgery is warmth, redness, and edema in the surgical
extremity because of increased blood flow.
7. After open-heart surgery a client develops a temperature of 102*F. The nurse notifies the
physician, because elevated temperatures:
A. Increase the cardiac output

B. May indicate cerebral edema
C. May be a forerunner of hemorrhage
D. Are related to diaphoresis and possible chilling
Ans-7. 1. Temperatures of 102*F or greater lead to an increased metabolism and cardiac

workload.
8. During a cardiac catherization blood samples from the right atrium, right ventricle, and
pulmonary artery are analyzed for their oxygen content. Normally:
A. All contain less CO2 than does pulmonary vein blood

B. All contain more oxygen than does pulmonary vein blood
C. The samples of blood all contain about the same amount of oxygen
D. Pulmonary artery blood contains more oxygen than the other samples
Ans-8. 3. Blood samples from the right atrium, right ventricle, and pulmonary artery would all be
about the same with regard to oxygen concentration. Such blood contains slightly less oxygen
than does systemic arterial blood.
9. The nurse prepares the client for insertion of a pulmonary artery catheter (Swan-Ganz
catheter). The nurse teaches the client that the catheter will be inserted to provide
information about:
A. Stroke volume
B. Cardiac output
C. Venous pressure
D. Left ventricular functioning
Ans-9. 4. The catheter is placed in the pulmonary artery. Information regarding left ventricular
function is obtained when the catheter balloon is inflated.
10. When preparing a client for discharge after surgery for a CABG, the nurse should teach
the client that there will be:
A. No further drainage from the incisions after hospitalizations

B. A mild fever and extreme fatigue for several weeks after surgery
C. Little incisional pain and tenderness after 3 to 4 weeks after surgery
D. Some increase in edema in the leg used for the donor graft when activity increases
Ans-10. 4. The client is up more at home, so dependent edema usually increases.

Serosanguineous drainage may persist after discharge.
11. What is the most important nursing action when measuring a pulmonary capillary wedge
pressure (PCWP)?
A. Have the client bear down when measuring the PCWP

B. Deflate the balloon as soon as the PCWP is measured
C. Place the client in a supine position before measuring the PCWP
D. Flush the catheter with heparin solution after the PCWP is determined.
Ans11. 2. While the balloon must be inflated to measure the capillary wedge pressure, leaving
the balloon inflated will interfere with blood flow to the lung. Bearing down will increase
intrathoracic pressure and alter the reading. While a supine position is preferred; it is not
essential. Agency protocols relative to flushing of unused ports must be followed.
12. The most important assessment for the nurse to make after a client has had a
femeropopiteal bypass for peripheral vascular disease would be:
A. Incisional pain
B. Pedal pulse rate
C. Capillary refill time
D. Degree of hair growth
Ans-12. 3. Checking capillary refill provides data about current perfusion of the extremity. While
the presence and quality of the pedal pulse provide data about peripheral circulation, it is not
necessary to count the rate.
13. Which signs cause the nurse to suspect cardiac tamponade after a client has cardiac
surgery? Check all that apply.
A. Tachycardia
B. Hypertension
C. Increased CVP
D. Increased urine output
E. Jugular vein distention
Ans-13. 1, 3, 5. Blood in the pericardial sac compresses the heart so the ventricles cannot fill;
this leads to a rapid thready pulse. Tamponade causes hypotension and a narrowed pulse
pressure. As the tamponade increases, pressure on the heart interferes with the ejection of blood
from the left ventricle, resulting in an increased pressure in the right side of the heart and the
systemic circulation. As the heart because more inefficient, there is a decrease in kidney
perfusion and therefore urine output. The increased venous pressure caused JVD.
14. A client has the diagnosis of left ventricular failure and a high pulmonary capillary wedge
pressure (PCWP). The physician orders dopamine to improve ventricular function. The
nurse will know the medication is working if the client’s:
A. Blood pressure rises

B. Blood pressure decreases
C. Cardiac index falls
D. PCWP rises
Ans-14. 1. If dopamine as a positive effect, it will cause vasoconstriction peripherally, but

increase renal perfusion and the blood pressure will rise. The cardiac index will also rise and the
PCWP should decrease.
15. A 35-year-old male was knifed in the street fight, admitted through the ER, and is now in
the ICU. An assessment of his condition reveals the following symptoms: respirations
shallow and rapid, CVP 15 cm H2O, BP 90 mm Hg systolic, skin cold and pale, urinary
output 60-100 mL/hr for the last 2 hours. Analyzing these symptoms, the nurse will base a
nursing diagnosis on the conclusion that the client has which of the following conditions?
A. Hypovolemic shock
B. Cardiac tamponade
C. Wound dehiscence
D. Atelectasis
Ans-15. 2. All of the client’s symptoms are found in both cardiac tamponade and hypovolemic
shock except the increase in urinary output.
Coronary Artery Disease and Hypertension
1) A client is scheduled for a cardiac catherization using a radiopaque dye. Which of the
following assessments is most critical before the procedure?
1. Intake and output

2. Baseline peripheral pulse rates
3. Height and weight
4. Allergy to iodine or shellfish
Ans-1. 4. This procedure requires an informed consent because it involves injection of a

radiopaque dye into the blood vessel. The risk of allergic reaction and possible anaphylaxis is
serious and must be assessed before the procedure.
2) A client with no history of cardiovascular disease comes into the ambulatory clinic
with flulike symptoms. The client suddenly complains of chest pain. Which of the following
questions would best help a nurse to discriminate pain caused by a non-cardiac problem?
1. “Have you ever had this pain before?”

2. “Can you describe the pain to me?”
3. “Does the pain get worse when you breathe in?”
4. “Can you rate the pain on a scale of 1-10, with 10 being the worst?”
Ans-2. 3. Chest pain is assessed by using the standard pain assessment parameters. Options 1, 2,
and 4 may or may not help discriminate the origin of pain. Pain of pleuropulmonary origin
usually worsens on inspiration.
3) A client with myocardial infarction has been transferred from a coronary care unit
to a general medical unit with cardiac monitoring via telemetry. A nurse plans to allow for
which of the following client activities?
1. Strict bed rest for 24 hours after transfer

2. Bathroom privileges and self-care activities
3. Unsupervised hallway ambulation with distances under 200 feet
4. Ad lib activities because the client is monitored.
Ans-3. 2. On transfer from the CCU, the client is allowed self-care activities and bathroom
privileges. Supervised ambulation for brief distances are encouraged, with distances gradually
increased (50, 100, 200 feet).
4) A nurse notes 2+ bilateral edema in the lower extremities of a client with myocardial
infarction who was admitted 2 days ago. The nurse would plan to do which of the following
next?
1. Review the intake and output records for the last 2 days
2. Change the time of diuretic administration from morning to evening
3. Request a sodium restriction of 1 g/day from the physician.
Order daily weights starting the following morning.
Ans-4. 1. Edema, the accumulation of excess fluid in the interstitial spaces, can be measured by
intake greater than output and by a sudden increase in weight. Diuretics should be given in the
morning whenever possible to avoid nocturia. Strict sodium restrictions are reserved for clients
with severe symptoms.
5) A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A
nurse sees no electrocardiogram complexes on the screen. The first action of the nurse is to:
1. Check the client status and lead placement

2. Press the recorder button on the electrocardiogram console.
4. Call a code blue
Ans-5. 1. Sudden loss of electrocardiogram complexes indicates ventricular asystole or possible

electrode displacement. Accurate assessment of the client and equipment is necessary to
determine the cause and identify the appropriate intervention.
6) A nurse is assessing the blood pressure of a client diagnosed with primary
hypertension. The nurse ensures accurate measurement by avoiding which of the
following?
1. Seating the client with arm bared, supported, and at heart level.
2. Measuring the blood pressure after the client has been seated quietly for 5 minutes.
3. Using a cuff with a rubber bladder that encircles at least 80% of the limb.
4. Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion.
Ans-6. 4. BP should be taken with the client seated with the arm bared, positioned with support
and at heart level. The client should sit with the legs on the floor, feet uncrossed, and not speak
during the recording. The client should not have smoked tobacco or taken in caffeine in the 30
minutes preceding the measurement. The client should rest quietly for 5 minutes before the
reading is taken. The cuff bladder should encircle at least 80% of the limb being measured.
Gauges other than a mercury sphygmomanometer should be calibrated every 6 months to ensure
accuracy.
7) IV heparin therapy is ordered for a client. While implementing this order, a nurse
ensures that which of the following medications is available on the nursing unit?
1. Vitamin K
2. Aminocaporic acid
3. Potassium chloride
4. Protamine sulfate
Ans-7. 4. The antidote to heparin is protamine sulfate and should be readily available for use if
excessive bleeding or hemorrhage should occur. Vitamin K is an antidote for warfarin.
8) A client is at risk for pulmonary embolism and is on anticoagulant therapy with
warfarin (Coumadin). The client’s prothrombin time is 20 seconds, with a control of 11
seconds. The nurse assesses that this result is:
1. The same as the client’s own baseline level

2. Lower than the needed therapeutic level
3. Within the therapeutic range
4. Higher than the therapeutic range
Ans-8. 3. The therapeutic range for prothrombin time is 1.5 to 2 times the control for clients at
risk for thrombus. Based on the client’s control value, the therapeutic range for this individual
would be 16.5 to 22 seconds. Therefore the result is within therapeutic range.
9) A client who has been receiving heparin therapy also is started on warfarin. The
client asks a nurse why both medications are being administered. In formulating a
response, the nurse incorporates the understanding that warfarin:
1. Stimulates the breakdown of specific clotting factors by the liver, and it takes 2-3 days for
this to exert an anticoagulant effect.
2. Inhibits synthesis of specific clotting factors in the liver, and it takes 3-4 days for this
medication to exert an anticoagulant effect.
3. Stimulates production of the body’s own thrombolytic substances, but it takes 2-4 days for
this to begin.
4. Has the same mechanism of action as Heparin, and the crossover time is needed for the
serum level of warfarin to be therapeutic.
Ans-9. 2. Warfarin works in the liver and inhibits synthesis of four vitamin K-dependent clotting
factors (X, IX, VII, and II), but it takes 3 to 4 days before the therapeutic effect of warfarin is
exhibited.
10) A 60-year-old male client comes into the emergency department with complaints of
crushing chest pain that radiates to his shoulder and left arm. The admitting diagnosis is
acute myocardial infarction. Immediate admission orders include oxygen by NC at 4L/minute,
blood work, chest x-ray, an ECG, and 2mg of morphine given intravenously. The nurse should
first:
1. Administer the morphine
2. Obtain a 12-lead ECG
3. Obtain the lab work
4. Order the chest x-ray
Ans10. 1. Although obtaining the ECG, chest x-ray, and blood work are all important, the
nurse’s priority action would be to relieve the crushing chest pain.
11) When administered a thrombolytic drug to the client experiencing an MI, the nurse
explains to him that the purpose of this drug is to:
1. Help keep him well hydrated

2. Dissolve clots he may have
3. Prevent kidney failure
4. Treat potential cardiac arrhythmias.
Ans-11. 2. Thrombolytic drugs are administered within the first 6 hours after onset of a MI to
lyse clots and reduce the extent of myocardial damage.
12) When interpreting an ECG, the nurse would keep in mind which of the following about
the P wave? Select all that apply.
1. Reflects electrical impulse beginning at the SA node

2. Indicated electrical impulse beginning at the AV node
3. Reflects atrial muscle depolarization
4. Identifies ventricular muscle depolarization
5. Has duration of normally 0.11 seconds or less.
Ans-12. 1, 3, 5. In a client who has had an ECG, the P wave represents the activation of the
electrical impulse in the SA node, which is then transmitted to the AV node. In addition, the P
wave represents atrial muscle depolarization, not ventricular depolarization. The normal duration
of the P wave is 0.11 seconds or less in duration and 2.5 mm or more in height.
13) A client has driven himself to the ER. He is 50 years old, has a history of hypertension,
and informs the nurse that his father died of a heart attack at 60 years of age. The client is
presently complaining of indigestion. The nurse connects him to an ECG monitor and begins
administering oxygen at 2 L/minute per NC. The nurse’s next action would be to:
1. Call for the doctor

2. Start an intravenous line
3. Obtain a portable chest radiograph
4. Draw blood for laboratory studies
Ans-13. 2. Advanced cardiac life support recommends that at least one or two intravenous lines
be inserted in one or both of the antecubital spaces. Calling the physician, obtaining a portable
chest radiograph, and drawing blood are important but secondary to starting the intravenous line.
14) The nurse receives emergency laboratory results for a client with chest pain and
immediately informs the physician. An increased myoglobin level suggests which of the
following?
1. Cancer
2. Hypertension
3. Liver disease
Ans14. 4. Detection of myoglobin is one diagnostic tool to determine whether myocardial

damage has occurred. Myoglobin is generally detected about one hour after a heart attack is
experienced and peaks within 4 to 6 hours after infarction (Remember, less than 90 mg/L is
normal).
15) When teaching a client about propranolol hydrochloride, the nurse should base the
information on the knowledge that propranolol hydrochloride:
1. Blocks beta-adrenergic stimulation and thus causes decreased heart rate, myocardial
contractility, and conduction.
2. Increases norepinephrine secretion and thus decreases blood pressure and heart rate.
3. Is a potent arterial and venous vasodilator that reduces peripheral vascular resistance and
lowers blood pressure.
4. Is an angiotensin-converting enzyme inhibitor that reduces blood pressure by blocking the
conversion of angiotensin I to angiotensin II.
Ans15. 1. Propranolol hydrochloride is a beta-adrenergic blocking agent. Actions of propranolol
hydrochloride include reducing heart rate, decreasing myocardial contractility, and slowing
conduction.
16) The most important long-term goal for a client with hypertension would be to:
1. Learn how to avoid stress

2. Explore a job change or early retirement
3. Make a commitment to long-term therapy
4. Control high blood pressure
Ans-16. 3. Compliance is the most critical element of hypertensive therapy. In most cases,
hypertensive clients require lifelong treatment and their hypertension cannot be managed
successfully without drug therapy. Stress management and weight management are important
components of hypertension therapy, but the priority goal is related to compliance.
17) Hypertension is known as the silent killer. This phrase is associated with the fact that
hypertension often goes undetected until symptoms of other system failures occur. This may
occur in the form of:
1. Cerebrovascular accident
2. Liver disease
4. Pulmonary disease
Ans-17. 1. Hypertension is referred to as the silent killer for adults, because until the adult has
significant damage to other systems, the hypertension may go undetected. CVA’s can be related
to long-term hypertension. Liver or pulmonary disease is generally not associated with
hypertension. Myocardial infarction is generally related to coronary artery disease.
18) During the previous few months, a 56-year-old woman felt brief twinges of chest pain
while working in her garden and has had frequent episodes of indigestion. She comes to the
hospital after experiencing severe anterior chest pain while raking leaves. Her evaluation
confirms a diagnosis of stable angina pectoris. After stabilization and treatment, the client is
discharged from the hospital. At her follow-up appointment, she is discouraged because she is
experiencing pain with increasing frequency. She states that she is visiting an invalid friend
twice a week and now cannot walk up the second flight of steps to the friend’s apartment
without pain. Which of the following measures that the nurse could suggest would most likely
help the client deal with this problem?
1. Visit her friend earlier in the day.

2. Rest for at least an hour before climbing the stairs.
3. Take a nitroglycerin tablet before climbing the stairs.
4. Lie down once she reaches the friend’s apartment.
Ans-18. 3. Nitroglycerin may be used prophylactically before stressful physical activities such as
stair climbing to help the client remain pain free. Visiting her friend early in the day would have
no impact on decreasing pain episodes. Resting before or after an activity is not as likely to help
prevent an activity-related pain episode.
19) Which of the following symptoms should the nurse teach the client with unstable angina
to report immediately to her physician?
1. A change in the pattern of her pain

2. Pain during sex
3. Pain during an argument with her husband
4. Pain during or after an activity such as lawnmowing
Ans-19. 1. The client should report a change in the pattern of chest pain. It may indicate
increasing severity of CAD.
20) The physician refers the client with unstable angina for a cardiac catherization. The
nurse explains to the client that this procedure is being used in this specific case to:
1. Open and dilate the blocked coronary arteries

2. Assess the extent of arterial blockage
3. Bypass obstructed vessels
4. Assess the functional adequacy of the valves and heart muscle.
Ans-20. 2. Cardiac catherization is done in clients with angina primarily to assess the extent and
severity of the coronary artery blockage, a decision about medical management, angioplasty, or
coronary artery bypass surgery will be based on the catherization results.
21) As an initial step in treating a client with angina, the physician prescribes nitroglycerin
tablets, 0.3mg given sublingually. This drug’s principle effects are produced by:
1. Antispasmotic effect on the pericardium

2. Causing an increased myocardial oxygen demand
3. Vasodilation of peripheral vasculature
4. Improved conductivity in the myocardium
Ans-21. 3. Nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen

consumption and demand. Vasodilation in coronary arteries and collateral vessels may also
increase blood flow to the ischemic areas of the heart. Nitroglycerin decreases myocardial
oxygen demand. Nitroglycerin does not have an effect on pericardial spasticity or conductivity in
the myocardium.
22) The nurse teaches the client with angina about the common expected side effects of
nitroglycerin, including:
1. Headache
2. High blood pressure
4. Stomach cramps
Ans-22. 1. Because of the widespread vasodilating effects, nitroglycerin often produces such side
effects as headache, hypotension, and dizziness. The client should lie or shit down to avoid
fainting. Nitro does not cause shortness of breath or stomach cramps.
23) Sublingual nitroglycerin tablets begin to work within 1 to 2 minutes. How should the
nurse instruct the client to use the drug when chest pain occurs?
1. Take one tablet every 2 to 5 minutes until the pain stops.

2. Take one tablet and rest for 10 minutes. Call the physician if pain persists after 10 minutes.
3. Take one tablet, then an additional tablet every 5 minutes for a total of 3 tablets. Call the
physician if pain persists after three tablets.
4. Take one tablet. If pain persists after 5 minutes, take two tablets. If pain still persists 5
minutes later, call the physician.
Ans-23. 3. The correct protocol for nitroglycerin used involves immediate administration, with
subsequent doses taken at 5-minute intervals as needed, for a total dose of 3 tablets. Sublingual
nitroglycerin appears in the blood stream within 2 to 3 minutes and is metabolized within about
10 minutes.
24) Which of the following arteries primarily feeds the anterior wall of the heart?
1. Circumflex artery
2. Internal mammary artery
3. Left anterior descending artery
4. Right coronary artery
Ans-24. 3. The left anterior descending artery is the primary source of blood flow for the anterior
wall of the heart. The circumflex artery supplies the lateral wall, the internal mammary supplies
the mammary, and the right coronary artery supplies the inferior wall of the heart.
25) When do coronary arteries primarily receive blood flow?
1. During inspiration
2. During diastolic
3. During expiration
4. During systole
Ans-25. 2. Although the coronary arteries may receive a minute portion of blood during systole,
most of the blood flow to coronary arteries is supplied during diastole. Breathing patterns are
irrelevant to blood flow.
26) Prolonged occlusion of the right coronary artery produces an infarction in which of the
following areas of the heart?
1. Anterior
2. Apical
3. Inferior
4. Lateral
Ans-26. 3. The right coronary artery supplies the right ventricle, or the inferior portion of the
heart. Therefore, prolonged occlusion could produce an infarction in that area. The right
coronary artery doesn’t supply the anterior portion (left ventricle), lateral portion (some of the
left ventricle and the left atrium), or the apical portion (left ventricle) of the heart.
27) A murmur is heard at the second left intercostal space along the left sternal border.
Which valve is this?
1. Aortic
2. Mitral
3. Pulmonic
4. Tricupsid
Ans-27. 3. Abnormalities of the pulmonic valve are auscultated at the second left intercostal
space along the left sternal border. Aortic valve abnormalities are heard at the second intercostal
space, to the right of the sternum. Mitral valve abnormalities are heard at the fifth intercostal
space in the midclavicular line. Tricuspid valve abnormalities are heard at the 3rd and
4th intercostal spaces along the sternal border.
28) Which of the following blood tests is most indicative of cardiac damage?
1. Lactate dehydrogenase
3. Troponin I
4. Creatine kinase (CK)
Ans-28. 3. Troponin I levels rise rapidly and are detectable within 1 hour of myocardial injury.
Troponin levels aren’t detectable in people without cardiac injury.
29) Which of the following diagnostic tools is most commonly used to determine the location
of myocardial damage?
2. Cardiac enzymes
3. Echocardiogram
4. Electrocardiogram (ECG)
Ans-29. 4. The ECG is the quickest, most accurate, and most widely used tool to determine the
location of myocardial infarction. Cardiac enzymes are used to diagnose MI but can’t determine
the location. An echocardiogram is used most widely to view myocardial wall function after an
MI has been diagnosed. Cardiac catherization is an invasive study for determining coronary
artery disease and may also indicate the location of myocardial damage, but the study may not be
performed immediately.
30) Which of the following types of pain is most characteristic of angina?
1. Knifelike
2. Sharp
3. Shooting
4. Tightness
Ans-30. 4. The pain of angina usually ranges from a vague feeling of tightness to heavy, intense
pain. Pain impulses originate in the most visceral muscles and may move to such areas as the
chest, neck, and arms.
31) Which of the following parameters is the major determinate of diastolic blood pressure?
1. Baroreceptors
2. Cardiac output
3. Renal function
4. Vascular resistance
Ans-31. 4. Vascular resistance is the impedance of blood flow by the arterioles that most
predominantly affects the diastolic pressure. Cardiac output determines systolic blood pressure.
32) Which of the following factors can cause blood pressure to drop to normal levels?
1. Kidneys’ excretion of sodium only

2. Kidneys’ retention of sodium and water
3. Kidneys’ excretion of sodium and water
4. Kidneys’ retention of sodium and excretion of water
Ans-32. 3. The kidneys respond to a rise in blood pressure by excreting sodium and excess
water. This response ultimately affects systolic pressure by regulating blood volume.
33) Baroreceptors in the carotid artery walls and aorta respond to which of the following
conditions?
1. Changes in blood pressure

2. Changes in arterial oxygen tension
3. Changes in arterial carbon dioxide tension
4. Changes in heart rate
Ans-33. 1. Baroreceptors located in the carotid arteries and aorta sense pulsatile pressure.
Decreases in pulsatile pressure cause a reflex increase in heart rate. Chemoreceptors in the
medulla are primarily stimulated by carbon dioxide. Peripheral chemoreceptors in the aorta and
carotid arteries are primarily stimulated by oxygen.
34) Which of the following terms describes the force against which the ventricle must expel
blood?
1. Afterload
2. Cardiac output
3. Overload
4. Preload
Ans-34. 1. Afterload refers to the resistance normally maintained by the aortic and pulmonic
valves, the condition and tone of the aorta, and the resistance offered by the systemic and
pulmonary arterioles. Cardiac output is the amount of blood expelled from the heart per minute.
Overload refers to an abundance of circulating volume. Preload is the volume of blood in the
ventricle at the end of diastole.
35) Which of the following terms is used to describe the amount of stretch on the
myocardium at the end of diastole?
1. Afterload
2. Cardiac index
3. Cardiac output
4. Preload
Ans-35. 4. Preload is the amount of stretch of the cardiac muscle fibers at the end of diastole.
The volume of blood in the ventricle at the end of diastole determines the preload. Afterload is
the force against which the ventricle must expel blood. Cardiac index is the individualized
measurement of cardiac output, based on the client’s body surface area. Cardiac output is the
amount of blood the heart is expelling per minute.
36) A 57-year-old client with a history of asthma is prescribed propanolol (Inderal) to control
hypertension. Before administered propranolol, which of the following actions should the
nurse take first?
1. Monitor the apical pulse rate

2. Instruct the client to take medication with food
3. Question the physician about the order
4. Caution the client to rise slowly when standing.
Ans-36. 3. Propranolol and other beta-adrenergic blockers are contraindicated in a client with
asthma, so the nurse should question the physician before giving the dose. The other responses
are appropriate actions for a client receiving propranolol, but questioning the physician takes
priority. The client’s apical pulse should always be checked before giving propranolol; if the
pulse rate is extremely low, the nurse should withhold the drug and notify the physician.
37) One hour after administering IV furosemide (Lasix) to a client with heart failure, a short
burst of ventricular tachycardia appears on the cardiac monitor. Which of the following
electrolyte imbalances should the nurse suspect?
1. Hypocalcemia
2. Hypermagnesemia
3. Hypokalemia
4. Hypernatremia
Ans-37. 3. Furosemide is a potassium-depleting diuretic than can cause hypokalemia. In turn,
hypokalemia increases myocardial excitability, leading to ventricular tachycardia.
38) A client is receiving spironolactone to treat hypertension. Which of the following

instructions should the nurse provide?
1. “Eat foods high in potassium.”

2. “Take daily potassium supplements.”
3. “Discontinue sodium restrictions.”
4. “Avoid salt substitutes.”
Ans38. 4. Because spironolactone is a potassium-sparing diuretic, the client should avoid salt
substitutes because of their high potassium content. The client should also avoid potassium-rich
foods and potassium supplements. To reduce fluid-volume overload, sodium restrictions should
continue.
39) When assessing an ECG, the nurse knows that the P-R interval represents the time it
takes for the:
1. Impulse to begin atrial contraction

2. Impulse to transverse the atria to the AV node
3. SA node to discharge the impulse to begin atrial depolarization
4. Impulse to travel to the ventricles.
Ans-39. 4. The P-R interval is measured on the ECG strip from the beginning of the P wave to
the beginning of the QRS complex. It is the time it takes for the impulse to travel to the ventricle.
40) Following a treadmill test and cardiac catheterization, the client is found to have
coronary artery disease, which is inoperative. He is referred to the cardiac rehabilitation unit.
During his first visit to the unit he says that he doesn’t understand why he needs to be there
because there is nothing that can be done to make him better. The best nursing response is:
1. “Cardiac rehabilitation is not a cure but can help restore you to many of your former
activities.”
2. “Here we teach you to gradually change your lifestyle to accommodate your heart disease.”
3. “You are probably right but we can gradually increase your activities so that you can live a
more active life.”
4. “Do you feel that you will have to make some changes in your life now?”
Ans40. 1. Such a response does not have false hope to the client but is positive and realistic. The
answer tells the client what cardiac rehabilitation is and does not dwell upon his negativity about
it.
41) To evaluate a client’s condition following cardiac catheterization, the nurse will palpate
the pulse:
1. In all extremities
2. At the insertion site
3. Distal to the catheter insertion
4. Above the catheter insertion
Ans-41. 3. Palpating pulses distal to the insertion site is important to evaluate for
thrombophlebitis and vessel occlusion. They should be bilateral and strong.
42) A client’s physician orders nuclear cardiography and makes an appointment for a
thallium scan. The purpose of injecting radioisotope into the bloodstream is to detect:
1. Normal vs. abnormal tissue

2. Damage in areas of the heart
3. Ventricular function
4. Myocardial scarring and perfusion
Ans-42. 4. This scan detects myocardial damage and perfusion, an acute or chronic MI. It is a
more specific answer than (1) or (2). Specific ventricular function is tested by a gated cardiac
blood pool scan.
43) A client enters the ER complaining of severe chest pain. A myocardial infarction is
suspected. A 12 lead ECG appears normal, but the doctor admits the client for further testing
until cardiac enzyme studies are returned. All of the following will be included in the nursing
care plan. Which activity has the highest priority?
1. Monitoring vital signs
2. Completing a physical assessment
3. Maintaining cardiac monitoring
4. Maintaining at least one IV access site
Ans-43. 3. Even though initial tests seem to be within normal range, it takes at least 3 hours for
the cardiac enzyme studies to register. In the meantime, the client needs to be watched for
bradycardia, heart block, ventricular irritability, and other arrhythmias. Other activities can be
accomplished around the MI monitoring.
44) A client is experiencing tachycardia. The nurse’s understanding of the physiological

basis for this symptom is explained by which of the following statements?
1. The demand for oxygen is decreased because of pleural involvement

2. The inflammatory process causes the body to demand more oxygen to meet its needs.
3. The heart has to pump faster to meet the demand for oxygen when there is lowered arterial
oxygen tension.
4. Respirations are labored.
Ans-44. 3. The arterial oxygen supply is lowered and the demand for oxygen is increased, which
results in the heart’s having to beat faster to meet the body’s needs for oxygen.
45) A client enters the ER complaining of chest pressure and severe epigastric distress. His
VS are 158/90, 94, 24, and 99*F. The doctor orders cardiac enzymes. If the client were
diagnosed with an MI, the nurse would expect which cardiac enzyme to rise within the next 3
to 8 hours?
1. Creatine kinase (CK or CPK)

2. Lactic dehydrogenase (LDH)
3. LDH-1
4. LDH-2
Ans-45. 1. Creatine kinase (CK, formally known as CPK) rises in 3-8 hours if an MI is present.
When the myocardium is damaged, CPK leaks out of the cell membranes and into the blood
stream. Lactic dehydrogenase rises in 24-48 hours, and LDH-1 and LDH-2 rises in 8-24 hours.
46) A 45-year-old male client with leg ulcers and arterial insufficiency is admitted to the
hospital. The nurse understands that leg ulcers of this nature are usually caused by:
1. Decreased arterial blood flow secondary to vasoconstriction

2. Decreased arterial blood flow leading to hyperemia
3. Atherosclerotic obstruction of the arteries
4. Trauma to the lower extremities
Ans-46. 1. Decreased arterial flow is a result of vasospasm. The etiology is unknown. It is more
problematic in colder climates or when the person is under stress. Hyperemia occurs when the
vasospasm is relieved.
47) Which of the following instructions should be included in the discharge teaching for a
patient discharged with a transdermal nitroglycerin patch?
1. “Apply the patch to a nonhairy, nonfatty area of the upper torso or arms.”
2. “Apply the patch to the same site each day to maintain consistent drug absorption.”
3. “If you get a headache, remove the patch for 4 hours and then reapply.”
4. “If you get chest pain, apply a second patch right next to the first patch.”
Ans-47. 1. A nitroglycerin patch should be applied to a nonhairy, nonfatty area for the best and
most consistent absorption rates. Sites should be rotated to prevent skin irritation, and the drug
should be continued if headache occurs because tolerance will develop. Sublingual nitroglycerin
should be used to treat chest pain.
48) In order to prevent the development of tolerance, the nurse instructs the patient to:
1. Apply the nitroglycerin patch every other day

2. Switch to sublingual nitroglycerin when the patient’s systolic blood pressure elevates to >140
mm Hg
3. Apply the nitroglycerin patch for 14 hours each and remove for 10 hours at night
4. Use the nitroglycerin patch for acute episodes of angina only
Ans-48. 3. Tolerance can be prevented by maintaining an 8- to 12-hour nitrate-free period each

day.
49) Direct-acting vasodilators have which of the following effects on the heart rate?
1. Heart rate decreases

2. Heart rate remains significantly unchanged
3. Heart rate increases
4. Heart rate becomes irregular
Ans-49. 3. Heart rate increases in response to decreased blood pressure caused by vasodilation.
50) When teaching a patient why spironolactone (Aldactone) and furosemide (Lasix) are
prescribed together, the nurse bases teaching on the knowledge that:
1. Moderate doses of two different types of diuretics are more effective than a large dose of one
type
2. This combination promotes diuresis but decreases the risk of hypokalemia
3. This combination prevents dehydration and hypovolemia
4. Using two drugs increases osmolality of plasma and the glomerular filtration rate
Ans-50. 2. Spironolactone is a potassium-sparing diuretic; furosemide is a potassium-losing

diuretic. Giving these together minimizes electrolyte imbalance.
Valvular disease and diet
1. A 68-year-old woman is scheduled to undergo mitral valve replacement for severe mitral
stenosis and mitral regurgitation. Although the diagnosis was made during childhood, she
did not have any symptoms until 4 years ago. Recently, she noticed increased symptoms,
despite daily doses of digoxin and furosemide. During the initial interview with the nice
lady, the nurse would most likely learn that the client’s childhood health history included:
A. Chicken pox
B. poliomyelitis
C. Rheumatic fever
D. Meningitis
Ans-1. 3. Most clients with mitral stenosis have a history of rheumatic fever or bacterial
endocarditis.
2. Which of the following signs and symptoms would most likely be found in a client with
mitral regurgitation?
A. Exertional dyspnea
B. Confusion
C. Elevated creatine phosphokinase concentration
D. Chest pain
Ans-2. 1. Weight gain, due to fluid retention and worsening heart failure, causes exertional
dyspnea in clients with mitral regurgitation. The rise in left atrial pressure that accompanies
mitral valve disease is transmitted backward into pulmonary veins, capillaries, and arterioles and
eventually to the right ventricle. Signs and symptoms of pulmonary and systemic venous
congestion follow.
3. The nurse expects that a client with mitral stenosis would demonstrate symptoms
associated with congestion in the:
A. Aorta
B. Right atrium
C. Superior vena cava
D. Pulmonary circulation
Ans-3. 4. When mitral stenosis is present, the left atrium has difficulty emptying its contents into
the left ventricle. Hence, because there is no valve to prevent backward flow into the pulmonary
vein, the pulmonary circulation is under pressure.
4. Because a client has mitral stenosis and is a prospective valve recipient, the nurse
preoperatively assesses the client’s past compliance with medical regimens. Lack of
compliance with which of the following regimens would pose the greatest health hazard to
this client?
A. Medication therapy
B. Diet modification
C. Activity restrictions
D. Dental care
Ans-4. 4. When mitral stenosis is present, the left atrium has difficulty emptying its contents into
the left ventricle. Hence, because there is no valve to prevent backward flow into the pulmonary
vein, the pulmonary circulation is under pressure.
5. Good dental care is an important measure in reducing the risk of endocarditis. A teaching
plan to promote good dental care in a client with mitral stenosis should include
demonstration of the proper use of:
A. A manual toothbrush
B. An electric toothbrush
C. An irrigation device
D. Dental floss
Ans-5. 1. Daily dental care and frequent checkups by a dentist who is informed about the client’s
condition are required to maintain good oral health. Use of an electric toothbrush, an irrigation
device, or dental floss may cause gums to bleed and allow bacteria to enter mucous membranes
and the blood stream, increasing the risk of endocarditis.
6. A client has been admitted to the hospital with a diagnosis of suspected bacterial
endocarditis. The complication the nurse will constantly observe for is:
A. Presence of heart murmur

B. Systemic emboli
C. Fever
D. Congestive heart failure
Ans-6. 2. Emboli are the major problem; those arising in the right heart chambers will terminate
in the lungs and left chamber emboli may travel anywhere in the arteries. Heart murmurs, fever,
and night sweats may be present, but do not indicate a problem with emboli. CHF may be a
result, but this is not as dangerous an outcome as emboli.
7. Cholesterol, frequently discussed in relation to atherosclerosis, is a substance that:

A. May be controlled by eliminating food sources
B. Is found in many foods, both plant and animal sources
C. All persons would be better off without because it causes the disease process
D. Circulates in the blood, the level of which usually decreases when unsaturated fats are
substituted for saturated fats.
Ans-7. 4. Cholesterol is a sterol found in tissue; it is attributed in part to diets high in saturated
fats.
8. When teaching a client with a cardiac problem, who is on a high-unsaturated fatty-acid

diet, the nurse should stress the importance of increasing the intake of:
A. Enriched whole milk
B. Red meats, such as beef
C. Vegetables and whole grains
D. Liver and other glandular organ meats
Ans-8. 3. Vegetables and whole grains are low in fat and may reduce the risk for heart disease.
9. A 2-gram sodium diet is prescribed for a client with severe hypertension. The client does
not like the diet, and the nurse hears the client request that the spouse “Bring in some
good home-cooked food.” It would be most effective for the nurse to plan to:
A. Call in the dietician for client teaching

B. Wait for the client’s family and discuss the diet with the client and family
C. Tell the client that the use of salt is forbidden, because it will raise BP
D. Catch the family members before they go into the client’s room and tell them about the
diet.
Ans-9. 2. Clients’ families should be included in dietary teaching; families provide support that
promotes adherence.
10. What criteria should the nurse use to determine normal sinus rhythm for a client on a
cardiac monitor? Check all that apply.
A. The RR intervals are relatively consistent
B. One P wave precedes each QRS complex
C. Four to eight complexes occur in a 6-second strip
D. The ST segment is higher than the PR interval
E. The QRS complex ranges from 0.12 to 0.2 seconds
Ans-10. 1 and 2. (1) The consistency of the RR interval indicates a regular rhythm. (2) A normal
P wave before each complex indicates the impulse originated in the SA node. (3) The number of
complexes in a 6-second strip is multiplied by 10 to approximate the heart rate; normal sinus
rhythm is 60 to 100. (4) Elevation of the ST segment is a sign of cardiac ischemia and is
unrelated to the rhythm. (5) The QRS duration should be less than 0.12 seconds; the PR interval
should be 0.12 to 0.2 seconds.
Ear
1. The nurse is performing a voice test to assess hearing. Which of the following describes
the accurate procedure for performing this test?
A. Stand 4 feet away from the client to ensure that the client can hear at this distance.
B. Whisper a statement and ask the client to repeat it.
C. Whisper a statement with the examiners back facing the client
D. Whisper a statement while the client blocks both ears.
Ans-1. 2. The examiner stands 1-2 feet away from the client and asks the client to block one
external ear canal. The nurse whispers a statement and asks the client to repeat it. Each ear is
tested separately.
2. During a hearing assessment, the nurse notes that the sound lateralizes to the clients left
ear with the Weber test. The nurse analyzes this result as:
1. A normal finding
2. A conductive hearing loss in the right ear
3. A sensorineural or conductive loss
4. The presence of nystagmus
Ans-2. 3. In the Weber tuning fork test the nurse places the vibrating tuning fork in the middle
of the client’s head, at the midline of the forehead, or above the upper lip over the teeth.
Normally, the sound is heard in equally in both ears by bone conduction. If the client has a
sensorineural hearing loss in one ear, the sound is heard in the other ear. If the client has a
conductive hearing loss in one ear, the sound is heard in that ear.
3. The nurse is caring for a client that is hearing impaired. Which of the following
approaches will facilitate communication?
1. Speak frequently
2. Speak loudly
3. Speak directly into the impaired ear
4. Speak in a normal tone
Ans-3. 4. Speaking in a normal tone to the client with impaired hearing and not shouting are
important. The nurse should talk directly to the client while facing the client and speak clearly. If
the client does not seem to understand what is said, the nurse should express it differently.
Moving closer to the client and toward the better ear may facilitate communication, but the nurse
should avoid talking directly into the impaired ear.
4. The nurse has conducted discharge teaching for a client who had a fenestration
procedure for the treatment of otosclerosis. Which of the following, if stated by the client,
would indicate that teaching was effective?
1. “I should drink liquids through a straw for the next 2-3 weeks.”
2. “It’s ok to take a shower and wash my hair.”
3. “I will take stool softeners as prescribed by my doctor.”
4. “I can resume my penis lessons starting next week.”
Ans-4. 3. Following ear surgery, the client needs to avoid straining while having a bowel
movement. The client needs to be instructed to avoid drinking through a straw for 2-3 weeks, air
travel, and coughing excessively. The client needs to avoid getting his or her hair wet, washing
hair, showering for 1 week, and rapidly moving the head, bouncing, and bending over for 3
weeks.
5. A client arrives at the emergency room with a foreign body in the left ear that has been
determined to be an insect. Which intervention would the nurse anticipate to be prescribed
initially?
1. Irrigation of the ear

2. Instillation of diluted alcohol
3. Instillation of antibiotic ear drops
4. Instillation of corticosteroids ear drops
Ans-5. 2. Insects are killed before removal unless they can be coaxed out by a flashlight or a
humming noise. Mineral oil or diluted alcohol is instilled into the ear to suffocate the insect,
which then is removed by using forceps. When the foreign object is vegetable matter, irrigation
is not used because this material expands with hydration and the impaction becomes worse.
6. The nurse has notes that the physician has a diagnosis of presbycusis on the client’s
chart. The nurse plans care knowing the condition is:
1. A sensorineural hearing loss that occurs with aging
2. A conductive hearing loss that occurs with aging.
3. Tinnitus that occurs with aging
4. Nystagmus that occurs with aging
Ans-6. 1. Presbycusis is a type of hearing loss that occurs with aging. Presbycusis is a gradual
sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve.
7. A client with Meniere’s disease is experiencing severe vertigo. Which instruction would
the nurse give to the client to assist in controlling the vertigo?
1. Increase fluid intake to 3000 ml a day

2. Avoid sudden head movements
3. Lie still and watch the television
4. Increase sodium in the diet
Ans-7. 2. The nurse instructs the client to make slow head movements to prevent worsening of
the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of
endolymphatic fluid sometimes are prescribed. Lying still and watching television will not
control vertigo.

8. The nurse is reviewing the physician’s orders for a client with Meniere’s disease. Which
diet will most likely be prescribed?
1. Low-cholesterol diet
2. Low-sodium diet
3. Low-carbohydrate diet
4. Low-fat diet
Ans-8. 2. Dietary changes such as salt and fluid restrictions that reduce the amount of
endolymphatic fluid sometimes are prescribed.
9. A client is diagnosed with a disorder involving the inner ear. Which of the following is
the most common client complaint associated with a disorder in this part of the ear?
1. Hearing loss
2. Pruritus
3. Tinnitus
4. Burning of the ear
Ans-9. 3. Tinnitus is the most common complaint of clients with otological disorders, especially
disorders involving the inner ear. Symptoms of tinnitus range from mild ringing in the ear, which
can go unnoticed during the day, to a loud roaring in the ear, which can interfere with the client’s
thinking process and attention span.
10. A nurse would question an order to irrigate the ear canal in which of the following
circumstances?
1. Ear pain
2. Hearing loss
3. Otitis externa
4. Perforated tympanic membrane
Ans-10. 4. Irrigation of the ear canal is contraindicated with perforation of the tympanic
membrane because the solution entering the inner ear may cause dizziness, nausea, vomiting, and
infection.
11. Which of the following interventions is essential when instilling Cortisporin suspension,
2 gtt right ear?
1. Verifying the proper client and route

2. Warming the solution to prevent dizziness
3. Holding an emesis basin under the client’s ear
4. Positioning the client in the semi-fowlers position
Ans-11. 1. When giving medications, a nurse follows the five R’s of medication administration.
The drops may be warmed to prevent pain or dizziness, but this action is not essential. An emesis
basin would be used for irrigation of the ear. Put the client in the lateral position to prevent the
drops from draining out for 5 minutes, not semi-fowlers position.

12. When teaching the client about Meniere’s disease, which of the following instructions
would a nurse give about vertigo?
1. Report dizziness at once

2. Drive in daylight hours only
3. Get up slowly, turning the entire body
4. Change your position using the logroll method
Ans-12. 3. Turning the entire body, not the head, will prevent vertigo. Dizziness is expected but
can be prevented. The client shouldn’t drive as he may reflexively turn the wheel to correct
vertigo. Turning the client in bed slowly and smoothly will be helpful; logrolling isn’t needed.
13. The part of the ear that contains the receptors for hearing is the:
1. Utricle
2. Cochlea
3. Middle ear
4. Tympanic cavity
Ans-13. 2. The dendrites of the cochlear nerve terminate on the hair cells of the organ of Corti in
the cochlea.
14. The ear bones that transmit vibrations to the oval window of the cochlea are found in
the:
1. Inner ear
2. Outer ear
3. Middle ear
4. Eustachian tube
Ans-14. 3. The bones in the middle ear transmit and amplify air pressure waves from the
tympanic membrane to the oval window of the cochlea, which is the inner ear. The tympanic
membrane separates the other from the middle ear.
15. Nerve deafness would most likely result from an injury or infection that damaged the:
1. Vagus nerve
2. Cochlear nerve
3. Vestibular nerve
4. Trigeminal nerve
Ans-15. 2. Because the organ of hearing is the organ of Corti, located in the cochlea, nerve
deafness would most likely accompany damage to the cochlear nerve.
16. A labyrinthectomy can be performed to treat Meniere’s syndrome. This procedure

results in:
1. Anosmia
2. Absence of pain
3. Reduction in cerumen
4. Permanent irreversible deafness
Ans-16. 4. The labyrinth is the inner ear and consists of the vestibule, cochlea, semicircular
canals, utricle, saccule, cochlear duct, and membraneous semicircular canals. A labrinthectomy
is preformed to alleviate the symptoms of vertigo but results in deafness, because the organ of
Corti and cochlear nerve are located in the inner ear.
17. Otosclerosis is a common cause of conductive hearing loss. Which such a partial
hearing loss:
1. Stapedectomy is the procedure of choice
2. Hearing aids usually restore some hearing
3. The client is usually unable to hear bass tones
4. Air conduction is more effective than bone conduction
Ans-17. 2. With a partial hearing loss that auditory ossicles have not yet become fixed; as long as
vibrations occur, a hearing aid may be beneficial.
18. A client who is complaining of tinnitus is describing a symptom that is:
1. Objective
2. Subjective
3. Functional
4. Prodromal
Ans-18. 2. A subjective symptom such as ringing in the ears can be felt only by the client.
19. Physiologically, the middle ear, containing the three ossicles, serves primarily to:
1. Maintain balance
2. Translate sound waves into nerve impulses
3. Amplify the energy of sound waves entering the ear
4. Communicate with the throat via the Eustachian tube.
Ans-19. 3. The middle ear contains the three ossicles—malleus, incus, and stapes—which, along
with the tympanic membrane and oval window, form an amplifying system.
Eye
1. The clinic nurse is preparing to test the visual acuity of a client using a Snellen’s chart.
Which of the following identifies the accurate procedure for this visual acuity test?
A. Both eyes are assessed together, followed by the assessment of the right and then the left
eye.
B. The right eye is tested followed by the left eye, and then both eyes are tested.
C. The client is asked to stand at a distance of 40ft. from the chart and is asked to read the
largest line on the chart.
D. The client is asked to stand at a distance of 40ft from the chart and to read the line than
can be read 200 ft. away by an individual with unimpaired vision.
Ans-1. 2. Visual acuity is assessed in one eye at a time, and then in both eyes together with the
client comfortably standing or sitting. The right eye is tested with the left eye covered; then the
left eye is tested with the right eye covered. Both eyes then are tested together. Visual acuity is
measured with or without corrective lenses and the client stands at a distance of 20ft. from the
chart.

2. The clinic nurse notes that the following several eye examinations, the physician has
documented a diagnosis of legal blindness in the client’s chart. The nurse reviews the results
of the Snellen’s chart test expecting to note which of the following?
1. 20/20 vision
2. 20/40 vision
3. 20/60 vision
4. 20/200 vision
Ans-2. 4. Legal blindness is defined as 20/200 or less with corrected vision (glasses or contact
lenses) or visual acuity of less than 20 degrees of the visual field in the better eye.
3. The client’s vision is tested with a Snellen’s chart. The results of the tests are documented
as 20/60. The nurse interprets this as:
1. The client can read at a distance of 60 feet what a client with normal vision can read at 20
feet.
2. The client is legally blind.
3. The client’s vision is normal
4. The client can read only at a distance of 20 feet what a client with normal vision can read at
60 feet.
Ans-3. 4. Vision that is 20/20 is normal, that is, the client is able to read from 20 feet what a
person with normal vision can read from 20 feet. A client with a visual acuity of 20/60 only can
read at a distance of 20 feet of what a person with normal vision can read at 60 feet.
4. Tonometry is performed on the client with a suspected diagnosis of glaucoma. The nurse
analyzes the test results as documented in the client’s chart and understands that normal
intraocular pressure is:
1. 2-7 mmHg
2. 10-21 mmHg
3. 22-30 mmHg
4. 31-35 mmHg
Ans-4. 2. Tonometry is the method of measuring intraocular fluid pressure using a calibrated
instrument that indents or flattens the corneal apex. Pressures between 10 and 21 mmHg are
considered within normal range.

5. The nurse is developing a plan of care for the client scheduled for cataract surgery. The
nurse documents which more appropriate nursing diagnosis in the plan of care?
1. Self-care deficit
2. Imbalanced nutrition
3. Disturbed sensory perception
4. Anxiety
Ans-5. 3. The most appropriate nursing diagnosis for the client scheduled for cataract surgery is
Disturbed sensory perception (visual) related to lens extraction and replacement. Although the
other options identify nursing diagnoses that may be appropriate, they are not related specifically
to cataract surgery.

6. The nurse is performing an assessment in a client with a suspected diagnosis of cataract.
The chief clinical manifestation that the nurse would expect to note in the early stages of
cataract formation is:
1. Eye pain
2. Floating spots
3. Blurred vision
4. Diplopia
Ans-6. 3. A gradual, painless blurring of central vision is the chief clinical manifestation of a
cataract. Early symptoms include slightly blurred vision and a decrease in color perception

7. In preparation for cataract surgery, the nurse is to administer prescribed eye drops. The
nurse reviews the physician’s orders, expecting which type of eye drops to be instilled?
1. An osmotic diuretic
2. A miotic agent
3. A mydriatic medication
4. A thiazide diuretic
Ans-7. 3. A mydriatic medication produces mydriasis or dilation of the pupil. Mydriatic

medications are used preoperatively in the cataract client. These medication act by dilating the
pupils. They also constrict blood vessels. An osmotic diuretic may be used to decrease
intraocular pressure. A miotic medication constricts the pupil. A thiazide diuretic is not likely to
be prescribed for a client with a cataract.
8. During the early postoperative period, the client who had a cataract extraction complains
of nausea and severe eye pain over the operative site. The initial nursing action is to:

2. Administer the ordered main medication and antiemetic
3. Reassure the client that this is normal.
4. Turn the client on his or her operative side
Ans-8. 1. Severe pain or pain accompanied by nausea is an indicator of increased intraocular

pressure and should be reported to the physician immediately. The other options are
inappropriate.
9. The client is being discharged from the ambulatory care unit following cataract removal.
The nurse provides instructions regarding home care. Which of the following, if stated by the
client, indicates an understanding of the instructions?
1. “I will take Aspirin if I have any discomfort.”

2. “I will sleep on the side that I was operated on.”
3. “I will wear my eye shield at night and my glasses during the day.”
4. “I will not lift anything if it weighs more than 10 pounds.”
Ans-9. 3. The client is instructed to wear a metal or plastic shield to protect the eye from
accidental and is instructed not to rub the eye. Glasses may be worn during the day. Aspirin or
medications containing aspirin are not to be administered or taken by the client and the client is
instructed to take acetaminophen as needed for pain. The client is instructed not to sleep on the
side of the body on which the operation occurred. The client is not to lift more than 5 pounds.

10. The client with glaucoma asks the nurse is complete vision will return. The most
appropriate response is:
1. “Although some vision has been lost and cannot be restored, further loss may be prevented
by adhering to the treatment plan.”
2. “Your vision will return as soon as the medications begin to work.”
3. “Your vision will never return to normal.”
4. “Your vision loss is temporary and will return in about 3-4 weeks.”
Ans-10. 1. Vision loss to glaucoma is irreparable. The client should be reassured that although
some vision has been lost and cannot be restored, further loss may be prevented by adhering to
the treatment plan. Option C does not provide reassurance to the client.
11. The nurse is developing a teaching plan for the client with glaucoma. Which of the
following instructions would the nurse include in the plan of care?
1. Decrease fluid intake to control the intraocular pressure

2. Avoid overuse of the eyes
3. Decrease the amount of salt in the diet
4. Eye medications will need to be administered lifelong.
Ans-11. 4. The administration of eye drops is a critical component of the treatment plan for the
client with glaucoma. The client needs to be instructed that medications will need to be taken for
the rest of his or her life.
12. The nurse is performing an admission assessment on a client with a diagnosis of
detached retina. Which of the following is associated with this eye disorder?
1. Pain in the affected eye

2. Total loss of vision
3. A sense of a curtain falling across the field of vision
4. A yellow discoloration of the sclera.
Ans-12. 3. A characteristic manifestation of retinal detachment described by the client is the

feeling that a shadow or curtain is falling across the field of vision. No pain is associated with
detachment of the retina. Options B and D are not characteristics of this disorder. A retinal
detachment is an ophthalmic emergency and even more so if visual acuity is still normal.
13. The nurse is caring for a client with a diagnosis of detached retina. Which assessment
sign would indicate that bleeding has occurred as a result of the retinal detachment?
1. Complaints of a burst of black spots or floaters

2. A sudden sharp pain in the eye
3. Total loss of vision
4. A reddened conjunctiva
Ans-13. 1. Complaints of a sudden burst of black spots or floaters indicate that bleeding has
occurred as a result of the detachment.

14. The client sustains a contusion of the eyeball following a traumatic injury with a blunt
object. Which intervention is initiated immediately?
1. Notify the physician

2. Irrigate the eye with cold water
3. Apply ice to the affected eye
4. Accompany the client to the emergency room
Ans-14. 3. Treatment for contusion begins at the time of injury. Ice is applied immediately. The
client then should be seen by a physician and receive a thorough eye examination to rule out the
presence of other eye injuries.
15. The client arrives in the emergency room with a penetrating eye injury from wood chips
while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the
eye, what is the initial nursing action?
1. Remove the piece of wood using a sterile eye clamp

2. Apply an eye patch
3. Perform visual acuity tests
4. Irrigate the eye with sterile saline.
Ans-15. 3. If the laceration is the result of a penetrating injury, an object may be noted
protruding from the eye. This object must never be removed except by the ophthalmologist
because it may be holding ocular structures in place. Application of an eye patch or irrigation of
the eye may disrupt the foreign body and cause further tearing of the sclera. (The only option that
will prevent further disruption is to assess visual acuity.)
16. The client arrives in the emergency room after sustaining a chemical eye injury from a
splash of battery acid. The initial nursing action is to:
1. Begin visual acuity testing

2. Irrigate the eye with sterile normal saline
3. Swab the eye with antibiotic ointment
4. Cover the eye with a pressure patch.
Ans-16. 2. Emergency care following a chemical burn to the eye includes irrigating the eye
immediately with sterile normal saline or ocular irrigating solution. In the emergency
department, the irrigation should be maintained for at least 10 minutes. Following this
emergency treatment, visual acuity is assessed.

17. The nurse is caring for a client following enucleation. The nurse notes the presence of
bright red blood drainage on the dressing. Which nursing action is appropriate?

2. Continue to monitor the drainage
3. Document the finding
4. Mark the drainage on the dressing and monitor for any increase in bleeding.
Ans-17. 1. If the nurse notes the presence of bright red drainage on the dressing, it must be
reported to the physician because this indicated hemorrhage.

18. When using a Snellen alphabet chart, the nurse records the client’s vision as 20/40.
Which of the following statements best describes 20/40 vision?
1. The client has alterations in near vision and is legally blind.

2. The client can see at 20 feet what the person with normal vision can see at 40 feet.
3. The client can see at 40 feet what the person with normal vision sees at 20 feet.
4. The client has a 20% decrease in acuity in one eye, and a 40% decrease in the other eye.
Ans-18. 2. The numerator refers to the client’s vision while comparing the normal vision in the
denominator.

19. Which of the following instruments is used to record intraocular pressure?
1. Goniometer
2. Ophthalmoscope
3. Slit lamp
4. Tonometer
Ans-19. 4. A tonometer is a device used in glaucoma screening to record intraocular pressure. A

goniometer measures joint movement and angles. An ophthalmoscope examines the interior of
the eye, especially the retina. A slit lamp evaluates structures in the anterior chamber in the eye.

20. After the nurse instills atropine drops into both eyes for a client undergoing ophthalmic
examination, which of the following instructions would be given to the client?
1. “Be careful because the blink reflex is paralyzed.”

2. “Avoid wearing your regular glasses when driving.”
3. “Be aware that the pupils may be unusually small.”
4. “Wear dark glasses in bright light because the pupils are dilated.”
Ans-20. 4. Atropine, an anticholinergic drug, has mydriatic effects causing pupil dilation. This
allows more light onto the retina and may cause photophobia and blurred vision. Atropine
doesn’t paralyze the blink reflex or cause miosis (pupil constriction). Driving may be
contraindicated to blurred vision.

21. Which of the following procedures or assessments must the nurse perform when
preparing a client for eye surgery?
1. Clipping the client’s eyelashes

2. Verifying the affected eye has been patched 24 hours before surgery
3. Verifying the client has been NPO since midnight, or at least 8 hours before surgery.
4. Obtaining informed consent with the client’s signature and placing the forms on the chart.
Ans-21. 3. Maintaining NPO status for at least 8 hours before surgical procedures prevents
vomiting and aspiration. There is no need to patch an eye before most surgeries or to clip the
eyelashes unless specifically ordered by the physician. The physician is responsible for obtaining
informed consent; the nurse validates that the consent is obtained.
22. Cataract surgery results in aphakia. Which of the following statements best describes
this term?
1. Absence of the crystalline lens

2. A “keyhole” pupil
3. Loss of accommodation
4. Retinal detachment
Ans-22. 1. Aphakia means without lens, a keyhole pupil results from iridectomy. Loss of
accommodation is a normal response to aging. A retinal detachment is usually associated with
retinal holes created by vitreous traction.

23. When developing a teaching session on glaucoma for the community, which of the
following statements would the nurse stress?
1. Glaucoma is easily corrected with eyeglasses

2. White and Asian individuals are at the highest risk for glaucoma.
3. Yearly screening for people ages 20-40 years is recommended.
4. Glaucoma can be painless and vision may be lost before the person is aware of a problem.
Ans-23. 4. Open-angle glaucoma causes a painless increase in intraocular pressure (IOP) with
loss of peripheral vision. A variety of miotics and agents to decrease IOP and occasional surgery
are used to treat glaucoma. Blacks have a threefold greater chance of developing with an
increased chance of blindness than other groups. Individuals older than 40 should be screened.

24. For a client having an episode of acute narrow-angle glaucoma, a nurse expects to give
which of the following medications?
1. Acetazolamide (Diamox)
2. Atropine
3. Furisemide (Lasix)
4. Urokinase (Abbokinase)
Ans-24. 1. Acetazolamide, a carbonic anhydrase inhibitor, decreases intraocular pressure (IOP)

by decreasing the secretion of aqueous humor. Atropine dilates the pupil and decreases outflow
of aqueous humor, causing further increase in IOP. Lasix is a loop diuretic, and Urokinase is a
thrombolytic agent; they aren’t used for the treatment of glaucoma. (Remember surgical nursing
and PVD? Ha!

25. Which of the following symptoms would occur in a client with a detached retina?
1. Flashing lights and floaters

2. Homonymous hemianopia
3. Loss of central vision
4. Ptosis
Ans-25. 1. Signs and symptoms of retinal detachment include abrupt flashing lights, floaters, loss
of peripheral vision, or a sudden shadow or curtain in the vision. Occasionally visual loss is
gradual.
26. A male client has just had a cataract operation without a lens implant. In discharge
teaching, the nurse will instruct the client’s wife to:
1. Feed him soft foods for several days to prevent facial movement
2. Keep the eye dressing on for one week
3. Have her husband remain in bed for 3 days
4. Allow him to walk upstairs only with assistance.
Ans-26. 4. Without a lens, the eye cannot accommodate. It is difficult to judge distance and
climb stairs when the eyes cannot accommodate. Therefore, the client should walk up and down
stairs only with assistance.
Gastro
1. A patient with chronic alcohol abuse is admitted with liver failure. You closely monitor the
patient’s blood pressure because of which change that is associated with the liver failure?
A. Hypoalbuminemia
B. Increased capillary permeability
C. Abnormal peripheral vasodilation
D. Excess rennin release from the kidneys
Ans-1. A Blood pressure decreases as the body is unable to maintain normal oncotic pressure
with liver failure, so patients with liver failure require close blood pressure monitoring.
Increased capillary permeability, abnormal peripheral vasodilation, and excess rennin
released from the kidneys aren’t direct ramifications of liver failure.
2. You’re assessing the stoma of a patient with a healthy, well-healed colostomy. You expect
the stoma to appear:
1. Pale, pink and moist

2. Red and moist
3. Dark or purple colored
4. Dry and black
Ans-2. 2. Good circulation causes tissues to be moist and red, so a healthy, well-healed stoma
appears red and moist.

3. You’re caring for a patient with a sigmoid colostomy. The stool from this colostomy is:
1. Formed
2. Semisolid
3. Semiliquid
4. Watery
Ans-3. 1. A colostomy in the sigmoid colon produces a solid, formed stool.

4. You’re advising a 21 y.o. with a colostomy who reports problems with flatus. What food
should you recommend?
1. Peas
2. Cabbage
3. Broccoli
4. Yogurt
Ans-4. D High-fiber foods stimulate peristalsis, and a result, flatus. Yogurt reduces gas
formation.
5. You have to teach ostomy self-care to a patient with a colostomy. You tell the patient to
measure and cut the wafer:
1. To the exact size of the stoma.

2. About 1/16” larger than the stoma.
3. About 1/8” larger than the stoma.
4. About 1/4″ larger than the stoma.
Ans-5. 2. A proper fit protects the skin, but doesn’t impair circulation. A 1/16” should be cut.

6. You’re performing an abdominal assessment on Brent who is 52 y.o. In which order do
you proceed?
1. Observation, percussion, palpation, auscultation

2. Observation, auscultation, percussion, palpation
3. Percussion, palpation, auscultation, observation
4. Palpation, percussion, observation, auscultation
Ans-6. 2. Observation, auscultation, percussion, palpation

7. You’re doing preoperative teaching with Gertrude who has ulcerative colitis who needs
surgery to create an ileoanal reservoir. Which information do you include?
1. A reservoir is created that exits through the abdominal wall.

2. A second surgery is required 12 months after the first surgery.
3. A permanent ileostomy is created.
4. The surgery occurs in two stages.
Ans-7. 4. An ileoanal reservoir is created in two stages. The two surgeries are about 2 to 3
months apart. First, diseased intestines are removed and a temporary loop ileostomy is created.
Second, the loop ileostomy is closed and stool goes to the reservoir and out through the anus.

8. You’re caring for Carin who has just had ileostomy surgery. During the first 24 hours
post-op, how much drainage can you expect from the ileostomy?
1. 100 ml
2. 500 ml
3. 1500 ml
4. 5000 ml
Ans-8. 3. The large intestine absorbs large amounts of water so the initial output from the
ileostomy may be as much as 1500 to 2000 ml/24 hours. Gradually, the small intestine absorbs
more fluid and the output decreases.
9. You’re preparing a teaching plan for a 27 y.o. named Jeff who underwent surgery to close
a temporary ileostomy. Which nutritional guideline do you include in this plan?
1. There is no need to change eating habits.

2. Eat six small meals a day.
3. Eat the largest meal in the evening.
4. Restrict fluid intake.
Ans-9. 2. To avoid overloading the small intestine, encourage the patient to eat six small,
regularly spaced meals.
10. Arthur has a family history of colon cancer and is scheduled to have a sigmoidoscopy. He
is crying as he tells you, “I know that I have colon cancer, too.” Which response is most
therapeutic?
1. “I know just how you feel.”

2. “You seem upset.”
3. “Oh, don’t worry about it, everything will be just fine.”
4. “Why do you think you have cancer?”
Ans-10. 2. Making observations about what you see or hear is a useful therapeutic technique.
This way, you acknowledge that you are interested in what the patient is saying and feeling.
11. You’re caring for Beth who underwent a Billroth II procedure (surgical removal of the
pylorus and duodenum) for treatment of a peptic ulcer. Which findings suggest that the
patient is developing dumping syndrome, a complication associated with this procedure?
1. Flushed, dry skin.

2. Headache and bradycardia.
3. Dizziness and sweating.
4. Dyspnea and chest pain.
Ans-11. 3. After a Billroth II procedure, a large amount of hypertonic fluid enters the intestine.
This causes extracellular fluid to move rapidly into the bowel, reducing circulating blood volume
and producing vasomotor symptoms. Vasomotor symptoms produced by dumping syndrome
include dizziness and sweating, tachycardia, syncope, pallor, and palpitations.
12. You’re developing the plan of care for a patient experiencing dumping syndrome after a
Billroth II procedure. Which dietary instructions do you include?
1. Omit fluids with meals.

2. Increase carbohydrate intake.
3. Decrease protein intake.
4. Decrease fat intake.
Ans-12. 1. Gastric emptying time can be delayed by omitting fluids from your patient’s meal. A
diet low in carbs and high in fat & protein is recommended to treat dumping syndrome.
13. You’re caring for Lewis, a 67 y.o. patient with liver cirrhosis who develops ascites and
requires paracentesis. Relief of which symptom indicated that the paracentesis was effective?
1. Pruritus
2. Dyspnea
3. Jaundice
4. Peripheral Neuropathy
Ans-13. 2. Ascites puts pressure on the diaphragm. Paracentesis is done to remove fluid and
reducing pressure on the diaphragm. The goal is to improve the patient’s breathing. The others
are signs of cirrhosis that aren’t relieved by paracentesis.
14. You’re caring for Jane, a 57 y.o. patient with liver cirrhosis who develops ascites and
requires paracentesis. Before her paracentesis, you instruct her to:
1. Empty her bladder.

2. Lie supine in bed.
3. Remain NPO for 4 hours.
4. Clean her bowels with an enema.
Ans-14. 1. A full bladder can interfere with paracentesis and be punctured inadvertently.
15. After abdominal surgery, your patient has a severe coughing episode that causes wound
evisceration. In addition to calling the doctor, which intervention is most appropriate?
1. Irrigate the wound & organs with Betadine.

2. Cover the wound with a saline soaked sterile dressing.
3. Apply a dry sterile dressing & binder.
4. Push the organs back & cover with moist sterile dressings.
Ans-15. 2. Cover the organs with a sterile, nonadherent dressing moistened with normal saline.
Do this to prevent infection and to keep the organs from drying out.
16. You’re caring for Betty with liver cirrhosis. Which of the following assessment findings
leads you to suspect hepatic encephalopathy in her?
1. Asterixis
2. Chvostek’s sign
3. Trousseau’s sign
4. Hepatojugular reflex
Ans-16. 1. Asterixis is an early neurologic sign of hepatic encephalopathy elicited by asking the
patient to hold her arms stretched out. Asterixis is present if the hands rapidly extend and flex.
17. You are developing a careplan on Sally, a 67 y.o. patient with hepatic encephalopathy.
Which of the following do you include?
1. Administering a lactulose enema as ordered

2. Encouraging a protein-rich diet.
3. Administering sedatives, as necessary.
4. Encouraging ambulation at least four times a day.
Ans-17. 1. You may administer the laxative lactulose to reduce ammonia levels in the colon.
18. You have a patient with achalasia (incomplete muscle relaxtion of the GI tract,
especially sphincter muscles). Which medications do you anticipate to administer?
1. Isosorbide dinitrate (Isordil)

3. Captopril (Capoten)
4. Propanolol (Inderal)
Ans-18. 1. Achalasia is characterized by incomplete relaxation of the LES, dilation of the lower
esophagus, and a lack of esophageal peristalsis. Because nitrates relax the lower esophageal
sphincter, expect to give Isordil orally or sublingually.
19. The student nurse is preparing a teaching care plan to help improve nutrition in a patient
with achalasia. You include which of the following:
1. Swallow foods while leaning forward.

2. Omit fluids at mealtimes.
3. Eat meals sitting upright.
4. Avoid soft and semisoft foods.
Ans-19. 3. Eating in the upright position aids in emptying the esophagus. Doing the opposite of
the other three also may be helpful.
20. Britney, a 20 y.o. student is admitted with acute pancreatitis. Which laboratory findings do
you expect to be abnormal for this patient?
1. Serum creatinine and BUN

2. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST)
3. Serum amylase and lipase
4. Cardiac enzymes
Ans-20. 3. Pancreatitis involves activation of pancreatic enzymes, such as amylase and lipase.
These levels are elevated in a patient with acute pancreatitis.
21. A patient with Crohn’s disease is admitted after 4 days of diarrhea. Which of the following
urine specific gravity values do you expect to find in this patient?
1. 1.005
2. 1.011
3. 1.020
4. 1.030
Ans-21. 4. The normal range of specific gravity of urine is 1.010 to 1.025; a value of 1.030 may
be seen with dehydration

22. Your goal is to minimize David’s risk of complications after a heriorrhaphy. You instruct
the patient to:
1. Avoid the use of pain medication.

2. Cough and deep breathe Q2H.
3. Splint the incision if he can’t avoid sneezing or coughing.
4. Apply heat to scrotal swelling.
Ans-22. 3. Teach the pt to avoid activities that increase intra-abdominal pressure such as
coughing, sneezing, or straining with a bowel movement.
23. Janice is waiting for discharge instructions after her herniorrhaphy. Which of the
following instructions do you include?
1. Eat a low-fiber diet.

2. Resume heavy lifting in 2 weeks.
3. Lose weight, if obese.
4. Resume sexual activity once discomfort is gone.
Ans-23. 3. Because obesity weakens the abdominal muscles, advise weight loss for the patient
who has had a hernia repair.
24. Develop a teaching care plan for Angie who is about to undergo a liver biopsy. Which
of the following points do you include?
1. “You’ll need to lie on your stomach during the test.”

2. “You’ll need to lie on your right side after the test.”
3. “During the biopsy you’ll be asked to exhale deeply and hold it.”
4. “The biopsy is performed under general anesthesia.”
Ans-24. 2. After a liver biopsy, the patient is placed on the right side to compress the liver and
to reduce the risk of bleeding or bile leakage.

25. Stephen is a 62 y.o. patient that has had a liver biopsy. Which of the following groups
of signs alert you to a possible pneumothorax?
1. Dyspnea and reduced or absent breath sounds over the right lung
2. Tachycardia, hypotension, and cool, clammy skin
3. Fever, rebound tenderness, and abdominal rigidity
4. Redness, warmth, and drainage at the biopsy site
Ans-25. 1. Signs and Symptoms of pneumothorax include dyspnea and decreased or absent
breath sounds over the affected lung (right lung).
26. Michael, a 42 y.o. man is admitted to the med-surg floor with a diagnosis of acute
pancreatitis. His BP is 136/76, pulse 96, Resps 22 and temp 101. His past history includes
hyperlipidemia and alcohol abuse. The doctor prescribes an NG tube. Before inserting the
tube, you explain the purpose to patient. Which of the following is a most accurate
explanation?
1. “It empties the stomach of fluids and gas.”

2. “It prevents spasms at the sphincter of Oddi.”
3. “It prevents air from forming in the small intestine and large intestine.”
4. “It removes bile from the gallbladder.”
Ans-26. 1. An NG tube is inserted into the patients stomach to drain fluid and gas.
27. Jason, a 22 y.o. accident victim, requires an NG tube for feeding. What should you
immediately do after inserting an NG tube for liquid enteral feedings?
1. Aspirate for gastric secretions with a syringe.

2. Begin feeding slowly to prevent cramping.
3. Get an X-ray of the tip of the tube within 24 hours.
4. Clamp off the tube until the feedings begin.
Ans-27. 1. Aspirating the stomach contents confirms correct placement. If an X-ray is ordered, it
should be done immediately, not in 24 hours.
28. Stephanie, a 28 y.o. accident victim, requires TPN. The rationale for TPN is to provide:
1. Necessary fluids and electrolytes to the body.

2. Complete nutrition by the I.V. route.
3. Tube feedings for nutritional supplementation.
4. Dietary supplementation with liquid protein given between meals.
Ans-28. 2. TPN is given I.V. to provide all the nutrients your patient needs. TPN isn’t a tube
feeding nor is it a liquid dietary supplement.
29. Type A chronic gastritis can be distinguished from type B by its ability to:
1. Cause atrophy of the parietal cells.

2. Affect only the antrum of the stomach.
3. Thin the lining of the stomach walls.
4. Decrease gastric secretions.
Ans-29. 1. Type A causes changes in parietal cells.
30. Matt is a 49 y.o. with a hiatal hernia that you are about to counsel. Health care
counseling for Matt should include which of the following instructions?
1. Restrict intake of high-carbohydrate foods.

2. Increase fluid intake with meals.
3. Increase fat intake.
4. Eat three regular meals a day.
Ans-30. 2. Increasing fluids helps empty the stomach. A high carb diet isn’t restricted and fat
intake shouldn’t be increased.

31. Jerod is experiencing an acute episode of ulcerative colitis. Which is priority for this
patient?
1. Replace lost fluid and sodium.

2. Monitor for increased serum glucose level from steroid therapy.
3. Restrict the dietary intake of foods high in potassium.
4. Note any change in the color and consistency of stools.
Ans-31. 1. Diarrhea d/t an acute episode of ulcerative colitis leads to fluid & electrolyte losses
so fluid replacement takes priority.
32. A 29 y.o. patient has an acute episode of ulcerative colitis. What diagnostic test confirms
this diagnosis?
1. Barium Swallow.
2. Stool examination.
3. Gastric analysis.
4. Sigmoidoscopy.

Ans-32. 4. Sigmoidoscopy allows direct observation of the colon mucosa for changes, and if
needed, biopsy.
33. Eleanor, a 62 y.o. woman with diverticulosis is your patient. Which interventions would
you expect to include in her care?
1. Low-fiber diet and fluid restrictions.

2. Total parenteral nutrition and bed rest.
3. High-fiber diet and administration of psyllium.
4. Administration of analgesics and antacids.
Ans-33. 3. She needs a high-fiber diet and a psyllium (bulk laxative) to promote normal soft
stools.
34. Regina is a 46 y.o. woman with ulcerative colitis. You expect her stools to look like:
1. Watery and frothy.

2. Bloody and mucoid.
3. Firm and well-formed.
4. Alternating constipation and diarrhea.
Ans-34. 2. Stools from ulcerative colitis are often bloody and contain mucus.

35. Donald is a 61 y.o. man with diverticulitis. Diverticulitis is characterized by:
1. Periodic rectal hemorrhage.

2. Hypertension and tachycardia.
3. Vomiting and elevated temperature.
4. Crampy and lower left quadrant pain and low-grade fever.
Ans-35. 4. One sign of acute diverticulitis is crampy lower left quadrant pain. A low-grade fever
is another common sign.
36. Brenda, a 36 y.o. patient is on your floor with acute pancreatitis. Treatment for her
includes:
1. Continuous peritoneal lavage.

2. Regular diet with increased fat.
3. Nutritional support with TPN.
4. Insertion of a T tube to drain the pancreas.
Ans-36. 3. With acute pancreatitis, you need to rest the GI tract by TPN as nutritional support.

37. Glenda has cholelithiasis (gallstones). You expect her to complain of:
1. Pain in the right upper quadrant, radiating to the shoulder.

2. Pain in the right lower quadrant, with rebound tenderness.
3. Pain in the left upper quadrant, with shortness of breath.
4. Pain in the left lower quadrant, with mild cramping.
Ans-37. 1. The gallbladder is located in the RUQ and a frequent sign of gallstones is pain
radiating to the shoulder.

38. After an abdominal resection for colon cancer, Madeline returns to her room with a
Jackson-Pratt drain in place. The purpose of the drain is to:
1. Irrigate the incision with a saline solution.

2. Prevent bacterial infection of the incision.
3. Measure the amount of fluid lost after surgery.
4. Prevent accumulation of drainage in the wound.
Ans-38. 4. A Jackson-Pratt drain promotes wound healing by allowing fluid to escape from the
wound.

39. Anthony, a 60 y.o. patient, has just undergone a bowel resection with a colostomy. During
the first 24 hours, which of the following observations about the stoma should you report to
the doctor?
1. Pink color.
2. Light edema.
3. Small amount of oozing.
4. Trickles of bright red blood.
Ans-39. 4. After creation of a colostomy, expect to see a stoma that is pink, slightly edematous,
with some oozing. Bright red blood, regardless of amount, indicates bleeding and should be
reported to the doctor.
40. Your teaching Anthony how to use his new colostomy. How much skin should remain
exposed between the stoma and the ring of the appliance?
1. 1/16”
2. 1/4″
3. 1/2”
4. 1”
Ans-40. 1. Only a small amount of skin should be exposed and more than 1/16” of skin allows
the excrement to irritate the skin.
41. Claire, a 33 y.o. is on your floor with a possible bowel obstruction. Which intervention is
priority for her?
1. Obtain daily weights.

2. Measure abdominal girth.
3. Keep strict intake and output.
4. Encourage her to increase fluids.
Ans-41. 2. Measuring abdominal girth provides quantitative information about increases or

decreases in the amount of distention.
42. Your patient has a GI tract that is functioning, but has the inability to swallow foods.
Which is the preferred method of feeding for your patient?
1. TPN
2. PPN
3. NG feeding
4. Oral liquid supplements
Ans-42. 3. Because the GI tract is functioning, feeding methods involve the enteral route which
bypasses the mouth but allows for a major portion of the GI tract to be used.

43. You’re patient is complaining of abdominal pain during assessment. What is your
priority?
1. Auscultate to determine changes in bowel sounds.

2. Observe the contour of the abdomen.
3. Palpate the abdomen for a mass.
4. Percuss the abdomen to determine if fluid is present.
Ans-43. B2. The first step in assessing the abdomen is to observe its shape and contour, then
auscultate, palpate, and then percuss.
44. Before bowel surgery, Lee is to administer enemas until clear. During administration, he
complains of intestinal cramps. What do you do next?
1. Discontinue the procedure.

2. Lower the height of the enema container.
3. Complete the procedure as quickly as possible.
4. Continue administration of the enema as ordered without making any adjustments.
Ans-44. 2. Lowering the height decreases the amount of flow, allowing him to tolerate more
fluid.

45. Leigh Ann is receiving pancrelipase (Viokase) for chronic pancreatitis. Which observation
best indicates the treatment is effective?
1. There is no skin breakdown.

2. Her appetite improves.
3. She loses more than 10 lbs.
4. Stools are less fatty and decreased in frequency.
Ans-45. 4. Pancrelipase provides the exocrine pancreatic enzyme necessary for proper protein,
fat, and carb digestion. With increased fat digestion and absorption, stools become less frequent
and normal in appearance.

46. Ralph has a history of alcohol abuse and has acute pancreatitis. Which lab value is most
likely to be elevated?
1. Calcium
2. Glucose
3. Magnesium
4. Potassium
Ans-46. 2. Glucose level increases and diabetes mellitus may result d/t the pancreatic damage to
the islets of langerhans.
47. Anna is 45 y.o. and has a bleeding ulcer. Despite multiple blood transfusions, her HGB is
7.5g/dl and HCT is 27%. Her doctor determines that surgical intervention is necessary and she
undergoes partial gastrectomy. Postoperative nursing care includes:
1. Giving pain medication Q6H.

2. Flushing the NG tube with sterile water.
3. Positioning her in high Fowler’s position.
4. Keeping her NPO until the return of peristalsis.
Ans-47. 4. After surgery, she remains NPO until peristaltic activity returns. This decreases the
risk for abdominal distention and obstruction.

48. Sitty, a 66 y.o. patient underwent a colostomy for ruptured diverticulum. She did well
during the surgery and returned to your med-surg floor in stable condition. You assess her
colostomy 2 days after surgery. Which finding do you report to the doctor?
1. Blanched stoma
2. Edematous stoma
3. Reddish-pink stoma
4. Brownish-black stoma
Ans-48. 4. A brownish-black color indicates lack of blood flow, and maybe necrosis.
49. Sharon has cirrhosis of the liver and develops ascites. What intervention is necessary to
decrease the excessive accumulation of serous fluid in her peritoneal cavity?
1. Restrict fluids
2. Encourage ambulation
3. Increase sodium in the diet
4. Give antacids as prescribed
Ans-49. 1. Restricting fluids decrease the amount of body fluid and the accumulation of fluid in
the peritoneal space.

50. Katrina is diagnosed with lactose intolerance. To avoid complications with lack of calcium
in the diet, which food should be included in the diet?
1. Fruit
2. Whole grains
3. Milk and cheese products
4. Dark green, leafy vegetables
Ans-50. 4. Dark green, leafy vegetables are rich in calcium.

51. Nathaniel has severe pruritus due to having hepatitis B. What is the best intervention for
his comfort?
1. Give tepid baths.

2. Avoid lotions and creams.
3. Use hot water to increase vasodilation.
4. Use cold water to decrease the itching.
Ans-51. 1. For pruritus, care should include tepid sponge baths and use of emollient creams and
lotions.

52. Rob is a 46 y.o. admitted to the hospital with a suspected diagnosis of Hepatitis B. He’s
jaundiced and reports weakness. Which intervention will you include in his care?
1. Regular exercise.
2. A low-protein diet.
3. Allow patient to select his meals.
4. Rest period after small, frequent meals.
Ans-52. 4. Rest periods and small frequent meals is indicated during the acute phase of hepatitis
B.
53. You’re discharging Nathaniel with hepatitis B. Which statement suggests understanding
by the patient?
1. “Now I can never get hepatitis again.”

2. “I can safely give blood after 3 months.”
3. “I’ll never have a problem with my liver again, even if I drink alcohol.”
4. “My family knows that if I get tired and start vomiting, I may be getting sick again.”
Ans-53. 4. Hepatitis B can recur. Patients who have had hepatitis are permanently barred from
donating blood. Alcohol is metabolized by the liver and should be avoided by those who have or
had hepatitis B.

54. Gail is scheduled for a cholecystectomy. After completion of preoperative teaching, Gail
states,”If I lie still and avoid turning after the operation, I’ll avoid pain. Do you think this is a
good idea?” What is the best response?
1. “You’ll need to turn from side to side every 2 hours.”

2. “It’s always a good idea to rest quietly after surgery.”
3. “The doctor will probably order you to lie flat for 24 hours.”
4. “Why don’t you decide about activity after you return from the recovery room?”
Ans-54. 1. To prevent venous stasis and improve muscle tone, circulation, and respiratory
function, encourage her to move after surgery.
55. You’re caring for a 28 y.o. woman with hepatitis B. She’s concerned about the duration of
her recovery. Which response isn’t appropriate?
1. Encourage her to not worry about the future.

2. Encourage her to express her feelings about the illness.
3. Discuss the effects of hepatitis B on future health problems.
4. Provide avenues for financial counseling if she expresses the need.
Ans-55. 1. Telling her not to worry minimizes her feelings.
56. Elmer is scheduled for a proctoscopy and has an I.V. The doctor wrote an order for 5mg
of I.V. diazepam (Valium). Which order is correct regarding diazepam?
1. Give diazepam in the I.V. port closest to the vein.

2. Mix diazepam with 50 ml of dextrose 5% in water and give over 15 minutes.
3. Give diazepam rapidly I.V. to prevent the bloodstream from diluting the drug mixture.
4. Question the order because I.V. administration of diazepam is contraindicated.
Ans-56. 1. Diazepam is absorbed by the plastic I.V. tubing and should be given in the port
closest to the vein.
57. Annebell is being discharged with a colostomy, and you’re teaching her about colostomy
care. Which statement correctly describes a healthy stoma?
1. “At first, the stoma may bleed slightly when touched.”

2. “The stoma should appear dark and have a bluish hue.”
3. “A burning sensation under the stoma faceplate is normal.”
4. “The stoma should remain swollen away from the abdomen.”
Ans-56. 1. Diazepam is absorbed by the plastic I.V. tubing and should be given in the port
closest to the vein.

58. A patient who underwent abdominal surgery now has a gaping incision due to delayed
wound healing. Which method is correct when you irrigate a gaping abdominal incision with
sterile normal saline solution, using a piston syringe?
1. Rapidly instill a stream of irrigating solution into the wound.

2. Apply a wet-to-dry dressing to the wound after the irrigation.
3. Moisten the area around the wound with normal saline solution after the irrigation.
4. Irrigate continuously until the solution becomes clear or all of the solution is used.
Ans-58. 4. To wash away tissue debris and drainage effectively, irrigate the wound until the
solution becomes clear or all the solution is used.
59. Hepatic encephalopathy develops when the blood level of which substance increases?
1. Ammonia
2. Amylase
3. Calcium
4. Potassium
Ans-59. 1. Ammonia levels increase d/t improper shunting of blood, causing ammonia to enter
systemic circulation, which carries it to the brain.

60. Your patient recently had abdominal surgery and tells you that he feels a popping
sensation in his incision during a coughing spell, followed by severe pain. You anticipate an
evisceration. Which supplies should you take to his room?
1. A suture kit.
2. Sterile water and a suture kit.
3. Sterile water and sterile dressings.
4. Sterile saline solution and sterile dressings.
Ans-60. 4. Saline solution is isotonic, or close to body fluids in content, and is used along with
sterile dressings to cover an eviscerated wound and keep it moist.

61. Findings during an endoscopic exam include a cobblestone appearance of the colon in
your patient. The findings are characteristic of which disorder?
1. Ulcer
2. Crohn’s disease
3. Chronic gastritis
4. Ulcerative colitis
Ans-61. 2. Crohn’s disease penetrates the mucosa of the colon through all layers and destroys
the colon in patches, which creates a cobblestone appearance.
62. What information is correct about stomach cancer?
1. Stomach pain is often a late symptom.

2. Surgery is often a successful treatment.
3. Chemotherapy and radiation are often successful treatments.
4. The patient can survive for an extended time with TPN.
Ans-62. 1. Stomach pain is often a late sign of stomach cancer; outcomes are particularly poor
when the cancer reaches that point. Surgery, chemotherapy, and radiation have minimal positive
effects. TPN may enhance the growth of the cancer.

63. Dark, tarry stools indicate bleeding in which location of the GI tract?
1. Upper colon.
2. Lower colon.
3. Upper GI tract.
4. Small intestine.
Ans-63. 3. Melena is the passage of dark, tarry stools that contain a large amount of digested
blood. It occurs with bleeding from the upper GI tract.
64. A patient has an acute upper GI hemorrhage. Your interventions include:
1. Treating hypovolemia.
2. Treating hypervolemia.
3. Controlling the bleeding source.
4. Treating shock and diagnosing the bleeding source.
Ans-64. 1. A patient with an acute upper GI hemorrhage must be treated for hypovolemia and
hemorrhagic shock. You as a nurse can’t diagnose the problem. Controlling the bleeding may
require surgery or intensive medical treatment.
65. You promote hemodynamic stability in a patient with upper GI bleeding by:
1. Encouraging oral fluid intake.

2. Monitoring central venous pressure.
3. Monitoring laboratory test results and vital signs.
4. Giving blood, electrolyte and fluid replacement.
Ans-65. 4. To stabilize a patient with acute bleeding, NS or LR solution is given I.V. until BP
rises and urine output returns to 30ml/hr.
66. You’re preparing a patient with a malignant tumor for colorectal surgery and subsequent
colostomy. The patient tells you he’s anxious. What should your initial step be in working with
this patient?
1. Determine what the patient already knows about colostomies.

2. Show the patient some pictures of colostomies.
3. Arrange for someone who has a colostomy to visit the patient.
4. Provide the patient with written material about colostomy care.
Ans-66. 1. Initially, you should assess the patient’s knowledge about colostomies and how it
will affect his lifestyle.
67. Your patient, Christopher, has a diagnosis of ulcerative colitis and has severe abdominal
pain aggravated by movement, rebound tenderness, fever, nausea, and decreased urine output.
This may indicate which complication?
1. Fistula.
2. Bowel perforation.
3. Bowel obstruction.
4. Abscess.
Ans-67. 2. An inflammatory condition that affects the surface of the colon, ulcerative colitis
causes friability and erosions with bleeding. Patients with ulcerative colitis are at increased risk
for bowel perforation, toxic megacolon, hemorrhage, cancer, and other anorectal and systemic
complications.-
68. A patient has a severe exacerbation of ulcerative colitis. Long-term medications will
probably include:
1. Antacids.
2. Antibiotics.
3. Corticosteroids.
4. Histamine2-receptor blockers.
Ans-68. 3. Medications to control inflammation such as corticosteroids are used for long-term
treatment.
69. The student nurse is teaching the family of a patient with liver failure. You instruct them
to limit which foods in the patient’s diet?
1. Meats and beans.

2. Butter and gravies.
3. Potatoes and pastas.
4. Cakes and pastries.
Ans-69. 1. Meats and beans are high-protein foods. In liver failure, the liver is unable to
metabolize protein adequately, causing protein by-products to build up in the body rather than be
excreted.
70. An intubated patient is receiving continuous enteral feedings through a Salem sump tube
at a rate of 60ml/hr. Gastric residuals have been 30-40ml when monitored Q4H. You check
the gastric residual and aspirate 220ml. What is your first response to this finding?
1. Notify the doctor immediately.

2. Stop the feeding, and clamp the NG tube.
3. Discard the 220ml, and clamp the NG tube.
4. Give a prescribed GI stimulant such as metoclopramide (Reglan).
Ans-70. 2. A gastric residual greater than 2 hours’ worth of feeding or 100-150ml is considered
too high. The feeding should be stopped; NG tube clamped, and then allow time for the stomach
to empty before additional feeding is added.

71. Your patient with peritonitis is NPO and complaining of thirst. What is your priority?
1. Increase the I.V. infusion rate.

2. Use diversion activities.
3. Provide frequent mouth care.
4. Give ice chips every 15 minutes.
Ans-71. 3. Frequent mouth care helps relieve dry mouth.

72. Kevin has a history of peptic ulcer disease and vomits coffee-ground emesis. What does
this indicate?
1. He has fresh, active upper GI bleeding.

2. He needs immediate saline gastric lavage.
3. His gastric bleeding occurred 2 hours earlier.
4. He needs a transfusion of packed RBC’s.
Ans-72. 3. Coffee-ground emesis occurs when there is upper GI bleeding that has undergone
gastric digestion. For blood to appear as coffee-ground emesis, it would have to be digested for
approximately 2 hours.
73. A 53 y.o. patient has undergone a partial gastrectomy for adenocarcinoma of the stomach.
An NG tube is in place and is connected to low continuous suction. During the immediate
postoperative period, you expect the gastric secretions to be which color?
1. Brown.
2. Clear.
3. Red.
4. Yellow.
Ans-73. 3. Normally, drainage is bloody for the first 24 hours after a partial gastrectomy; then it
changes to brown-tinged and then to yellow or clear.

74. Your patient has a retractable gastric peptic ulcer and has had a gastric vagotomy. Which
factor increases as a result of vagotomy?
1. Peristalsis.
2. Gastric acidity.
3. Gastric motility.
4. Gastric pH.
Ans-74. 4. If the vagus nerve is cut as it enters the stomach, gastric acid secretion is decreased,
but intestinal motility is also decreased and gastric emptying is delayed. Because gastric acids
are decreased, gastric pH increases.
75. Christina is receiving an enteral feeding that requires a concentration of 80ml of

supplement mixed with 20 ml of water. How much water do you mix with an 8 oz (240ml) can
of feeding?
1. 60 ml.
2. 70 ml.
3. 80 ml.
4. 90 ml.
Ans-75. 1. Dosage problem. It’s 80/20 = 240/X. X=60.

76. Which stoma would you expect a malodorous, enzyme-rich, caustic liquid output that is
yellow, green, or brown?
1. Ileostomy.
2. Ascending colostomy.
3. Transverse colostomy.
4. Descending colostomy.
Ans-76. 1. The output from an Ileostomy is described.

77. George has a T tube in place after gallbladder surgery. Before discharge, what
information or instructions should be given regarding the T tube drainage?
1. “If there is any drainage, notify the surgeon immediately.”

2. “The drainage will decrease daily until the bile duct heals.”
3. “First, the drainage is dark green; then it becomes dark yellow.”
4. “If the drainage stops, milk the tube toward the puncture wound.”
Ans-77. 2. As healing occurs from the bile duct, bile drains from the tube; the amount of bile
should decrease. Teach the patient to expect dark green drainage and to notify the doctor if
drainage stops.
78. Your patient Maria takes NSAIDS for her degenerative joint disease, has developed peptic
ulcer disease. Which drug is useful in preventing NSAID-induced peptic ulcer disease?
1. Calcium carbonate (Tums)

2. Famotidine (Pepcid)
3. Misoprostol (Cytotec)
4. Sucralfate (Carafate)
Ans-78. 3. Misoprostol restores prostaglandins that protect the stomach from NSAIDS, which
diminish the prostaglandins.
79. The student nurse is participating in colorectal cancer-screening program. Which patient
has the fewest risk factors for colon cancer?
1. Janice, a 45 y.o. with a 25-year history of ulcerative colitis

2. George, a 50 y.o. whose father died of colon cancer
3. Herman, a 60 y.o. who follows a low-fat, high-fiber diet
4. Sissy, a 72 y.o. with a history of breast cancer
Ans-79. 3.

80. You’re patient, post-op drainage of a pelvic abscess secondary to diverticulitis, begins
to cough violently after drinking water. His wound has ruptured and a small segment of
the bowel is protruding. What’s your priority?
1. Ask the patient what happened, call the doctor, and cover the area with a water-soaked
bedsheet.
2. Obtain vital signs, call the doctor, and obtain emergency orders.
3. Have a CAN hold the wound together while you obtain vital signs, call the doctor and flex
the patient’s knees.
4. Have the doctor called while you remain with the patient, flex the patient’s knees, and cover
the wound with sterile towels soaked in sterile saline solution.
Ans-80. 4
Gastro 2
1. Which of the following complications is thought to be the most common cause of

appendicitis?
A. A fecalith
B. Bowel kinking
C. Internal bowel occlusion
D. Abdominal bowel swelling
Ans-1. A. A fecalith is a fecal calculus, or stone, that occludes the lumen of the appendix and is
the most common cause of appendicitis. Bowel wall swelling, kinking of the appendix, and
external occlusion, not internal occlusion, of the bowel by adhesions can also be causes of
appendicitis.
2. Which of the following terms best describes the pain associated with appendicitis?
1. Aching
2. Fleeting
3. Intermittent
4. Steady
Ans-2. 4. The pain begins in the epigastrium or periumbilical region, then shifts to the right
lower quadrant and becomes steady. The pain may be moderate to severe.
3. Which of the following nursing interventions should be implemented to manage a client
with appendicitis?
1. Assessing for pain

2. Encouraging oral intake of clear fluids
3. Providing discharge teaching
4. Assessing for symptoms of peritonitis
Ans-3. 4. The focus of care is to assess for peritonitis, or inflammation of the peritoneal cavity.
Peritonitis is most commonly caused by appendix rupture and invasion of bacteria, which could
be lethal. The client with appendicitis will have pain that should be controlled with analgesia.
The nurse should discourage oral intake in preparation of surgery. Discharge teaching is
important; however, in the acute phase, management should focus on minimizing preoperative
complications and recognizing when such may be occurring.
4. Which of the following definitions best describes gastritis?
1. Erosion of the gastric mucosa

2. Inflammation of a diverticulum
3. Inflammation of the gastric mucosa
4. Reflux of stomach acid into the esophagus
Ans-3. Gastritis is an inflammation of the gastric mucosa that may be acute (often resulting from
exposure to local irritants) or chronic (associated with autoimmune infections or atrophic
disorders of the stomach). Erosion of the mucosa results in ulceration. Inflammation of a
diverticulum is called diverticulitis; reflux of stomach acid is known as gastroesophageal disease.
5. Which of the following substances is most likely to cause gastritis?
1. Milk
2. Bicarbonate of soda, or baking soda
3. Enteric coated aspirin
4. Nonsteriodal anti-inflammatory drugs
Ans-4. NSAIDS are a common cause of gastritis because they inhibit prostaglandin synthesis.
Milk, once thought to help gastritis, has little effect on the stomach mucosa. Bicarbonate of soda,
or baking soda, may be used to neutralize stomach acid, but it should be used cautiously because
it may lead to metabolic acidosis. ASA with enteric coating shouldn’t contribute significantly to
gastritis because the coating limits the aspirin’s effect on the gastric mucosa.

6. Which of the following definitions best describes diverticulosis?
1. An inflamed outpouching of the intestine

2. A noninflamed outpouching of the intestine
3. The partial impairment of the forward flow of intestinal contents
4. An abnormal protrusion of an organ through the structure that usually holds it.
Ans-6. 2. Diverticulosis involves a noninflamed outpouching of the intestine. Diverticulitis

involves an inflamed outpouching. The partial impairment of forward flow of the intestine is an
obstruction; abnormal protrusion of an organ is a hernia.

7. Which of the following types of diets is implicated in the development of diverticulosis?
1. Low-fiber diet
2. High-fiber diet
3. High-protein diet
4. Low-carbohydrate diet
Ans-7. 1. Low-fiber diets have been implicated in the development of diverticula because these
diets decrease the bulk in the stool and predispose the person to the development of constipation.
A high-fiber diet is recommended to help prevent diverticulosis. A high-protein or low-
carbohydrate diet has no effect on the development of diverticulosis.
8. Which of the following mechanisms can facilitate the development of diverticulosis into
diverticulitis?
1. Treating constipation with chronic laxative use, leading to dependence on laxatives

2. Chronic constipation causing an obstruction, reducing forward flow of intestinal contents
3. Herniation of the intestinal mucosa, rupturing the wall of the intestine
4. Undigested food blocking the diverticulum, predisposing the area to bacteria invasion.
Ans-8. 4. Undigested food can block the diverticulum, decreasing blood supply to the area and
predisposing the area to invasion of bacteria. Chronic laxative use is a common problem in
elderly clients, but it doesn’t cause diverticulitis. Chronic constipation can cause an obstruction
—not diverticulitis. Herniation of the intestinal mucosa causes an intestinal perforation.
9. Which of the following symptoms indicated diverticulosis?
1. No symptoms exist
2. Change in bowel habits
3. Anorexia with low-grade fever
4. Episodic, dull, or steady midabdominal pain
Ans-9. 1. Diverticulosis is an asymptomatic condition. The other choices are signs and symptoms
of diverticulitis.

10. Which of the following tests should be administered to a client suspected of having
diverticulosis?
1. Abdominal ultrasound
2. Barium enema
3. Barium swallow
4. Gastroscopy
Ans-10. 2. A barium enema will cause diverticula to fill with barium and be easily seen on x-ray.
An abdominal US can tell more about structures, such as the gallbladder, liver, and spleen, than
the intestine. A barium swallow and gastroscopy view upper GI structures.

11. Medical management of the client with diverticulitis should include which of the
following treatments?
1. Reduced fluid intake

2. Increased fiber in diet
3. Administration of antibiotics
4. Exercises to increase intra-abdominal pressure
Ans-11. 3. Antibiotics are used to reduce the inflammation. The client isn’t typically isn’t
allowed anything orally until the acute episode subsides. Parenteral fluids are given until the
client feels better; then it’s recommended that the client drink eight 8-ounce glasses of water per
day and gradually increase fiber in the diet to improve intestinal motility. During the acute phase,
activities that increase intra-abdominal pressure should be avoided to decrease pain and the
chance of intestinal obstruction.
12. Crohn’s disease can be described as a chronic relapsing disease. Which of the following
areas in the GI system may be involved with this disease?
1. The entire length of the large colon

2. Only the sigmoid area
3. The entire large colon through the layers of mucosa and submucosa
4. The small intestine and colon; affecting the entire thickness of the bowel
Ans-12. 4. Crohn’s disease can involve any segment of the small intestine, the colon, or both,
affecting the entire thickness of the bowel. Answers 1 and 3 describe ulcerative colitis, answer 2
is too specific and therefore, not likely.

13. Which area of the alimentary canal is the most common location for Crohn’s disease?
1. Ascending colon
2. Descending colon
3. Sigmoid colon
4. Terminal ileum
Ans-13. 4. Crohn’s disease can involve any segment of the small intestine, the colon, or both,
affecting the entire thickness of the bowel. Answers 1 and 3 describe ulcerative colitis, answer 2
is too specific and therefore, not likely.

14. Which of the following factors is believed to be linked to Crohn’s disease?
1. Constipation
2. Diet
3. Hereditary
4. Lack of exercise
Ans-14. 3. Although the definite cause of Crohn’s disease is unknown, it’s thought to be
associated with infectious, immune, or psychological factors. Because it has a higher incidence
in siblings, it may have a genetic cause.

15. Which of the following factors is believed to cause ulcerative colitis?
1. Acidic diet
2. Altered immunity
3. Chronic constipation
4. Emotional stress
Ans-15. 2. Several theories exist regarding the cause of ulcerative colitis. One suggests altered
immunity as the cause based on the extraintestinal characteristics of the disease, such as
peripheral arthritis and cholangitis. Diet and constipation have no effect on the development of
ulcerative colitis. Emotional stress can exacerbate the attacks but isn’t believed to be the primary
cause.

16. Fistulas are most common with which of the following bowel disorders?
1. Crohn’s disease
2. Diverticulitis
3. Diverticulosis
Ans-16. 1. The lesions of Crohn’s disease are transmural; that is, they involve all thickness of
the bowel. These lesions may perforate the bowel wall, forming fistulas with adjacent structures.
Fistulas don’t develop in diverticulitis or diverticulosis. The ulcers that occur in the submucosal
and mucosal layers of the intestine in ulcerative colitis usually don’t progress to fistula formation
as in Crohn’s disease.

17. Which of the following areas is the most common site of fistulas in client’s with Crohn’s
disease?
1. Anorectal
2. Ileum
3. Rectovaginal
4. Transverse colon
Ans-17. 1. Fistulas occur in all these areas, but the anorectal area is most common because of
the relative thinness of the intestinal wall in this area.

18. Which of the following associated disorders may a client with ulcerative colitis exhibit?
1. Gallstones
2. Hydronephrosis
3. Nephrolithiasis
4. Toxic megacolon
Ans-18. 4. Toxic megacolon is extreme dilation of a segment of the diseased colon caused by
paralysis of the colon, resulting in complete obstruction. This disorder is associated with both
Crohn’s disease and ulcerative colitis. The other disorders are more commonly associated with
Crohn’s disease.

19. Which of the following associated disorders may the client with Crohn’s disease exhibit?
1. Ankylosing spondylitis
2. Colon cancer
3. Malabsorption
4. Lactase deficiency
Ans-19. 3. Because of the transmural nature of Crohn’s disease lesions, malaborption may occur
with Crohn’s disease. Ankylosing spondylitis and colon cancer are more commonly associated
with ulcerative colitis. Lactase deficiency is caused by a congenital defect in which an enzyme
isn’t present.

20. Which of the following symptoms may be exhibited by a client with Crohn’s disease?
1. Bloody diarrhea
2. Narrow stools
3. N/V
4. Steatorrhea
Ans-20. 4. Steatorrhea from malaborption can occur with Crohn’s disease. N/V, and bloody
diarrhea are symptoms of ulcerative colitis. Narrow stools are associated with diverticular
disease.

21. Which of the following symptoms is associated with ulcerative colitis?
1. Dumping syndrome
2. Rectal bleeding
3. Soft stools
4. Fistulas
Ans-21. 2. In ulcerative colitis, rectal bleeding is the predominant symptom. Soft stools are
more commonly associated with Crohn’s disease, in which malabsorption is more of a problem.
Dumping syndrome occurs after gastric surgeries. Fistulas are associated with Crohn’s disease.
22. If a client had irritable bowel syndrome, which of the following diagnostic tests would
determine if the diagnosis is Crohn’s disease or ulcerative colitis?
1. Abdominal computed tomography (CT) scan

2. Abdominal x-ray
3. Barium swallow
4. Colonoscopy with biopsy
Ans-22. 4. A colonoscopy with biopsy can be performed to determine the state of the colon’s
mucosal layers, presence of ulcerations, and level of cytologic development. An abdominal
x-ray or CT scan wouldn’t provide the cytologic information necessary to diagnose which
disease it is. A barium swallow doesn’t involve the intestine.
23. Which of the following interventions should be included in the medical management of
Crohn’s disease?
1. Increasing oral intake of fiber

2. Administering laxatives
3. Using long-term steroid therapy
4. Increasing physical activity
Ans-23. 3. Management of Crohn’s disease may include long-term steroid therapy to reduce the
inflammation associated with the deeper layers of the bowel wall. Other management focuses on
bowel rest (not increasing oral intake) and reducing diarrhea with medications (not giving
laxatives). The pain associated with Crohn’s disease may require bed rest, not an increase in
physical activity.
24. In a client with Crohn’s disease, which of the following symptoms should not be a direct
result from antibiotic therapy?
1. Decrease in bleeding
2. Decrease in temperature
3. Decrease in body weight
4. Decrease in the number of stools
Ans-24. 3. A decrease in body weight may occur during therapy due to inadequate dietary
intake, but isn’t related to antibiotic therapy. Effective antibiotic therapy will be noted by a
decrease in temperature, number of stools, and bleeding.
25. Surgical management of ulcerative colitis may be performed to treat which of the
following complications?
1. Gastritis
2. Bowel herniation
3. Bowel outpouching
4. Bowel perforation
Ans-25. 4. Perforation, obstruction, hemorrhage, and toxic megacolon are common

complications of ulcerative colitis that may require surgery. Herniation and gastritis aren’t
associated with irritable bowel diseases, and outpouching of the bowel is diverticulosis.
26. Which of the following medications is most effective for treating the pain associated with
irritable bowel disease?
1. Acetaminophen
2. Opiates
3. Steroids
4. Stool softeners
Ans-26. 3. The pain with irritable bowel disease is caused by inflammation, which steroids can
reduce. Stool softeners aren’t necessary. Acetaminophen has little effect on the pain, and opiate
narcotics won’t treat its underlying cause (I feel this is untrue—dilaudid will helpanything!)
27. During the first few days of recovery from ostomy surgery for ulcerative colitis, which of
the following aspects should be the first priority of client care?
1. Body image
2. Ostomy care
3. Sexual concerns
4. Skin care
Ans-27. 2. Although all of these are concerns the nurse should address, being able to safely
manage the ostomy is crucial for the client before discharge.
28. Colon cancer is most closely associated with which of the following conditions?
1. Appendicitis
2. Hemorrhoids
3. Hiatal hernia
Ans-28. 4. Chronic ulcerative colitis, granulomas, and familial polposis seem to increase a
person’s chance of developing colon cancer. The other conditions listed have no known effect on
colon cancer risk.
29. Which of the following diets is most commonly associated with colon cancer?
1. Low-fiber, high fat

2. Low-fat, high-fiber
3. Low-protein, high-carbohydrate
4. Low carbohydrate, high protein
Ans-29. 1. A low-fiber, high-fat diet reduced motility and increases the chance of constipation.
The metabolic end products of this type of diet are carcinogenic. A low-fat, high-fiber diet is
recommended to prevent colon cancer.
30. Which of the following diagnostic tests should be performed annually over age 50 to
screen for colon cancer?
1. Abdominal CT scan
2. Abdominal x-ray
3. Colonoscopy
4. Fecal occult blood test
Ans-30. 4. Surface blood vessels of polyps and cancers are fragile and often bleed with the
passage of stools. Abdominal x-ray and CT scan can help establish tumor size and metastasis. A
colonoscopy can help locate a tumor as well as polyps, which can be removed before they
become malignant.
31. Radiation therapy is used to treat colon cancer before surgery for which of the following
reasons?
1. Reducing the size of the tumor

2. Eliminating the malignant cells
3. Curing the cancer
4. Helping the bowel heal after surgery
Ans-31. 1. Radiation therapy is used to treat colon cancer before surgery to reduce the size of
the tumor, making it easier to be resected. Radiation therapy isn’t curative, can’t eliminate the
malignant cells (though it helps define tumor margins), can could slow postoperative healing.
32. Which of the following symptoms is a client with colon cancer most likely to exhibit?
1. A change in appetite
2. A change in bowel habits
3. An increase in body weight
4. An increase in body temperature
Ans-32. 2. The most common complaint of the client with colon cancer is a change in bowel
habits. The client may have anorexia, secondary abdominal distention, or weight loss. Fever isn’t
associated with colon cancer.
33. A client has just had surgery for colon cancer. Which of the following disorders might the
client develop?
1. Peritonitis
2. Diverticulosis
3. Partial bowel obstruction
4. Complete bowel obstruction
Ans-33. 1. Bowel spillage could occur during surgery, resulting in peritonitis. Complete or
partial bowel obstruction may occur before bowel resection. Diverticulosis doesn’t result from
surgery or colon cancer.
34. A client with gastric cancer may exhibit which of the following symptoms?
1. Abdominal cramping
2. Constant hunger
3. Feeling of fullness
4. Weight gain
Ans-34. 3. The client with gastric cancer may report a feeling of fullness in the stomach, but not
enough to cause him to seek medical attention. Abdominal cramping isn’t associated with gastric
cancer. Anorexia and weight loss (not increased hunger or weight gain) are common symptoms
of gastric cancer.
35. Which of the following diagnostic tests may be performed to determine if a client has
gastric cancer?
1. Barium enema
2. Colonoscopy
3. Gastroscopy
4. Serum chemistry levels
Ans-35. A gastroscopy will allow direct visualization of the tumor. A colonoscopy or a barium
enema would help diagnose colon cancer. Serum chemistry levels don’t contribute data useful to
the assessment of gastric cancer.

36. A client with gastric cancer can expect to have surgery for resection. Which of the
following should be the nursing management priority for the preoperative client with gastric
cancer?
1. Discharge planning
2. Correction of nutritional deficits
3. Prevention of DVT
4. Instruction regarding radiation treatment
Ans-36. 2. Client’s with gastric cancer commonly have nutritional deficits and may be
cachectic. Discharge planning before surgery is important, but correcting the nutrition deficit is a
higher priority. At present, radiation therapy hasn’t been proven effective for gastric cancer, and
teaching about it preoperatively wouldn’t be appropriate. Prevention of DVT also isn’t a high
priority to surgery, though it assumes greater importance after surgery.
37. Care for the postoperative client after gastric resection should focus on which of the
following problems?
1. Body image
2. Nutritional needs
3. Skin care
4. Spiritual needs
Ans-37. 2. After gastric resection, a client may require total parenteral nutrition or jejunostomy
tube feedings to maintain adequate nutritional status.
38. Which of the following complications of gastric resection should the nurse teach the client
to watch for?
1. Constipation
2. Dumping syndrome
3. Gastric spasm
4. Intestinal spasms
Ans-38. 2. Dumping syndrome is a problem that occurs postprandially after gastric resection
because ingested food rapidly enters the jejunum without proper mixing and without the normal
duodenal digestive processing. Diarrhea, not constipation, may also be a symptom. Gastric or
intestinal spasms don’t occur, but antispasmidics may be given to slow gastric emptying.
39. A client with rectal cancer may exhibit which of the following symptoms?
1. Abdominal fullness
2. Gastric fullness
3. Rectal bleeding
4. Right upper quadrant pain
Ans-39. 3. Rectal bleeding is a common symptom of rectal cancer. Rectal cancer may be
missed because other conditions such as hemorrhoids can cause rectal bleeding. Abdominal
fullness may occur with colon cancer, gastric fullness may occur with gastric cancer, and right
upper quadrant pain may occur with liver cancer.
40. A client with which of the following conditions may be likely to develop rectal cancer?
1. Adenomatous polyps
2. Diverticulitis
3. Hemorrhoids
Ans-40. 1. A client with adenomatous polyps has a higher risk for developing rectal cancer than
others do. Clients with diverticulitis are more likely to develop colon cancer. Hemorrhoids don’t
increase the chance of any type of cancer. Clients with peptic ulcer disease have a higher
incidence of gastric cancer.
41. Which of the following treatments is used for rectal cancer but not for colon cancer?
1. Chemotherapy
2. Colonoscopy
3. Radiation
4. Surgical resection
Ans-41. 3. A client with rectal cancer can expect to have radiation therapy in addition to
chemotherapy and surgical resection of the tumor. A colonoscopy is performed to diagnose the
disease. Radiation therapy isn’t usually indicated in colon cancer.
42. Which of the following conditions is most likely to directly cause peritonitis?
1. Cholelithiasis
2. Gastritis
3. Perforated ulcer
4. Incarcerated hernia
Ans-42. 3. The most common cause of peritonitis is a perforated ulcer, which can pour
contaminates into the peritoneal cavity, causing inflammation and infection within the cavity.
The other conditions don’t by themselves cause peritonitis. However, if cholelithiasis leads to
rupture of the gallbladder, gastritis leads to erosion of the stomach wall, or an incarcerated hernia
leads to rupture of the intestines, peritonitis may develop.
43. Which of the following symptoms would a client in the early stages of peritonitis
exhibit?
1. Abdominal distention
2. Abdominal pain and rigidity
3. Hyperactive bowel sounds
4. Right upper quadrant pain
Ans-43. 2. Abdominal pain causing rigidity of the abdominal muscles is characteristic of

peritonitis. Abdominal distention may occur as a late sign but not early on. Bowel sounds may be
normal or decreased but not increased. Right upper quadrant pain is characteristic of cholecystitis
or hepatitis.
44. Which of the following laboratory results would be expected in a client with peritonitis?
1. Partial thromboplastin time above 100 seconds

2. Hemoglobin level below 10 mg/dL
3. Potassium level above 5.5 mEq/L
4. White blood cell count above 15,000
Ans-44. 4. Because of infection, the client’s WBC count will be elevated. A hemoglobin level
below 10 mg/dl may occur from hemorrhage. A PT time longer than 100 seconds may suggest
disseminated intravascular coagulation, a serious complication of septic shock. A potassium
level above 5.5 mEq/L may indicate renal failure.
45. Which of the following therapies is not included in the medical management of a client
with peritonitis?
1. Broad-spectrum antibiotics
2. Electrolyte replacement
3. I.V. fluids
4. Regular diet
Ans-45. 4. The client with peritonitis usually isn’t allowed anything orally until the source of
peritonitis is confirmed and treated. The client also requires broad-spectrum antibiotics to
combat the infection. I.V. fluids are given to maintain hydration and hemodynamic stability and
to replace electrolytes.
46. Which of the following aspects is the priority focus of nursing management for a client
with peritonitis?
1. Fluid and electrolyte balance

2. Gastric irrigation
3. Pain management
4. Psychosocial issues
Ans-46. 1. Peritonitis can advance to shock and circulatory failure, so fluid and electrolyte
balance is the priority focus of nursing management. Gastric irrigation may be needed
periodically to ensure patency of the nasogastric tube. Although pain management is important
for comfort and psychosocial care will address concerns such as anxiety, focusing on fluid and
electrolyte imbalance will maintain hemodynamic stability.
47. A client with irritable bowel syndrome is being prepared for discharge. Which of the
following meal plans should the nurse give the client?
1. Low fiber, low-fat

2. High fiber, low-fat
3. Low fiber, high-fat
4. High-fiber, high-fat
Ans-47. 2. The client with irritable bowel syndrome needs to be on a diet that contains at least
25 grams of fiber per day. Fatty foods are to be avoided because they may precipitate symptoms.
48. A client presents to the emergency room, reporting that he has been vomiting every 30 to
40 minutes for the past 8 hours. Frequent vomiting puts him at risk for which of the
following?
1. Metabolic acidosis with hyperkalemia

2. Metabolic acidosis with hypokalemia
3. Metabolic alkalosis with hyperkalemia
4. Metabolic alkalosis with hypokalemia
Ans-48. 4. Gastric acid contains large amounts of potassium, chloride, and hydrogen ions.
Excessive loss of these substances, such as from vomiting, can lead to metabolic alkalosis and
hypokalemia.
49. Five days after undergoing surgery, a client develops a small-bowel obstruction. A Miller-
Abbott tube is inserted for bowel decompression. Which nursing diagnosis takes priority?
1. Imbalanced nutrition: Less than body requirements

2. Acute pain
3. Deficient fluid volume
4. Excess fluid volume
Ans-49. 3. Fluid shifts to the site of the bowel obstruction, causing a fluid deficit in the
intravascular spaces. If the obstruction isn’t resolved immediately, the client may experience an
imbalanced nutritional status (less than body requirements); however, deficient fluid volume
takes priority. The client may also experience pain, but that nursing diagnosis is also of lower
priority than deficient fluid volume.
50. When teaching an elderly client how to prevent constipation, which of the following
instructions should the nurse include?
1. “Drink 6 glasses of fluid each day.”

2. “Avoid grain products and nuts.”
3. “Add at least 4 grams of brain to your cereal each morning.”
4. “Be sure to get regular exercise.”
Ans-50. 4. Exercise helps prevent constipation. Fluids and dietary fiber promote normal bowel
function. The client should drink eight to ten glasses of fluid each day. Although adding bran to
cereal helps prevent constipation by increasing dietary fiber, the client should start with a small
amount and gradually increase the amount as tolerated to a maximum of 2 grams a day.
51. In a client with diarrhea, which outcome indicates that fluid resuscitation is successful?
1. The client passes formed stools at regular intervals

2. The client reports a decrease in stool frequency and liquidity
3. The client exhibits firm skin turgor
4. The client no longer experiences perianal burning.
Ans-51. 3. A client with diarrhea has a nursing diagnosis of Deficient fluid volume related to
excessive fluid loss in the stool. Expected outcomes include firm skin turgor, moist mucous
membranes, and urine output of at least 30 ml/hr. The client also has a nursing diagnosis of
diarrhea, with expected outcomes of passage of formed stools at regular intervals and a decrease
in stool frequency and liquidity. The client is at risk for impaired skin integrity related to
irritation from diarrhea; expected outcomes for this diagnosis include absence of erythema in
perianal skin and mucous membranes and absence of perianal tenderness or burning.
52. When teaching a community group about measures to prevent colon cancer, which
instruction should the nurse include?
1. “Limit fat intake to 20% to 25% of your total daily calories.”

2. “Include 15 to 20 grams of fiber into your daily diet.”
3. “Get an annual rectal examination after age 35.”
4. “Undergo sigmoidoscopy annually after age 50.”
Ans-52. 1. To help prevent colon cancer, fats should account for no more than 20% to 25% of
total daily calories and the diet should include 25 to 30 grams of fiber per day. A digital rectal
examination isn’t recommended as a stand-alone test for colorectal cancer. For colorectal cancer
screening, the American Cancer society advises clients over age 50 to have a flexible
sigmoidoscopy every 5 years, yearly fecal occult blood tests, yearly fecal occult blood tests
PLUS a flexible sigmoidoscopy every 5 years, a double-contrast barium enema every 5 years, or
a colonoscopy every 10 years.
53. A 30-year old client experiences weight loss, abdominal distention, crampy abdominal
pain, and intermittent diarrhea after birth of her 2nd child. Diagnostic tests reveal gluten-
induced enteropathy. Which foods must she eliminate from her diet permanently?
1. Milk and dairy products

2. Protein-containing foods
3. Cereal grains (except rice and corn)
4. Carbohydrates
Ans-53. 3. To manage gluten-induced enteropathy, the client must eliminate gluten, which
means avoiding all cereal grains except for rice and corn. In initial disease management, clients
eat a high calorie, high-protein diet with mineral and vitamin supplements to help normalize
nutritional status.
54. After a right hemicolectomy for treatment of colon cancer, a 57-year old client is reluctant
to turn while on bed rest. Which action by the nurse would be appropriate?
1. Asking a co-worker to help turn the client

2. Explaining to the client why turning is important.
3. Allowing the client to turn when he’s ready to do so
4. Telling the client that the physician’s order states he must turn every 2 hours
Ans-54. 2. The appropriate action is to explain the importance of turning to avoid postoperative
complications. Asking a coworker to help turn the client would infringe on his rights. Allowing
him to turn when he’s ready would increase his risk for postoperative complications. Telling him
he must turn because of the physician’s orders would put him on the defensive and exclude him
from participating in care decision.
55. A client has a percutaneous endoscopic gastrostomy tube inserted for tube feedings.
Before starting a continuous feeding, the nurse should place the client in which position?
1. Semi-Fowlers
2. Supine
3. Reverse Trendelenburg
4. High Fowler’s
Ans-55. 1. To prevent aspiration of stomach contents, the nurse should place the client in semi-
Fowler’s position. High Fowler’s position isn’t necessary and may not be tolerated as well as
semi-Fowler.
56. An enema is prescribed for a client with suspected appendicitis. Which of the following
actions should the nurse take?
1. Prepare 750 ml of irrigating solution warmed to 100*F

2. Question the physician about the order
3. Provide privacy and explain the procedure to the client
4. Assist the client to left lateral Sim’s position
Ans-56. 2. Enemas are contraindicated in an acute abdominal condition of unknown origin as

well as after recent colon or rectal surgery or myocardial infarction. The other answers are
correct only when enema administration is appropriate.
57. The client being seen in a physician’s office has just been scheduled for a barium swallow
the next day. The nurse writes down which of the following instructions for the client to follow
before the test?
1. Fast for 8 hours before the test

2. Eat a regular supper and breakfast
3. Continue to take all oral medications as scheduled.
4. Monitor own bowel movement pattern for constipation
Ans-57. 1. A barium swallow is an x-ray study that uses a substance called barium for contrast
to highlight abnormalities in the GI tract. The client should fast for 8 to 12 hours before the test,
depending on the physician instructions. Most oral medications also are withheld before the test.
After the procedure the nurse must monitor for constipation, which can occur as a result of the
presence of barium in the GI tract.
58. The nurse is monitoring a client for the early signs of dumping syndrome. Which
symptom indicates this occurrence?
1. Abdominal cramping and pain

2. Bradycardia and indigestion
3. Sweating and pallor
4. Double vision and chest pain
Ans-58. 3. Early manifestations of dumping syndrome occur 5 to 30 minutes after eating.

Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to
lie down.
59. The nurse is preparing a discharge teaching plan for the client who had an umbilical
hernia repair. Which of the following would the nurse include in the plan?
1. Restricting pain medication

2. Maintaining bed rest
3. Avoiding coughing
4. Irrigating the drain
Ans-59. 3. Bedrest is not required following this surgical procedure. The client should take
analgesics as needed and as prescribed to control pain. A drain is not used in this surgical
procedure, although the client may be instructed in simple dressing changes. Coughing is
avoided to prevent disruption of the tissue integrity, which can occur because of the location of
this surgical procedure.
60. The nurse is caring for a hospitalized client with a diagnosis of ulcerative colitis. Which
finding, if noted on assessment of the client, would the nurse report to the physician?
1. Bloody diarrhea
2. Hypotension
3. A hemoglobin of 12 mg/dL
4. Rebound tenderness
Ans-60. 4. Rebound tenderness may indicate peritonitis. Bloody diarrhea is expected to occur in
ulcerative colitis. Because of the blood loss, the client may be hypotensive and the hemoglobin
level may be lower than normal. Signs of peritonitis must be reported to the physician.
61. The nurse is reviewing the record of a client with Crohn’s disease. Which of the following
stool characteristics would the nurse expect to note documented on the client’s record?
1. Chronic constipation
2. Diarrhea
3. Constipation alternating with diarrhea
4. Stool constantly oozing from the rectum
Ans-61. 2. Crohn’s disease is characterized by nonbloody diarrhea of usually not more than four
to five stools daily. Over time, the diarrhea episodes increase in frequency, duration and severity.
The other option are not associated with diarrhea.
62. The nurse is performing a colostomy irrigation on a client. During the irrigation, a client
begins to complain of abdominal cramps. Which of the following is the most appropriate
nursing action?

2. Increase the height of the irrigation
3. Stop the irrigation temporarily.
4. Medicate with dilaudid and resume the irrigation
Ans-62. 3. If cramping occurs during a colostomy irrigation, the irrigation flow is stopped
temporarily and the client is allowed to rest. Cramping may occur from an infusion that is too
rapid or is causing too much pressure. Increasing the height of the irrigation will cause further
discomfort. The physician does not need to be notified. Medicating the client for pain is not the
most appropriate action (damn).
63. The nurse is teaching the client how to perform a colostomy irrigation. To enhance the
effectiveness of the irrigation and fecal returns, what measure should the nurse instruct the
client to do?
1. Increase fluid intake

2. Reduce the amount of irrigation solution
3. Perform the irrigation in the evening
4. Place heat on the abdomen

Ans-63. 1. To enhance effectiveness of the irrigation and fecal returns, the client is instructed to
increase fluid intake and prevent constipation.
64. The nurse is reviewing the physician’s orders written for a client admitted with acute
pancreatitis. Which physician order would the nurse question if noted on the client’s chart?
1. NPO status
2. Insert a nasogastric tube
3. An anticholinergic medication
4. Morphine for pain
Ans-64. 4. Meperidine (Demerol) rather than morphine is the medication of choice because
morphine can cause spasm in the sphincter of Oddi.
65. The nurse is doing an admission assessment on a client with a history of duodenal ulcer.
To determine whether the problem is currently active, the nurse would assess the client for
which of the following most frequent symptom(s) of duodenal ulcer?
1. Pain that is relieved by food intake

2. Pain that radiated down the right arm
3. N/V
4. Weight loss
Ans-65. 1. The most frequent symptom of duodenal ulcer is pain that is relieved by food intake.
These clients generally describe the pain as burning, heavy, sharp, or “hungry” pain that often
localizes in the midepigastric area. The client with duodenal ulcer usually does not experience
weight loss or N/V. These symptoms are usually more typical in the client with a gastric ulcer.
66. The nurse instructs the ileostomy client to do which of the following as a part of essential
care of the stoma?
1. Cleanse the peristomal skin meticulously

2. Take in high-fiber foods such as nuts
3. Massage the area below the stoma
4. Limit fluid intake to prevent diarrhea.
Ans-66. 1. The peristomal skin must receive meticulous cleansing because the ileostomy
drainage has more enzymes and is more caustic to the skin than colostomy drainage. Foods such
as nuts and those with seeds will pass through the ileostomy. The client should be taught that
these foods will remain undigested. The area below the ileostomy may be massaged if needed if
the ileostomy becomes blocked by high fiber foods. Fluid intake should be maintained to at least
six to eight glasses of water per day to prevent dehydration.
67. The client who has undergone creation of a colostomy has a nursing diagnosis of
Disturbed body image. The nurse would evaluate that the client is making the most significant
progress toward identified goals if the client:
1. Watches the nurse empty the colostomy bag

2. Looks at the ostomy site
3. Reads the ostomy product literature
4. Practices cutting the ostomy appliance
Ans-67. 4. The client is expected to have a body image disturbance after colostomy. The client
progresses through normal grieving stages to adjust to this change. The client demonstrates the
greatest deal of acceptance when the client participates in the actual colostomy care. Each of the
incorrect options represents an interest in colostomy care but is a passive activity. The correct
option shows the client is participating in self-care.
68. The nurse is assessing for stoma prolapse in a client with a colostomy. The nurse would
observe which of the following if stoma prolapse occurred?
1. Sunken and hidden stoma

2. Dark- and bluish-colored stoma
3. Narrowed and flattened stoma
4. Protruding stoma
Ans-68. 4. A prolapsed stoma is one which the bowel protruded through the stoma. A stoma
retraction is characterized by sinking of the stoma. Ischemia of the stoma would be associated
with dusky or bluish color. A stoma with a narrowed opening at the level of the skin or fascia is
said to be stenosed.
69. The client with a new colostomy is concerned about the odor from the stool in the ostomy
drainage bag. The nurse teaches the client to include which of the following foods in the diet
to reduce odor?
1. Yogurt
2. Broccoli
3. Cucumbers
4. Eggs
Ans-69. 1. The client should be taught to include deodorizing foods in the diet, such a beet
greens, parsley, buttermilk, and yogurt. Spinach also reduces odor but is a gas forming food as
well. Broccoli, cucumbers, and eggs are gas forming foods.
70. The nurse has given instructions to the client with an ileostomy about foods to eat to
thicken the stool. The nurse determines that the client needs further instructions if the client
stated to eat which of the following foods to make the stools less watery?
1. Pasta
2. Boiled rice
3. Bran
4. Low-fat cheese
Ans-70. 3. Foods that help thicken the stool of the client with an ileostomy include pasta, boiled
rice, and low-fat cheese. Bran is high in dietary fiber and thus will increase output of watery
stool by increasing propulsion through the bowel. Ileostomy output is liquid. Addition or
elimination of various foods can help thicken or loosen this liquid drainage.
71. The client has just had surgery to create an ileostomy. The nurse assesses the client in the
immediate post-op period for which of the following most frequent complications of this type
of surgery?
1. Intestinal obstruction
2. Fluid and electrolyte imbalance
3. Malabsorption of fat
4. Folate deficiency
Ans-71. 2. A major complication that occurs most frequent following an ileostomy is fluid and

electrolyte imbalance. The client requires constant monitoring of intake and output to prevent
this from happening. Losses require replacement by intravenous infusion until the client can
tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and
folate deficiency are complications that could occur later in the postoperative period.
72. The nurse is doing pre-op teaching with the client who is about to undergo creation of a
Kock pouch. The nurse interprets that the client has the best understanding of the nature of
the surgery if the client makes which of the following statements?
1. “I will need to drain the pouch regularly with a catheter.”

2. “I will need to wear a drainage bag for the rest of my life.”
3. “The drainage from this type of ostomy will be formed.”
4. “I will be able to pass stool from my rectum eventually.”
Ans-72. 1. A Kock pouch is a continent ileostomy. As the ileostomy begins to function, the
client drains it every 3 to 4 hours and then decreases the draining to about 3 times a day or as
needed when full. The client does not need to wear a drainage bag but should wear an absorbent
dressing to absorb mucus drainage from the stoma. Ileostomy drainage is liquid. The client
would be able to pass stool only from the rectum if an ileal-anal pouch or anastamosis were
created. This type of operation is a two-stage procedure.
73. The client with a colostomy has an order for irrigation of the colostomy. The nurse used
which solution for irrigation?
1. Distilled water
2. Tap water
3. Sterile water
4. Lactated Ringer’s
Ans-73. 2. Warm tap water or saline solution is used to irrigate a colostomy. If the tap water is
not suitable for drinking, then bottled water should be used.
74. A nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis.
The client is scheduled for surgery in 2 hours. The client begins to complain of increased
abdominal pain and begins to vomit. On assessment the nurse notes that the abdomen is
distended and the bowel sounds are diminished. Which of the following is the most
appropriate nursing intervention?
1. Administer dilaudid
3. Call and ask the operating room team to perform the surgery as soon as possible
4. Reposition the client and apply a heating pad on a warm setting to the client’s abdomen.
Ans-74. 2. Based on the signs and symptoms presented in the question, the nurse should suspect
peritonitis and should notify the physician. Administering pain medication is not an appropriate
intervention. Heat should never be applied to the abdomen of a client with suspected
appendicitis. Scheduling surgical time is not within the scope of nursing practice, although the
physician probably would perform the surgery earlier than the prescheduled time.
75. The client has been admitted with a diagnosis of acute pancreatitis. The nurse would
assess this client for pain that is:
1. Severe and unrelenting, located in the epigastric area and radiating to the back.
2. Severe and unrelenting, located in the left lower quadrant and radiating to the groin.
3. Burning and aching, located in the epigastric area and radiating to the umbilicus.
4. Burning and aching, located in the left lower quadrant and radiating to the hip.
Ans-75. 1. The pain associated with acute pancreatitis is often severe and unrelenting, is located
in the epigastric region, and radiates to the back.
76. The client with Crohn’s disease has a nursing diagnosis of acute pain. The nurse would
teach the client to avoid which of the following in managing this problem?
1. Lying supine with the legs straight

2. Massaging the abdomen
3. Using antispasmodic medication
4. Using relaxation techniques
Ans-76. 1. The pain associated with Crohn’s disease is alleviated by the use of analgesics and
antispasmodics and also is reduced by having the client practice relaxation techniques, applying
local cold or heat to the abdomen, massaging the abdomen, and lying with the legs flexed. Lying
with the legs extended is not useful because it increases the muscle tension in the abdomen,
which could aggravate the inflamed intestinal tissues as the abdominal muscles are stretched.
77. A client with ulcerative colitis has an order to begin salicylate medication to reduce
inflammation. The nurse instructs the client to take the medication:
1. 30 minutes before meals

2. On an empty stomach
3. After meals
4. On arising
Ans-77. 3. Salicylate compounds act by inhibiting prostaglandin synthesis and reducing

inflammation. The nurse teaches the client to take the medication with a full glass of water and to
increase fluid intake throughout the day. This medication needs to be taken after meals to reduce
GI irritation.
78. During the assessment of a client’s mouth, the nurse notes the absence of saliva. The
client is also complaining of pain near the area of the ear. The client has been NPO for
several days because of the insertion of a NG tube. Based on these findings, the nurse suspects
that the client is developing which of the following mouth conditions?
1. Stomatitis
2. Oral candidiasis
3. Parotitis
4. Gingivitis
Ans-78. 4. The lack of saliva, pain near the area of the ear, and the prolonged NPO status of the
client should lead the nurse to suspect the development of parotitis, or inflammation of the
parotid gland. Parotitis usually develops in cases of dehydration combined with poor oral
hygiene or when clients have been NPO for an extended period. Preventative measures include
the use of sugarless hard candy or gum to stimulate saliva production, adequate hydration, and
frequent mouth care. Stomatitis (inflammation of the mouth) produces excessive salivation and a
sore mouth.
79. The nurse evaluates the client’s stoma during the initial post-op period. Which of the
following observations should be reported immediately to the physician?
1. The stoma is slightly edematous

2. The stoma is dark red to purple
3. The stoma oozes a small amount of blood
4. The stoma does not expel stool
Ans-79. 2. A dark red to purple stoma indicates inadequate blood supply. Mild edema and slight
oozing of blood are normal in the early post-op period. The colostomy would typically not begin
functioning until 2-4 days after surgery.
80. When planning care for a client with ulcerative colitis who is experiencing symptoms,
which client care activities can the nurse appropriately delegate to an unlicensed assistant?
1. Assessing the client’s bowel sounds

2. Providing skin care following bowel movements
3. Evaluating the client’s response to antidiarrheal medications
4. Maintaining intake and output records
5. Obtaining the client’s weight.
Ans-80. 2, 4, and 5. The nurse can delegate the following basic care activities to the unlicensed
assistant: providing skin care following bowel movements, maintaining intake and output
records, and obtaining the client’s weight. Assessing the client’s bowel sounds and evaluating
the client’s response to medication are registered nurse activities that cannot be delegated.
81. Which goal of the client’s care should take priority during the first days of hospitalization
for an exacerbation of ulcerative colitis?
1. Promoting self-care and independence

2. Managing diarrhea
3. Maintaining adequate nutrition
4. Promoting rest and comfort
Ans-81. 2. Diarrhea is the primary symptom in an exacerbation of ulcerative colitis, and

decreasing the frequency of stools is the first goal of treatment. The other goals are ongoing and
will be best achieved by halting the exacerbation. The client may receive antidiarrheal
medications, antispasmodic agents, bulk hydrophilic agents, or anti-inflammatory drugs.
82. A client’s ulcerative colitis symptoms have been present for longer than 1 week. The nurse
recognizes that the client should be assessed carefully for signs of which of the following
complications?
1. Heart failure
2. DVT
3. Hypokalemia
4. Hypocalcemia
Ans-82. 3. Excessive diarrhea causes significant depletion of the body’s stores of sodium and
potassium as well as fluid. The client should be closely monitored for hypokalemia and
hyponatremia. Ulcerative colitis does not place the client at risk for heart failure, DVT, or
hypocalcemia.
83. A client who has ulcerative colitis has persistent diarrhea. He is thin and has lost 12
pounds since the exacerbation of his ulcerative colitis. The nurse should anticipate that the
physician will order which of the following treatment approaches to help the client meet his
nutritional needs?
1. Initiate continuous enteral feedings

2. Encourage a high protein, high-calorie diet
3. Implement total parenteral nutrition
4. Provide six small meals a day.
Ans-83. 3. Food will be withheld from the client with severe symptoms of ulcerative colitis to
rest the bowel. To maintain the client’s nutritional status, the client will be started on TPN.
Enteral feedings or dividing the diet into 6 small meals does not allow the bowel to rest. A high-
calorie, high-protein diet will worsen the client’s symptoms.
Gastro 3
1. Which of the following conditions can cause a hiatal hernia?
A. Increased intrathoracic pressure

B. Weakness of the esophageal muscle
C. Increased esophageal muscle pressure
D. Weakness of the diaphragmic muscle
Ans-1. 4. A hiatal hernia is caused by weakness of the diaphragmic muscle and increased intra-
abdominal—not intrathoracic—pressure. This weakness allows the stomach to slide into the
esophagus. The esophageal supports weaken, but esophageal muscle weakness or increased
esophageal muscle pressure isn’t a factor in hiatal hernia.
2. Risk factors for the development of hiatal hernias are those that lead to increased
abdominal pressure. Which of the following complications can cause increased abdominal
pressure?
1. Obesity
2. Volvulus
3. Constipation
4. Intestinal obstruction
Ans-2. 1. Obesity may cause increased abdominal pressure that pushes the lower portion of the
stomach into the thorax.
3. Which of the following symptoms is common with a hiatal hernia?
1. Left arm pain

2. Lower back pain
3. Esophageal reflux
Ans-3. 3. Esophageal reflux is a common symptom of hiatal hernia. This seems to be associated
with chronic exposure of the lower esophageal sphincter to the lower pressure of the thorax,
making it less effective.
4. Which of the following tests can be performed to diagnose a hiatal hernia?
1. Colonoscopy
2. Lower GI series
3. Barium swallow
4. Abdominal x-rays
Ans-4. 3. A barium swallow with fluoroscopy shows the position of the stomach in relation to
the diaphragm. A colonoscopy and a lower GI series show disorders of the intestine.
5. Which of the following measures should the nurse focus on for the client with esophageal
varices?
1. Recognizing hemorrhage
2. Controlling blood pressure
3. Encouraging nutritional intake
4. Teaching the client about varices
Ans-5. 1. Recognizing the rupture of esophageal varices, or hemorrhage, is the focus of nursing
care because the client could succumb to this quickly. Controlling blood pressure is also
important because it helps reduce the risk of variceal rupture. It is also important to teach the
client what varices are and what foods he should avoid such as spicy foods.
6. Which of the following tests can be used to diagnose ulcers?
1. Abdominal x-ray
2. Barium swallow
3. Computed tomography (CT) scan
4. Esophagogastroduodenoscopy (EGD)
Ans-6. 4. The EGD can visualize the entire upper GI tract as well as allow for tissue specimens
and electrocautery if needed. The barium swallow could locate a gastric ulcer. A CT scan and an
abdominal x-ray aren’t useful in the diagnosis of an ulcer.
7. Which of the following best describes the method of action of medications, such as
ranitidine (Zantac), which are used in the treatment of peptic ulcer disease?
1. Neutralize acid
2. Reduce acid secretions
3. Stimulate gastrin release
4. Protect the mucosal barrier
Ans-7. 2. Ranitidine is a histamine-2 receptor antagonist that reduces acid secretion by inhibiting
gastrin secretion.
8. The hospitalized client with GERD is complaining of chest discomfort that feels like
heartburn following a meal. After administering an ordered antacid, the nurse encourages the
client to lie in which of the following positions?
1. Supine with the head of the bed flat

2. On the stomach with the head flat
3. On the left side with the head of the bed elevated 30 degrees
4. On the right side with the head of the bed elevated 30 degrees.
Ans-8. 3. The discomfort of reflux is aggravated by positions that compress the abdomen and the
stomach. These include lying flat on the back or on the stomach after a meal of lying on the right
side. The left side-lying position with the head of the bed elevated is most likely to give relief to
the client.
9. The nurse is caring for a client following a Billroth II procedure. On review of the post-
operative orders, which of the following, if prescribed, would the nurse question and verify?
1. Irrigating the nasogastric tube

2. Coughing a deep breathing exercises
3. Leg exercises
4. Early ambulation
Ans-9. 1. In a Billroth II procedure the proximal remnant of the stomach is anastomased to the
proximal jejunum. Patency of the NG tube is critical for preventing the retention of gastric
secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery,
unless specifically ordered by the physician. In this situation, the nurse would clarify the order.
10. The nurse is providing discharge instructions to a client following gastrectomy. Which
measure will the nurse instruct the client to follow to assist in preventing dumping syndrome?
1. Eat high-carbohydrate foods

2. Limit the fluids taken with meals
3. Ambulate following a meal
4. Sit in a high-Fowlers position during meals
Ans-10. 2. The nurse should instruct the client to decrease the amount of fluid taken at meals
and to avoid high carbohydrate foods including fluids such as fruit nectars; to assume a low-
Fowler’s position during meals; to lie down for 30 minutes after eating to delay gastric
emptying; and to take antispasmidocs as prescribed.
11. The nurse instructs the nursing assistant on how to provide oral hygiene for a client who
cannot perform this task for himself. Which of the following techniques should the nurse tell
the assistant to incorporate into the client’s daily care?
1. Assess the oral cavity each time mouth care is given and record observations
2. Use a soft toothbrush to brush the client’s teeth after each meal
3. Swab the client’s tongue, gums, and lips with a soft foam applicator every 2 hours.
4. Rinse the client’s mouth with mouthwash several times a day.
Ans-11. 2. A soft toothbrush should be used to brush the client’s teeth after each meal and more
often as needed. Mechanical cleaning is necessary to maintain oral health, simulate gingiva, and
remove plaque. Assessing the oral cavity and recording observations is the responsibility of the
nurse, not the nursing assistant. Swabbing with a safe foam applicator does not provide enough
friction to clean the mouth. Mouthwash can be a drying irritant and is not recommended for
frequent use.
12. A client with suspected gastric cancer undergoes an endoscopy of the stomach. Which of
the following assessments made after the procedure would indicate the development of a
potential complication?
1. The client complains of a sore throat

2. The client displays signs of sedation
3. The client experiences a sudden increase in temperature
4. The client demonstrates a lack of appetite
Ans-12. 3. The most likely complication of an endoscopic procedure is perforation. A sudden

temperature spike with 1 to 2 hours after the procedure is indicative of a perforation and should
be reported immediately to the physician. A sore throat is to be anticipated after an endoscopy.
Clients are given sedatives during the procedure, so it is expected that they will display signs of
sedation after the procedure is completed. A lack of appetite could be the result of many factors,
including the disease process.
13. A client has been diagnosed with adenocarcinoma of the stomach and is scheduled to
undergo a subtotal gastrectomy (Billroth II procedure). During pre-operative teaching, the
nurse is reinforcing information about the procedure. Which of the following explanations is
most accurate?
1. The procedure will result in enlargement of the pyloric sphincter

2. The procedure will result in anastomosis of the gastric stump to the jejunum
3. The procedure will result in removal of the duodenum
4. The procedure will result in repositioning of the vagus nerve
Ans-13. 2. A Billroth II procedure bypasses the duodenum and connects the gastric stump
directly to the jejunum. The pyloric sphincter is removed, along with some of the stomach
fundus.
14. After a subtotal gastrectomy, the nurse should anticipate that nasogastric tube drainage
will be what color for about 12 to 24 hours after surgery?
1. Dark brown
2. Bile green
3. Bright red
4. Cloudy white
Ans-14. 1. About 12 to 24 hours after a subtotal gastrectomy, gastric drainage is normally

brown, which indicates digested blood. Bile green or cloudy white drainage is not expected
during the first 12 to 24 hours after a subtotal gastrectomy. Drainage during the first 6 to 12
hours contains some bright red blood, but large amounts of blood or excessively bloody drainage
should be reported to the physician promptly.
15. After a subtotal gastrectomy, care of the client’s nasogastric tube and drainage system
should include which of the following nursing interventions?
1. Irrigate the tube with 30 ml of sterile water every hour, if needed.

2. Reposition the tube if it is not draining well
3. Monitor the client for N/V, and abdominal distention
4. Turn the machine to high suction of the drainage is sluggish on low suction.
Ans-15. 3. Nausea, vomiting, or abdominal distention indicated that gas and secretions are
accumulating within the gastric pouch due to impaired peristalsis or edema at the operative site
and may indicate that the drainage system is not working properly. Saline solution is used to
irrigate nasogastric tubes. Hypotonic solutions such as water increase electrolyte loss. In
addition, a physician’s order is needed to irrigate the NG tube, because this procedure could
disrupt the suture line. After gastric surgery, only the surgeon repositions the NG tube because of
the danger of rupturing or dislodging the suture line. The amount of suction varies with the type
of tube used and is ordered by the physician. High suction may create too much tension on the
gastric suture line.
16. Which of the following would be an expected nutritional outcome for a client who has
undergone a subtotal gastrectomy for cancer?
1. Regain weight loss within 1 month after surgery

2. Resume normal dietary intake of three meals per day
3. Control nausea and vomiting through regular use of antiemetics
4. Achieve optimal nutritional status through oral or parenteral feedings
Ans-16. 4. An appropriate expected outcome is for the client to achieve optimal nutritional
status through the use of oral feedings or total parenteral nutrition (TPN). TPN may be used to
supplement oral intake, or it may be used alone if the client cannot tolerate oral feedings. The
client would not be expected to regain lost weight within 1 month after surgery or to tolerate a
normal dietary intake of three meals per day. Nausea and vomiting would not be considered an
expected outcome of gastric surgery, and regular use of antiemetics would not be anticipated.
17. The client with GERD complains of a chronic cough. The nurse understands that in a
client with GERD this symptom may be indicative of which of the following conditions?
1. Development of laryngeal cancer

2. Irritation of the esophagus
3. Esophageal scar tissue formation
4. Aspiration of gastric contents
Ans-17. 4. Clients with GERD can develop pulmonary symptoms such as coughing, wheezing,
and dyspnea that are caused by the aspiration of gastric contents. GERD does not predispose the
client to the development of laryngeal cancer. Irritation of the esophagus and esophageal scar
tissue formation can develop as a result of GERD. However, GERD is more likely to cause
painful and difficult swallowing.
18. Which of the following dietary measures would be useful in preventing esophageal
reflux?
1. Eating small, frequent meals

2. Increasing fluid intake
3. Avoiding air swallowing with meals
4. Adding a bedtime snack to the dietary plan
Ans-18. 1. Esophageal reflux worsens when the stomach is overdistended with food. Therefore,
an important measure is to eat small, frequent meals. Fluid intake should be decreased during
meals to reduce abdominal distention. Avoiding air swallowing does not prevent esophageal
reflux. Food intake in the evening should be strictly limited to reduce the incidence of nighttime
reflux, so bedtime snacks are not recommended.
19. A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a
bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric area
along with a rigid, boardlike abdomen. These clinical manifestations most likely indicate
which of the following?
1. An intestinal obstruction has developed

2. Additional ulcers have developed
3. The esophagus has become inflamed
4. The ulcer has perforated
20. When obtaining a nursing history on a client with a suspected gastric ulcer, which signs
and symptoms would the nurse expect to see? Select all that apply.
1. Epigastric pain at night

2. Relief of epigastric pain after eating
3. Vomiting
4. Weight loss
Ans-20. 3 and 4. Vomiting and weight loss are common with gastric ulcers. Clients with a
gastric ulcer are most likely to complain of a burning epigastric pain that occurs about one hour
after eating. Eating frequently aggravates the pain. Clients with duodenal ulcers are more likely
to complain about pain that occurs during the night and is frequently relieved by eating.
21. The nurse is caring for a client who has had a gastroscopy. Which of the following
symptoms may indicate that the client is developing a complication related to the procedure?
1. The client complains of a sore throat

2. The client has a temperature of 100*F
3. The client appears drowsy following the procedure
4. The client complains of epigastric pain
5. The client experiences hematemesis
Ans-21. 2, 4, and 5. Following a gastroscopy, the nurse should monitor the client for
complications, which include perforation and the potential for aspiration. An elevated
temperature, complaints of epigastric pain, or the vomiting of blood (hematemesis) are all
indications of a possible perforation and should be reported promptly. A sore throat is a common
occurrence following a gastroscopy. Clients are usually sedated to decrease anxiety and the nurse
would anticipate that the client will be drowsy following the procedure.
22. A client with peptic ulcer disease tells the nurse that he has black stools, which he has not
reported to his physician. Based on this information, which nursing diagnosis would be
appropriate for this client?
1. Ineffective coping related to fear of diagnosis of chronic illness

2. Deficient knowledge related to unfamiliarity with significant signs and symptoms
3. Constipation related to decreased gastric motility
4. Imbalanced nutrition: Less than body requirements due to gastric bleeding
Ans-22. 2. Black, tarry stools are an important warning sign of bleeding in peptic ulcer disease.
Digested blood in the stomach causes it to be black. The odor of the stool is very stinky. Clients
with peptic ulcer disease should be instructed to report the incidence of black stools promptly to
their physician.
23. A client with a peptic ulcer reports epigastric pain that frequently awakens her at night, a
feeling of fullness in the abdomen, and a feeling of anxiety about her health. Based on this
information, which nursing diagnosis would be most appropriate?
1. Imbalanced Nutrition: Less than Body Requirements related to anorexia.

2. Disturbed Sleep Pattern related to epigastric pain
3. Ineffective Coping related to exacerbation of duodenal ulcer
4. Activity Intolerance related to abdominal pain
Ans-23. 2. Based on the data provided, the most appropriate nursing diagnosis would be
Disturbed Sleep pattern. A client with a duodenal ulcer commonly awakens at night with pain.
The client’s feelings of anxiety do not necessarily indicate that she is coping ineffectively.
24. While caring for a client with peptic ulcer disease, the client reports that he has been
nauseated most of the day and is now feeling lightheaded and dizzy. Based upon these
findings, which nursing actions would be most appropriate for the nurse to take? Select all
that apply.
1. Administering an antacid hourly until nausea subsides.

2. Monitoring the client’s vital signs
3. Notifying the physician of the client’s symptoms
4. Initiating oxygen therapy
5. Reassessing the client on an hour
Ans-24. 2 and 3. The symptoms of nausea and dizziness in a client with peptic ulcer disease may
be indicative of hemorrhage and should not be ignored. The appropriate nursing actions at this
time are for the nurse to monitor the client’s vital signs and notify the physician of the client’s
symptoms. To administer an antacid hourly or to wait one hour to reassess the client would be
inappropriate; prompt intervention is essential in a client who is potentially experiencing a
gastrointestinal hemorrhage. The nurse would notify the physician of assessment findings and
then initiate oxygen therapy if ordered by the physician.
25. A client is to take one daily dose of ranitidine (Zantac) at home to treat her peptic ulcer.
The nurse knows that the client understands proper drug administration of ranitidine when
she says that she will take the drug at which of the following times?
1. Before meals
2. With meals
3. At bedtime
4. When pain occurs
Ans-25. 3. Ranitidine blocks secretion of hydrochloric acid. Clients who take only one daily
dose of ranitidine are usually advised to take it at bedtime to inhibit nocturnal secretion of acid.
Clients who take the drug twice a day are advised to take it in the morning and at bedtime.
26. A client has been taking aluminum hydroxide 30 mL six times per day at home to treat his
peptic ulcer. He tells the nurse that he has been unable to have a bowel movement for 3 days.
Based on this information, the nurse would determine that which of the following is the most
likely cause of the client’s constipation?
1. The client has not been including enough fiber in his diet
2. The client needs to increase his daily exercise
3. The client is experiencing a side effect of the aluminum hydroxide.
4. The client has developed a gastrointestinal obstruction.
Ans-26. 3. It is most likely that the client is experiencing a side effect of the antacid. Antacids
with aluminum salt products, such as aluminum hydroxide, form insoluble salts in the body.
These precipitate and accumulate in the intestines, causing constipation. Increasing dietary fiber
intake or daily exercise may be a beneficial lifestyle change for the client but is not likely to
relieve the constipation caused by the aluminum hydroxide. Constipation, in isolation from other
symptoms, is not a sign of bowel obstruction.
27. A client is taking an antacid for treatment of a peptic ulcer. Which of the following
statements best indicates that the client understands how to correctly take the antacid?
1. “I should take my antacid before I take my other medications.”

2. “I need to decrease my intake of fluids so that I don’t dilute the effects of my antacid.”
3. “My antacid will be most effective if I take it whenever I experience stomach pains.”
4. “It is best for me to take my antacid 1 to 3 hours after meals.”
Ans-27. 4. Antacids are most effective if taken 1 to 3 hours after meals and at bedtime. When an
antacid is taken on an empty stomach, the duration of the drug’s action is greatly decreased.
Taking antacids 1 to 3 hours after a meal lengthens the duration of action, thus increasing the
therapeutic action of the drug. Antacids should be administered about 2 hours after other
medications to decrease the chance of drug interactions. It is not necessary to decrease fluid
intake when taking antacids.
28. The nurse is caring for a client with chronic gastritis. The nurse monitors the client,
knowing that this client is at risk for which of the following vitamin deficiencies?
1. Vitamin A
2. Vitamin B12
3. Vitamin C
4. Vitamin E
Ans-28. 2. Chronic gastritis causes deterioration and atrophy of the lining of the stomach,
leading to the loss of the functioning parietal cells. The source of the intrinsic factor is lost,
which results in the inability to absorb vitamin B12. This leads to the development of pernicious
anemia.
29. The nurse is reviewing the medication record of a client with acute gastritis. Which
medication, if noted on the client’s record, would the nurse question?
2. Indomethacin (Indocin)
4. Propranolol hydrochloride (Inderal)
Ans-29. 2. Indomethacin (Indocin) is a NSAID and can cause ulceration of the esophagus,
stomach, duodenum, or small intestine. Indomethacin is contraindicated in a client with GI
disorders.
30. The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that
the T-tube has drained 750ml of green-brown drainage. Which nursing intervention is most
appropriate?

3. Irrigate the T-tube
4. Clamp the T-tube
Ans-30. 2. Following cholecystectomy, drainage from the T-tube is initially bloody and then
turns to green-brown. The drainage is measured as output. The amount of expected drainage will
range from 500 to 1000 ml per day. The nurse would document the output.
31. The nurse provides medication instructions to a client with peptic ulcer disease. Which
statement, if made by the client, indicates the best understanding of the medication therapy?
1. “The cimetidine (Tagamet) will cause me to produce less stomach acid.”

2. “Sucralfate (Carafate) will change the fluid in my stomach.”
3. “Antacids will coat my stomach.”
4. “Omeprazole (Prilosec) will coat the ulcer and help it heal.”
Ans-31. 1. Cimetidine (Tagamet), a histamine H2 receptor antagonist, will decrease the secretion
of gastric acid. Sucralfate (Carafate) promotes healing by coating the ulcer. Antacids neutralize
acid in the stomach. Omeprazole (Prilosec) inhibits gastric acid secretion
32. The client with peptic ulcer disease is scheduled for a pyloroplasty. The client asks the
nurse about the procedure. The nurse plans to respond knowing that a pyloroplasty involves:
1. Cutting the vagus nerve

2. Removing the distal portion of the stomach
3. Removal of the ulcer and a large portion of the cells that produce hydrochloric acid
4. An incision and resuturing of the pylorus to relax the muscle and enlarge the opening from
the stomach to the duodenum.
Ans-32. 4. Option 4 describes the procedure for a pyloroplasty. A vagotomy involves cutting the
vagus nerve. A subtotal gastrectomy involves removing the distal portion of the stomach. A
Billroth II procedure involves removal of the ulcer and a large portion of the tissue that produces
hydrochloric acid.
33. A client with a peptic ulcer is scheduled for a vagotomy. The client asks the nurse about
the purpose of this procedure. The nurse tells the client that the procedure:
1. Decreases food absorption in the stomach

2. Heals the gastric mucosa
3. Halts stress reactions
4. Reduces the stimulus to acid secretions
Ans-33. 4. A vagotomy, or cutting the vagus nerve, is done to eliminate parasympathetic

stimulation of gastric secretion.
34. The nurse would assess the client experiencing an acute episode of cholecysitis for pain
that is located in the right
1. Upper quadrant and radiates to the left scapula and shoulder

2. Upper quadrant and radiates to the right scapula and shoulder
3. Lower quadrant and radiates to the umbilicus
4. Lower quadrant and radiates to the back
Ans-34. 2. During an acute “gallbladder attack,” the client may complain of severe right upper
quadrant pain that radiates to the right scapula and shoulder. This is governed by the pattern on
dermatones in the body.
35. Which of the following tasks should be included in the immediate postoperative
management of a client who has undergone gastric resection?
1. Monitoring gastric pH to detect complications

2. Assessing for bowel sounds
3. Providing nutritional support
4. Monitoring for symptoms of hemorrhage
Ans-35. 4. The client should be monitored closely for signs and symptoms of hemorrhage, such
as bright red blood in the nasogastric tube suction, tachycardia, or a drop in blood pressure.
Gastric pH may be monitored to evaluate the need for histamine-2 receptor antagonists. Bowel
sounds may not return for up to 72 hours postoperatively. Nutritional needs should be addressed
soon after surgery.
36. If a gastric acid perforates, which of the following actions should not be included in the
immediate management of the client?
1. Blood replacement
2. Antacid administration
3. Nasogastric tube suction
4. Fluid and electrolyte replacement
Ans-36. 2. Antacids aren’t helpful in perforation. The client should be treated with antibiotics as
well as fluid, electrolyte, and blood replacement. NG tube suction should also be performed to
prevent further spillage of stomach contents into the peritoneal cavity.
37. Mucosal barrier fortifiers are used in peptic ulcer disease management for which of the
following indications?
1. To inhibit mucus production

2. To neutralize acid production
3. To stimulate mucus production
4. To stimulate hydrogen ion diffusion back into the mucosa
Ans-37. 3. The mucosal barrier fortifiers stimulate mucus production and prevent hydrogen ion
diffusion back into the mucosa, resulting in accelerated ulcer healing. Antacids neutralize acid
production.
38. When counseling a client in ways to prevent cholecystitis, which of the following
guidelines is most important?
1. Eat a low-protein diet

2. Eat a low-fat, low-cholesterol diet
3. Limit exercise to 10 minutes/day
4. Keep weight proportionate to height
Ans-38. 4. Obesity is a known cause of gallstones, and maintaining a recommended weight will
help protect against gallstones. Excessive dietary intake of cholesterol is associated with the
development of gallstones in many people. Dietary protein isn’t implicated in cholecystitis.
Liquid protein and low-calorie diets (with rapid weight loss of more than 5 lb [2.3kg] per
week) are implicated as the cause of some cases of cholecystitis. Regular exercise (30
minutes/three times a week) may help reduce weight and improve fat metabolism. Reducing
stress may reduce bile production, which may also indirectly decrease the chances of developing
cholecystitis.
39. Which of the following symptoms best describes Murphy’s sign?
1. Periumbilical ecchymosis exists

2. On deep palpitation and release, pain in elicited
3. On deep inspiration, pain is elicited and breathing stops
4. Abdominal muscles are tightened in anticipation of palpation
Ans-39. 3. Murphy’s sign is elicited when the client reacts to pain and stops breathing. It’s a
common finding in clients with cholecystitis. Periumbilical ecchymosis, Cullen’s sign, is present
in peritonitis. Pain on deep palpation and release is rebound tenderness. Tightening up abdominal
muscles in anticipation of palpation is guarding.
40. Which of the following tests is most commonly used to diagnose cholecystitis?
1. Abdominal CT scan
2. Abdominal ultrasound
3. Barium swallow
4. Endoscopy
Ans-40. 2. An abdominal ultrasound can show if the gallbladder is enlarged, if gallstones are
present, if the gallbladder wall is thickened, or if distention of the gallbladder lumen is present.
An abdominal CT scan can be used to diagnose cholecystitis, but it usually isn’t necessary. A
barium swallow looks at the stomach and the duodenum. Endoscopy looks at the esophagus,
stomach, and duodenum.
41. Which of the following factors should be the main focus of nursing management for a
client hospitalized for cholecystitis?
1. Administration of antibiotics
2. Assessment for complications
3. Preparation for lithotripsy
4. Preparation for surgery
Ans-41. 2. The client with acute cholecystitis should first be monitored for perforation, fever,
abscess, fistula, and sepsis. After assessment, antibiotics will be administered to reduce the
infection. Lithotripsy is used only for a small percentage of clients. Surgery is usually done after
the acute infection has subsided.
42. A client being treated for chronic cholecystitis should be given which of the following
instructions?
1. Increase rest
2. Avoid antacids
3. Increase protein in diet
4. Use anticholinergics as prescribed
Ans-42. 4. Conservative therapy for chronic cholecystitis includes weight reduction by

increasing physical activity, a low-fat diet, antacid use to treat dyspepsia, and anticholinergic use
to relax smooth muscles and reduce ductal tone and spasm, thereby reducing pain.
43. The client with a duodenal ulcer may exhibit which of the following findings on
assessment?
1. Hematemesis
2. Malnourishment
3. Melena
4. Pain with eating
43. 3. The client with a duodenal ulcer may have bleeding at the ulcer site, which shows up as
melena (black tarry poop). The other findings are consistent with a gastric ulcer.
44. The pain of a duodenal ulcer can be distinguished from that of a gastric ulcer by which of
the following characteristics?
1. Early satiety
2. Pain on eating
3. Dull upper epigastric pain
4. Pain on empty stomach
Ans-44. 4. Pain on empty stomach is relieved by taking foods or antacids. The other symptoms
are those of a gastric ulcer.
45. The client has orders for a nasogastric (NG) tube insertion. During the procedure,
instructions that will assist in the insertion would be:
1. Instruct the client to tilt his head back for insertion in the nostril, then flex his neck for the
final insertion
2. After insertion into the nostril, instruct the client to extend his neck
3. Introduce the tube with the client’s head tilted back, then instruct him to keep his head
upright for final insertion
4. Instruct the client to hold his chin down, then back for insertion of the tube
Ans-45. 1. NG insertion technique is to have the client first tilt his head back for insertion into
the nostril, then to flex his neck forward and swallow. Extension of the neck (2) will impede NG
tube insertion.
46. The most important pathophysiologic factor contributing to the formation of esophageal
varices is:
1. Decreased prothrombin formation

2. Decreased albumin formation by the liver
3. Portal hypertension
4. Increased central venous pressure
Ans-46. 3. As the liver cells become fatty and degenerate, they are no longer able to
accommodate the large amount of blood necessary for homeostasis. The pressure in the liver
increases and causes increased pressure in the venous system. As the portal pressure increases,
fluid exudes into the abdominal cavity. This is called ascites.
47. The client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted
to control the bleeding. The most important assessment is for the nurse to:
1. Check that the hemostat is on the bedside

2. Monitor IV fluids for the shift
3. Regularly assess respiratory status
4. Check that the balloon is deflated on a regular basis
Ans-47. 3. The respiratory system can become occluded if the balloon slips and moves up the
esophagus, putting pressure on the trachea. This would result in respiratory distress and should
be assessed frequently. Scissors should be kept at the bedside to cut the tube if distress occurs.
This is a safety intervention.
48. A female client complains of gnawing epigastric pain for a few hours after meals. At
times, when the pain is severe, vomiting occurs. Specific tests are indicated to rule out:
1. Cancer of the stomach

3. Chronic gastritis
4. Pylorospasm
Ans-48. 2. Peptic ulcer disease is characteristically gnawing epigastric pain that may radiate to
the back. Vomiting usually reflects pyloric spasm from muscular spasm or obstruction. Cancer
(1) would not evidence pain or vomiting unless the pylorus was obstructed.
49. When a client has peptic ulcer disease, the nurse would expect a priority intervention to
be:
1. Assisting in inserting a Miller-Abbott tube

2. Assisting in inserting an arterial pressure line
3. Inserting a nasogastric tube
4. Inserting an I.V.
Ans-49. 3. An NG tube insertion is the most appropriate intervention because it will determine
the presence of active GI bleeding. A Miller-Abbott tube (1) is a weighted, mercury-filled
ballooned tube used to resolve bowel obstructions. There is no evidence of shock or fluid
overload in the client; therefore, an arterial line (2) is not appropriate at this time and an IV (4) is
optional.
50. A 40-year-old male client has been hospitalized with peptic ulcer disease. He is being
treated with a histamine receptor antagonist (cimetidine), antacids, and diet. The nurse doing
discharge planning will teach him that the action of cimetidine is to:
1. Reduce gastric acid output

2. Protect the ulcer surface
3. Inhibit the production of hydrochloric acid (HCl)
4. Inhibit vagus nerve stimulation
Ans-50. 1. These drugs inhibit action of histamine on the H2 receptors of parietal cells, thus
reducing gastric acid output.
Growth and Development
1. Which age group has the greatest potential to demonstrate regression when they are sick?
A. Adolescent
B. Young Adult
C. Toddler
D. Infant
Ans-1. C.
2. Which is a major concern when providing drug therapy for older adults?
1. Alcohol is used by older adults to cope with the multiple problems of aging
2. Hepatic clearance is reduced in older adults
3. Older adults have difficulty in swallowing large tablets
4. Older adults may chew on tablets instead of swallowing them.
Ans-2. B
3. One of the participants attending a parenting class asks the teacher “what is the leading
cause of death during the first month of life?
1. Congenital Abnormalities
2. Low birth weight
3. SIDS
4. Infection
Ans-3. 3
4. Which stage of development is most unstable and challenging regarding development of
personal identity?
1. Adolescence
2. Toddler hood
3. Childhood
4. Infancy
Ans-4. A
5. Which age group would have a tendency towards eating disorders?
A. Adolescence
B. Toddler hood
C. Childhood
D. Infancy
Ans-5. A
6. When assessing an older adult. The nurse may expect an increase in:
1. Nail growth
2. Skin turgor
3. Urine residual
4. Nerve conduction
Ans-6. C
7. A maternity nurse is providing instruction to a new mother regarding the psychosocial
development of the newborn infant. Using Erikson’s psychosocial development theory, the
nurse would instruct the mother to
1. Allow the newborn infant to signal a need
2. Anticipate all of the needs of the newborn infant
3. Avoid the newborn infant during the first 10 minutes of crying
4. Attend to the newborn infant immediately when crying
Ans-7. A. According to Erikson, the caregiver should not try to anticipate the newborn infant’s
needs at all times but must allow the newborn infant to signal needs. If a newborn is not allowed
to signal a need, the newborn will not learn how to control the environment. Erikson believed
that a delayed or prolonged response to a newborn’s signal would inhibit the development of
trust and lead to mistrust of others.
8. A mother of a 3-year-old tells a clinic nurse that the child is rebelling constantly and
having temper tantrums. The nurse most appropriately tells the mother to:
1. Punish the child every time the child says “no”, to change the behavior
2. Allow the behavior because this is normal at this age period
3. Set limits on the child’s behavior
4. Ignore the child when this behavior occurs
Ans-8. C. According to Erikson, the child focuses on independence between ages 1 and 3
years. Gaining independence often means that the child has to rebel against the parents’ wishes.
Saying things like “no” or “mine” and having temper tantrums are common during this period of
development. Being consistent and setting limits on the child’s behavior are the necessary
elements.
9. The parents of a 2-year-old arrive at a hospital to visit their child. The child is in the
playroom when the parents arrive. When the parents enter the playroom, the child does not
readily approach the parents. The nurse interprets this behavior as indicating that:
1. The child is withdrawn

2. The child is self-centered
3. The child has adjusted to the hospitalized setting
4. This is a normal pattern
Ans-9. D. The phases through which young children progress when separated from their parents
include protest, despair, and denial or detachment. In the stage of protest, when the parents
return, the child readily goes to them. In the stage of despair, the child may not approach them
readily or may cling to a parent. In denial or detachment, when the parents return, the child
becomes cheerful, interested in the environment and new persons (seemingly unaware of the lost
parents), friendly with the staff, and interested in developing superficial relationships.
10. The mother of a 3-year-old is concerned because her child still is insisting on a bottle at
nap time and at bedtime. Which of the following is the most appropriate suggestion to the
mother?
1. Do not allow the child to have the bottle
2. Allow the bottle during naps but not at bedtime
3. Allow the bottle if it contains juice
4. Allow the bottle if it contains water
Ans-10. D. A toddler should never be allowed to fall asleep with a bottle containing milk, juice,
soda, or sweetened water because of the risk or nursing caries. If a bottle is allowed at nap time
or bedtime, it should contain only water.
11. A nurse is evaluating the developmental level of a 2-year-old. Which of the following does
the nurse expect to observe in this child?
1. Uses a fork to eat

2. Uses a cup to drink
3. Uses a knife for cutting food
4. Pours own milk into a cup
Ans-11. B. By age 2 years, the child can use a cup and can use a spoon correctly but with some
spilling. By ages 3 to 4, the child begins to use a fork. By the end of the preschool period, the
child should be able to pour milk into a cup and begin to use a knife for cutting.
12. The nurse is providing an educational session to new employees, and the topic is abuse to
the older client. The nurse tells the employees that which client is most characteristic of a
victim of abuse
1. A 90-year-old woman with advanced Parkinson’s disease

2. A 68-year-old man with newly diagnosed cataracts
3. A 70-year-old woman with early diagnosed Lyme’s disease
4. A 74-year-old man with moderate hypertension
Ans-12. A. The typical abuse victim is a woman of advanced age with few social contacts and
at least one physical or mental impairment that limits the ability to perform activities of daily
living. In addition, the client usually lives alone or with the abuser and depends on the abuser for
care.
13. The home care nurse is visiting an older female client whose husband died 6 months ago.
Which behavior, by the client, indicates ineffective coping?
1. Visiting her husband’s grave once a month

2. Participating in a senior citizens program
3. Looking at old snapshots of her family
4. Neglecting her personal grooming
Ans-13. D. Coping mechanisms are behaviors used to decrease stress and anxiety. In response
to a death, ineffective coping is manifested by an extreme behavior that in some instances may
be harmful to the individual physically or psychologically. Option D is indicative of a behavior
that indentifies an ineffective coping behavior in the grieving process.
14. A clinic nurse assesses the communication patterns of a 5-month-old infant. The nurse
determines that the infant is demonstrating the highest level of developmental achievement
expected if the infant:
1. Uses simple words such as “mama”

2. Uses monosyllabic babbling
3. Links syllables together
4. Coos when comforted
Ans-14. B. Using monosyllabic babbling occurs between 3 and 6 months of age. Using simple
words such as “mama” occurs between 9 and 12 months. Linking syllables together when
communicating occurs between 6 and 9 months. Cooing begins at birth and continues until 2
months.
15. A nurse is preparing to care for a 5-year-old who has been placed in traction following a
fracture of the femur. The nurse plans care, knowing that which of the following is the most
appropriate activity for this child?
1. Large picture books

2. A radio
3. Crayons and coloring book
4. A sports video
Ans-15. C. In the preschooler, play is simple and imaginative and includes activities such as
crayons and coloring books, puppets, felt and magnetic boards, and Play-Doh. Large picture
books are most appropriate for the infant. A radio and a sports video are most appropriate for the
adolescent.
16. A 16-year-old is admitted to the hospital for acute appendicitis, and an appendectomy is
performed. Which of the following nursing interventions is most appropriate to facilitate
normal growth and development?
1. Allow the family to bring in the child’s favorite computer games

2. Encourage the parents to room-in with the child
3. Encourage the child to rest and read
4. Allow the child to participate in activities with other individuals in the same age group when
the condition permits
Ans-16. D. Adolescents often are not sure whether they want their parents with them when they
are hospitalized. Because of the importance of the peer group, separation from friends is a
source of anxiety. Ideally, the members of the peer group will support their ill friend. Options a,
b, and c isolate the child from the peer group.
17. The mother of a toddler asks a nurse when it is safe to place the car safety seat in a face-
forward position. The best nursing response is which of the following?
1. When the toddler weighs 20 lbs

2. The seat should not be placed in a face-forward position unless there are safety locks in the
car
3. The seat should never be place in a face-forward position because the risk of the child
unbuckling the harness
4. When the weight of the toddler is greater than 40 lbs
Ans-17. A. The transition point for switching to the forward facing position is defined by the
manufacturer of the convertible car safety seat but is generally at a body weight of 9 kg or 20 lb
and 1 year of age. Convertible car safety seats are used until the child weighs at least 40 lb.
Options b, c, and d are incorrect
18. The nurse is caring for an agitated older client with Alzheimer’s disease. Which nursing
intervention most likely would calm the client?
1. Playing a radio
2. Turning the lights out
3. Putting an arm around the client’s waist
4. Encouraging group participation
Ans-18. C. Nursing interventions for the client with Alzheimer’s disease who is angry,
frustrated, or hostile include decreasing environmental stimuli, approaching the client calmy and
with assurance, not demanding anything from the client, and distracting the client. For the nurse
to reach out, touch, hold a hand, put an arm around the waist, or in some way maintain physical
contact is important. Playing a radio may increase stimuli, and turning the lights out may
produce more agitation. The client with Alzheimer’s disease would not be a candidate for group
work if the client is agitated.
19. The nurse who volunteers at a senior citizens center is planning activities for the members
who attend the center. Which activity would best promote health and maintenance for these
senior citizens?
1. Gardening every day for an hour

2. Cycling 3 times a week for 20 minutes
3. Sculpting once a week for 40 minutes
4. Walking 3 to 5 times a week for 30 minutes
Ans-19. D. Exercise and activity are essential for health promotion and maintenance in the
older adult and to achieve an optimal level of functioning. About half of the physical
deterioration of the older client is caused by disuse rather than by the aging process or disease.
One of the best exercises for an older adult is walking, progressing to 30 minutes session 3 to 5
times each week. Swimming and dancing are also beneficial.
Legal & ethical, cultural
1. The best explanation of what Title VI of the Civil Rights Act mandates is the freedom to:
A. Pick any physician and insurance company despite one’s income

B. Receive free medical benefits as needed within the county of residence
C. Have equal access to all health care regardless of race and religion
D. Have basic care with a sliding scale payment plan from all health care facilities
Ans-1. C
2. Which statement would best explain the role of the nurse when planning care for a
culturally diverse population? The nurse will plan care to:
A. Include care that is culturally congruent with the staff from predetermined criteria
B. Focus only on the needs of the client, ignoring the nurse’s beliefs and practices
C. Blend the values of the nurse that are for the good of the client and minimize the client’s
individual values and beliefs during care
D. Provide care while aware of one’s own bias, focusing on the client’s individual needs
rather than the staff’s practices
Ans-2. D. Without understanding one’s own beliefs and values, a bias or preconceived belief by
the nurse could create an unexpected conflict or an area of neglect in the plan of care for a client
(who might be expecting something totally different from the care). During assessment values,
beliefs, practices should be identified by the nurse and used as a guide to identify the choices by
the nurse to meet specific needs/outcomes of that client. Therefore identification of values,
beliefs, and practices allows for planning meaningful and beneficial care specific for this client.
3. Which factor is least significant during assessment when gathering information about

cultural practices?
A. Language, timing
B. Touch, eye contact
C. Biocultural needs
D. Pain perception, management expectations
Ans-3. C. Cultural practices do not influence biocultural needs because they are inborn risks that
are related to a biological need and not a learned cultural belief or practice.
4. Transcultural nursing implies:
A. Using a comparative study of cultures to understand similarities and differences across

human groups to provide specific individualized care that is culturally appropriate
B. Working in another culture to practice nursing within their limitations
C. Combining all cultural beliefs into a practice that is a nonthreatening approach to
minimize cultural barriers for all clients’ equality of care
D. Ignoring all cultural differences to provide the best generalized care to all clients.
Ans-4. A. Transcultural care means that by understanding and learning about specific cultural
practices the nurse can integrate these practices into the plan of care for a specific individual
client who has the same beliefs or practices to meet the client’s needs in a holistic manner of
care.
5. What should the nurse do when planning nursing care for a client with a different cultural
background? The nurse should:
A. Allow the family to provide care during the hospital stay so no rituals or customs are
broken
B. Identify how these cultural variables affect the health problem
C. Speak slowly and show pictures to make sure the client always understands
D. Explain how the client must adapt to hospital routines to be effectively cared for while in
the hospital
Ans-5. B. Without assessment and identification of the cultural needs, the nurse cannot begin to
understand how these might influence the health problem or health care management.
6. Which activity would not be expected by the nurse to meet the cultural needs of the client?
A. Promote and support attitudes, behaviors, knowledge, and skills to respectfully meet
client’s cultural needs despite the nurse’s own beliefs and practices
B. Ensure that the interpreter understands not only the language of the client but feelings and
attitudes behind cultural practices to make sure an ethical balance can be achieved
C. Develop structure and process for meeting cultural needs on a regular basis and means to
avoid overlooking these needs with clients
D. Expect the family to keep an interpreter present at all times to assist in meeting
the communication needs all day and night while hospitalized
Ans-6. D. It is not the family’s responsibility to assist in the communication process. Many
families will leave someone to help at times, but it is the hospital’s legal obligation to find an
interpreter for continued understanding by the client to make sure the client is fully informed and
comprehends in his or her primary language.
7. Ethical principles for professional nursing practice in a clinical setting are guided by the
principles of conduct that are written as the:
A. American Nurses Association’s (ANA’s) Code of Ethics

B. Nurse Practice Act (NPA) written by state legislation
C. Standards of care from experts in the practice field
D. Good Samaritan laws for civil guidelines
Ans-7. A. This set of ethical principles provides the professional guidelines established by the
ANA to maintain the highest standards for ideal conduct in practice. As a profession, the ANA
wanted to establish rules and then incorporate guidelines for accountability and responsibility of
each nurse within the practice setting.
8. A bioethical issue should be described as:
A. The physician’s making all decisions of client management without getting input from
the client
B. A research project that included treating all the white men and not treating all the black
men to compare the outcomes of a specific drug therapy.
C. The withholding of food and treatment at the request of the client in a written advance
directive given before a client acquired permanent brain damage from an accident.
D. After the client gives permission, the physician’s disclosing all information to the family
for their support in the management of the client.
Ans-1. B. The ethical issue was the inequality of treatment based strictly upon racial differences.
Secondly, the drug was deliberately withheld even after results showed that the drug was
working to cure the disease process in the white men for many years. So after many years, the
black men were still not treated despite the outcome of the research process that showed the drug
to be effective in controlling the disease early in the beginning of the research project. Therefore
harm was done. Nonmaleficence, veracity, and justice were not followed.
9. When the nurse described the client as “that nasty old man in 354,” the nurse is exhibiting
which ethical dilemma?
A. Gender bias and ageism

B. HIPPA violation
C. Beneficence
D. Code of ethics violation
Ans-9. A. Stereotyping an “old man” as “nasty “is a gender bias and an ageism issue. The nurse
is verbalizing a negative descriptor about the client.
10. The distribution of nurses to areas of “most need” in the time of a nursing shortage is an
example of:
1. Utilitarianism theory
2. Deontological theory
3. Justice
4. Beneficence
Ans-10. C. Justice is defined as the fairness of distribution of resources. However, guidelines for
a hierarchy of needs have been established, such as with organ transplantation. Nurses are moved
to areas of greatest need when shortages occur on the floors. No floor is left without staff, and
another floor that had five staff will give up two to go help the floor that had no staff.
11. Nurses are bound by a variety of laws. Which description of a type of law is correct?
1. Statutory law is created by elected legislature, such as the state legislature that defines the
Nurse Practice Act (NPA).
2. Regulatory law includes prevention of harm for the public and punishment for those laws that
are broken.
3. Common law protects the rights of the individual within society for fair and equal treatment.
4. Criminal law creates boards that pass rules and regulations to control society.
Ans-11. A. Statutory law is created by legislature. It creates statues such as the NPA, which
defines the role of the nurse and expectations of the performance of one’s duties and explains
what is contraindicated as guidelines for breach of those regulations.
12. Besides the Joint Commission on Accreditation of Healthcare Organizations (JACHO),

which governing agency regulates hospitals to allow continued safe services to be provided,
funding to be received from the government and penalties if guidelines are not followed?
1. Board of Nursing Examiners (BNE)

2. Nurse Practice Act (NPA)
3. American Nurses Association (ANA)
4. Americans With Disabilities Act (ADA)
Ans-12. D. If the hospital fails to follow ADA guidelines for meeting special needs, the facility
loses funding and status for receiving low-income loans or reimbursement of expenses. ADA
protects the civil rights of disabled people. It applies to both the hospital clients and hospital
staff. Privacy issues for persons who are positive for human immunodeficiency virus (HIV) have
been one issue in relationship to getting information when hospital staff have been exposed to
unclean sticks. The ADA allows the infected client the right to choose whether or not to disclose
that information.
13. When a client is confused, left alone with the side rails down, and the bed in a high
position, the client falls and breaks a hip. What law has been broken?
1. Assault
2. Battery
3. Negligence
4. Civil tort
Ans-13. C. Knowing what to do to prevent injury is a part of the standards of care for nurses to
follow. Safety guidelines dictate raising the side rails, staying with the client, lowering the bed,
and observing the client until the environment is safe. As a nurse, these activities are known as
basic safety measures that prevent injuries, and to not perform them is not acting in a safe
manner. Negligence is conduct that falls below the standard of care that protects others against
unreasonable risk of harm.
14. When signing a form as a witness, your signature shows that the client:
1. Is fully informed and is aware of all consequences.

2. Was awake and fully alert and not medicated with narcotics.
3. Was free to sign without pressure
4. Has signed that form and the witness saw it being done
Ans-14. D. Your signature as a witness only states that the person signing the form was the
person who was listed in the procedure.
15. Which criterion is needed for someone to give consent to a procedure?
1. An appointed guardianship
2. Unemancipated minor
3. Minimum of 21 years or older
4. An advocate for a child
Ans-15. A. A guardian has been appointed by a court and has full legal rights to choose
management of care.
16. Which statement is correct?
1. Consent for medical treatment can be given by a minor with a sexually transmitted disease
(STD).
2. A second trimester abortion can be given without state involvement.
3. Student nurses cannot be sued for malpractice while in a nursing clinical class.
4. Nurses who get sick and leave during a shift are not abandoning clients if they call their
supervisor and leave a message about their emergency illness.
Ans-16. A. Anyone, at any age, can be treated without parental permission for an STD infection.
The client is “advised” to contact sexual partners but is not “required” to give names. Permission
from parents is not needed, based upon current privacy laws.
17. Most litigation in the hospital comes from the:
1. Nurse abandoning the clients when going to lunch

2. Nurse following an order that is incomplete or incorrect
3. Nurse documenting blame on the physician when a mistake is made
4. Supervisor watching a new employee check his or her skills level
Ans-17. B. The nurse is responsible for clarifying all orders that are illegible, unreasonable,
unsafe, or incorrect. The failure of the nurse to question the physician about an order creates an
area of liability on the nurse’s part because this is perceived as a medical action and not the role
of the nurse to write orders. Some RNs do have prescriptive privileges based upon advanced
degrees and certification. Therefore the nurse who cannot correct the order must document that
the physician was called and clarification or a new order was given to correct the unclear or
illegible one that was currently on the chart. Phone calls, follow-up, and lack of follow-up by the
physician should also be documented if there is a problem with getting the information in a
timely manner. The nurse must show the sequence of events of a situation in a clear manner if
there is any conflict or question about any orders or procedures that were not appropriate.
Assessments and documentation of the client’s status should also be included if there is a
potential risk for harm present. Contact of the staff’s chain of command should also be
specifically stated for the proof of the responsibilities being followed according to hospital
policy.
18. The nurse places an aquathermia pad on a client with a muscle sprain. The nurse
informs the client the pad should be removed in 30 minutes. Why will the nurse return in 30
minutes to remove the pad?
1. Reflex vasoconstriction occurs.

2. Reflex vasodilation occurs.
3. Systemic response occurs.
4. Local response occurs.
Ans-18. A. If heat is applied for 1 hour or more, blood flow is reduced by reflex
vasoconstriction. Vasoconstriction is the opposite of the desired effect of heat application
19. A client has recently been told he has terminal cancer. As the nurse enters the room, he
yells, “My eggs are cold, and I’m tired of having my sleep interrupted by noisy nurses!” The
nurse may interpret the client’s behavior as:
1. An expression of the anger stage of dying

2. An expression of disenfranchised grief
3. The result of maturational loss
4. The result of previous losses
Ans-19. A. In the anger stage of Kubler-Ross’s stages of dying, the individual resists the loss
and may strike out at everyone and everything, in this case, the nurse.
20. When helping a person through grief work, the nurse knows:
1. Coping mechanisms that were effective in the past are often disregarded in response to the
pain of a loss
2. A person’s perception of a loss has little to do with the grieving process.
3. The sequencing of stages of grief may occur in order, they may be skipped, or they may
reoccur.
4. Most clients want to be left alone.
Ans-20. C. Grief is manifested in a variety of ways that are unique to an individual and based on
personal experiences, cultural expectations, and spiritual beliefs. The sequencing of stages or
behaviors of grief may occur in order, they may be skipped, or they may reoccur. The amount of
time to resolve grief also varies among individuals.
21. A client is hospitalized in the end stage of terminal cancer. His family members are sitting
at his bedside. What can the nurse do to best aid the family at this time?
1. Limit the time visitors may stay so they do not become overwhelmed by the situation.
2. Avoid telling family members about the client’s actual condition so they will not lose hope.
3. Discourage spiritual practices because this will have little connection to the client at this
time.
4. Find simple and appropriate care activities for the family to perform.
Ans-21. D. It is helpful for the nurse to find simple care activities for the family to perform, such
as feeding the client, washing the client’s face, combing hair, and filling out the client’s menu.
This helps the family demonstrate their caring for the client and enables the client to feel their
closeness and concern. a. Older adults often become particularly lonely at night and may feel
more secure if a family member stays at the bedside during the night. The nurse should allow
visitors to remain with dying clients at any time if the client wants them. It is up to the family to
determine if they are feeling overwhelmed, not the nurse.
22. When caring for a terminally ill client, it is important for the nurse maintain the client’s
dignity. This can be facilitated by:
1. Spending time to let clients share their life experiences

2. Decreasing emphasis on attending to the clients’ appearance because it only increases their
fatigue
3. Making decisions for clients so they do not have to make them
4. Placing the client in a private room to provide privacy at all times
Ans-22. A. Spending time to let clients share their life experiences enables the nurse to know
clients better. Knowing clients then facilitates choice of therapies that promote client decision
making and autonomy, thus promoting a client’s self-esteem and dignity.
23. What are the stages of dying according to Elizabeth Kubler-Ross?
1. Numbing; yearning and searching; disorganization and despair; and reorganization.

2. Accepting the reality of loss, working through the pain of grief, adjusting to the environment
without the deceased, and emotionally relocating the deceased and moving on with life.
3. Anticipatory grief, perceived loss, actual loss, and renewal.
4. Denial, anger, bargaining, depression, and acceptance.
Ans-23. D.
24. Bereavement may be defined as:
1. The emotional response to loss.

2. The outward, social expression of loss.
3. Postponing the awareness of the reality of the loss.
4. The inner feeling and outward reactions of the survivor.
Ans-24. D.
25. A client who had a “Do Not Resuscitate” order passed away. After verifying there is no
pulse or respirations, the nurse should next:
1. Have family members say goodbye to the deceased.

2. Call the transplant team to retrieve vital organs.
3. Remove all tubes and equipment (unless organ donation is to take place), clean the body, and
position appropriately.
4. Call the funeral director to come and get the body.
Ans-25. C. The body of the deceased should be prepared before the family comes in to view and
say their goodbyes. This includes removing all equipment, tubes, supplies, and dirty linens
according to protocol, bathing the client, applying clean sheets, and removing trash from the
room.
26. A client’s family member says to the nurse, “The doctor said he will provide palliative
care. What does that mean?” The nurse’s best response is:
1. “Palliative care is given to those who have less than 6 months to live.”
2. “Palliative care aims to relieve or reduce the symptoms of a disease.”
3. “The goal of palliative care is to affect a cure of a serious illness or disease.”
4. “Palliative care means the client and family take a more passive role and the doctor focuses
on the physiological needs of the client. The location of death will most likely occur in the
hospital setting.”
Ans-26. B. The goal of palliative care is the prevention, relief, reduction, or soothing of
symptoms of disease or disorders without effecting a cure.
27. Which of the following is not included in evaluating the degree of heritage consistency in
a client?
1. Gender
2. Culture
3. Ethnicity
4. Religion
Ans-27. A.
28. When providing care to clients with varied cultural backgrounds, it is imperative for the
nurse to recognize that:
1. Cultural considerations must be put aside if basic needs are in jeopardy.

2. Generalizations about the behavior of a particular group may be inaccurate.
3. Current health standards should determine the acceptability of cultural practices.
4. Similar reactions to stress will occur when individuals have the same cultural background.
Ans-28. B.
29. To respect a client’s personal space and territoriality, the nurse:
1. Avoids the use of touch

2. Explains nursing care and procedures
3. Keeps the curtains pulled around the clients bed
4. Stands 8 feet away from the bed, if possible.
Ans-29. B.
30. To be effective in meeting various ethnic needs, the nurse should:
1. Treat all clients alike.

2. Be aware of clients’ cultural differences.
3. Act as if he or she is comfortable with the client’s behavior.
4. Avoid asking questions about the client’s cultural background.
Ans-30. B.
31. The most important factor in providing nursing care to clients in a specific ethnic group
is:
1. Communication
2. Time orientation
3. Biological variation
4. Environmental control
Ans-31. A.
32. A health care issue often becomes an ethical dilemma because:

1. A clients legal rights coexist with a health professional’s obligation.
2. Decisions must be made quickly, often under stressful conditions.
3. Decisions must be made based on value systems.
4. The choices involved do not appear to be clearly right or wrong.
Ans-32. D.
33. A document that lists the medical treatment a person chooses to refuse if unable to make
decisions is the:
1. Durable power of attorney

2. Informed consent
3. Living will
4. Advance directives
Ans-33. D.
34. Which statement about an institutional ethics committee is correct?
1. The ethics committee is an additional resource for clients and health care professionals.
2. The ethics committee relieves health care professionals from dealing with ethical issues.
3. The ethics committee would be the first option in addressing an ethical dilemma.
4. The ethics committee replaces decision making by the client and health care providers.
Ans-33. D.
35. The nurse is working with parents of a seriously ill newborn. Surgery has been proposed
for the infant, but the chances of success are unclear. In helping the parents resolve this
ethical conflict, the nurse knows that the first step is:
1. Exploring reasonable courses of action

2. Collecting all available information about the situation
3. Clarifying values related to the cause of the dilemma.
4. Identifying people who can solve the difficulty
Ans-35. B.
36. Miss Magu, an 88-year old woman, believes that life should not be prolonged when hope
is gone. She has decided that she does not want extraordinary measures taken when her life is
at its end. Because she feels this way, she has talked with her daughter about her desires,
completing a living will and left directions with her physician. This is an example of:
1. Affirming a value
2. Choosing a value
3. Prizing a value
4. Reflecting a value
Ans-36. C.
37. The scope of nursing practice is legally defined by:
1. State nurses practice acts

2. Professional nursing organizations
3. Hospital policy and procedure manuals
4. Physicians in the employing institutions
Ans-37. A.
38. A student nurse who is employed as a nursing assistant may perform any functions that:
1. Have been learned about in school

2. Are expected of a nurse at that level
3. Are identified in the positions job description
4. Require technical rather than professional skill.
Ans-38. C.
39. A confused client who fell out of bed because side rails were not used is an example of
which type of liability?
1. Felony
2. Assault
3. Battery
4. Negligence
Ans-39. D.
40. The nurse puts a restraint jacket on a client without the client’s permission and without
the physicians order. The nurse may be guilty of:
1. Assault
2. Battery
3. Invasion of privacy
4. Neglect
Ans-40. B.
41. In a situation in which there is insufficient staff to implement competent care, a nurse
should:
1. Organize a strike
2. Inform the clients of the situation
3. Refuse the assignment
4. Accept the assignment but make a protest in writing to the administration.
Ans-41. D.
42. Which statement about loss is accurate?
1. Loss is only experienced when there is an actual absence of something valued.

2. The more the individual has invested in what is lost, the less the feeling of loss.
3. Loss may be maturational, situational, or both.
4. The degree of stress experienced is unrelated to the type of loss.
Ans-42. C.
43. Trying questionable and experimental forms of therapy is a behavior that is characterized
of which stage of dying?
1. Anger
2. Depression
3. Bargaining
4. Acceptance
Ans-43. C.
44. All of the following are crucial needs of the dying client except:
1. Control of pain
2. Preservation of dignity and self-worth
3. Love and belonging
4. Freedom from decision making
Ans-44. D.
45. Cultural awareness is an in-depth self-examination of one’s:
1. Background, recognizing biases and prejudices.

2. Social, cultural, and biophysical factors
3. Engagement in cross-cultural interactions
4. Motivation and commitment to caring.
Ans-45. A. Cultural awareness is an in-depth examination of one’s own background,
recognizing biases and prejudices and assumptions about other people.
46. Cultural competence is the process of:
1. Learning about vast cultures

2. Acquiring specific knowledge, skills, and attitudes
3. Influencing treatment and care of clients
4. Motivation and commitment to caring.
Ans-46. B. Cultural competence is the process of acquiring specific knowledge, skills, and
attitudes that ensure delivery of culturally congruent care.
47. Ethnocentrism is the root of:
1. Biases and prejudices

2. Meanings by which people make sense of their experiences.
3. Cultural beliefs
4. Individualism and self-reliance in achieving and maintaining health.
Ans-47. A.
48. When action is taken on one’s prejudices:
1. Discrimination occurs
2. Sufficient comparative knowledge of diverse groups is obtained.
3. Delivery of culturally congruent care is ensured.
4. People think/know you are a dumbass for being prejudiced.
Ans-48. A.
49. The dominant value orientation in North American society is:
1. Use of rituals symbolizing the supernatural.

2. Group reliance and interdependence
3. Healing emphasizing naturalistic modalities
4. Individualism and self-reliance in achieving and maintaining health.
Ans-49. D.
50. Disparities in health outcomes between the rich and the poor illustrates: a (an)
1. Illness attributed to natural, impersonal, and biological forces.
2. Creation of own interpretation and descriptions of biological and psychological malfunctions.
3. Influence of socioeconomic factors in morbidity and mortality.
4. Combination of naturalistic, religious, ad supernatural modalities.
Ans-50. C. Disparities in health outcomes between the rich and the poor illustrate the influence
of socioeconomic factors in morbidity and mortality. Social factors such as poverty and lack of
universal medical insurance compromise the health status of the poor and unemployed.
51. Culture strongly influences pain expression and need for pain medication. However,
cultural pain:
1. May be suffered by a client whose valued way of life is disregarded by practitioners.

2. Is more intense, thus necessitating more medication.
3. Is not expressed verbally or physically
4. Is expressed only to others of like culture.
Ans-51. A. Nurses need not assume that pain relief is equally valued across groups. Cultural
pain may be suffered by a client whose valued way of life is disregarded by practitioners.
52. The dominant values in American society on individual autonomy and self-determination:
1. Rarely have an effect on other cultures

2. Do have an effect on healthcare
3. May hinder ability to get into a hospice program
4. May be in direct conflict with diverse groups.
Ans-52. D. The dominant value in American society of individual autonomy and self-
determination may be in direct conflict with diverse groups. Advance directives, informed
consent, and consent for hospice are examples of mandates that my violate client’s values.
53. In the United States, access to health care usually depends on a client’s ability to pay for
health care, either through insurance or by paying cash. The client the nurse is caring for
needs a liver transplant to survive. This client has been out of work for several months and
does not have insurance or enough cash. A discussion about the ethics of this situation would
involve predominately the principle of:
1. Accountability, because you as the nurse are accountable for the wellbeing of this client.
2. Respect of autonomy, because this client’s autonomy will be violated if he does not receive
the liver transplant.
3. Ethics of care, because the caring thing that a nurse could provide this patient is resources for
a liver transplant.
4. Justice, because the first and greatest question in this situation is how to determine the just
distribution of resources.
Ans-53. D. Justice refers to fairness. Health care providers agree to strive for justice in health
care. The term often is used during discussions about resources. Decisions about who should
receive available organs are always difficult.
54. The code of ethics for nurses is composed and published by:
1. The national league for Nursing

2. The American Nurses Association
3. The Medical American Association
4. The National Institutes of Health, Nursing division.
Ans-54. B. the ANA has established widely accepted codes that professional nurses attempt to
follow.
55. Nurses agree to be advocates for their patients. Practice of advocacy calls for the nurse to:
1. Seek out the nursing supervisor in conflicting situations

2. Work to understand the law as it applies to the client’s clinical condition.
3. Assess the client’s point of view and prepare to articulate this point of view.
4. Document all clinical changes in the medical record in a timely manner.
Ans-55. C. Nurses strengthen their ability to advocate for a client when nurses are able to
identify personal values and then accurately identify the values of the client and articulate the
client’s point of view.
56. Successful ethical discussion depends on people who have a clear sense of personal
values. When many people share the same values it may be possible to identify a philosophy of
utilitarianism, with proposes that:
1. The value of people is determined solely by leaders in the Unitarian church.

2. The decision to perform a liver transplant depends on a measure of the moral life that the
client has led so far.
3. The best way to determine the solution to an ethical dilemma is to refer the case to the
attending physician.
4. The value of something is determined by its usefulness to society.
Ans-56. D. A utilitarian system of ethics proposes that the value of something is determined by
its usefulness.
57. The philosophy sometimes called the code of ethics of care suggests that ethical dilemmas
can best be solved by attention to:
1. Relationships
2. Ethical principles
3. Clients
4. Code of ethics for nurses.
Ans-57. A. The ethic of care explores the notion of care as a central activity of human behavior.
Those who write about the ethics of care advocate a more female biased theory that is based on
understanding relationships, especially personal narratives.
58. In most ethical dilemmas, the solution to the dilemma requires negotiation among
members of the health care team. The nurse’s point of view is valuable because:
1. Nurses have a legal license that encourages their presence during ethical discussions.
2. The principle of autonomy guides all participates to respect their own self-worth.
3. Nurses develop a relationship to the client that is unique among all professional health care
providers.
4. The nurse’s code of ethics recommends that a nurse be present at any ethical discussion
about client care.
Ans-58. C. When ethical dilemmas arise, the nurses point of view unique and critical. The nurse
usually interacts with clients over longer time intervals than do other disciples.
59. Ethical dilemmas often arise over a conflict of opinion. Once the nurse has determined
that the dilemma is ethical, a critical first step in negotiating the difference of opinion would
be to:
1. Consult a professional ethicist to ensure that the steps of the process occur in full.
2. Gather all relevant information regarding the clinical, social, and spiritual aspects of the
dilemma.
3. List the ethical principles that inform the dilemma so that negotiations agree on the language
of the discussion.
4. Ensure that the attending physician has written an order for an ethics consultation to support
the ethics process.
Ans-59. B. Each step in the processing of an ethical dilemma resembles steps in critical
thinking. The nurse begins by gathering information and moves through assessment,
identification of the problem, planning, implementation, and evaluation.
60. The nurse practice acts are an example of:
1. Statutory law
2. Common law
3. Civil law
4. Criminal law
Ans-60. A
61. The scope of Nursing Practice, the established educational requirements for nurses, and
the distinction between nursing and medical practice is defined by:
1. Statutory law
2. Common law
3. Civil law
4. Nurse practice acts
Ans-61. D.
62. The client’s right to refuse treatment is an example of:
1. Statutory law
2. Common law
3. Civil laws
4. Nurse practice acts
Ans-62. B.
63. Even though the nurse may obtain the clients signature on a form, obtaining informed
consent is the responsibility of the:
1. Client
2. Physician
3. Student nurse
4. Supervising nurse.
Ans-63. B.
64. The nurse is obligated to follow a physician’s order unless:
1. The order is a verbal order

2. The physicians order is illegible
3. The order has not been transcribed
4. The order is an error, violates hospital policy, or would be detrimental to the client.
Ans-64. D.
Neuro – ICP, LOC, meningitis
1) A client admitted to the hospital with a subarachnoid hemorrhage has complaints of
severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture
(LP) would be contraindicated in this client in which of the following circumstances?
1. Vomiting continues
2. Intracranial pressure (ICP) is increased
3. The client needs mechanical ventilation
4. Blood is anticipated in the cerebralspinal fluid (CSF)
Ans-1. 2. Sudden removal of CSF results in pressures lower in the lumbar area than the brain and
favors herniation of the brain; therefore, LP is contraindicated with increased ICP. Vomiting may
be caused by reasons other than increased ICP; therefore, LP isn’t strictly contraindicated. An LP
may be performed on clients needing mechanical ventilation. Blood in the CSF is diagnostic for
subarachnoid hemorrhage and was obtained before signs and symptoms of ICP.
2) A client with a subdural hematoma becomes restless and confused, with dilation of the
ipsilateral pupil. The physician orders mannitol for which of the following reasons?
1. To reduce intraocular pressure

2. To prevent acute tubular necrosis
3. To promote osmotic diuresis to decrease ICP
4. To draw water into the vascular system to increase blood pressure
Ans-2. 3. Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid
from intracellular to intravascular spaces. Although mannitol is used for all the reasons
described, the reduction of ICP in this client is a concern.
3) A client with subdural hematoma was given mannitol to decrease intracranial pressure
(ICP). Which of the following results would best show the mannitol was effective?
1. Urine output increases

2. Pupils are 8 mm and nonreactive
3. Systolic blood pressure remains at 150 mm Hg
4. BUN and creatinine levels return to normal
Ans-3. 1. Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal
tubes. Fixed and dilated pupils are symptoms of increased ICP or cranial nerve damage. No
information is given about abnormal BUN and creatinine levels or that mannitol is being given
for renal dysfunction or blood pressure maintenance.
4) Which of the following values is considered normal for ICP?
1. 0 to 15 mm Hg
2. 25 mm Hg
3. 35 to 45 mm Hg
4. 120/80 mm Hg
Ans-4. 1. Normal ICP is 0-15 mm Hg.
5) Which of the following symptoms may occur with a phenytoin level of 32 mg/dl?
1. Ataxia and confusion

2. Sodium depletion
3. Tonic-clonic seizure
4. Urinary incontinence
Ans-5. 1. A therapeutic phenytoin level is 10 to 20 mg/dl. A level of 32 mg/dl indicates toxicity.

Symptoms of toxicity include confusion and ataxia. Phenytoin doesn’t cause hyponatremia,
seizure, or urinary incontinence. Incontinence may occur during or after a seizure.
6) Which of the following signs and symptoms of increased ICP after head trauma would
appear first?
1. Bradycardia
2. Large amounts of very dilute urine
3. Restlessness and confusion
4. Widened pulse pressure
Ans-6. 3. The earliest symptom of elevated ICP is a change in mental status. Bradycardia,
widened pulse pressure, and bradypnea occur later. The client may void large amounts of very
dilute urine if there’s damage to the posterior pituitary.
7) Problems with memory and learning would relate to which of the following lobes?
1. Frontal
2. Occipital
3. Parietal
4. Temporal
Ans-7. 4. The temporal lobe functions to regulate memory and learning problems because of the
integration of the hippocampus. The frontal lobe primarily functions to regulate thinking,
planning, and judgment. The occipital lobe functions regulate vision. The parietal lobe primarily
functions with sensory function.
8) While cooking, your client couldn’t feel the temperature of a hot oven. Which lobe could
be dysfunctional?
1. Frontal
2. Occipital
3. Parietal
4. Temporal
Ans-8. 3. The parietal lobe regulates sensory function, which would include the ability to sense
hot or cold objects. The frontal lobe regulates thinking, planning, and judgment, and the occipital
lobe is primarily responsible for vision function. The temporal lobe regulates memory.
9) The nurse is assessing the motor function of an unconscious client. The nurse would
plan to use which of the following to test the client’s peripheral response to pain?
1. Sternal rub
2. Pressure on the orbital rim
3. Squeezing the sternocleidomastoid muscle
4. Nail bed pressure
Ans-9. 4. Motor testing on the unconscious client can be done only by testing response to painful
stimuli. Nailbed pressure tests a basic peripheral response. Cerebral responses to pain are testing
using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or
sternocleidomastoid muscle.
10) The client is having a lumbar puncture performed. The nurse would plan to place the
client in which position for the procedure?
1. Side-lying, with legs pulled up and head bent down onto the chest
2. Side-lying, with a pillow under the hip
3. Prone, in a slight Trendelenburg’s position
4. Prone, with a pillow under the abdomen.
Ans-10. 1. The client undergoing lumbar puncture is positioned lying on the side, with the legs
pulled up to the abdomen, and with the head bent down onto the chest. This position helps to
open the spaces between the vertebrae.
11) A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious
client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate
movements toward the left followed by a rapid nystagmus toward the right. The nurse
understands that this indicates the client has:
1. A cerebral lesion
2. A temporal lesion
3. An intact brainstem
4. Brain death
Ans-11. 3. Caloric testing provides information about differentiating between cerebellar and
brainstem lesions. After determining patency of the ear canal, cold or warm water is injected in
the auditory canal. A normal response that indicates intact function of cranial nerves III, IV, and
VIII is conjugate eye movements toward the side being irrigated, followed by rapid nystagmus to
the opposite side. Absent or dysconjugate eye movements indicate brainstem damage.
12) The nurse is caring for the client with increased intracranial pressure. The nurse would
note which of the following trends in vital signs if the ICP is rising?
1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure.

2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.
3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure.
4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.
Ans-12. 2. A change in vital signs may be a late sign of increased intracranial pressure. Trends
include increasing temperature and blood pressure and decreasing pulse and respirations.
Respiratory irregularities also may arise.
13) The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse
would suspect the client is developing meningitis as a complication of surgery if the client
exhibits:
1. A positive Brudzinski’s sign

2. A negative Kernig’s sign
3. Absence of nuchal rigidity
4. A Glascow Coma Scale score of 15
Ans-13. 1. Signs of meningeal irritation compatible with meningitis include nuchal rigidity,
positive Brudzinski’s sign, and positive Kernig’s sign. Nuchal rigidity is characterized by a stiff
neck and soreness, which is especially noticeable when the neck is fixed. Kernig’s sign is
positive when the client feels pain and spasm of the hamstring muscles when the knee and thigh
are extended from a flexed-right angle position. Brudzinski’s sign is positive when the client
flexes the hips and knees in response to the nurse gently flexing the head and neck onto the
chest. A Glascow Coma Scale of 15 is a perfect score and indicates the client is awake and alert
with no neurological deficits.
14) A client is arousing from a coma and keeps saying, “Just stop the pain.” The nurse
responds based on the knowledge that the human body typically and automatically responds to
pain first with attempts to:
1. Tolerate the pain

2. Decrease the perception of pain
3. Escape the source of pain
4. Divert attention from the source of pain.
Ans-14. 3. The client’s innate responses to pain are directed initially toward escaping from the
source of pain. Variations in individuals’ tolerance and perception of pain are apparent only in
conscious clients, and only conscious clients are able to employ distraction to help relieve pain.
15) During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of
the following would be most appropriate to institute?
1. Limiting conversation with the child

2. Keeping extraneous noise to a minimum
3. Allowing the child to play in the bathtub
4. Performing treatments quickly
Ans-15. 2. A child in the acute stage of meningitis is irritable and hypersensitive to loud noise
and light. Therefore, extraneous noise should be minimized and bright lights avoided as much as
possible. There is no need to limit conversations with the child. However, the nurse should speak
in a calm, gentle, reassuring voice. The child needs gentle and calm bathing. Because of the
acuteness of the infection, sponge baths would be more appropriate than tub baths. Although
treatments need to be completed as quickly as possible to prevent overstressing the child, any
treatments should be performed carefully and at a pace that avoids sudden movements to prevent
startling the child and subsequently increasing intracranial pressure.
16) Which of the following would lead the nurse to suspect that a child with meningitis has
developed disseminated intravascular coagulation?
1. Hemorrhagic skin rash

2. Edema
3. Cyanosis
4. Dyspnea on exertion
Ans-16. 1. DIC is characterized by skin petechiae and a purpuric skin rash caused by
spontaneous bleeding into the tissues. An abnormal coagulation phenomenon causes the
condition.
17) When interviewing the parents of a 2-year-old child, a history of which of the following
illnesses would lead the nurse to suspect pneumococcal meningitis?
1. Bladder infection
2. Middle ear infection
3. Fractured clavicle
4. Septic arthritis
Ans-17. 2. Organisms that cause bacterial meningitis, such as pneumococci or meningococci,

are commonly spread in the body by vascular dissemination from a middle ear infection. The
meningitis may also be a direct extension from the paranasal and mastoid sinuses. The causative
organism is a pneumonococcus. A chronically draining ear is frequently also found.
18) The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs
and symptoms would the nurse expect the child to demonstrate? Select all that apply.
1. Head tilt
2. Vomiting
3. Polydipsia
4. Lethargy
6. Increased pulse
Ans-18. 1, 2, 4. Head tilt, vomiting, and lethargy are classic signs assessed in a child with a
brain tumor. Clinical manifestations are the result of location and size of the tumor.
19) A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF
is obtained for analysis. A nurse reviews the results of the CSF analysis and determines that
which of the following results would verify the diagnosis?
1. Cloudy CSF, decreased protein, and decreased glucose

2. Cloudy CSF, elevated protein, and decreased glucose
3. Clear CSF, elevated protein, and decreased glucose
4. Clear CSF, decreased pressure, and elevated protein
Ans-19. 2. A diagnosis of meningitis is made by testing CSF obtained by lumbar puncture. In

the case of bacterial meningitis, findings usually include an elevated pressure, turbid or cloudy
CSF, elevated leukocytes, elevated protein, and decreased glucose levels.
20) A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of
transmission of this infection, which of the following would be included in the plan of care?
1. No precautions are required as long as antibiotics have been started

2. Maintain enteric precautions
3. Maintain respiratory isolation precautions for at least 24 hours after the initiation of
antibiotics
4. Maintain neutropenic precautions
Ans-20. 3. A major priority of nursing care for a child suspected of having meningitis is to
administer the prescribed antibiotic as soon as it is ordered. The child is also placed on
respiratory isolation for at least 24 hours while culture results are obtained and the antibiotic is
having an effect.
21) A nurse is reviewing the record of a child with increased ICP and notes that the child has
exhibited signs of decerebrate posturing. On assessment of the child, the nurse would expect to
note which of the following if this type of posturing was present?
1. Abnormal flexion of the upper extremities and extension of the lower extremities
2. Rigid extension and pronation of the arms and legs
3. Rigid pronation of all extremities
4. Flaccid paralysis of all extremities
Ans-21. 2. Decebrate posturing is characterized by the rigid extension and pronation of the arms
and legs.
22) Which of the following assessment data indicated nuchal rigidity?
1. Positive Kernig’s sign

2. Negative Brudzinski’s sign
3. Positive homan’s sign
4. Negative Kernig’s sign
Ans-22. 1. A positive Kernig’s sign indicated nuchal rigidity, caused by an irritative lesion of
the subarachnoid space. Brudzinski’s sign is also indicative of the condition.
23) Meningitis occurs as an extension of a variety of bacterial infections due to which of the
following conditions?
1. Congenital anatomic abnormality of the meninges

2. Lack of acquired resistance to the various etiologic organisms
3. Occlusion or narrowing of the CSF pathway
4. Natural affinity of the CNS to certain pathogens
Ans-23. 2. Extension of a variety of bacterial infections is a major causative factor of meningitis

and occurs as a result of a lack of acquired resistance to the etiologic organisms. Preexisting
CNS anomalies are factors that contribute to susceptibility.
24) Which of the following pathologic processes is often associated with aseptic meningitis?
1. Ischemic infarction of cerebral tissue

2. Childhood diseases of viral causation such as mumps
3. Brain abscesses caused by a variety of pyogenic organisms
4. Cerebral ventricular irritation from a traumatic brain injury
Ans-24. 2. Aseptic meningitis is caused principally by viruses and is often associated with other
diseases such as measles, mumps, herpes, and leukemia. Incidences of brain abscess are high in
bacterial meningitis, and ischemic infarction of cerebral tissue can occur with tubercular
meningitis. Traumatic brain injury could lead to bacterial (not viral) meningitis.
Neuro – CVA (Stroke)
1. Regular oral hygiene is an essential intervention for the client who has had a stroke.
Which of the following nursing measures is inappropriate when providing oral hygiene?
1. Placing the client on the back with a small pillow under the head.
2. Keeping portable suctioning equipment at the bedside.
3. Opening the client’s mouth with a padded tongue blade.
4. Cleaning the client’s mouth and teeth with a toothbrush.
Ans-1. 1. A helpless client should be positioned on the side, not on the back. This lateral
position helps secretions escape from the throat and mouth, minimizing the risk of aspiration. It
may be necessary to suction, so having suction equipment at the bedside is necessary. Padded
tongue blades are safe to use. A toothbrush is appropriate to use.
2. A 78 year old client is admitted to the emergency department with numbness and weakness
of the left arm and slurred speech. Which nursing intervention is priority?
1. Prepare to administer recombinant tissue plasminogen activator (rt-PA).

2. Discuss the precipitating factors that caused the symptoms.
3. Schedule for A STAT computer tomography (CT) scan of the head.
4. Notify the speech pathologist for an emergency consult.
Ans-2. 3. A CT scan will determine if the client is having a stroke or has a brain tumor or
another neurological disorder. This would also determine if it is a hemorrhagic or ischemic
accident and guide the treatment, because only an ischemic stroke can use rt-PA. This would
make (1) not the priority since if a stroke was determined to be hemorrhagic, rt-PA is
contraindicated. Discuss the precipitating factors for teaching would not be a priority and slurred
speech would as indicate interference for teaching. Referring the client for speech therapy would
be an intervention after the CVA emergency treatment is administered according to protocol.
3. A client arrives in the emergency department with an ischemic stroke and receives tissue
plasminogen activator (t-PA) administration. Which is the priority nursing assessment?
1. Current medications.
2. Complete physical and history.
3. Time of onset of current stroke.
4. Upcoming surgical procedures.
Ans-3. 3. The time of onset of a stroke to t-PA administration is critical. Administration within
3 hours has better outcomes. A complete history is not possible in emergency care. Upcoming
surgical procedures will need to be delay if t-PA is administered. Current medications are
relevant, but onset of current stroke takes priority.
4. During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal
is to control the client’s:
1. Pulse
2. Respirations
3. Blood pressure
4. Temperature
Ans-4. 3. Controlling the blood pressure is critical because an intracerebral hemorrhage is the
major adverse effect of thrombolytic therapy. Blood pressure should be maintained according to
physician and is specific to the client’s ischemic tissue needs and risks of bleeding from
treatment. Other vital signs are monitored, but the priority is blood pressure.
5. What is a priority nursing assessment in the first 24 hours after admission of the client
with a thrombotic stroke?
1. Cholesterol level
2. Pupil size and papillary response
3. Vowel sounds
4. Echocardiogram
Ans-5. 2. It is crucial to monitor the pupil size and pupillary response to indicate changes around
the cranial nerves. Cholesterol level is an assessment to be addressed for long-term healthy
lifestyle rehabilitation. Bowel sounds need to be assessed because an ileus or constipation can
develop, but is not a priority in the first 24 hours. An echocardiogram is not needed for the client
with a thrombotic stroke.
6. What is the expected outcome of thrombolytic drug therapy?

1. Increased vascular permeability.
2. Vasoconstriction.
3. Dissolved emboli.
4. Prevention of hemorrhage
Ans-6. 3. Thrombolytic therapy is use to dissolve emboli and reestablish cerebral perfusion.
7. The client diagnosed with atrial fibrillation has experienced a transient ischemic attack
(TIA). Which medication would the nurse anticipate being ordered for the client on
discharge?
1. An oral anticoagulant medication.

2. A beta-blocker medication.
3. An anti-hyperuricemic medication.
4. A thrombolytic medication.
Ans-7. 1. Thrombi form secondary to atrial fibrillation, therefore, an anticoagulant would be
anticipated to prevent thrombi formation; and oral (warfarin [Coumadin]) at discharge verses
intravenous. Beta blockers slow the heart rate and lower the blood pressure. Anti-hyperuricemic
medication is given to clients with gout. Thrombolytic medication might have been given at
initial presentation but would not be a drug prescribed at discharge.
8. Which client would the nurse identify as being most at risk for experiencing a CVA?
1. A 55-year-old African American male.
2. An 84-year-old Japanese female.
3. A 67-year-old Caucasian male.
4. A 39-year-old pregnant female.
Ans-8. 1. Africana Americans have twice the rate of CVA’s as Caucasians; males are more
likely to have strokes than females except in advanced years. Oriental’s have a lower risk,
possibly due to their high omega-3 fatty acids. Pregnancy is a minimal risk factor for CVA.
9. Which assessment data would indicate to the nurse that the client would be at risk for a
hemorrhagic stroke?
1. A blood glucose level of 480 mg/dl.

2. A right-sided carotid bruit.
3. A blood pressure of 220/120 mm Hg.
4. The presence of bronchogenic carcinoma.
Ans-9. 3. Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a rupture
blood vessel in the cranium. A bruit in the carotid artery would predispose a client to an embolic
or ischemic stroke. High blood glucose levels could predispose a patient to ischemic stroke, but
not hemorrhagic. Cancer is not a precursor to stroke.
10. The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-
sided paralysis. Which action by the UAP requires the nurse to intervene?
1. The assistant places a gait belt around the client’s waist prior to ambulating.
2. The assistant places the client on the back with the client’s head to the side.
3. The assistant places her hand under the client’s right axilla to help him/her move up in
bed.
4. The assistant praises the client for attempting to perform ADL’s independently.
Ans-10. 3. This action is inappropriate and would require intervention by the nurse because
pulling on a flaccid shoulder joint could cause shoulder dislocation; as always use a lift sheet for
the client and nurse safety. All the other actions are appropriate.
Neuro – Seizures
1) An 18-year-old client is admitted with a closed head injury sustained in a MVA. His
intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse
perform first?
1. Reposition the client to avoid neck flexion

2. Administer 1 g Mannitol IV as ordered
3. Increase the ventilator’s respiratory rate to 20 breaths/minute
4. Administer 100mg of pentobarbital IV as ordered.
Ans-1. 1. The nurse should first attempt nursing interventions, such as repositioning the client to
avoid neck flexion, which increases venous return and lowers ICP. If nursing measures prove
ineffective, notify the physician, who may prescribe mannitol, pentobarbital, or hyperventilation
therapy.
2) A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of
Dilantin IV. Which consideration is most important when administering this dose?
1. Therapeutic drug levels should be maintained between 20 to 30 mg/ml.

2. Rapid Dilantin administration can cause cardiac arrhythmias.
3. Dilantin should be mixed in dextrose in water before administration.
4. Dilantin should be administered through an IV catheter in the client’s hand.
Ans-2. 2. Dilantin IV shouldn’t be given at a rate exceeding 50 mg/minute. Rapid administration

can depress the myocardium, causing arrhythmias. Therapeutic drug levels range from 10 to 20
mg/ml. Dilantin shouldn’t be mixed in solution for administration. However, because it’s
compatible with normal saline solution, it can be injected through an IV line containing normal
saline. When given through an IV catheter hand, Dilantin may cause purple glove syndrome.
3) A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry
mucous membranes. Which of the following nursing interventions is the most appropriate to
perform initially?
1. Evaluate urine specific gravity

2. Anticipate treatment for renal failure
3. Provide emollients to the skin to prevent breakdown
4. Slow down the IV fluids and notify the physician
Ans-3. 1. Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the
pituitary to produce anti-diuretic hormone. This may occur with increased intracranial pressure
and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity,
and dehydration. There’s no evidence that the client is experiencing renal failure. Providing
emollients to prevent skin breakdown is important, but doesn’t need to be performed
immediately. Slowing the rate of IV fluid would contribute to dehydration when polyuria is
present.
4) When evaluating an ABG from a client with a subdural hematoma, the nurse notes the
PaCO2 is 30 mm Hg. Which of the following responses best describes this result?
1. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP).

2. Emergent; the client is poorly oxygenated.
3. Normal
4. Significant; the client has alveolar hypoventilation.
Ans-4. 1. A normal PaCO2 value is 35 to 45 mm Hg. CO2 has vasodilating properties; therefore,

lowering PaCO2 through hyperventilation will lower ICP caused by dilated cerebral vessels.
Oxygenation is evaluated through PaO2 and oxygen saturation. Alveolar hypoventilation would be
reflected in an increased PaCO2.
5) A client who had a transsphenoidal hypophysectomy should be watched carefully for
hemorrhage, which may be shown by which of the following signs?
1. Bloody drainage from the ears

2. Frequent swallowing
3. Guaiac-positive stools
4. Hematuria
Ans-5. 2. Frequent swallowing after brain surgery may indicate fluid or blood leaking from the
sinuses into the oropharynx. Blood or fluid draining from the ear may indicate a basilar skull
fracture.
6) After a hypophysectomy, vasopressin is given IM for which of the following reasons?
1. To treat growth failure

2. To prevent syndrome of inappropriate antidiuretic hormone (SIADH)
3. To reduce cerebral edema and lower intracranial pressure
4. To replace antidiuretic hormone (ADH) normally secreted by the pituitary.
Ans-6. 4. After hypophysectomy, or removal of the pituitary gland, the body can’t synthesize
ADH. Somatropin or growth hormone, not vasopressin is used to treat growth failure. SIADH
results from excessive ADH secretion. Mannitol or corticosteroids are used to decrease cerebral
edema.
7) A client comes into the ER after hitting his head in an MVA. He’s alert and oriented.
Which of the following nursing interventions should be done first?
1. Assess full ROM to determine extent of injuries

2. Call for an immediate chest x-ray
3. Immobilize the client’s head and neck
4. Open the airway with the head-tilt chin-lift maneuver
Ans-7. 3. All clients with a head injury are treated as if a cervical spine injury is present until x-
rays confirm their absence. ROM would be contraindicated at this time. There is no indication
that the client needs a chest x-ray. The airway doesn’t need to be opened since the client appears
alert and not in respiratory distress. In addition, the head-tilt chin-lift maneuver wouldn’t be used
until the cervical spine injury is ruled out.
8) A client with a C6 spinal injury would most likely have which of the following
symptoms?
1. Aphasia
2. Hemiparesis
3. Paraplegia
4. Tetraplegia
Ans-8. 4. Tetraplegia occurs as a result of cervical spine injuries. Paraplegia occurs as a result of
injury to the thoracic cord and below.
9) A 30-year-old was admitted to the progressive care unit with a C5 fracture from a
motorcycle accident. Which of the following assessments would take priority?
1. Bladder distension
2. Neurological deficit
3. Pulse ox readings
4. The client’s feelings about the injury
Ans-9. 3. After a spinal cord injury, ascending cord edema may cause a higher level of injury.
The diaphragm is innervated at the level of C4, so assessment of adequate oxygenation and
ventilation is necessary. Although the other options would be necessary at a later time,
observation for respiratory failure is the priority.
10) While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40, pulse 48,
and RR of 18. The nurse suspects which of the following conditions?
1. Autonomic dysreflexia
2. Hemorrhagic shock
3. Neurogenic shock
4. Pulmonary embolism
Ans-10. 3. Symptoms of neurogenic shock include hypotension, bradycardia, and warm, dry
skin due to the loss of adrenergic stimulation below the level of the lesion. Hypertension,
bradycardia, flushing, and sweating of the skin are seen with autonomic dysreflexia.
Hemorrhagic shock presents with anxiety, tachycardia, and hypotension; this wouldn’t be
suspected without an injury. Pulmonary embolism presents with chest pain, hypotension,
hypoxemia, tachycardia, and hemoptysis; this may be a later complication of spinal cord injury
due to immobility.
11) A client is admitted with a spinal cord injury at the level of T12. He has limited movement
of his upper extremities. Which of the following medications would be used to control edema
of the spinal cord?
1. Acetazolamide (Diamox)
3. Methylprednisolone (Solu-Medrol)
4. Sodium bicarbonate
Ans-11. 3. High doses of Solu-Medrol are used within 24 hours of spinal injury to reduce cord
swelling and limit neurological deficit. The other drugs aren’t indicated in this circumstance.
12) A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure
of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be
done first?
1. Place the client flat in bed

2. Assess patency of the indwelling urinary catheter
3. Give one SL nitroglycerin tablet
4. Raise the head of the bed immediately to 90 degrees
Ans-12. 4. Anxiety, flushing above the level of the lesion, piloerection, hypertension, and
bradycardia are symptoms of autonomic dysreflexia, typically caused by such noxious stimuli
such as a full bladder, fecal impaction, or decubitus ulcer. Putting the client flat will cause the
blood pressure to increase even more. The indwelling urinary catheter should be assessed
immediately after the HOB is raised. Nitroglycerin is given to reduce chest pain and reduce
preload; it isn’t used for hypertension or dysreflexia.
13) A client with a cervical spine injury has Gardner-Wells tongs inserted for which of the
following reasons?
1. To hasten wound healing

2. To immobilize the surgical spine
3. To prevent autonomic dysreflexia
4. To hold bony fragments of the skull together
Ans-13. 2. Gardner-Wells, Vinke, and Crutchfield tongs immobilize the spine until surgical
stabilization is accomplished.
14) Which of the following interventions describes an appropriate bladder program for a
client in rehabilitation for spinal cord injury?
1. Insert an indwelling urinary catheter to straight drainage

2. Schedule intermittent catherization every 2 to 4 hours
3. Perform a straight catherization every 8 hours while awake
4. Perform Crede’s maneuver to the lower abdomen before the client voids.
Ans-14. 2. Intermittent catherization should begin every 2 to 4 hours early in the treatment.
When residual volume is less than 400 ml, the schedule may advance to every 4 to 6 hours.
Indwelling catheters may predispose the client to infection and are removed as soon as possible.
Crede’s maneuver is not used on people with spinal cord injury.
15) A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma.
The underlying cause of epidural hematoma is usually related to which of the following
conditions?
1. Laceration of the middle meningeal artery
2. Rupture of the carotid artery
3. Thromboembolism from a carotid artery
4. Venous bleeding from the arachnoid space
Ans-15. 1. Epidural hematoma or extradural hematoma is usually caused by laceration of the

middle meningeal artery. An embolic stroke is a thromboembolism from a carotid artery that
ruptures. Venous bleeding from the arachnoid space is usually observed with subdural
hematoma.
16) A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear
fluid draining from his ears and nose. Which of the following nursing interventions should be
done first?
1. Position the client flat in bed

2. Check the fluid for dextrose with a dipstick
3. Suction the nose to maintain airway patency
4. Insert nasal and ear packing with sterile gauze
Ans-16. 2. Clear fluid from the nose or ear can be determined to be cerebral spinal fluid or
mucous by the presence of dextrose. Placing the client flat in bed may increase ICP and promote
pulmonary aspiration. The nose wouldn’t be suctioned because of the risk for suctioning brain
tissue through the sinuses. Nothing is inserted into the ears or nose of a client with a skull
fracture because of the risk of infection.
17) When discharging a client from the ER after a head trauma, the nurse teaches the
guardian to observe for a lucid interval. Which of the following statements best described a
lucid interval?
1. An interval when the client’s speech is garbled

2. An interval when the client is alert but can’t recall recent events
3. An interval when the client is oriented but then becomes somnolent
4. An interval when the client has a “warning” symptom, such as an odor or visual disturbance.
Ans-17. 3. A lucid interval is described as a brief period of unconsciousness followed by

alertness; after several hours, the client again loses consciousness. Garbled speech is known as
dysarthria. An interval in which the client is alert but can’t recall recent events is known as
amnesia. Warning symptoms or auras typically occur before seizures.
18) Which of the following clients on the rehab unit is most likely to develop autonomic
dysreflexia?
1. A client with a brain injury

2. A client with a herniated nucleus pulposus
3. A client with a high cervical spine injury
4. A client with a stroke
Ans-18. 3. Autonomic dysreflexia refers to uninhibited sympathetic outflow in clients with
spinal cord injuries about the level of T10. The other clients aren’t prone to dysreflexia.
19) Which of the following conditions indicates that spinal shock is resolving in a client with
C7 quadriplegia?
1. Absence of pain sensation in chest

2. Spasticity
3. Spontaneous respirations
4. Urinary continence
Ans-19. 3. Spasticity, the return of reflexes, is a sign of resolving shock. Spinal or neurogenic
shock is characterized by hypotension, bradycardia, dry skin, flaccid paralysis, or the absence of
reflexes below the level of injury. The absence of pain sensation in the chest doesn’t apply to
spinal shock. Spinal shock descends from the injury, and respiratory difficulties occur at C4 and
above.
20) A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the
following conditions can cause autonomic dysreflexia?
1. Headache
2. Lumbar spinal cord injury
3. Neurogenic shock
4. Noxious stimuli
Ans-20. 4. Noxious stimuli, such as a full bladder, fecal impaction, or a decub ulcer, may cause
autonomic dysreflexia. A headache is a symptom of autonomic dysreflexia, not a cause.
Autonomic dysreflexia is most commonly seen with injuries at T10 or above. Neurogenic shock
isn’t a cause of dysreflexia.
21) During an episode of autonomic dysreflexia in which the client becomes hypertensive, the
nurse should perform which of the following interventions?
1. Elevate the client’s legs

2. Put the client flat in bed
3. Put the client in the Trendelenburg’s position
4. Put the client in the high-Fowler’s position
Ans-21. 4. Putting the client in the high-Fowler’s position will decrease cerebral blood flow,
decreasing hypertension. Elevating the client’s legs, putting the client flat in bed, or putting the
bed in the Trendelenburg’s position places the client in positions that improve cerebral blood
flow, worsening hypertension.
22) A client with a T1 spinal cord injury arrives at the emergency department with a BP of
82/40, pulse 34, dry skin, and flaccid paralysis of the lower extremities. Which of the following
conditions would most likely be suspected?
1. Autonomic dysreflexia
2. Hypervolemia
3. Neurogenic shock
4. Sepsis
Ans-22. 3. Loss of sympathetic control and unopposed vagal stimulation below the level of
injury typically cause hypotension, bradycardia, pallor, flaccid paralysis, and warm, dry skin in
the client in neurogenic shock. Hypervolemia is indicated by rapid and bounding pulse and
edema. Autonomic dysreflexia occurs after neurogenic shock abates. Signs of sepsis would
include elevated temperature, increased heart rate, and increased respiratory rate.
23) A client has a cervical spine injury at the level of C5. Which of the following conditions
would the nurse anticipate during the acute phase?
1. Absent corneal reflex

2. Decerebate posturing
3. Movement of only the right or left half of the body
4. The need for mechanical ventilation
Ans-23. 4. The diaphragm is stimulated by nerves at the level of C4. Initially, this client may
need mechanical ventilation due to cord edema. This may resolve in time. Absent corneal
reflexes, decerebate posturing, and hemiplegia occur with brain injuries, not spinal cord injuries.
24) A client with C7 quadriplegia is flushed and anxious and complains of a pounding
headache. Which of the following symptoms would also be anticipated?
1. Decreased urine output or oliguria

2. Hypertension and bradycardia
3. Respiratory depression
4. Symptoms of shock
Ans-24. 2. Hypertension, bradycardia, anxiety, blurred vision, and flushing above the lesion
occur with autonomic dysreflexia due to uninhibited sympathetic nervous system discharge. The
other options are incorrect.
25) A 40-year-old paraplegic must perform intermittent catherization of the bladder. Which of
the following instructions should be given?
1. “Clean the meatus from back to front.”

2. “Measure the quantity of urine.”
3. “Gently rotate the catheter during removal.”
4. “Clean the meatus with soap and water.”
Ans-25. 4. Intermittent catherization may be performed chronically with clean technique, using
soap and water to clean the urinary meatus. The meatus is always cleaned from front to back in a
woman, or in expanding circles working outward from the meatus in a man. It isn’t necessary to
measure the urine. The catheter doesn’t need to be rotated during removal.
26) An 18-year-old client was hit in the head with a baseball during practice. When
discharging him to the care of his mother, the nurse gives which of the following instructions?
1. “Watch him for keyhole pupil the next 24 hours.”

2. “Expect profuse vomiting for 24 hours after the injury.”
3. “Wake him every hour and assess his orientation to person, time, and place.”
4. “Notify the physician immediately if he has a headache.”
Ans-26. 3. Changes in LOC may indicate expanding lesions such as subdural hematoma;
orientation and LOC are assessed frequently for 24 hours. A keyhole pupil is found after
iridectomy. Profuse or projectile vomiting is a symptom of increased ICP and should be reported
immediately. A slight headache may last for several days after concussion; severe or worsening
headaches should be reported.
27) Which neurotransmitter is responsible for many of the functions of the frontal lobe?
1. Dopamine
2. GABA
3. Histamine
4. Norepinephrine
Ans-27. 1. The frontal lobe primarily functions to regulate thinking, planning, and affect.
Dopamine is known to circulate widely throughout this lobe, which is why it’s such an important
neurotransmitter in schizophrenia.
28) The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of
a client with massive cerebral hemorrhage and loss of consciousness. It would be most
accurate for the nurse to tell family members that the test measures which of the following
conditions?
1. Extent of intracranial bleeding

2. Sites of brain injury
3. Activity of the brain
4. Percent of functional brain tissue
Ans-28. 3. An EEG measures the electrical activity of the brain. Extent of intracranial bleeding
and location of the injury site would be determined by CT or MRI. Percent of functional brain
tissue would be determined by a series of tests.
29) A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan
of the head shows a collection of blood between the skull and dura mater. Which type of head
injury does this finding suggest?
1. Subdural hematoma
2. Subarachnoid hemorrhage
3. Epidural hematoma
4. Contusion
Ans-29. 3. An epidural hematoma occurs when blood collects between the skull and the dura
mater. In a subdural hematoma, venous blood collects between the dura mater and the arachnoid
mater. In a subarachnoid hemorrhage, blood collects between the pia mater and arachnoid
membrane. A contusion is a bruise on the brain’s surface.
30) After falling 20’, a 36-year-old man sustains a C6 fracture with spinal cord transaction.
Which other findings should the nurse expect?
1. Quadriplegia with gross arm movement and diaphragmic breathing

2. Quadriplegia and loss of respiratory function
3. Paraplegia with intercostal muscle loss
4. Loss of bowel and bladder control
Ans-30. 1. A client with a spinal cord injury at levels C5 to C6 has quadriplegia with gross arm
movement and diaphragmic breathing. Injury levels C1 to C4 leads to quadriplegia with total
loss of respiratory function. Paraplegia with intercostal muscle loss occurs with injuries at T1 to
L2. Injuries below L2 cause paraplegia and loss of bowel and bladder control.
31) A 20-year-old client who fell approximately 30’ is unresponsive and breathless. A cervical
spine injury is suspected. How should the first-responder open the client’s airway for rescue
breathing?
1. By inserting a nasopharyngeal airway

2. By inserting a oropharyngeal airway
3. By performing a jaw-thrust maneuver
4. By performing the head-tilt, chin-lift maneuver
Ans-31. 3. If the client has a suspected cervical spine injury, a jaw-thrust maneuver should be
used to open the airway. If the tongue or relaxed throat muscles are obstructing the airway, a
nasopharyngeal or oropharyngeal airway can be inserted; however, the client must have
spontaneous respirations when the airway is open. The head-tilt, chin-lift maneuver requires neck
hyperextension, which can worsen the cervical spine injury.
32) The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment,
the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The
client reports a severe, pounding headache. Which of the following nursing interventions
would be appropriate for this client? Select all that apply.
1. Elevate the HOB to 90 degrees

2. Loosen constrictive clothing
3. Use a fan to reduce diaphoresis
4. Assess for bladder distention and bowel impaction
5. Administer antihypertensive medication
6. Place the client in a supine position with legs elevated
Ans-32. 1, 2, 4, 5. The client has signs and symptoms of autonomic dysreflexia. The potentially
life-threatening condition is caused by an uninhibited response from the sympathetic nervous
system resulting from a lack of control over the autonomic nervous system. The nurse should
immediately elevate the HOB to 90 degrees and place extremities dependently to decrease
venous return to the heart and increase venous return from the brain. Because tactile stimuli can
trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should
also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia,
and correct any problems. Elevated blood pressure is the most life-threatening complication of
autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering
event doesn’t reduce the client’s blood pressure, IV antihypertensives should be administered. A
fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia.
33) The client with a head injury has been urinating copious amounts of dilute urine through
the Foley catheter. The client’s urine output for the previous shift was 3000 ml. The nurse
implements a new physician order to administer:
1. Desmopressin (DDAVP, stimate)

2. Dexamethasone (Decadron)
3. Ethacrynic acid (Edecrin)
4. Mannitol (Osmitrol)
Ans-33. 1. A complication of a head injury is diabetes insipidus, which can occur with insult to
the hypothalamus, the antidiuretic storage vesicles, or the posterior pituitary gland. Urine output
that exceeds 9 L per day generally requires treatment with desmopressin. Dexamethasone, a
glucocorticoid, is administered to treat cerebral edema. This medication may be ordered for the
head injured patient. Ethacrynic acid and mannitol are diuretics, which would be contraindicated.
34) The nurse is caring for the client in the ER following a head injury. The client
momentarily lost consciousness at the time of the injury and then regained it. The client now
has lost consciousness again. The nurse takes quick action, knowing this is compatible with:
1. Skull fracture
2. Concussion
3. Subdural hematoma
4. Epidural hematoma
Ans-34. 4. The changes in neurological signs from an epidural hematoma begin with a loss of
consciousness as arterial blood collects in the epidural space and exerts pressure. The client
regains consciousness as the cerebral spinal fluid is reabsorbed rapidly to compensate for the
rising intracranial pressure. As the compensatory mechanisms fail, even small amounts of
additional blood can cause the intracranial pressure to rise rapidly, and the client’s neurological
status deteriorates quickly.
35) The nurse is caring for a client who suffered a spinal cord injury 48 hours ago. The nurse
monitors for GI complications by assessing for:
1. A flattened abdomen
2. Hematest positive nasogastric tube drainage
3. Hyperactive bowel sounds
4. A history of diarrhea
Ans-35. 2. After spinal cord injury, the client can develop paralytic ileus, which is characterized
by the absence of bowel sounds and abdominal distention. Development of a stress ulcer can be
detected by hematest positive NG tube aspirate or stool. A history of diarrhea is irrelevant.
36) A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The
nurse would avoid which of the following measures to minimize the risk of recurrence?
1. Strict adherence to a bowel retraining program

2. Limiting bladder catherization to once every 12 hours
3. Keeping the linen wrinkle-free under the client
4. Preventing unnecessary pressure on the lower limbs
Ans-36. 2. The most frequent cause of autonomic dysreflexia is a distended bladder. Straight
catherization should be done every 4 to 6 hours, and Foley catheters should be checked
frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so
maintaining bowel regularity is important. Other causes include stimulation of the skin from
tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.
37) The nurse is planning care for the client in spinal shock. Which of the following actions
would be least helpful in minimizing the effects of vasodilation below the level of the injury?
1. Monitoring vital signs before and during position changes

2. Using vasopressor medications as prescribed
3. Moving the client quickly as one unit
4. Applying Teds or compression stockings.
Ans-37. 3. Reflex vasodilation below the level of the spinal cord injury places the client at risk
for orthostatic hypotension, which may be profound. Measures to minimize this include
measuring vital signs before and during position changes, use of a tilt-table with early
mobilization, and changing the client’s position slowly. Venous pooling can be reduced by using
Teds (compression stockings) or pneumatic boots. Vasopressor medications are administered per
protocol.
38) The nurse is caring for a client admitted with spinal cord injury. The nurse minimizes the
risk of compounding the injury most effectively by:
1. Keeping the client on a stretcher

2. Logrolling the client on a firm mattress
3. Logrolling the client on a soft mattress
4. Placing the client on a Stryker frame
Ans-38. 4. Spinal immobilization is necessary after spinal cord injury to prevent further damage
and insult to the spinal cord. Whenever possible, the client is placed on a Stryker frame, which
allows the nurse to turn the client to prevent complications of immobility, while maintaining
alignment of the spine. If a Stryker frame is not available, a firm mattress with a bed board
should be used.
39) The nurse is evaluating neurological signs of the male client in spinal shock following
spinal cord injury. Which of the following observations by the nurse indicates that spinal
shock persists?
1. Positive reflexes
2. Hyperreflexia
3. Inability to elicit a Babinski’s reflex
4. Reflex emptying of the bladder
Ans-39. 3. Resolution of spinal shock is occurring when there is a return of reflexes (especially
flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, reflex
emptying of the bladder, and a positive Babinski’s reflex.
40) A client with a spinal cord injury suddenly experiences an episode of autonomic
dysreflexia. After checking the client’s vital signs, list in order of priority, the nurse’s actions
(Number 1 being the first priority and number 5 being the last priority).
1. Check for bladder distention

2. Raise the head of the bed
3. Contact the physician
4. Loosen tight clothing on the client
5. Administer an antihypertensive medication
Ans-40. 3, 1, 4, 2, 5. Autonomic dysreflexia is characterized by severe hypertension,

bradycardia, severe headache, nasal stuffiness, and flushing. The cause is a noxious stimulus,
most often a distended bladder or constipation. Autonomic dysreflexia is a neurological
emergency and must be treated promptly to prevent a hypertensive stroke. Immediate nursing
actions are to sit the client up in bed in a high-Fowler’s position and remove the noxious
stimulus. The nurse should loosen any tight clothing and then check for bladder distention. If the
client has a Foley catheter, the nurse should check for kinks in the tubing. The nurse also would
check for a fecal impaction and disimpact if necessary. The physician is contacted especially if
these actions do not relieve the signs and symptoms. Antihypertensive medications may be
prescribed by the physician to minimize cerebral hypertension.
41) A client is at risk for increased ICP. Which of the following would be a priority for the
nurse to monitor?
1. Unequal pupil size
2. Decreasing systolic blood pressure
3. Tachycardia
4. Decreasing body temperature
Ans-41. 1. Increasing ICP causes unequal pupils as a result of pressure on the third cranial
nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional
pressure needed to perfuse the brain. It increases the pressure on the vagus nerve, which
produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.
42) Which of the following respiratory patterns indicate increasing ICP in the brain stem?
1. Slow, irregular respirations

2. Rapid, shallow respirations
3. Asymmetric chest expansion
4. Nasal flaring
Ans-42. 1. Neural control of respiration takes place in the brain stem. Deterioration and pressure
produce irregular respiratory patterns. Rapid, shallow respirations, asymmetric chest movements,
and nasal flaring are more characteristic of respiratory distress or hypoxia.
43) Which of the following nursing interventions is appropriate for a client with an ICP of 20
mm Hg?
1. Give the client a warming blanket

2. Administer low-dose barbiturate
3. Encourage the client to hyperventilate
4. Restrict fluids
Ans-43. 3. Normal ICP is 15 mm Hg or less. Hyperventilation causes vasoconstriction, which

reduces CSF and blood volume, two important factors for reducing a sustained ICP of 20 mm
Hg. A cooling blanket is used to control the elevation of temperature because a fever increases
the metabolic rate, which in turn increases ICP. High doses of barbiturates may be used to reduce
the increased cellular metabolic demands. Fluid volume and inotropic drugs are used to maintain
cerebral perfusion by supporting the cardiac output and keeping the cerebral perfusion pressure
greater than 80 mm Hg.
44) A client has signs of increased ICP. Which of the following is an early indicator of
deterioration in the client’s condition?
1. Widening pulse pressure

2. Decrease in the pulse rate
3. Dilated, fixed pupil
4. Decrease in LOC
Ans-44. 4. A decrease in the client’s LOC is an early indicator of deterioration of the client’s
neurological status. Changes in LOC, such as restlessness and irritability, may be subtle.
Widening of the pulse pressure, decrease in the pulse rate, and dilated, fixed pupils occur later if
the increased ICP is not treated.
45) A client who is regaining consciousness after a craniotomy becomes restless and attempts
to pull out her IV line. Which nursing intervention protects the client without increasing her
ICP?
1. Place her in a jacket restraint

2. Wrap her hands in soft “mitten” restraints
3. Tuck her arms and hands under the draw sheet
4. Apply a wrist restraint to each arm
Ans-45. 2. It is best for the client to wear mitts which help prevent the client from pulling on the
IV without causing additional agitation. Using a jacket or wrist restraint or tucking the client’s
arms and hands under the draw sheet restrict movement and add to feelings of being confined, all
of which would increase her agitation and increase ICP.
46) Which of the following describes decerebrate posturing?
1. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers
2. Back hunched over, rigid flexion of all four extremities with supination of arms and plantar
flexion of the feet
3. Supination of arms, dorsiflexion of feet
4. Back arched; rigid extension of all four extremities.
Ans-46. 4. Decerebrate posturing occurs in patients with damage to the upper brain stem,
midbrain, or pons and is demonstrated clinically by arching of the back, rigid extension of the
extremities, pronation of the arms, and plantar flexion of the feet. Internal rotation and adduction
of arms with flexion of the elbows, wrists, and fingers described decorticate posturing, which
indicates damage to corticospinal tracts and cerebral hemispheres.
47) A client receiving vent-assisted mode ventilation begins to experience cluster breathing
after recent intracranial occipital bleeding. Which action would be most appropriate?
1. Count the rate to be sure the ventilations are deep enough to be sufficient
2. Call the physician while another nurse checks the vital signs and ascertains the patient’s
Glasgow Coma score.
3. Call the physician to adjust the ventilator settings.
4. Check deep tendon reflexes to determine the best motor response
Ans-47. 2. Cluster breathing consists of clusters of irregular breaths followed by periods of

apnea on an irregular basis. A lesion in the upper medulla or lower pons is usually the cause of
cluster breathing. Because the client had a bleed in the occipital lobe, which is superior and
posterior to the pons and medulla, clinical manifestations that indicate a new lesion are
monitored very closely in case another bleed ensues. The physician is notified immediately so
that treatment can begin before respirations cease. Another nurse needs to assess vital signs and
score the client according to the GCS, but time is also of the essence. Checking deep tendon
reflexes is one part of the GCS analysis.
48) In planning the care for a client who has had a posterior fossa (infratentorial)
craniotomy, which of the following is contraindicates when positioning the client?
1. Keeping the client flat on one side or the other

2. Elevating the head of the bed to 30 degrees
3. Log rolling or turning as a unit when turning
4. Keeping the head in neutral position
Ans-48. 2. Elevating the HOB to 30 degrees is contraindicated for infratentorial craniotomies

because it could cause herniation of the brain down onto the brain stem and spinal cord, resulting
in sudden death. Elevation of the head of the bed to 30 degrees with the head turned to the side
opposite of the incision, if not contraindicated by the ICP; is used
forsupratentorial craniotomies.
49) A client has been pronounced brain dead. Which findings would the nurse assess? Check
all that apply.
1. Decerebrate posturing
2. Dilated non-reactive pupils
3. Deep tendon reflexes
4. Absent corneal reflex
Ans-49. 2, 3, 4. A client who is brain dead typically demonstrates nonreactive dilated pupils and
nonreactive or absent corneal and gag reflexes. The client may still have spinal reflexes such as
deep tendon and Babinski reflexes in brain death. Decerebrate or decorticate posturing would not
be seen.
Nursing Process – 1
1. Once a nurse assesses a client’s condition and identifies appropriate nursing diagnoses,
a:
A. Plan is developed for nursing care.

B. Physical assessment begins
C. List of priorities is determined.
D. Review of the assessment is conducted with other team members.
Ans-1. A (1-10 from FON; Chapter 17)
2. Planning is a category of nursing behaviors in which:

1. The nurse determines the health care needed for the client.
2. The Physician determines the plan of care for the client.
3. Client-centered goals and expected outcomes are established.
4. The client determines the care needed.
Ans-2. B
3. Priorities are established to help the nurse anticipate and sequence nursing interventions
when a client has multiple problems or alterations. Priorities are determined by the client’s:
1. Physician
2. Nonemergent, non-life threatening needs
3. Future well-being.
4. Urgency of problems
Ans-3. D
4. A client centered goal is a specific and measurable behavior or response that reflects a
client’s:
1. Desire for specific health care interventions

2. Highest possible level of wellness and independence in function.
3. Physician’s goal for the specific client.
4. Response when compared to another client with a like problem.
Ans-4. B
5. For clients to participate in goal setting, they should be:
1. Alert and have some degree of independence.

2. Ambulatory and mobile.
3. Able to speak and write.
4. Able to read and write.
Ans-5. A
6. The nurse writes an expected outcome statement in measurable terms. An example is:
1. Client will have less pain.

2. Client will be pain free.
3. Client will report pain acuity less than 4 on a scale of 0-10.
4. Client will take pain medication every 4 hours around the clock.
Ans-6. C
7. As goals, outcomes, and interventions are developed, the nurse must:
1. Be in charge of all care and planning for the client.

2. Be aware of and committed to accepted standards of practice from nursing and other
disciples.
3. Not change the plan of care for the client.
4. Be in control of all interventions for the client.
Ans-7. B
8. When establishing realistic goals, the nurse:
1. Bases the goals on the nurse’s personal knowledge.

2. Knows the resources of the health care facility, family, and the client.
3. Must have a client who is physically and emotionally stable.
4. Must have the client’s cooperation.
Ans-8. B
9. To initiate an intervention the nurse must be competent in three areas, which include:
1.
A. Knowledge, function, and specific skills
B. Experience, advanced education, and skills.
C. Skills, finances, and leadership.
D. Leadership, autonomy, and skills.
Ans-9. A
10. Collaborative interventions are therapies that require:
1. Physician and nurse interventions.

2. Nurse and client interventions.
3. Client and Physician intervention.
4. Multiple health care professionals.
Ans-10. D
11. Well formulated, client-centered goals should:
1. Meet immediate client needs.

2. Include preventative health care.
3. Include rehabilitation needs.
4. All of the above.
Ans-11. D (11-15 from FON SG, Chapter 17)
12. The following statement appears on the nursing care plan for an immunosuppressed
client: The client will remain free from infection throughout hospitalization. This statement is
an example of a (an):
1. Nursing diagnosis
2. Short-term goal
3. Long-term goal
4. Expected outcome
Ans-12. D
13. The following statements appear on a nursing care plan for a client after a mastectomy:
Incision site approximated; absence of drainage or prolonged erythema at incision site; and
client remains afebrile. These statements are examples of:
1. Nursing interventions
2. Short-term goals
3. Long-term goals
4. Expected outcomes.
Ans-13. D
14. The planning step of the nursing process includes which of the following activities?
1. Assessing and diagnosing

2. Evaluating goal achievement.
3. Performing nursing actions and documenting them.
4. Setting goals and selecting interventions.
Ans-14. D
15. The nursing care plan is:
1. A written guideline for implementation and evaluation.

2. A documentation of client care.
3. A projection of potential alterations in client behaviors
4. A tool to set goals and project outcomes.
Ans-15. A
16. After determining a nursing diagnosis of acute pain, the nurse develops the following
appropriate client-centered goal:
1. Encourage client to implement guided imagery when pain begins.
2. Determine effect of pain intensity on client function.
3. Administer analgesic 30 minutes before physical therapy treatment.
4. Pain intensity reported as a 3 or less during hospital stay.
Ans-16. D. This is measurable and objective. (16-22 from Evolve website)
17. When developing a nursing care plan for a client with a fractured right tibia, the nurse
includes in the plan of care independent nursing interventions, including:
1. Apply a cold pack to the tibia.

2. Elevate the leg 5 inches above the heart.
3. Perform range of motion to right leg every 4 hours.
4. Administer aspirin 325 mg every 4 hours as needed.
Ans-17. B. This does not require a physician’s order. (A & D require an order; C is not
appropriate for a fractured tibia)
18. Which of the following nursing interventions are written correctly? (Select all that apply.)
1. Apply continuous passive motion machine during day.

2. Perform neurovascular checks.
3. Elevate head of bed 30 degrees before meals.
4. Change dressing once a shift.
Ans-18. C. It is specific in what to do and when.
19. A client’s wound is not healing and appears to be worsening with the current treatment.
The nurse first considers:
A. Notifying the physician.

B. Calling the wound care nurse
C. Changing the wound care treatment.
D. Consulting with another nurse.
Ans-19. B. Calling in the wound care nurse as a consultant is appropriate because he or she is a
specialist in the area of wound management. Professional and competent nurses recognize
limitations and seek appropriate consultation. (a. This might be appropriate after deciding on a
plan of action with the wound care nurse specialist. The nurse may need to obtain orders for
special wound care products.
c. Unless the nurse is knowledgeable in wound management, this could delay wound healing.
Also, the current wound management plan could have been ordered by the physician. d. Another
nurse most likely will not be knowledgeable about wounds, and the primary nurse would know
the history of the wound management plan.)
20. When calling the nurse consultant about a difficult client-centered problem, the primary
nurse is sure to report the following:
A. Length of time the current treatment has been in place.

B. The spouse’s reaction to the client’s dressing change.
C. Client’s concern about the current treatment.
D. Physician’s reluctance to change the current treatment plan.
Ans-20. A. This gives the consulting nurse facts that will influence a new plan.
(b, c, and d. These are all subjective and emotional issues/conclusions about the current
treatment plan and may cause a bias in the decision of a new treatment plan by the nurse
consultant.)
21. The primary nurse asked a clinical nurse specialist (CNS) to consult on a difficult nursing
problem. The primary nurse is obligated to:
A. Implement the specialist’s recommendations.

B. Report the recommendations to the primary physician.
C. Clarify the suggestions with the client and family members.
D. Discuss and review advised strategies with CNS.
Ans-21. D. Because the primary nurse requested the consultation, it is important that they
communicate and discuss recommendations. The primary nurse can then accept or reject the
CNS recommendations. (a. Some of the recommendations may not be appropriate for this client.
The primary nurse would know this information. A consultation requires review of the
recommendations, but not immediate implementation. b. This would be appropriate after first
talking with the CNS about recommended changes in the plan of care and the rationale. Then the
primary nurse should call the physician. c. The client and family do not have the knowledge to
determine whether new strategies are appropriate or not. Better to wait until the new plan of care
is agreed upon by the primary nurse and physician before talking with the client and/or family.)
22. After assessing the client, the nurse formulates the following diagnoses. Place them in
order of priority, with the most important (classified as high) listed first.
A. Constipation
B. Anticipated grieving
C. Ineffective airway clearance
D. Ineffective tissue perfusion.
Ans-22. C, D, A, B.
23. The nurse is reviewing the critical paths of the clients on the nursing unit. In performing
a variance analysis, which of the following would indicate the need for further action and
analysis?
A. A client’s family attending a diabetic teaching session.
B. Canceling physical therapy sessions on the weekend.
C. Normal VS and absence of wound infection in a post-op client.
D. A client demonstrating accurate medication administration following teaching.
Ans-23. B. (23 & 24 from Saunders NCLEX, 3rd edition)
24. The RN has received her client assignment for the day-shift. After making the initial
rounds and assessing the clients, which client would the RN need to develop a care plan first?
A. A client who is ambulatory.

B. A client, who has a fever, is diaphoretic and restless.
C. A client scheduled for OT at 1300.
D. A client who just had an appendectomy and has just received pain medication.
Ans-24. B. This clients’ needs are a priority.
Nursing Process – 2
1. What are the steps in the nursing process?
Ans-1. Assess, Diagnose, Plan, Implement, Evaluate
2. Mr. Anderson says that his head has been hurting for 3 weeks. The nurse knows this is
what kind of data?
A. Primary objective data

B. Primary subjective data
C. Secondary objective data
D. Secondary subjective data
Ans-2. B
3. Mr. Jones comes into the doctor’s office with his wife. During the initial interview with
the nurse assessing the reason for the visit, the wife says that her husband has been feeling
bad for three days. The nurse knows this is what type of data?
A. Primary objective data

B. Primary subjective data
C. Secondary objective data
D. Secondary subjective data
Ans-3. D
4. Pain is always which kind of symptom
A. Subjective
B. Objective
Ans-4. A
5. Subjective or Objective?
1. Feeling tired
2. Feeling warm skin
3. Seeing spots
4. Seeing a rash
5. A fever
6. Needing to cough
7. Hearing a cough
Ans-5.
6. The nurse needs to interview a client in the hospital room. What is the idea setting for
this interview?
Ans-6. Client in no pain, no TV or other interruptions, should be private, comfortable, seated eye
level, at a comfortable distance according to culture, use laymen terminology, or translator as
necessary
7. What are the 5 types of Nursing Diagnoses?
Ans-7. Actual, Risk, Wellness, Possible, Syndrome
8. What is the Basic Three Part Statement format for a Nursing Diagnosis?
Ans-8. Problem related to (r/t) Etiology as evidenced by (AEB) defining characteristics (or signs
and symptoms)
9. What can a Nursing Diagnosis not ever have as the Etiology?
Ans-9. A medical diagnosis
10. What is different about the format of a Risk Diagnosis compared to an Actual Diagnosis?
Ans-10. A Risk Diagnosis does not have any defining characteristics, because if it did, it would
be an actual problem, not a risk. It is a Two Part Statement.
11. What is another name for “defining characteristics”?
Ans-11. Signs and symptoms.
12. What is the proper format of a Nursing Diagnosis that contains a medical diagnosis
Ans-12. Problem r/t Etiology, secondary to Medical Diagnosis, AEB S&S
13. What kind of Nursing Diagnosis uses a One Part Statement?
Ans-13. Wellness, Syndrome
14. How do you always start an intervention statement?
Ans-14. “The nurse will…”
15. How do you always start an outcome or goal statement?
Ans-15. “The patient will…”
16. Outcome must always be Smart. What does this mean?
Ans-16. Specific, Measurable, Appropriate, Realistic, Timely
17. Which of these is a properly written outcome?
A. The nurse will assist the patient to the nurse’s station twice during this shift.
B. The client will walk unassisted to the bathroom.
C. The client will get out of bed into the chair for two hours today.
D. The client will be free of pain.
Ans-17. C
18. When does discharge planning begin?
Ans-18. Upon admission
19. What step in the nursing process does writing desired outcomes occur?
Ans-19. Planning
20. Desired outcomes are based on what part of the Three Part Statement?
Ans-20. Problem
21. Interventions focus on what part of the Three Part Statement?
Ans-21. Eriology
22. Which of the following is a not independent nursing intervention?
A. Keep the side rails raised x 2.

B. Give a patient his medication
C. Turn patient every 2 hours
D. Take vital signs every 4 hours
Ans-22. B, this is a dependent intervention because it must have a doctor’s order.
23. What are the two things a nurse must do in the intervention step of the nursing process?
Ans-23. Do the intervention and document the intervention.
24. The CNA reports that the patient who is scheduled to be discharge at 11:00 has a blood
pressure of 160/90. What is the nurses’ first action?
1. Check the medication list to see if there is any medication to give for high blood pressure
2. Check the blood pressure
4. Get the charge nurse
Ans-24. B. The nurse should always validate cues that seem out of the ordinary. Also in
priority questions, the answer is normally an independent nursing intervention first.
Nutrition – 1 (not NCLEX)
1. List two examples of essential nutrients:
Ans-1. Carbohydrates, Proteins, fats, vitamins, minerals, water.
2. How many calories equal 1 kilocalorie?

Ans-2. 1000 calories = 1 kcalorie.
3. 1 gram of carbohydrates = _____ kilocalorie.
Ans-3. 4
4. 1 gram of fat = ____ kilocalorie.
Ans-4. 9
5. 1 gram of protein = ___ kilocalorie.
Ans-5. 4
6. The recommended carbohydrate % is ______ % of total daily intake.
Ans-6. 50-60%
7. Simple sugars include:
Ans-7. Glucose, Fructose, Galactose
8. What type of simple sugars are found in IV solutions?

A. Galactose
B. Dextrose
C. Complex sugars
D. Refined blood sugars
Ans-8. B. Dextrose
9. What provides a source of blood glucose that lasts over time?
1. Starches
2. Simple sugars
3. Proteins
4. Fats
Ans-9. A. Starches.

10. List 2 examples of complete proteins:
Ans-10. Meats, chicken, fish, eggs, cheese, milk

11. True or false: Complete proteins contain all essential amino acids.
Ans-11. True.
12. True or False: Incomplete proteins are proteins of the plant origin.
Ans-12. True. This includes legumes, grains, seeds, nuts.
13. Recommended protein % is _____ % of total daily intake.
Ans-13. 15-20%.
14. What 4 vitamins are fat soluble?
Ans-14. A, D, E, K.
15. What fraction of the American population is overweight?
Ans-15. 1/3
16. Which cholesterol is considered the “bad guys”? LDL or HDL?
Ans-16. LDL (low-density lipoproteins). Come from saturated fats from animals.
17. True or false: Polyunsaturated fats lower both the LDL and HDL.
Ans-17. True. Polyunsaturated fats are considered plant fat. Found primarily in vegetable oils,
corn oil, and soybean oil.
18. True or False: Monounsaturated fats raise the HDL cholesterol.
Ans-18. True. Raises the HDL cholesterol. Considered the “good guys” of the fats. Foods
include peanut oil, olive oil, almonds, pecans, and peanuts.
19. Name two water soluble vitamins:
Ans-19. The B-vitamins and C.
20. Which 2 vitamins rely on each other for activation? Pantothenic acid and Vitamin B6
1. Folate and Vitamin B12

2. Biotin and Niacin
3. B2 and Thiamin
Ans-20. B. Folate (folic acid) and Vitamin B12. Closely related to one another.
21. The disease “Pellegria” is caused by a deficiency in what vitamin?
1. Niacin
2. Riboflavin
3. Vitamin B12
4. Thiamin
Ans-21. A. Niacin.
22. True or False: Pantothenic Acid and Biotin deficiencies are rare.
Ans-22. True. Are widespread in foods.
23. What foods would be recommended for people who suffer from the disease “Beri-Beri”?
1. Tuna and chicken.

2. Broccoli and grapefruits
3. Meats and sunflower seeds
4. Milk products and oranges.
Ans-23. C. Meats (pork and ham), legumes, sunflower seeds and whole-wheat bread are
examples.
24. What disease is associated with a Vitamin C deficiency?
1. Pellegria
2. Neural tube defects
3. Scurvy
4. Pitted edema
Ans-24. C. Scurvy. (Bleeding, muscles degenerate, wounds won’t heal, teeth loosen)
25. True or False: Vitamin B6 is also called Folate.
Ans-25. False. The correct answer would be pyridoxine.

26. List an example of the nutritional goal from the Healthy People 2010 report. How many
nutritional goals are in this report?
Ans-26. Reduce the incidence of overweight people by 23%. There are 21 nutritional goals
listed.
27. A patient comes in with the diagnosis of Rickets. What vitamin is she deficient in?
1. Vitamin A
2. Vitamin B
3. Vitamin C
4. Vitamin D
Ans-27. D. Vitamin D helps with the absorption of calcium and is used for the calcification of
bones.
28. A man has been experiencing night-blindness. What vitamin could he be deficient in?
1. Vitamin A
2. Vitamin B
3. Vitamin C
4. Vitamin D
Ans-28. A. Vitamin A helps with visual activity and adaptations from light to dark and vice
versa.
29. A 59 year old woman is diagnosed with Hemolytic anemia. What foods would be
recommended for her to eat?
1. Fish oils
2. Eggs, cheese
3. Yellow fruits
4. Grains, nuts.
Ans-29. D. She would be deficient in the vitamin E. Other foods that would be recommended
would be green leafy vegetables, fats, oils, and liver.
30. Hypercalcemia is caused by the toxicity of what vitamin?
1. Vitamin A
2. Vitamin D
3. Vitamin E
4. Vitamin K
Ans-30. B. Vitamin D toxicity also caused renal cancull
31. Blood clotting is the function of which vitamin?
1. Vitamin A
2. Vitamin D
3. Vitamin E
4. Vitamin K
Ans-31. D. Vitamin K. A deficiency can cause bleeding and bruising.
32. When evaluating the history of a client who has gastrointestinal (GI) upset, the nurse is
sure to assess the client for routine ingestion of the following (select all that apply):
1. High fiber foods

2. Beer
3. Acetaminophen
4. Aspirin
Ans-32. B and D. Alcohol and aspirin are two substances directly absorbed through the lining of
the stomach. This can contribute to GI upset.
33. A client has gained 2 pounds of weight in the past day. The nurse calculates this weight
gain to be ______ ml of fluid.
Ans-33. 1000 ml. Each pound = 500ml of fluid.
34. What is the ideal BMI? _____%
Ans-34. 25% or lower.
35. A BMI greater than ____% places a client in a higher risk for coronary heart disease,
some cancers, DM, and hypertension.
Ans-34. 25% or lower.
Nutrition – 2
1. Which nutrition is the body’s most preferred energy source?

A. Protein
B. Fat
C. Carbohydrate
D. Vitamins
Ans-1. C

2. A client who has been hospitalized after experiencing a heart attack will most likely receive
a diet consisting of:
1. Low fat, low sodium, and high carbohydrates

2. Low fat, high protein, and carbohydrates
3. Low fat, low sodium, and low carbohydrates
4. Liquids for several days, progressing to a soft and then a regular diet.
Ans-2. 1
3. Nutrition therapy for hypertension includes:
1. A moderate or low residue diet

2. Reduction in kilocalories, soft textured foods, and amounts of fat, sodium, and cholesterol.
3. Kilocalorie reduction to promote weight loss as appropriate, decreased sodium intake, and
potassium rich foods if potassium wasting diuretics are part of the treatment.
4. A high fiber diet.
Ans-3. 3
4. When teaching an athletic teenager about nutritional intake, the nurse should explain
that the carbohydrate food that would provide the quickest source of energy is a:
1. Glass of milk
2. Slice of bread
3. Snickers
4. Glass of orange juice
Ans-4. OJ has a higher proportion of simple sugars, which are readily available for conversion to
energy.
5. Clients receiving hypertonic tune feedings most commonly develop diarrhea because of:
1. Increased fiber intake

2. Bacterial contamination
3. Inappropriate positioning
4. High osmolality of the feedings
Ans-5. 4. The increased osmolarity (concentration) of many formulas draws fluid into the
interstitial tract, which would cause diarrhea; such feedings may need to be diluted initially until
the client develops tolerance.
6. Identify the components of a therapeutic diet for a client recovering from an acute episode
of alcoholism that included esophageal involvement. Select all that apply:
1. Soft diet
2. Regular diet
3. Low-protein diet
4. High protein diet
5. Low carbohydrate diet
6. High carbohydrate diet
Ans-6. 1, 4, 6. 1. Soft foods avoid irritation of esophageal varices if present. 4. A high protein
intake is necessary to correct severe malnutrition in the absence of hepatic coma. 6. A high
carbohydrate intake provides for energy needs.
7. A client eats a meal that contains 13 grams of fat, 31 grams of carbohydrates, and 5 grams
of protein. What is this client’s total caloric intake for this meal?
Ans-7. 261 kilocalories. Fat = 9 kcals/gram, carbs and proteins = 4 kcals/gram.
8. A client is receiving TPN after extensive colon surgery. The purpose of TPN is to:
1. To provide short term nutrition after surgery

2. Assist in providing supplemental nutrition for the client
3. Provide total nutrition when GI function is questionable
4. Assist people who are unable to eat but have active GI function.
Ans-8. 3. When GI absorption is inadequate; TPN is the nutritional therapy of choice because it
provides needed nutrients.
9. Spironolactone (Aldactone) a potassium-sparing diuretic, is prescribed for a client with

CHF. A nurse produces dietary instructions to the client and instructs the client to avoid foods
that are high in which electrolyte?
1. Calcium
2. Potassium
3. Magnesium
4. Phosphorus

Ans-9. 2. The client should avoid foods high in potassium. If the client does not avoid foods
high in potassium, Hyperkalemia could occur
10. A client who is recovering from gastric surgery has been advanced from a clear liquid diet
to a full liquid diet. The client is looking forward to the diet change because he has been
“bored” with the clear liquid diet. The nurse would most appropriately which full liquid item
to the client?
1. Gelatin
2. Custard
3. Tea
4. Popsicle

Ans-10. 2. Full liquid food items include items such as plain ice cream, sherbet, breakfast
drinks, milk, pudding, and custard, soups that are strained, and strained vegetable juices. Options
A, C, and D are clear liquids.
11. A post-op client has been placed on a clear liquid diet. Select all of the items that the client
is allowed to consume on this diet:
1. Broth
2. Gelatin
3. Pudding
4. Pureed vegetables
5. Coffee
6. Vegetable juice
Ans-11. 1, 2, 5
12. A client has had abdominal surgery and the physician has ordered a bland diet 3 days
post-surgery. Which of the following trays would have portions removed because it does not
adhere to the dietary regimen?
1. Scrambled eggs, cereal, and white toast

2. Baked potato, cottage cheese, and coffee
3. Cream soup, jello, and white toast
4. Cooked cereal, boiled egg, and milk.
Ans-12. 2. Coffee is one food eliminated from a bland diet because it is chemically irritating to
the stomach. All of the other foods are allowed on a bland diet. Other foods eliminated are raw,
spicy, gas forming, very hot or very cold foods, alcohol, and carbonated drinks.
13. What is the main mineral lost during a hemorrhage?
1. Potassium
2. Iron
3. Sodium
4. Phosphorus
Ans-13. 2. See page 4 in nutrition notes)

14. A seriously ill client with a lot of drainage would require how much fluid per day?
1. 2000 ml
2. 3000 ml
3. 6000 ml
4. 7000 ml
Ans-14. 4. That’s up to 7 IV bags!
15. Which statement is false regarding a full liquid diet?
1. This diet is for patients unable to tolerate solid foods

2. This diet is low in iron
3. This diet is low in protein
4. This diet is low in cholesterol.
Ans-15. 4. Full liquid diets are high in cholesterol.
OB/GYN – Intrapartum
1. A nurse is caring for a client in labor. The nurse determines that the client is beginning in
the 2nd stage of labor when which of the following assessments is noted?
1. The client begins to expel clear vaginal fluid
2. The contractions are regular
3. The membranes have ruptured
4. The cervix is dilated completely
Ans-1. 4. The second stage of labor begins when the cervix is dilated completely and ends with
the birth of the neonate.
2. A nurse in the labor room is caring for a client in the active phases of labor. The nurse
is assessing the fetal patterns and notes a late deceleration on the monitor strip. The
most appropriate nursing action is to:
1. Place the mother in the supine position

2. Document the findings and continue to monitor the fetal patterns
3. Administer oxygen via face mask
4. Increase the rate of pitocin IV infusion
Ans-2. 3. Late decelerations are due to uteroplacental insufficiency as the result of decreased
blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia;
therefore oxygen is necessary. The supine position is avoided because it decreases uterine blood
flow to the fetus. The client should be turned to her side to displace pressure of the gravid uterus
on the inferior vena cava. An intravenous pitocin infusion is discontinued when a late
deceleration is noted.
3. A nurse is performing an assessment of a client who is scheduled for a cesarean delivery.
Which assessment finding would indicate a need to contact the physician?
1. Fetal heart rate of 180 beats per minute

2. White blood cell count of 12,000
3. Maternal pulse rate of 85 beats per minute
4. Hemoglobin of 11.0 g/dL
Ans-3. 1. A normal fetal heart rate is 120-160 beats per minute. A count of 180 beats per minute
could indicate fetal distress and would warrant physician notification. By full term, a normal
maternal hemoglobin range is 11-13 g/dL as a result of the hemodilution caused by an increase in
plasma volume during pregnancy.
4. A client in labor is transported to the delivery room and is prepared for a cesarean
delivery. The client is transferred to the delivery room table, and the nurse places the client in
the:
1. Trendelenburg’s position with the legs in stirrups

2. Semi-Fowler position with a pillow under the knees
3. Prone position with the legs separated and elevated
4. Supine position with a wedge under the right hip
Ans-4. 4. Vena cava and descending aorta compression by the pregnant uterus impedes blood
return from the lower trunk and extremities. This leads to decreasing cardiac return, cardiac
output, and blood flow to the uterus and the fetus. The best position to prevent this would be
side-lying with the uterus displaced off of abdominal vessels. Positioning for abdominal surgery
necessitates a supine position; however, a wedge placed under the right hip provides
displacement of the uterus.
5. A nurse is caring for a client in labor and prepares to auscultate the fetal heart rate by
using a Doppler ultrasound device. The nurse most accurately determines that the fetal heart
sounds are heard by:
1. Noting if the heart rate is greater than 140 BPM

2. Placing the diaphragm of the Doppler on the mother abdomen
3. Performing Leopold’s maneuvers first to determine the location of the fetal heart
4. Palpating the maternal radial pulse while listening to the fetal heart rate
Ans-5. 4. The nurse simultaneously should palpate the maternal radial or carotid pulse and
auscultate the fetal heart rate to differentiate the two. If the fetal and maternal heart rates are
similar, the nurse may mistake the maternal heart rate for the fetal heart rate. Leopold’s
maneuvers may help the examiner locate the position of the fetus but will not ensure a distinction
between the two rates.
6. A nurse is caring for a client in labor who is receiving Pitocin by IV infusion to stimulate
uterine contractions. Which assessment finding would indicate to the nurse that the infusion
needs to be discontinued?
1. Three contractions occurring within a 10-minute period

2. A fetal heart rate of 90 beats per minute
3. Adequate resting tone of the uterus palpated between contractions
4. Increased urinary output
Ans-6. 2. A normal fetal heart rate is 120-160 BPM. Bradycardia or late or variable decelerations
indicate fetal distress and the need to discontinue to pitocin. The goal of labor augmentation is to
achieve three good-quality contractions in a 10-minute period.
7. A nurse is beginning to care for a client in labor. The physician has prescribed an IV
infusion of Pitocin. The nurse ensures that which of the following is implemented before
initiating the infusion?
1. Placing the client on complete bed rest

2. Continuous electronic fetal monitoring
3. An IV infusion of antibiotics
4. Placing a code cart at the client’s bedside
Ans-7. 2. Continuous electronic fetal monitoring should be implemented during an IV infusion

of Pitocin.
8. A nurse is monitoring a client in active labor and notes that the client is having
contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate
between contractions is 100 BPM. Which of the following nursing actions is most
appropriate?
1. Encourage the client’s coach to continue to encourage breathing exercises

2. Encourage the client to continue pushing with each contraction
3. Continue monitoring the fetal heart rate
4. Notify the physician or nurse mid-wife
Ans-8. 4. A normal fetal heart rate is 120-160 beats per minute. Fetal bradycardia between
contractions may indicate the need for immediate medical management, and the physician or
nurse mid-wife needs to be notified.
9. A nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The
nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing.
Which of the following actions is most appropriate?
1. Document the findings and tell the mother that the monitor indicates fetal well-being
2. Take the mothers vital signs and tell the mother that bed rest is required to conserve oxygen.
3. Notify the physician or nurse mid-wife of the findings.
4. Reposition the mother and check the monitor for changes in the fetal tracing
Ans-9. 1. Accelerations are transient increases in the fetal heart rate that often accompany
contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of
fetal-well-being and adequate oxygen reserve.
10. A nurse is admitting a pregnant client to the labor room and attaches an external
electronic fetal monitor to the client’s abdomen. After attachment of the monitor, the initial
nursing assessment is which of the following?
1. Identifying the types of accelerations

2. Assessing the baseline fetal heart rate
3. Determining the frequency of the contractions
4. Determining the intensity of the contractions
Ans-10. 2. Assessing the baseline fetal heart rate is important so that abnormal variations of the
baseline rate will be identified if they occur. Options 1 and 3 are important to assess, but not as
the first priority.
11. A nurse is reviewing the record of a client in the labor room and notes that the nurse
midwife has documented that the fetus is at -1 station. The nurse determines that the fetal
presenting part is:
1. 1 cm above the ischial spine

2. 1 fingerbreadth below the symphysis pubis
3. 1 inch below the coccyx
4. 1 inch below the iliac crest
Ans-11. 1. Station is the relationship of the presenting part to an imaginary line drawn between
the ischial spines, is measured in centimeters, and is noted as a negative number above the line
and a positive number below the line. At -1 station, the fetal presenting part is 1 cm above the
ischial spines.
12. A pregnant client is admitted to the labor room. An assessment is performed, and the
nurse notes that the client’s hemoglobin and hematocrit levels are low, indicating anemia. The
nurse determines that the client is at risk for which of the following?
1. A loud mouth
2. Low self-esteem
3. Hemorrhage
4. Postpartum infections
Ans-12. 4. Anemic women have a greater likelihood of cardiac decompensation during labor,
postpartum infection, and poor wound healing. Anemia does not specifically present a risk for
hemorrhage. Having a loud mouth is only related to the person typing up this test.
13. A nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse
observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse
documents these observations as signs of:
1. Hematoma
2. Placenta previa
3. Uterine atony
4. Placental separation
Ans-13. 4. As the placenta separates, it settles downward into the lower uterine segment. The
umbilical cord lengthens, and a sudden trickle or spurt of blood appears.
14. A client arrives at a birthing center in active labor. Her membranes are still intact, and the
nurse-midwife prepares to perform an amniotomy. A nurse who is assisting the nurse-midwife
explains to the client that after this procedure, she will most likely have:
1. Less pressure on her cervix

2. Increased efficiency of contractions
3. Decreased number of contractions
4. The need for increased maternal blood pressure monitoring
Ans-14. 2. Amniotomy can be used to induce labor when the condition of the cervix is favorable
(ripe) or to augment labor if the process begins to slow. Rupturing of membranes allows the fetal
head to contact the cervix more directly and may increase the efficiency of contractions.
15. A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if
which of the following is noted on the external monitor tracing during a contraction?
1. Early decelerations
2. Variable decelerations
3. Late decelerations
4. Short-term variability
Ans-15. 2. Variable decelerations occur if the umbilical cord becomes compressed, thus
reducing blood flow between the placenta and the fetus. Early decelerations result from pressure
on the fetal head during a contraction. Late decelerations are an ominous pattern in labor because
it suggests uteroplacental insufficiency during a contraction. Short-term variability refers to the
beat-to-beat range in the fetal heart rate.
16. A nurse explains the purpose of effleurage to a client in early labor. The nurse tells the
client that effleurage is:
1. A form of biofeedback to enhance bearing down efforts during delivery
2. Light stroking of the abdomen to facilitate relaxation during labor and provide tactile
stimulation to the fetus
3. The application of pressure to the sacrum to relieve a backache
4. Performed to stimulate uterine activity by contracting a specific muscle group while other
parts of the body rest
Ans-16. 2. Effleurage is a specific type of cutaneous stimulation involving light stroking of the
abdomen and is used before transition to promote relaxation and relieve mild to moderate pain.
Effleurage provides tactile stimulation to the fetus.
17. A nurse is caring for a client in the second stage of labor. The client is experiencing
uterine contractions every 2 minutes and cries out in pain with each contraction. The nurse
recognizes this behavior as:
1. Exhaustion
2. Fear of losing control
3. Involuntary grunting
4. Valsalva’s maneuver
Ans-17. 2. Pains, helplessness, panicking, and fear of losing control are possible behaviors in the
2nd stage of labor.
18. A nurse is monitoring a client in labor who is receiving Pitocin and notes that the client is
experiencing hypertonic uterine contractions. List in order of priority the actions that the
nurse takes.
1. Stop of Pitocin infusion

2. Perform a vaginal examination
3. Reposition the client
4. Check the client’s blood pressure and heart rate
5. Administer oxygen by face mask at 8 to 10 L/min
Ans-18. 1, 4, 2. 5, 3. If uterine hypertonicity occurs, the nurse immediately would intervene to

reduce uterine activity and increase fetal oxygenation. The nurse would stop the Pitocin infusion
and increase the rate of the nonadditive solution, check maternal BP for hyper or hypotension,
position the woman in a side-lying position, and administer oxygen by snug face mask at 8-10
L/min. The nurse then would attempt to determine the cause of the uterine hypertonicity and
perform a vaginal exam to check for prolapsed cord.-
19. A nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a
slowing labor. The nurse is reviewing the physician’s orders and would expect to note which
of the following prescribed treatments for this condition?
1. Medication that will provide sedation

2. Increased hydration
3. Oxytocin (Pitocin) infusion
4. Administration of a tocolytic medication
Ans-19. 3. Therapeutic management for hypotonic uterine dysfunction includes oxytocin

augmentation and amniotomy to stimulate a labor that slows.
20. A nurse in the labor room is preparing to care for a client with hypertonic uterine
dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that
are erratic in their frequency, duration, and intensity. The priority nursing intervention would
be to:
1. Monitor the Pitocin infusion closel

2. Provide pain relief measures
3. Prepare the client for an amniotomy
4. Promote ambulation every 30 minutes
Ans-20. 2. Management of hypertonic labor depends on the cause. Relief of pain is the primary
intervention to promote a normal labor pattern.
21. A nurse is developing a plan of care for a client experiencing dystocia and includes
several nursing interventions in the plan of care. The nurse prioritizes the plan of care and
selects which of the following nursing interventions as the highest priority?
1. Keeping the significant other informed of the progress of the labor

2. Providing comfort measures
3. Monitoring fetal heart rate
4. Changing the client’s position frequently
Ans-21. 3. The priority is to monitor the fetal heart rate.
22. A maternity nurse is preparing to care for a pregnant client in labor who will be delivering
twins. The nurse monitors the fetal heart rates by placing the external fetal monitor:
1. Over the fetus that is most anterior to the mothers abdomen

2. Over the fetus that is most posterior to the mothers abdomen
3. So that each fetal heart rate is monitored separately
4. So that one fetus is monitored for a 15-minute period followed by a 15 minute fetal
monitoring period for the second fetus
Ans-22. 3. In a client with a multi-fetal pregnancy, each fetal heart rate is monitored separately.
23. A nurse in the postpartum unit is caring for a client who has just delivered a newborn
infant following a pregnancy with placenta previa. The nurse reviews the plan of care and
prepares to monitor the client for which of the following risks associated with placenta previa?
1. Disseminated intravascular coagulation

2. Chronic hypertension
3. Infection
4. Hemorrhage
Ans-23. 4. Because the placenta is implanted in the lower uterine segment, which does not
contain the same intertwining musculature as the fundus of the uterus, this site is more prone to
bleeding.
24. A nurse in the delivery room is assisting with the delivery of a newborn infant. After the
delivery of the newborn, the nurse assists in delivering the placenta. Which observation would
indicate that the placenta has separated from the uterine wall and is ready for delivery?
1. The umbilical cord shortens in length and changes in color

2. A soft and boggy uterus
3. Maternal complaints of severe uterine cramping
4. Changes in the shape of the uterus
Ans-24. 4. Signs of placental separation include lengthening of the umbilical cord, a sudden
gush of dark blood from the introitus (vagina), a firmly contracted uterus, and the uterus
changing from a discoid (like a disk) to a globular (like a globe) shape. The client may
experience vaginal fullness, but not severe uterine cramping. I am going to look more into this
answer. According to our book on page 584, this is not one of our options.
25. A nurse in the labor room is performing a vaginal assessment on a pregnant client in
labor. The nurse notes the presence of the umbilical cord protruding from the vagina. Which
of the following would be the initial nursing action?
1. Place the client in Trendelenburg’s position

2. Call the delivery room to notify the staff that the client will be transported immediately
3. Gently push the cord into the vagina
4. Find the closest telephone and stat page the physician
Ans-25. 1. When cord prolapse occurs, prompt actions are taken to relieve cord compression and
increase fetal oxygenation. The mother should be positioned with the hips higher than the head to
shift the fetal presenting part toward the diaphragm. The nurse should push the call light to
summon help, and other staff members should call the physician and notify the delivery room.
No attempt should be made to replace the cord. The examiner, however, may place a gloved
hand into the vagina and hold the presenting part off of the umbilical cord. Oxygen at 8 to 10
L/min by face mask is delivered to the mother to increase fetal oxygenation.
26. A maternity nurse is caring for a client with abruptio placenta and is monitoring the client
for disseminated intravascular coagulopathy. Which assessment finding is least likely to be
associated with disseminated intravascular coagulation?
1. Swelling of the calf in one leg

2. Prolonged clotting times
3. Decreased platelet count
4. Petechiae, oozing from injection sites, and hematuria
Ans-26. 1. DIC is a state of diffuse clotting in which clotting factors are consumed, leading to
widespread bleeding. Platelets are decreased because they are consumed by the process;
coagulation studies show no clot formation (and are thus normal to prolonged); and fibrin plugs
may clog the microvasculature diffusely, rather than in an isolated area. The presence of
petechiae, oozing from injection sites, and hematuria are signs associated with DIC. Swelling
and pain in the calf of one leg are more likely to be associated with thrombophebitis.
27. A nurse is assessing a pregnant client in the 2nd trimester of pregnancy who was admitted
to the maternity unit with a suspected diagnosis of abruptio placentae. Which of the following
assessment findings would the nurse expect to note if this condition is present?
1. Absence of abdominal pain

2. A soft abdomen
3. Uterine tenderness/pain
4. Painless, bright red vaginal bleeding
Ans-27. 3. In abruptio placentae, acute abdominal pain is present. Uterine tenderness and pain
accompanies placental abruption, especially with a central abruption and trapped blood behind
the placenta. The abdomen will feel hard and boardlike on palpation as the blood penetrates the
myometrium and causes uterine irritability. Observation of the fetal monitoring often reveals
increased uterine resting tone, caused by failure of the uterus to relax in attempt to constrict
blood vessels and control bleeding.
28. A maternity nurse is preparing for the admission of a client in the 3rd trimester of
pregnancy that is experiencing vaginal bleeding and has a suspected diagnosis of placenta
previa. The nurse reviews the physician’s orders and would question which order?
1. Prepare the client for an ultrasound

2. Obtain equipment for external electronic fetal heart monitoring
3. Obtain equipment for a manual pelvic examination
4. Prepare to draw a Hgb and Hct blood sample
Ans-28. 3. Manual pelvic examinations are contraindicated when vaginal bleeding is apparent in
the 3rd trimester until a diagnosis is made and placental previa is ruled out. Digital examination of
the cervix can lead to maternal and fetal hemorrhage. A diagnosis of placenta previa is made by
ultrasound. The H/H levels are monitored, and external electronic fetal heart rate monitoring is
initiated. External fetal monitoring is crucial in evaluating the fetus that is at risk for severe
hypoxia.
29. An ultrasound is performed on a client at term gestation that is experiencing moderate

vaginal bleeding. The results of the ultrasound indicate that an abruptio placenta is present.
Based on these findings, the nurse would prepare the client for:
1. Complete bed rest for the remainder of the pregnancy

2. Delivery of the fetus
3. Strict monitoring of intake and output
4. The need for weekly monitoring of coagulation studies until the time of delivery.
Ans-29. 2. The goal of management in abruptio placentae is to control the hemorrhage and
deliver the fetus as soon as possible. Delivery is the treatment of choice if the fetus is at term
gestation or if the bleeding is moderate to severe and the mother or fetus is in jeopardy.
30. A nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The
nurse would monitor the client closely for the risk of uterine rupture if which of the following
occurred?
1. Hypotonic contractions
2. Forceps delivery
3. Schultz delivery
4. Weak bearing down efforts
Ans-30. 2. Excessive fundal pressure, forceps delivery, violent bearing down efforts, tumultuous
labor, and shoulder dystocia can place a woman at risk for traumatic uterine rupture. Hypotonic
contractions and weak bearing down efforts do not alone add to the risk of rupture because they
do not add to the stress on the uterine wall.
31. A client is admitted to the birthing suite in early active labor. The priority nursing
intervention on admission of this client would be:
1. Auscultating the fetal heart

2. Taking an obstetric history
3. Asking the client when she last ate
4. Ascertaining whether the membranes were ruptured
Ans-31. 1. Determining the fetal well-being supersedes all other measures. If the FHR is absent
or persistently decelerating, immediate intervention is required.
32. A client who is gravida 1, para 0 is admitted in labor. Her cervix is 100% effaced, and she is
dilated to 3 cm. Her fetus is at +1 station. The nurse is aware that the fetus’ head is:
1. Not yet engaged

2. Entering the pelvic inlet
3. Below the ischial spines
4. Visible at the vaginal opening
Ans-32. 3. A station of +1 indicates that the fetal head is 1 cm below the ischial spines.
33. After doing Leopold’s maneuvers, the nurse determines that the fetus is in the ROP
position. To best auscultate the fetal heart tones, the Doppler is placed:
1. Above the umbilicus at the midline
2. Above the umbilicus on the left side
3. Below the umbilicus on the right side
4. Below the umbilicus near the left groin
Ans-33. 3. Fetal heart tones are best auscultated through the fetal back; because the position is
ROP (right occiput presenting), the back would be below the umbilicus and on the right side.
34. The physician asks the nurse the frequency of a laboring client’s contractions. The nurse
assesses the client’s contractions by timing from the beginning of one contraction:
1. Until the time it is completely over

2. To the end of a second contraction
3. To the beginning of the next contraction
4. Until the time that the uterus becomes very firm
Ans34. 3. This is the way to determine the frequency of the contractions
35. The nurse observes the client’s amniotic fluid and decides that it appears normal, because
it is:
1. Clear and dark amber in color

2. Milky, greenish yellow, containing shreds of mucus
3. Clear, almost colorless, and containing little white specks
4. Cloudy, greenish-yellow, and containing little white specks
Ans-35. 3. By 36 weeks’ gestation, normal amniotic fluid is colorless with small particles of
vernix caseosa present.
36. At 38 weeks’ gestation, a client is having late decelerations. The fetal pulse oximeter
shows 75% to 85%. The nurse should:
1. Discontinue the catheter, if the reading is not above 80%

2. Discontinue the catheter, if the reading does not go below 30%
3. Advance the catheter until the reading is above 90% and continue monitoring
4. Reposition the catheter, recheck the reading, and if it is 55%, keep monitoring
Ans-36. 4. Adjusting the catheter would be indicated. Normal fetal pulse oximetry should be
between 30% and 70%. 75% to 85% would indicate maternal readings.
37. When examining the fetal monitor strip after rupture of the membranes in a laboring
client, the nurse notes variable decelerations in the fetal heart rate. The nurse should:
1. Stop the oxytocin infusion

2. Change the client’s position
3. Prepare for immediate delivery
4. Take the client’s blood pressure
Ans-37. 2. Variable decelerations usually are seen as a result of cord compression; a change of
position will relieve pressure on the cord.
38. When monitoring the fetal heart rate of a client in labor, the nurse identifies an elevation
of 15 beats above the baseline rate of 135 beats per minute lasting for 15 seconds. This should
be documented as:
1. An acceleration
2. An early elevation
3. A sonographic motion
4. A tachycardic heart rate
Ans-38. 1. An acceleration is an abrupt elevation above the baseline of 15 beats per minute for
15 seconds; if the acceleration persists for more than 10 minutes it is considered a change in
baseline rate. A tachycardic FHR is above 160 beats per minute.
39. A laboring client complains of low back pain. The nurse replies that this pain occurs most
when the position of the fetus is:
1. Breech
2. Transverse
3. Occiput anterior
4. Occiput posterior
Ans-39. 4. A persistent occiput-posterior position causes intense back pain because of fetal
compression of the sacral nerves. Occiput anterior is the most common fetal position and does
not cause back pain.
40. The breathing technique that the mother should be instructed to use as the fetus’ head is
crowning is:
1. Blowing
2. Slow chest
3. Shallow
4. Accelerated-decelerated
Ans-40. 1. Blowing forcefully through the mouth controls the strong urge to push and allows for
a more controlled birth of the head.
41. During the period of induction of labor, a client should be observed carefully for signs of:
1. Severe pain
2. Uterine tetany
3. Hypoglycemia
4. Umbilical cord prolapse
Ans-41. 2. Uterine tetany could result from the use of oxytocin to induce labor. Because
oxytocin promotes powerful uterine contractions, uterine tetany may occur. The oxytocin
infusion must be stopped to prevent uterine rupture and fetal compromise.
42. A client arrives at the hospital in the second stage of labor. The fetus’ head is crowning,
the client is bearing down, and the birth appears imminent. The nurse should:
1. Transfer her immediately by stretcher to the birthing unit

2. Tell her to breathe through her mouth and not to bear down
3. Instruct the client to pant during contractions and to breathe through her mouth
4. Support the perineum with the hand to prevent tearing and tell the client to pant.
Ans-42. 4. Gentle pressure is applied to the baby’s head as it emerges so it is not born too
rapidly. The head is never held back, and it should be supported as it emerges so there will be no
vaginal lacerations. It is impossible to push and pant at the same time.
43. A laboring client is to have a pudendal block. The nurse plans to tell the client that once
the block is working she:
1. Will not feel the episiotomy

2. May lose bladder sensation
3. May lose the ability to push
4. Will no longer feel contractions
Ans-43. 1. A pudendal block provides anesthesia to the perineum.
44. Which of the following observations indicates fetal distress?
1. Fetal scalp pH of 7.14

2. Fetal heart rate of 144 beats/minute
3. Acceleration of fetal heart rate with contractions
4. Presence of long term variability
Ans-44. 1. A fetal scalp pH below 7.25 indicates acidosis and fetal hypoxia.
45. Which of the following fetal positions is most favorable for birth?
1. Vertex presentation
2. Transverse lie
3. Frank breech presentation
4. Posterior position of the fetal head
Ans-45. 1. Vertex presentation (flexion of the fetal head) is the optimal presentation for passage
through the birth canal. Transverse lie is an unacceptable fetal position for vaginal birth and
requires a C-section. Frank breech presentation, in which the buttocks present first, can be a
difficult vaginal delivery. Posterior positioning of the fetal head can make it difficult for the fetal
head to pass under the maternal symphysis pubis.
46. A laboring client has external electronic fetal monitoring in place. Which of the following
assessment data can be determined by examining the fetal heart rate strip produced by the
external electronic fetal monitor?
1. Gender of the fetus

2. Fetal position
3. Labor progress
4. Oxygenation
Ans-46. 4. Oxygenation of the fetus may be indirectly assessed through fetal monitoring by
closely examining the fetal heart rate strip. Accelerations in the fetal heart rate strip indicate
good oxygenation, while decelerations in the fetal heart rate sometimes indicate poor fetal
oxygenation.
47. A laboring client is in the first stage of labor and has progressed from 4 to 7 cm in
cervical dilation. In which of the following phases of the first stage does cervical dilation
occur most rapidly?
1. Preparatory phase
2. Latent phase
3. Active phase
4. Transition phase
Ans-47. 3. Cervical dilation occurs more rapidly during the active phase than any of the
previous phases. The active phase is characterized by cervical dilation that progresses from 4 to 7
cm. The preparatory, or latent, phase begins with the onset of regular uterine contractions and
ends when rapid cervical dilation begins. Transition is defined as cervical dilation beginning at 8
cm and lasting until 10 cm or complete dilation.
48. A multiparous client who has been in labor for 2 hours states that she feels the urge to
move her bowels. How should the nurse respond?
1. Let the client get up to use the potty

2. Allow the client to use a bedpan
3. Perform a pelvic examination
4. Check the fetal heart rate
Ans-48. 3. A complaint of rectal pressure usually indicates a low presenting fetal part, signaling
imminent delivery. The nurse should perform a pelvic examination to assess the dilation of the
cervix and station of the presenting fetal part. Don’t let the client use the potty or bedpan before
she is examined because she could birth that there baby right there in that darn potty.
49. Labor is a series of events affected by the coordination of the five essential factors. One of
these is the passenger (fetus). Which are the other four factors?
1. Contractions, passageway, placental position and function, pattern of care

2. Contractions, maternal response, placental position, psychological response
3. Passageway, contractions, placental position and function, psychological response
4. Passageway, placental position and function, paternal response, psychological response
Ans-49. 3. The five essential factors (5 P’s) are passenger (fetus), passageway (pelvis), powers
(contractions), placental position and function, and psyche (psychological response of the
mother).
50. Fetal presentation refers to which of the following descriptions?
1. Fetal body part that enters the maternal pelvis first

2. Relationship of the presenting part to the maternal pelvis
3. Relationship of the long axis of the fetus to the long axis of the mother
4. A classification according to the fetal part
Ans-50. 1. Presentation is the fetal body part that enters the pelvis first; it’s classified by the
presenting part; the three main presentations are cephalic/occipital, breech, and shoulder. The
relationship of the presenting fetal part to the maternal pelvis refers to fetal position. The
relationship of the long axis to the fetus to the long axis of the mother refers to fetal lie; the three
possible lies are longitudinal, transverse, and oblique.
51. A client is admitted to the L & D suite at 36 weeks’ gestation. She has a history of C-
section and complains of severe abdominal pain that started less than 1 hour earlier. When the
nurse palpates titanic contractions, the client again complains of severe pain. After the client
vomits, she states that the pain is better and then passes out. Which is the probable cause of
her signs and symptoms?
1. Hysteria compounded by the flu

2. Placental abruption
3. Uterine rupture
4. Dysfunctional labor
Ans-51. 3. Uterine rupture is a medical emergency that may occur before or during labor. Signs
and symptoms typically include abdominal pain that may ease after uterine rupture, vomiting,
vaginal bleeding, hypovolemic shock, and fetal distress. With placental abruption, the client
typically complains of vaginal bleeding and constant abdominal pain.
52. Upon completion of a vaginal examination on a laboring woman, the nurse records: 50%,
6 cm, -1. Which of the following is a correct interpretation of the data?
1. Fetal presenting part is 1 cm above the ischial spines
2. Effacement is 4 cm from completion
3. Dilation is 50% completed
4. Fetus has achieved passage through the ischial spines
Ans-52. 1. Station of – 1 indicates that the fetal presenting part is above the ischial spines and
has not yet passed through the pelvic inlet. A station of zero would indicate that the presenting
part has passed through the inlet and is at the level of the ischial spines or is engaged. Passage
through the ischial spines with internal rotation would be indicated by a plus station, such as + 1.
Progress of effacement is referred to by percentages with 100% indicating full effacement and
dilation by centimeters (cm) with 10 cm indicating full dilation.
53. Which of the following findings meets the criteria of a reassuring FHR pattern?
1. FHR does not change as a result of fetal activity

2. Average baseline rate ranges between 100 – 140 BPM
3. Mild late deceleration patterns occur with some contractions
4. Variability averages between 6 – 10 BPM
Ans-53. 4. Variability indicates a well oxygenated fetus with a functioning autonomic nervous
system. FHR should accelerate with fetal movement. Baseline range for the FHR is 120 to 160
beats per minute. Late deceleration patterns are never reassuring, though early and mild variable
decelerations are expected, reassuring findings.
54. Late deceleration patterns are noted when assessing the monitor tracing of a woman
whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying
position, and her vital signs are stable and fall within a normal range. Contractions are
intense, last 90 seconds, and occur every 1 1/2 to 2 minutes. The nurse’s immediate action
would be to:
1. Change the woman’s position

2. Stop the Pitocin
3. Elevate the woman’s legs
4. Administer oxygen via a tight mask at 8 to 10 liters/minute
Ans-54. 2. Late deceleration patterns noted are most likely related to alteration in uteroplacental
perfusion associated with the strong contractions described. The immediate action would be to
stop the Pitocin infusion since Pitocin is an oxytocic which stimulates the uterus to contract. The
woman is already in an appropriate position for uteroplacental perfusion. Elevation of her legs
would be appropriate if hypotension were present. Oxygen is appropriate but not the immediate
action.
55. The nurse should realize that the most common and potentially harmful maternal
complication of epidural anesthesia would be:
1. Severe postpartum headache

2. Limited perception of bladder fullness
3. Increase in respiratory rate
4. Hypotension
Ans-55. 4. Epidural anesthesia can lead to vasodilation and a drop in blood pressure that could
interfere with adequate placental perfusion. The woman must be well hydrated before and
during epidural anesthesia to prevent this problem and maintain an adequate blood pressure.
Headache is not a side effect since the spinal fluid is not disturbed by this anesthetic as it would
be with a low spinal (saddle block) anesthetic; 2 is an effect of epidural anesthesia but is not the
most harmful. Respiratory depression is a potentially serious complication.
OB/GYN 2 – Antepartum
1. A nursing instructor is conducting lecture and is reviewing the functions of the female
reproductive system. She asks Mark to describe the follicle-stimulating hormone (FSH)
and the luteinizing hormone (LH). Mark accurately responds by stating that:
1. FSH and LH are released from the anterior pituitary gland.

2. FSH and LH are secreted by the corpus luteum of the ovary
3. FSH and LH are secreted by the adrenal glands
4. FSH and LH stimulate the formation of milk during pregnancy.
Ans-1. 1. FSH and LH, when stimulated by gonadotropin-releasing hormone from the
hypothalamus, are released from the anterior pituitary gland to stimulate follicular growth and
development, growth of the graafian follicle, and production of progesterone.
2. A nurse is describing the process of fetal circulation to a client during a prenatal visit. The
nurse accurately tells the client that fetal circulation consists of:
1. Two umbilical veins and one umbilical artery

2. Two umbilical arteries and one umbilical vein
3. Arteries carrying oxygenated blood to the fetus
4. Veins carrying deoxygenated blood to the fetus
Ans-2. 2. Blood pumped by the embryo’s heart leaves the embryo through two umbilical arteries.
Once oxygenated, the blood then is returned by one umbilical vein. Arteries carry deoxygenated
blood and waste products from the fetus, and veins carry oxygenated blood and provide oxygen
and nutrients to the fetus.
3. During a prenatal visit at 38 weeks, a nurse assesses the fetal heart rate. The nurse
determines that the fetal heart rate is normal if which of the following is noted?
1. 80 BPM
2. 100 BPM
3. 150 BPM
4. 180 BPM
Ans-3. 3. The fetal heart rate depends in gestational age and ranges from 160-170 BPM in the
first trimester but slows with fetal growth to 120-160 BPM near or at term. At or near term, if the
fetal heart rate is less than 120 or more than 160 BPM with the uterus at rest, the fetus may be in
distress.
4. A client arrives at a prenatal clinic for the first prenatal assessment. The client tells a
nurse that the first day of her last menstrual period was September 19th, 2005. Using Nagele’s
rule, the nurse determines the estimated date of confinement as:
1. July 26, 2006

2. June 12, 2007
3. June 26, 2006
4. July 12, 2007
Ans-4. 3. Accurate use of Nagele’s rule requires that the woman have a regular 28-day menstrual
cycle. Add 7 days to the first day of the last menstrual period, subtract three months, and then
add one year to that date.
5. A nurse is collecting data during an admission assessment of a client who is pregnant
with twins. The client has a healthy 5-year old child that was delivered at 37 weeks and tells
the nurse that she doesn’t have any history of abortion or fetal demise. The nurse would
document the GTPAL for this client as:
1. G = 3, T = 2, P = 0, A = 0, L =1
2. G = 2, T = 0, P = 1, A = 0, L =1
3. G = 1, T = 1. P = 1, A = 0, L = 1
4. G = 2, T = 0, P = 0, A = 0, L = 1
Ans-5. 2. Pregnancy outcomes can be described with the acronym GTPAL. G is gravidity, the
number of pregnancies. T is term births, the number born at term (38-41 weeks). P is preterm
births, the number born before 38 weeks gestation. A is abortions or miscarriages (included in
gravida if before 20 weeks gestation; included in parity if past 20 weeks gestation). L is live
births, the number of live births or living children. Therefore, a woman who is pregnant with
twins and has a child has a gravida of 2. Because the child was delivered at 37 weeks, the
number of preterm births is 1, and the number of term births is 0. The number of abortions is 0,
and the number of live births is 1.
6. A nurse is performing an assessment of a primapira who is being evaluated in a clinic
during her second trimester of pregnancy. Which of the following indicates an abnormal
physical finding necessitating further testing?
1. Consistent increase in fundal height

2. Fetal heart rate of 180 BPM
3. Braxton hicks contractions
4. Quickening
Ans-6. 2. The normal range of the fetal heart rate depends on gestational age. The heart rate is
usually 160-170 BPM in the first trimester and slows with fetal growth, near and at term, the
fetal heart rate ranges from 120-160 BPM. The other options are expected.
7. A nurse is reviewing the record of a client who has just been told that a pregnancy test is
positive. The physician has documented the presence of a Goodell’s sign. The nurse
determines this sign indicates:
1. A softening of the cervix

2. A soft blowing sound that corresponds to the maternal pulse during auscultation of the
uterus.
3. The presence of hCG in the urine
4. The presence of fetal movement
Ans-7. 1. In the early weeks of pregnancy the cervix becomes softer as a result of increased
vascularity and hyperplasia, which causes the Goodell’s sign.
8. A nursing instructor asks a nursing student who is preparing to assist with the assessment
of a pregnant client to describe the process of quickening. Which of the following statements if
made by the student indicates an understanding of this term?
1. “It is the irregular, painless contractions that occur throughout pregnancy.”

2. “It is the soft blowing sound that can be heard when the uterus is auscultated.”
3. “It is the fetal movement that is felt by the mother.”
4. “It is the thinning of the lower uterine segment.”
Ans-8. 3. Quickening is fetal movement and may occur as early as the 16th and 18th week of
gestation, and the mother first notices subtle fetal movements that gradually increase in intensity.
Braxton Hicks contractions are irregular, painless contractions that may occur throughout the
pregnancy. A thinning of the lower uterine segment occurs about the 6th week of pregnancy and
is called Hegar’s sign.
9. A nurse midwife is performing an assessment of a pregnant client and is assessing the
client for the presence of ballottement. Which of the following would the nurse implement to
test for the presence of ballottement?
1. Auscultating for fetal heart sounds
2. Palpating the abdomen for fetal movement
3. Assessing the cervix for thinning
4. Initiating a gentle upward tap on the cervix
Ans-9. 4. Ballottement is a technique of palpating a floating structure by bouncing it gently and

feeling it rebound. In the technique used to palpate the fetus, the examiner places a finger in the
vagina and taps gently upward, causing the fetus to rise. The fetus then sinks, and the examiner
feels a gentle tap on the finger.
10. A nurse is assisting in performing an assessment on a client who suspects that she is
pregnant and is checking the client for probable signs of pregnancy. Select allprobable signs
of pregnancy.
1. Uterine enlargement
2. Fetal heart rate detected by nonelectric device
3. Outline of the fetus via radiography or ultrasound
4. Chadwick’s sign
5. Braxton Hicks contractions
6. Ballottement
Ans-10. 1, 4, 5, and 6. The probable signs of pregnancy include uterine enlargement, Hegar’s

sign (softening and thinning of the uterine segment that occurs at week 6), Goodell’s sign
(softening of the cervix that occurs at the beginning of the 2nd month), Chadwick’s sign (bluish
coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at week 6),
ballottement (rebounding of the fetus against the examiners fingers of palpation), Braxton Hicks
contractions and a positive pregnancy test measuring for hCG. Positive signs of pregnancy
include fetal heart rate detected by electronic device (Doppler) at 10-12 weeks and by
nonelectronic device (fetoscope) at 20 weeks gestation, active fetal movements palpable by the
examiner, and an outline of the fetus via radiography or ultrasound.
11. A pregnant client calls the clinic and tells a nurse that she is experiencing leg cramps and
is awakened by the cramps at night. To provide relief from the leg cramps, the nurse tells the
client to:
1. Dorsiflex the foot while extending the knee when the cramps occur
2. Dorsiflex the foot while flexing the knee when the cramps occur
3. Plantar flex the foot while flexing the knee when the cramps occur
4. Plantar flex the foot while extending the knee when the cramps occur.
Ans-11. 1. Legs cramps occur when the pregnant woman stretches the leg and plantar flexes the
foot. Dorsiflexion of the foot while extending the knee stretches the affected muscle, prevents the
muscle from contracting, and stops the cramping.
12. A nurse is providing instructions to a client in the first trimester of pregnancy regarding
measures to assist in reducing breast tenderness. The nurse tells the client to:
1. Avoid wearing a bra
2. Wash the nipples and areola area daily with soap, and massage the breasts with lotion.
3. Wear tight-fitting blouses or dresses to provide support
4. Wash the breasts with warm water and keep them dry
Ans-12. 4. The pregnant woman should be instructed to wash the breasts with warm water and
keep them dry. The woman should be instructed to avoid using soap on the nipples and areola
area to prevent the drying of tissues. Wearing a supportive bra with wide adjustable straps can
decrease breast tenderness. Tight-fitting blouses or dresses will cause discomfort (especially on
test days, even if you’re not pregnant. Yo.).
13. A pregnant client in the last trimester has been admitted to the hospital with a diagnosis of
severe preeclampsia. A nurse monitors for complications associated with the diagnosis and
assesses the client for:
1. Any bleeding, such as in the gums, petechiae, and purpura.

2. Enlargement of the breasts
3. Periods of fetal movement followed by quiet periods
4. Complaints of feeling hot when the room is cool
Ans-13. 1. Severe Preeclampsia can trigger disseminated intravascular coagulation (DIC;

remember the Peds lecture?) because of the widespread damage to vascular integrity. Bleeding is
an early sign of DIC and should be reported to the M.D.
14. A client in the first trimester of pregnancy arrives at a health care clinic and reports that
she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse
instructs the client regarding management of care. Which statement, if made by the client,
indicates a need for further education?
1. “I will maintain strict bedrest throughout the remainder of pregnancy.”

2. “I will avoid sexual intercourse until the bleeding has stopped, and for 2 weeks following
the last evidence of bleeding.”
3. “I will count the number of perineal pads used on a daily basis and note the amount and
color of blood on the pad.”
4. “I will watch for the evidence of the passage of tissue.”
Ans-14. 1. Strict bed rest throughout the remainder of pregnancy is not required. The woman is
advised to curtail sexual activities until the bleeding has ceased, and for 2 weeks following the
last evidence of bleeding or as recommended by the physician. The woman is instructed to count
the number of perineal pads used daily and to note the quantity and color of blood on the pad.
The woman also should watch for the evidence of the passage of tissue.
15. A prenatal nurse is providing instructions to a group of pregnant client regarding

measures to prevent toxoplasmosis. Which statement if made by one of the clients indicates
a need for further instructions?
1. “I need to cook meat thoroughly.”
2. “I need to avoid touching mucous membranes of the mouth or eyes while handling raw
meat.”
3. “I need to drink unpasteurized milk only.”
4. “I need to avoid contact with materials that are possibly contaminated with cat feces.”
Ans-15. 3. All pregnant women should be advised to do the following to prevent the
development of toxoplasmosis. Women should be instructed to cook meats thoroughly, avoid
touching mucous membranes and eyes while handling raw meat; thoroughly wash all kitchen
surfaces that come into contact with uncooked meat, wash the hands thoroughly after handling
raw meat; avoid uncooked eggs and unpasteurized milk; wash fruits and vegetables before
consumption, and avoid contact with materials that possibly are contaminated with cat feces,
such as cat litter boxes, sand boxes, and garden soil.
16. A homecare nurse visits a pregnant client who has a diagnosis of mild Preeclampsia and
who is being monitored for pregnancy induced hypertension (PIH). Which assessment
finding indicates a worsening of the Preeclampsia and the need to notify the physician?
1. Blood pressure reading is at the prenatal baseline

2. Urinary output has increased
3. The client complains of a headache and blurred vision
4. Dependent edema has resolved
Ans-16. 3. If the client complains of a headache and blurred vision, the physician should be
notified because these are signs of worsening Preeclampsia.
17. A nurse implements a teaching plan for a pregnant client who is newly diagnosed with
gestational diabetes. Which statement if made by the client indicates a need for further
education?
1. “I need to stay on the diabetic diet.”

2. “I will perform glucose monitoring at home.”
3. “I need to avoid exercise because of the negative effects of insulin production.”
4. “I need to be aware of any infections and report signs of infection immediately to my
health care provider.”
Ans-17. 3. Exercise is safe for the client with gestational diabetes and is helpful in lowering the
blood glucose level.
18. A primagravida is receiving magnesium sulfate for the treatment of pregnancy induced
hypertension (PIH). The nurse who is caring for the client is performing assessments every
30 minutes. Which assessment finding would be of most concern to the nurse?
1. Urinary output of 20 ml since the previous assessment

2. Deep tendon reflexes of 2+
3. Respiratory rate of 10 BPM
4. Fetal heart rate of 120 BPM
Ans-18. 3. Magnesium sulfate depresses the respiratory rate. If the respiratory rate is less than 12
breaths per minute, the physician or other health care provider needs to be notified, and
continuation of the medication needs to be reassessed. A urinary output of 20 ml in a 30 minute
period is adequate; less than 30 ml in one hour needs to be reported. Deep tendon reflexes of 2+
are normal. The fetal heart rate is WNL for a resting fetus.
19. A nurse is caring for a pregnant client with Preeclampsia. The nurse prepares a plan of
care for the client and documents in the plan that if the client progresses from Preeclampsia to
eclampsia, the nurse’s first action is to:
1. Administer magnesium sulfate intravenously

2. Assess the blood pressure and fetal heart rate
3. Clean and maintain an open airway
4. Administer oxygen by face mask
Ans-3. The immediate care during a seizure (eclampsia) is to ensure a patent airway. The other
options are actions that follow or will be implemented after the seizure has ceased.
20. A nurse is monitoring a pregnant client with pregnancy induced hypertension who is at
risk for Preeclampsia. The nurse checks the client for which specific signs of Preeclampsia
(select all that apply)?
1. Elevated blood pressure

2. Negative urinary protein
3. Facial edema
4. Increased respirations
Ans-20. 1 and 3. The three classic signs of preeclampsia are hypertension, generalized edema,
and protenuria. Increased respirations are not a sign of preeclampsia.
21. Rho (D) immune globulin (RhoGAM) is prescribed for a woman following delivery of a
newborn infant and the nurse provides information to the woman about the purpose of the
medication. The nurse determines that the woman understands the purpose of the medication
if the woman states that it will protect her next baby from which of the following?
1. Being affected by Rh incompatibility

2. Having Rh positive blood
3. Developing a rubella infection
4. Developing physiological jaundice
Ans-21. 1. Rh incompatibility can occur when an Rh-negative mom becomes sensitized to the Rh
antigen. Sensitization may develop when an Rh-negative woman becomes pregnant with a fetus
who is Rh positive. During pregnancy and at delivery, some of the baby’s Rh positive blood can
enter the maternal circulation, causing the woman’s immune system to form antibodies against
Rh positive blood. Administration of Rho(D) immune globulin prevents the woman from
developing antibodies against Rh positive blood by providing passive antibody protection against
the Rh antigen.
22. A pregnant client is receiving magnesium sulfate for the management of preeclampsia. A
nurse determines the client is experiencing toxicity from the medication if which of the
following is noted on assessment?
1. Presence of deep tendon reflexes

2. Serum magnesium level of 6 mEq/L
3. Proteinuria of +3
4. Respirations of 10 per minute
Ans-22. 4. Magnesium toxicity can occur from magnesium sulfate therapy. Signs of toxicity
relate to the central nervous system depressant effects of the medication and include respiratory
depression, loss of deep tendon reflexes, and a sudden drop in the fetal heart rate and maternal
heart rate and blood pressure. Therapeutic levels of magnesium are 4-7 mEq/L. Proteinuria of +3
would be noted in a client with preeclampsia.
23. A woman with preeclampsia is receiving magnesium sulfate. The nurse assigned to care
for the client determines that the magnesium therapy is effective if:
1. Ankle clonus in noted
2. The blood pressure decreases
3. Seizures do not occur
4. Scotoma’s are present
Ans-23. 3. For a client with preeclampsia, the goal of care is directed at preventing eclampsia
(seizures). Magnesium sulfate is an anticonvulsant, not an antihypertensive agent. Although a
decrease in blood pressure may be noted initially, this effect is usually transient. Ankle clonus
indicated hyperrelexia and may precede the onset of eclampsia. Scotomas are areas of complete
or partial blindness. Visual disturbances, such as scotomas, often precede an eclamptic seizure.
24. A nurse is caring for a pregnant client with severe preeclampsia who is receiving IV
magnesium sulfate. Select all nursing interventions that apply in the care for the client.
1. Monitor maternal vital signs every 2 hours

2. Notify the physician if respirations are less than 18 per minute.
3. Monitor renal function and cardiac function closely
4. Keep calcium gluconate on hand in case of a magnesium sulfate overdose
5. Monitor deep tendon reflexes hourly
6. Monitor I and O’s hourly
7. Notify the physician if urinary output is less than 30 ml per hour.
Ans-24. 3, 4, 5, 6, and 7. When caring for a client receiving magnesium sulfate therapy, the nurse
would monitor maternal vital signs, especially respirations, every 30-60 minutes and notify the
physician if respirations are less than 12, because this would indicate respiratory depression.
Calcium gluconate is kept on hand in case of magnesium sulfate overdose, because calcium
gluconate is the antidote for magnesium sulfate toxicity. Deep tendon reflexes are assessed
hourly. Cardiac and renal function is monitored closely. The urine output should be maintained
at 30 ml per hour because the medication is eliminated through the kidneys.
25. In the 12th week of gestation, a client completely expels the products of conception.
Because the client is Rh negative, the nurse must:
1. Admister RhoGAM within 72 hours

2. Make certain she receives RhoGAM on her first clinic visit
3. Not give RhoGAM, since it is not used with the birth of a stillborn
4. Make certain the client does not receive RhoGAM, since the gestation only lasted 12
weeks.
Ans-25. 1. RhoGAM is given within 72 hours postpartum if the client has not been sensitized
already.
26. In a lecture on sexual functioning, the nurse plans to include the fact that ovulation
occurs when the:
1. Oxytocin is too high

2. Blood level of LH is too high
3. Progesterone level is high
4. Endometrial wall is sloughed off.
Ans-26. 2. It is the surge of LH secretion in midcycle that is responsible for ovulation.
27. The chief function of progesterone is the:
1. Development of the female reproductive system

2. Stimulation of the follicles for ovulation to occur
3. Preparation of the uterus to receive a fertilized egg
4. Establishment of secondary male sex characteristics
Ans-27. 3. Progesterone stimulates differentiation of the endometrium into a secretory type of

tissue.
28. The developing cells are called a fetus from the:
1. Time the fetal heart is heard

2. Eighth week to the time of birth
3. Implantation of the fertilized ovum
4. End of the send week to the onset of labor
Ans-28. 2. In the first 7-14 days the ovum is known as a blastocyst; it is called an embryo until
the eighth week; the developing cells are then called a fetus until birth.
29. After the first four months of pregnancy, the chief source of estrogen and progesterone is
the:
1. Placenta
2. Adrenal cortex
3. Corpus luteum
4. Anterior hypophysis
Ans-29. 1. When placental formation is complete, around the 16th week of pregnancy; it produces
estrogen and progesterone.
30. The nurse recognizes that an expected change in the hematologic system that occurs
during the 2nd trimester of pregnancy is:
1. A decrease in WBC’s
2. In increase in hematocrit
3. An increase in blood volume
4. A decrease in sedimentation rate
Ans-30. 3. The blood volume increases by approximately 40-50% during pregnancy. The peak
blood volume occurs between 30 and 34 weeks of gestation. The hematocrit decreases as a result
of the increased blood volume.
31. The nurse is aware than an adaptation of pregnancy is an increased blood supply to the
pelvic region that results in a purplish discoloration of the vaginal mucosa, which is known
as:
1. Ladin’s sign
2. Hegar’s sign
3. Goodell’s sign
4. Chadwick’s sign
Ans-31. 4. A purplish color results from the increased vascularity and blood vessel engorgement
of the vagina.
32. A pregnant client is making her first Antepartal visit. She has a two year old son born at 40
weeks, a 5 year old daughter born at 38 weeks, and 7 year old twin daughters born at 35
weeks. She had a spontaneous abortion 3 years ago at 10 weeks. Using the GTPAL format, the
nurse should identify that the client is:
1. G4 T3 P2 A1 L4
2. G5 T2 P2 A1 L4
3. G5 T2 P1 A1 L4
4. G4 T3 P1 A1 L4
Ans-32. 3. 5 pregnancies; 2 term births; twins count as 1; one abortion; 4 living children.
33. An expected cardiopulmonary adaptation experienced by most pregnant women is:
1. Tachycardia
2. Dyspnea at rest
3. Progression of dependent edema
4. Shortness of breath on exertion
Ans-33. 4. This is an expected cardiopulmonary adaptation during pregnancy; it is caused by an

increased ventricular rate and elevated diaphragm.
34. Nutritional planning for a newly pregnant woman of average height and weighing 145
pounds should include:
1. A decrease of 200 calories a day

2. An increase of 300 calories a day
3. An increase of 500 calories a day
4. A maintenance of her present caloric intake per day
Ans-34. 2. This is the recommended caloric increase for adult women to meet the increased
metabolic demands of pregnancy.
35. During a prenatal examination, the nurse draws blood from a young Rh negative client
and explain that an indirect Coombs test will be performed to predict whether the fetus is at
risk for:
1. Acute hemolytic disease

2. Respiratory distress syndrome
3. Protein metabolic deficiency
4. Physiologic hyperbilirubinemia
Ans-35. 1. When an Rh negative mother carries an Rh positive fetus there is a risk for maternal
antibodies against Rh positive blood; antibodies cross the placenta and destroy the fetal RBC’s.
36. When involved in prenatal teaching, the nurse should advise the clients that an increase in
vaginal secretions during pregnancy is called leukorrhea and is caused by increased:
1. Metabolic rates
2. Production of estrogen
3. Functioning of the Bartholin glands
4. Supply of sodium chloride to the cells of the vagina
Ans-36. 2. The increase of estrogen during pregnancy causes hyperplasia of the vaginal mucosa,
which leads to increased production of mucus by the endocervical glands. The mucus contains
exfoliated epithelial cells.
37. A 26-year old multigravida is 14 weeks’ pregnant and is scheduled for an alpha-
fetoprotein test. She asks the nurse, “What does the alpha-fetoprotein test indicate?” The
nurse bases a response on the knowledge that this test can detect:
1. Kidney defects
2. Cardiac defects
3. Neural tube defects
4. Urinary tract defects
Ans-37. 3. The alpha-fetoprotein test detects neural tube defects and Down syndrome.
38. At a prenatal visit at 36 weeks’ gestation, a client complains of discomfort with irregularly
occurring contractions. The nurse instructs the client to:
1. Lie down until they stop

2. Walk around until they subside
3. Time contraction for 30 minutes
4. Take 10 grains of aspirin for the discomfort
Ans-38. 2. Ambulation relieves Braxton Hicks.
39. The nurse teaches a pregnant woman to avoid lying on her back. The nurse has based this
statement on the knowledge that the supine position can:
1. Unduly prolong labor

2. Cause decreased placental perfusion
3. Lead to transient episodes of hypotension
4. Interfere with free movement of the coccyx
Ans-39. 2. This is because impedance of venous return by the gravid uterus, which causes
hypotension and decreased systemic perfusion.
40. The pituitary hormone that stimulates the secretion of milk from the mammary glands is:
1. Prolactin
2. Oxytocin
3. Estrogen
4. Progesterone
Ans-40. 1. Prolactin is the hormone from the anterior pituitary gland that stimulates mammary
gland secretion. Oxytocin, a posterior pituitary hormone, stimulates the uterine musculature to
contract and causes the “let down” reflex.
41. Which of the following symptoms occurs with a hydatidiform mole?
1. Heavy, bright red bleeding every 21 days

2. Fetal cardiac motion after 6 weeks gestation
3. Benign tumors found in the smooth muscle of the uterus
4. “snowstorm” pattern on ultrasound with no fetus or gestational sac
Ans-41. 4. The chorionic villi of a molar pregnancy resemble a snowstorm pattern on ultrasound.
Bleeding with a hydatidiform mole is often dark brown and may occur erratically for weeks or
months.
42. Which of the following terms applies to the tiny, blanced, slightly raised end arterioles
found on the face, neck, arms, and chest during pregnancy?
1. Epulis
2. Linea nigra
3. Striae gravidarum
4. Telangiectasias
Ans-42. 4. The dilated arterioles that occur during pregnancy are due to the elevated level of
circulating estrogen. The linea nigra is a pigmented line extending from the symphysis pubis to
the top of the fundus during pregnancy.
43. Which of the following conditions is common in pregnant women in the 2ndtrimester of
pregnancy?
1. Mastitis
3. Physiologic anemia
Ans-43. 3. Hemoglobin and hematocrit levels decrease during pregnancy as the increase in
plasma volume exceeds the increase in red blood cell production.
44. A 21-year old client, 6 weeks’ pregnant is diagnosed with hyperemesis gravidarum. This
excessive vomiting during pregnancy will often result in which of the following conditions?
1. Bowel perforation
2. Electrolyte imbalance
3. Miscarriage
4. Pregnancy induced hypertension (PIH)
Ans-44. 2. Excessive vomiting in clients with hyperemesis gravidarum often causes weight loss
and fluid, electrolyte, and acid-base imbalances.
45. Clients with gestational diabetes are usually managed by which of the following therapies?
1. Diet
2. NPH insulin (long-acting)
3. Oral hypoglycemic drugs
4. Oral hypoglycemic drugs and insulin
Ans-45. 1. Clients with gestational diabetes are usually managed by diet alone to control their
glucose intolerance. Oral hypoglycemic agents are contraindicated in pregnancy. NPH isn’t
usually needed for blood glucose control for GDM.
46. The antagonist for magnesium sulfate should be readily available to any client receiving
IV magnesium. Which of the following drugs is the antidote for magnesium toxicity?
1. Calcium gluconate
2. Hydralazine (Apresoline)
3. Narcan
4. RhoGAM
Ans-46. 1. Calcium gluconate is the antidote for magnesium toxicity. Ten ml of 10% calcium
gluconate is given IV push over 3-5 minutes. Hydralazine is given for sustained elevated blood
pressures in preeclamptic clients
47. Which of the following answers best describes the stage of pregnancy in which maternal
and fetal blood are exchanged?
1. Conception
2. 9 weeks’ gestation, when the fetal heart is well developed
3. 32-34 weeks gestation
4. maternal and fetal blood are never exchanged
Ans-47. 4. Only nutrients and waste products are transferred across the placenta. Blood exchange
only occurs in complications and some medical procedures accidentally.
48. Gravida refers to which of the following descriptions?
1. A serious pregnancy
2. Number of times a female has been pregnant
3. Number of children a female has delivered
4. Number of term pregnancies a female has had.
Ans-48. 2. Gravida refers to the number of times a female has been pregnant, regardless of
pregnancy outcome or the number of neonates delivered.
49. A pregnant woman at 32 weeks’ gestation complains of feeling dizzy and lightheaded while
her fundal height is being measured. Her skin is pale and moist. The nurse’s initial response
would be to:
1. Assess the woman’s blood pressure and pulse

2. Have the woman breathe into a paper bag
3. Raise the woman’s legs
4. Turn the woman on her side.
Ans-49. 4. During a fundal height measurement the woman is placed in a supine position. This
woman is experiencing supine hypotension as a result of uterine compression of the vena cava
and abdominal aorta. Turning her on her side will remove the compression and restore cardiac
output and blood pressure. Then vital signs can be assessed. Raising her legs will not solve the
problem since pressure will still remain on the major abdominal blood vessels, thereby
continuing to impede cardiac output. Breathing into a paper bag is the solution for dizziness
related to respiratory alkalosis associated with hyperventilation.
50. A pregnant woman’s last menstrual period began on April 8, 2005, and ended on April 13.
Using Nägele’s rule her estimated date of birth would be:
1. January 15, 2006

2. January 20, 2006
3. July 1, 2006
4. November 5, 2005
Ans-50. 1. Nägele’s rule requires subtracting 3 months and adding 7 days and 1 year if
appropriate to the first day of a pregnant woman’s last menstrual period. When this rule, is used
with April 8, 2005, the estimated date of birth is January 15, 2006.
OB/GYN 3 – Newborn
1) A nurse in a delivery room is assisting with the delivery of a newborn infant. After the
delivery, the nurse prepares to prevent heat loss in the newborn resulting from evaporation by:
1. Warming the crib pad

2. Turning on the overhead radiant warmer
3. Closing the doors to the room
4. Drying the infant in a warm blanket
Ans-1. 4. Evaporation of moisture from a wet body dissipates heat along with the moisture.
Keeping the newborn dry by drying the wet newborn infant will prevent hypothermia via
evaporation.
2) A nurse is assessing a newborn infant following circumcision and notes that the
circumcised area is red with a small amount of bloody drainage. Which of the following
nursing actions would be most appropriate?

3. Circle the amount of bloody drainage on the dressing and reassess in 30 minutes
4. Reinforce the dressing
Ans-2. 1. The penis is normally red during the healing process. A yellow exudate may be noted
in 24 hours, and this is a part of normal healing. The nurse would expect that the area would be
red with a small amount of bloody drainage. If the bleeding is excessive, the nurse would apply
gentle pressure with sterile gauze. If bleeding is not controlled, then the blood vessel may need to
be ligated, and the nurse would contact the physician. Because the findings identified in the
question are normal, the nurse would document the assessment.
3) A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory
distress syndrome. Which assessment signs if noted in the newborn infant would alert the
nurse to the possibility of this syndrome?
1. Hypotension and Bradycardia

2. Tachypnea and retractions
3. Acrocyanosis and grunting
4. The presence of a barrel chest with grunting
Ans-3. 2. The infant with respiratory distress syndrome may present with signs of cyanosis,
tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts.
4) A nurse in a newborn nursery is performing an assessment of a newborn infant. The

nurse is preparing to measure the head circumference of the infant. The nurse would most
appropriately:
1. Wrap the tape measure around the infant’s head and measure just above the eyebrows.
2. Place the tape measure under the infants head at the base of the skull and wrap around to the
front just above the eyes
3. Place the tape measure under the infants head, wrap around the occiput, and measure just
above the eyes
4. Place the tape measure at the back of the infant’s head, wrap around across the ears, and
measure across the infant’s mouth.
Ans-4. 3. To measure the head circumference, the nurse should place the tape measure under the
infant’s head, wrap the tape around the occiput, and measure just above the eyebrows so that the
largest area of the occiput is included. (The 4th option was pretty damn funny though.)
5) A postpartum nurse is providing instructions to the mother of a newborn infant with
hyperbilirubinemia who is being breastfed. The nurse provides which most appropriate
instructions to the mother?
1. Switch to bottle feeding the baby for 2 weeks

2. Stop the breast feedings and switch to bottle-feeding permanently
3. Feed the newborn infant less frequently
4. Continue to breast-feed every 2-4 hours
Ans-5. 4. Breast feeding should be initiated within 2 hours after birth and every 2-4 hours
thereafter. The other options are not necessary.
6) A nurse on the newborn nursery floor is caring for a neonate. On assessment the infant
is exhibiting signs of cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress
syndrome is diagnosed, and the physician prescribes surfactant replacement therapy. The
nurse would prepare to administer this therapy by:
1. Subcutaneous injection
2. Intravenous injection
3. Instillation of the preparation into the lungs through an endotracheal tube
4. Intramuscular injection
Ans-6. 3. The aim of therapy in RDS is to support the disease until the disease runs its course
with the subsequent development of surfactant. The infant may benefit from surfactant
replacement therapy. In surfactant replacement, an exogenous surfactant preparation is instilled
into the lungs through an endotracheal tube.
7) A nurse is assessing a newborn infant who was born to a mother who is addicted to
drugs. Which of the following assessment findings would the nurse expect to note during the
assessment of this newborn?
1. Sleepiness
2. Cuddles when being held
3. Lethargy
4. Incessant crying
Ans-7. 4. A newborn infant born to a woman using drugs is irritable. The infant is overloaded
easily by sensory stimulation. The infant may cry incessantly and posture rather than cuddle
when being held.
8) A nurse prepares to administer a vitamin K injection to a newborn infant. The mother
asks the nurse why her newborn infant needs the injection. The best response by the nurse
would be:
1. “You infant needs vitamin K to develop immunity.”

2. “The vitamin K will protect your infant from being jaundiced.”
3. “Newborn infants are deficient in vitamin K, and this injection prevents your infant from
abnormal bleeding.”
4. “Newborn infants have sterile bowels, and vitamin K promotes the growth of bacteria in the
bowel.”
Ans-8. 3. Vitamin K is necessary for the body to synthesize coagulation factors. Vitamin K is
administered to the newborn infant to prevent abnormal bleeding. Newborn infants are vitamin K
deficient because the bowel does not have the bacteria necessary for synthesizing fat-soluble
vitamin K. The infant’s bowel does not have support the production of vitamin K until bacteria
adequately colonizes it by food ingestion.
9) A nurse in a newborn nursery receives a phone call to prepare for the admission of a
43-week-gestation newborn with Apgar scores of 1 and 4. In planning for the admission of
this infant, the nurse’s highest priority should be to:
1. Connect the resuscitation bag to the oxygen outlet

2. Turn on the apnea and cardiorespiratory monitors
3. Set up the intravenous line with 5% dextrose in water
4. Set the radiant warmer control temperature at 36.5* C (97.6*F)
Ans-9. 1. The highest priority on admission to the nursery for a newborn with low Apgar scores
is airway, which would involve preparing respiratory resuscitation equipment. The other options
are also important, although they are of lower priority.
10) Vitamin K is prescribed for a neonate. A nurse prepares to administer the medication in
which muscle site?
1. Deltoid
2. Triceps
3. Vastus lateralis
4. Biceps
Ans-10. 3.
11) A nursing instructor asks a nursing student to describe the procedure for administering
erythromycin ointment into the eyes if a neonate. The instructor determines that the student
needs to research this procedure further if the student states:
1. “I will cleanse the neonate’s eyes before instilling ointment.”

2. “I will flush the eyes after instilling the ointment.”
3. “I will instill the eye ointment into each of the neonate’s conjunctival sacs within one hour
after birth.”
4. “Administration of the eye ointment may be delayed until an hour or so after birth so that eye
contact and parent-infant attachment and bonding can occur.”
Ans-11. 2. Eye prophylaxis protects the neonate against Neisseria gonorrhea and Chlamydia

trachomatis. The eyes are not flushed after instillation of the medication because the flush will
wash away the administered medication.
12) A baby is born precipitously in the ER. The nurses’ initial action should be to:
1. Establish an airway for the baby
2. Ascertain the condition of the fundus
3. Quickly tie and cut the umbilical cord
4. Move mother and baby to the birthing unit
Ans-12. 1. The nurse should position the baby with head lower than chest and rub the infant’s
back to stimulate crying to promote oxygenation. There is no haste in cutting the cord.
13) The primary critical observation for Apgar scoring is the:
1. Heart rate
2. Respiratory rate
3. Presence of meconium
4. Evaluation of the Moro reflex
Ans-13. 1. The heart rate is vital for life and is the most critical observation in Apgar scoring.
Respiratory effect rather than rate is included in the Apgar score; the rate is very erratic.
14) When performing a newborn assessment, the nurse should measure the vital signs in the
following sequence:
1. Pulse, respirations, temperature

2. Temperature, pulse, respirations
3. Respirations, temperature, pulse
4. Respirations, pulse, temperature
Ans-14. 4. This sequence is least disturbing. Touching with the stethoscope and inserting the
thermometer increase anxiety and elevate vital signs.
15) Within 3 minutes after birth the normal heart rate of the infant may range between:
1. 100 and 180

2. 130 and 170
3. 120 and 160
4. 100 and 130
Ans-15. 3. The heart rate varies with activity; crying will increase the rate, whereas deep sleep
will lower it; a rate between 120 and 160 is expected.
16) The expected respiratory rate of a neonate within 3 minutes of birth may be as high as:
1. 50
2. 60
3. 80
4. 100
Ans-16. 2. The respiratory rate is associated with activity and can be as rapid as 60 breaths per
minute; over 60 breaths per minute are considered tachypneic in the infant.
17) The nurse is aware that a healthy newborn’s respirations are:
1. Regular, abdominal, 40-50 per minute, deep

2. Irregular, abdominal, 30-60 per minute, shallow
3. Irregular, initiated by chest wall, 30-60 per minute, deep
4. Regular, initiated by the chest wall, 40-60 per minute, shallow
Ans-17. 2. Normally the newborn’s breathing is abdominal and irregular in depth and rhythm;
the rate ranges from 30-60 breaths per minute.
18) To help limit the development of hyperbilirubinemia in the neonate, the plan of care
should include:
1. Monitoring for the passage of meconium each shift

2. Instituting phototherapy for 30 minutes every 6 hours
3. Substituting breastfeeding for formula during the 2nd day after birth
4. Supplementing breastfeeding with glucose water during the first 24 hours
Ans-18. 1. Bilirubin is excreted via the GI tract; if meconium is retained, the bilirubin is
reabsorbed.
19) A newborn has small, whitish, pinpoint spots over the nose, which the nurse knows are
caused by retained sebaceous secretions. When charting this observation, the nurse identifies
it as:
1. Milia
2. Lanugo
3. Whiteheads
4. Mongolian spots
Ans-19. 1. Milia occur commonly, are not indicative of any illness, and eventually disappear.
20) When newborns have been on formula for 36-48 hours, they should have a:
1. Screening for PKU

2. Vitamin K injection
3. Test for necrotizing enterocolitis
4. Heel stick for blood glucose level
Ans-20. 1. By now the newborn will have ingested an ample amount of the amino acid
phenylalanine, which, if not metabolized because of a lack of the liver enzyme, can deposit
injurious metabolites into the blood stream and brain; early detection can determine if the liver
enzyme is absent.
21) The nurse decides on a teaching plan for a new mother and her infant. The plan should
include:
1. Discussing the matter with her in a non-threatening manner

2. Showing by example and explanation how to care for the infant
3. Setting up a schedule for teaching the mother how to care for her baby
4. Supplying the emotional support to the mother and encouraging her independence
Ans-21. 2. Teaching the mother by example is a non-threatening approach that allows her to
proceed at her own pace.
22) Which action best explains the main role of surfactant in the neonate?
1. Assists with ciliary body maturation in the upper airways

2. Helps maintain a rhythmic breathing pattern
3. Promotes clearing mucus from the respiratory tract
4. Helps the lungs remain expanded after the initiation of breathing
Ans-22. 4. Surfactant works by reducing surface tension in the lung. Surfactant allows the lung
to remain slightly expanded, decreasing the amount of work required for inspiration.
23) While assessing a 2-hour old neonate, the nurse observes the neonate to have
acrocyanosis. Which of the following nursing actions should be performed initially?
1. Activate the code blue or emergency system

2. Do nothing because acrocyanosis is normal in the neonate
3. Immediately take the newborn’s temperature according to hospital policy
4. Notify the physician of the need for a cardiac consult
Ans-23. 2. Acrocyanosis, or bluish discoloration of the hands and feet in the neonate (also called
peripheral cyanosis), is a normal finding and shouldn’t last more than 24 hours after birth.
24) The nurse is aware that a neonate of a mother with diabetes is at risk for what
complication?
1. Anemia
2. Hypoglycemia
3. Nitrogen loss
4. Thrombosis
Ans-24. 2. Neonates of mothers with diabetes are at risk for hypoglycemia due to increased
insulin levels. During gestation, an increased amount of glucose is transferred to the fetus across
the placenta. The neonate’s liver cannot initially adjust to the changing glucose levels after birth.
This may result in an overabundance of insulin in the neonate, resulting in hypoglycemia.
25) A client with group AB blood whose husband has group O has just given birth. The
major sign of ABO blood incompatibility in the neonate is which complication or test result?
1. Negative Coombs test

2. Bleeding from the nose and ear
3. Jaundice after the first 24 hours of life
4. Jaundice within the first 24 hours of life
Ans-25. 4. The neonate with ABO blood incompatibility with its mother will have jaundice
(pathologic) within the first 24 hours of life. The neonate would have a positive Coombs test
result.
26) A client has just given birth at 42 weeks’ gestation. When assessing the neonate, which
physical finding is expected?
1. A sleepy, lethargic baby

2. Lanugo covering the body
3. Desquamation of the epidermis
4. Vernix caseosa covering the body
Ans-26. 3. Postdate fetuses lose the vernix caseosa, and the epidermis may become desquamated.
These neonates are usually very alert. Lanugo is missing in the postdate neonate.
27) After reviewing the client’s maternal history of magnesium sulfate during labor, which
condition would the nurse anticipate as a potential problem in the neonate?
1. Hypoglycemia
2. Jitteriness
3. Respiratory depression
4. Tachycardia
Ans-27. 3. Magnesium sulfate crosses the placenta and adverse neonatal effects are respiratory
depression, hypotonia, and Bradycardia.
28) Neonates of mothers with diabetes are at risk for which complication following birth?
1. Atelectasis
2. Microcephaly
3. Pneumothorax
4. Macrosomia
Ans-28. 4. Neonates of mothers with diabetes are at increased risk for macrosomia (excessive
fetal growth) as a result of the combination of the increased supply of maternal glucose and an
increase in fetal insulin.
29) By keeping the nursery temperature warm and wrapping the neonate in blankets, the
nurse is preventing which type of heat loss?
1. Conduction
2. Convection
3. Evaporation
4. Radiation
Ans-29. 2. Convection heat loss is the flow of heat from the body surface to the cooler air.
30) A neonate has been diagnosed with caput succedaneum. Which statement is correct about
this condition?
1. It usually resolves in 3-6 weeks

2. It doesn’t cross the cranial suture line
3. It’s a collection of blood between the skull and the periosteum
4. It involves swelling of tissue over the presenting part of the presenting head.
Ans-30. 4. Caput succedaneum is the swelling of tissue over the presenting part of the fetal scalp
due to sustained pressure; it resolves in 3-4 days.
31) The most common neonatal sepsis and meningitis infections seen within 24 hours after
birth are caused by which organism?
1. Candida albicans
2. Chlamydia trachomatis
3. Escherichia coli
4. Group B beta-hemolytic streptococci
Ans-31. 4. Transmission of Group B beta-hemolytic streptococci to the fetus results in

respiratory distress that can rapidly lead to septic shock.
32) When attempting to interact with a neonate experiencing drug withdrawal, which
behavior would indicate that the neonate is willing to interact?
1. Gaze aversion
2. Hiccups
3. Quiet alert state
4. Yawning
Ans-32. 3. When caring for a neonate experiencing drug withdrawal, the nurse needs to be alert
for distress signals from the neonate. Stimuli should be introduced one at a time when the
neonate is in a quiet and alert state. Gaze aversion, yawning, sneezing, hiccups, and body arching
are distress signals that the neonate cannot handle stimuli at that time.
33) When teaching umbilical cord care to a new mother, the nurse would include which
information?
1. Apply peroxide to the cord with each diaper change

2. Cover the cord with petroleum jelly after bathing
3. Keep the cord dry and open to air
4. Wash the cord with soap and water each day during a tub bath.
Ans-33. 3. Keeping the cord dry and open to air helps reduce infection and hastens drying.
34) A mother of a term neonate asks what the thick, white, cheesy coating is on his skin.
Which correctly describes this finding?
1. Lanugo
2. Milia
3. Nevus flammeus
4. Vernix
Ans-34. 4.
35) Which condition or treatment best ensures lung maturity in an infant?
1. Meconium in the amniotic fluid

2. Glucocorticoid treatment just before delivery
3. Lecithin to sphingomyelin ratio more than 2:1
4. Absence of phosphatidylglycerol in amniotic fluid
Ans-35. 3. Lecithin and sphingomyelin are phospholipids that help compose surfactant in the
lungs; lecithin peaks at 36 weeks and sphingomyelin concentrations remain stable.
36) When performing nursing care for a neonate after a birth, which intervention has the
highest nursing priority?
1. Obtain a dextrostix
2. Give the initial bath
3. Give the vitamin K injection
4. Cover the neonates head with a cap
Ans-36. 4. Covering the neonates head with a cap helps prevent cold stress due to excessive
evaporative heat loss from the neonate’s wet head. Vitamin K can be given up to 4 hours after
birth.
37) When performing an assessment on a neonate, which assessment finding is most

suggestive of hypothermia?
1. Bradycardia
2. Hyperglycemia
4. Shivering
Ans-37. 1. Hypothermic neonates become bradycardic proportional to the degree of core

temperature. Hypoglycemia is seen in hypothermic neonates.
38) A woman delivers a 3.250 g neonate at 42 weeks’ gestation. Which physical finding is
expected during an examination if this neonate?
1. Abundant lanugo
2. Absence of sole creases
3. Breast bud of 1-2 mm in diameter
4. Leathery, cracked, and wrinkled skin
Ans-38. 4. Neonatal skin thickens with maturity and is often peeling by post term.
39) A healthy term neonate born by C-section was admitted to the transitional nursery 30
minutes ago and placed under a radiant warmer. The neonate has an axillary temperature of
99.5*F, a respiratory rate of 80 breaths/minute, and a heel stick glucose value of 60 mg/dl.
Which action should the nurse take?
1. Wrap the neonate warmly and place her in an open crib

2. Administer an oral glucose feeding of 10% dextrose in water
3. Increase the temperature setting on the radiant warmer
4. Obtain an order for IV fluid administration
Ans-39. 4. Assessment findings indicate that the neonate is in respiratory distress—most likely
from transient tachypnea, which is common after cesarean delivery. A neonate with a rate of 80
breaths a minute shouldn’t be fed but should receive IV fluids until the respiratory rate returns to
normal. To allow for close observation for worsening respiratory distress, the neonate should be
kept unclothed in the radiant warmer.
40) Which neonatal behavior is most commonly associated with fetal alcohol syndrome
(FAS)?
1. Hypoactivity
2. High birth weight
3. Poor wake and sleep patterns
4. High threshold of stimulation
Ans-40. 3. Altered sleep patterns are caused by disturbances in the CNS from alcohol exposure
in utero. Hyperactivity is a characteristic generally noted. Low birth weight is a physical defect
seen in neonates with FAS. Neonates with FAS generally have a low threshold for stimulation.
OB/GYN 3a – Newborn
1. Which of the following behaviors would indicate that a client was bonding with her baby?
A. The client asks her husband to give the baby a bottle of water.
B. The client talks to the baby and picks him up when he cries.
C. The client feeds the baby every three hours.
D. The client asks the nurse to recommend a good childcare manual.
Ans-1. B
2. A newborn’s mother is alarmed to find small amounts of blood on her infant girl’s diaper.
When the nurse checks the infant’s urine it is straw colored and has no offensive odor.
Which explanation to the newborn’s mother is most appropriate?
A. “It appears your baby has a kidney infection”

B. “Breast-fed babies often experience this type of bleeding problem due to lack of vitamin
C in the breast milk”
C. “The baby probably passed a small kidney stone”
D. “Some infants experience menstruation like bleeding when hormones from the mother
are not available”
Ans-2. D
3. An insulin-dependent diabetic delivered a 10-pound male. When the baby is brought to the
nursery, the priority of care is to
A. clean the umbilical cord with Betadine to prevent infection
B. give the baby a bath
C. call the laboratory to collect a PKU screening test
D. check the baby’s serum glucose level and administer glucose if < 40 mg/dL
Ans-3. D
4. Soon after delivery a neonate is admitted to the central nursery. The nursery nurse begins
the initial assessment by
A. Auscultating bowel sounds.
B. Determining chest circumference.
C. Inspecting the posture, color, and respiratory effort.
D. Checking for identifying birthmarks.
Ans-4. C
5. The home health nurse visits the Cox family 2 weeks after hospital discharge. She observes
that the umbilical cord has dried and fallen off. The area appears healed with no drainage
or erythema present. The mother can be instructed to
A. Cover the umbilicus with a band-aid.

B. Continue to clean the stump with alcohol for one week.
C. Apply an antibiotic ointment to the stump.
D. Give him a bath in an infant tub now.
Ans-5. D
6. A neonate is admitted to a hospital’s central nursery. The neonate’s vital signs are:
temperature = 96.5 degrees F., heart rate = 120 bpm, and respirations = 40/minute. The
infant is pink with slight acrocyanosis. The priority nursing diagnosis for the neonate is
A. Ineffective thermoregulation related to fluctuating environmental temperatures.

B. Potential for infection related to lack of immunity.
C. Altered nutrition, less than body requirements related to diminish sucking reflex.
D. Altered elimination pattern related to lack of nourishment.
Ans-6. A
7. The nurse hears the mother of a 5-pound neonate telling a friend on the telephone, “As
soon as I get home, I’ll give him some cereal to get him to gain weight?” The nurse
recognizes the need for further instruction about infant feeding and tells her
A. “If you give the baby cereal, be sure to use Rice to prevent allergy.”
B. “The baby is not able to swallow cereal, because he is too small.”
C. “The infant’s digestive tract cannot handle complex carbohydrates like cereal.”
D. “If you want him to gain weight, just double his daily intake of formula.”
Ans-7. C
8. The nurse instructs a primipara about safety considerations for the neonate. The nurse
determines that the client does not understand the instructions when she says
A. “All neonates should be in an approved car seat when in an automobile.”

B. “It’s acceptable to prop the infant’s bottle once in a while.”
C. “Pillows should not be used in the infant’s crib.”
D. “Infants should never be left unattended on an unguarded surface.”
Ans-8. B
9. The nurse manager is presenting education to her staff to promote consistency in the
interventions used with lactating mothers. She emphasizes that the optimum time to initiate
lactation is
A. As soon as possible after the infant’s birth.

B. After the mother has rested for 4-6 hours.
C. During the infant’s second period of reactivity.
D. After the infant has taken sterile water without complications.
Ans-9. A.
10. The nurse is preparing to discharge a multipara 24 hours after a vaginal

delivery. The client is breast-feeding her newborn. The nurse instructs the client that if
engorgement occurs the client should
A. Wear a tight fitting bra or breast binder.

B. Apply warm, moist heat to the breasts.
C. Contact the nurse midwife for a lactation suppressant.
D. Restrict fluid intake to 1000 ml. daily.
Ans-10. B
11. All of the following are important in the immediate care of the premature neonate. Which
nursing activity should have the greatest priority?
A. Instillation of antibiotic in the eyes
B. Identification by bracelet and foot prints
C. Placement in a warm environment
D. Neurological assessment to determine gestational age
Ans-11. C
OB/GYN 4 – Postpartum
1) A postpartum nurse is preparing to care for a woman who has just delivered a healthy
newborn infant. In the immediate postpartum period the nurse plans to take the woman’s vital
signs:
1. Every 30 minutes during the first hour and then every hour for the next two hours.
2. Every 15 minutes during the first hour and then every 30 minutes for the next two hours.
3. Every hour for the first 2 hours and then every 4 hours
4. Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours.
Ans-1. 2. Not providing a rationale ‘because you all should know this crap.
2) A postpartum nurse is taking the vital signs of a woman who delivered a healthy
newborn infant 4 hours ago. The nurse notes that the mother’s temperature is 100.2*F. Which
of the following actions would be most appropriate?
1. Retake the temperature in 15 minutes

4. Increase hydration by encouraging oral fluids
Ans-2. 4. The mother’s temperature may be taken every 4 hours while she is awake.
Temperatures up to 100.4 (38 C) in the first 24 hours after birth are often related to the
dehydrating effects of labor. The most appropriate action is to increase hydration by encouraging
oral fluids, which should bring the temperature to a normal reading. Although the nurse would
document the findings, the most appropriate action would be to increase the hydration.
3) The nurse is assessing a client who is 6 hours PP after delivering a full-term healthy
infant. The client complains to the nurse of feelings of faintness and dizziness. Which of the
following nursing actions would be most appropriate?
1. Obtain hemoglobin and hematocrit levels

2. Instruct the mother to request help when getting out of bed
3. Elevate the mother’s legs
4. Inform the nursery room nurse to avoid bringing the newborn infant to the mother until the
feelings of light-headedness and dizziness have subsided.
Ans-3. 2. Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of
faintness or dizziness are signs that should caution the nurse to be aware of the client’s safety.
The nurse should advise the mother to get help the first few times the mother gets out of bed.
Obtaining an H/H requires a physician’s order.
4) A nurse is preparing to perform a fundal assessment on a postpartum client. The initial
nursing action in performing this assessment is which of the following?
1. Ask the client to turn on her side

2. Ask the client to lie flat on her back with the knees and legs flat and straight.
3. Ask the mother to urinate and empty her bladder
4. Massage the fundus gently before determining the level of the fundus.
Ans-4. 3. Before starting the fundal assessment, the nurse should ask the mother to empty her
bladder so that an accurate assessment can be done. When the nurse is performing fundal
assessment, the nurse asks the woman to lie flat on her back with the knees flexed. Massaging
the fundus is not appropriate unless the fundus is boggy and soft, and then it should be massaged
gently until firm.
5) The nurse is assessing the lochia on a 1 day PP patient. The nurse notes that the lochia
is red and has a foul-smelling odor. The nurse determines that this assessment finding is:
1. Normal
2. Indicates the presence of infection
3. Indicates the need for increasing oral fluids
4. Indicates the need for increasing ambulation
Ans-5. 2. Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually
decreases in amount. Normal lochia has a fleshy odor. Foul smelling or purulent lochia usually
indicates infection, and these findings are not normal. Encouraging the woman to drink fluids or
increase ambulation is not an accurate nursing intervention.
6) When performing a PP assessment on a client, the nurse notes the presence of clots in
the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which of
the following nursing actions is most appropriate?

3. Reassess the client in 2 hours
4. Encourage increased intake of fluids.
Ans-6. 2. Normally, one may find a few small clots in the first 1 to 2 days after birth from
pooling of blood in the vajayjay. Clots larger than 1 cm are considered abnormal. The cause of
these clots, such as uterine atony or retained placental fragments, needs to be determined and
treated to prevent further blood loss. Although the findings would be documented, the most
appropriate action is to notify the physician.
7) A nurse in a PP unit is instructing a mother regarding lochia and the amount of
expected lochia drainage. The nurse instructs the mother that the normal amount of lochia
may vary but should never exceed the need for:
1. One peripad per day

2. Two peripads per day
3. Three peripads per day
4. Eight peripads per day
Ans-7. 4. The normal amount of lochia may vary with the individual but should never exceed 4
to 8 peripads per day. The average number of peripads is 6 per day.
8) A PP nurse is providing instructions to a woman after delivery of a healthy newborn

infant. The nurse instructs the mother that she should expect normal bowel elimination to
return:
1. One the day of the delivery

2. 3 days PP
3. 7 days PP
4. within 2 weeks PP
Ans-8. 2. After birth, the nurse should auscultate the woman’s abdomen in all four quadrants to
determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days PP.
Surgery, anesthesia, and the use of narcotics and pain control agents also contribute to the longer
period of altered bowel function.
9) Select all of the physiological maternal changes that occur during the PP period.
1. Cervical involution ceases immediately

2. Vaginal distention decreases slowly
3. Fundus begins to descend into the pelvis after 24 hours
4. Cardiac output decreases with resultant tachycardia in the first 24 hours
5. Digestive processes slow immediately.
Ans-9. 1 and 3. In the PP period, cervical healing occurs rapidly and cervical involution occurs.
After 1 week the muscle begins to regenerate and the cervix feels firm and the external os is the
width of a pencil. Although the vaginal mucosa heals and vaginal distention decreases, it takes
the entire PP period for complete involution to occur and muscle tone is never restored to the
pregravid state. The fundus begins to descent into the pelvic cavity after 24 hours, a process
known as involution. Despite blood loss that occurs during delivery of the baby, a transient
increase in cardiac output occurs. The increase in cardiac output, which persists about 48 hours
after childbirth, is probably caused by an increase in stroke volume because Bradycardia is often
noted during the PP period. Soon after childbirth, digestion begins to begin to be active and the
new mother is usually hungry because of the energy expended during labor.
10) A nurse is caring for a PP woman who has received epidural anesthesia and is
monitoring the woman for the presence of a vulva hematoma. Which of the following
assessment findings would best indicate the presence of a hematoma?
1. Complaints of a tearing sensation

2. Complaints of intense pain
3. Changes in vital signs
4. Signs of heavy bruising
Ans-10. 3. Because the woman has had epidural anesthesia and is anesthetized, she cannot feel
pain, pressure, or a tearing sensation. Changes in vitals indicate hypovolemia in the anesthetized
PP woman with vulvar hematoma. Heavy bruising may be visualized, but vital sign changes
indicate hematoma caused by blood collection in the perineal tissues.
11) A nurse is developing a plan of care for a PP woman with a small vulvar hematoma. The
nurse includes which specific intervention in the plan during the first 12 hours following the
delivery of this client?
1. Assess vital signs every 4 hours

2. Inform health care provider of assessment findings
3. Measure fundal height every 4 hours
4. Prepare an ice pack for application to the area.
Ans-11. 4. Application of ice will reduce swelling caused by hematoma formation in the vulvar
area. The other options are not interventions that are specific to the plan of care for a client with
a small vulvar hematoma.
12) A new mother received epidural anesthesia during labor and had a forceps delivery after
pushing 2 hours. At 6 hours PP, her systolic blood pressure has dropped 20 points, her
diastolic BP has dropped 10 points, and her pulse is 120 beats per minute. The client is
anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the
health care provider, the nurse immediately plans to:
1. Monitor fundal height

2. Apply perineal pressure
3. Prepare the client for surgery.
4. Reassure the client
Ans-12. 3. The use of an epidural, prolonged second stage labor and forceps delivery are
predisposing factors for hematoma formation, and a collection of up to 500 ml of blood can
occur in the vaginal area. Although the other options may be implemented, the immediate action
would be to prepare the client for surgery to stop the bleeding.
13) A nurse is monitoring a new mother in the PP period for signs of hemorrhage. Which of
the following signs, if noted in the mother, would be an early sign of excessive blood loss?
1. A temperature of 100.4*F
2. An increase in the pulse from 88 to 102 BPM
3. An increase in the respiratory rate from 18 to 22 breaths per minute
4. A blood pressure change from 130/88 to 124/80 mm Hg
Ans-13. 2. During the 4th stage of labor, the maternal blood pressure, pulse, and respiration
should be checked every 15 minutes during the first hour. A rising pulse is an early sign of
excessive blood loss because the heart pumps faster to compensate for reduced blood volume.
The blood pressure will fall as the blood volume diminishes, but a decreased blood pressure
would not be the earliest sign of hemorrhage. A slight rise in temperature is normal. The
respiratory rate is increased slightly.
14) A nurse is preparing to assess the uterine fundus of a client in the immediate
postpartum period. When the nurse locates the fundus, she notes that the uterus feels soft
and boggy. Which of the following nursing interventions would be most appropriate
initially?
1. Massage the fundus until it is firm

2. Elevate the mothers legs
3. Push on the uterus to assist in expressing clots
4. Encourage the mother to void
Ans-14. 1. If the uterus is not contracted firmly, the first intervention is to massage the fundus
until it is firm and to express clots that may have accumulated in the uterus. Pushing on an
uncontracted uterus can invert the uterus and cause massive hemorrhage. Elevating the client’s
legs and encouraging the client to void will not assist in managing uterine atony. If the uterus
does not remain contracted as a result of the uterine massage, the problem may be distended
bladder and the nurse should assist the mother to urinate, but this would not be the initial action.
15) A PP nurse is assessing a mother who delivered a healthy newborn infant by C-section.
The nurse is assessing for signs and symptoms of superficial venous thrombosis. Which of the
following signs or symptoms would the nurse note if superficial venous thrombosis were
present?
1. Paleness of the calf area

2. Enlarged, hardened veins
3. Coolness of the calf area
4. Palpable dorsalis pedis pulses
Ans-15. 2. Thrombosis of the superficial veins is usually accompanied by signs and symptoms of

inflammation. These include swelling of the involved extremity and redness, tenderness, and
warmth.
16) A nurse is providing instructions to a mother who has been diagnosed with mastitis.
Which of the following statements if made by the mother indicates a need for further
teaching?
1. “I need to take antibiotics, and I should begin to feel better in 24-48 hours.”
2. “I can use analgesics to assist in alleviating some of the discomfort.”
3. “I need to wear a supportive bra to relieve the discomfort.”
4. “I need to stop breastfeeding until this condition resolves.”
Ans-16. 4. In most cases, the mother can continue to breast feed with both breasts. If the affected
breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is
important to prevent abscess formation. Antibiotic therapy assists in resolving the mastitis within
24-48 hours. Additional supportive measures include ice packs, breast supports, and analgesics.
17) A PP client is being treated for DVT. The nurse understands that the client’s response to
treatment will be evaluated by regularly assessing the client for:
1. Dysuria, ecchymosis, and vertigo

2. Epistaxis, hematuria, and dysuria
3. Hematuria, ecchymosis, and epistaxis
4. Hematuria, ecchymosis, and vertigo
Ans-17. 3. The treatment for DVT is anticoagulant therapy. The nurse assesses for bleeding,
which is an adverse effect of anticoagulants. This includes hematuria, ecchymosis, and epistaxis.
Dysuria and vertigo are not associated specifically with bleeding.
18) A nurse performs an assessment on a client who is 4 hours PP. The nurse notes that the
client has cool, clammy skin and is restless and excessively thirsty. The nurse prepares
immediately to:
1. Assess for hypovolemia and notify the health care provider

2. Begin hourly pad counts and reassure the client
3. Begin fundal massage and start oxygen by mask
4. Elevate the head of the bed and assess vital signs
Ans-18. 1. Symptoms of hypovolemia include cool, clammy, pale skin, sensations of anxiety or
impending doom, restlessness, and thirst. When these symptoms are present, the nurse should
further assess for hypovolemia and notify the health care provider.
19) A nurse is assessing a client in the 4th stage if labor and notes that the fundus is firm but
that bleeding is excessive. The initial nursing action would be which of the following?
1. Massage the fundus

2. Place the mother in the Trendelenburg’s position
4. Record the findings
Ans-19. 3. If the bleeding is excessive, the cause may be laceration of the cervix or birth canal.
Massaging the fundus if it is firm will not assist in controlling the bleeding. Trendelenburg’s
position is to be avoided because it may interfere with cardiac function.
20) A nurse is caring for a PP client with a diagnosis of DVT who is receiving a continuous
intravenous infusion of heparin sodium. Which of the following laboratory results will the
nurse specifically review to determine if an effective and appropriate dose of the heparin is
being delivered?
1. Prothrombin time
2. Internationalized normalized ratio
3. Activated partial thromboplastin time
4. Platelet count
Ans-20. 3. Anticoagulation therapy may be used to prevent the extension of thrombus by

delaying the clotting time of the blood. Activated partial thromboplastin time should be
monitored, and a heparin dose should be adjusted to maintain a therapeutic level of 1.5 to 2.5
times the control. The prothrombin time and the INR are used to monitor coagulation time when
warfarin (Coumadin) is used.
21) A nurse is preparing a list of self-care instructions for a PP client who was diagnosed
with mastitis. Select all instructions that would be included on the list.
1. Take the prescribed antibiotics until the soreness subsides.

2. Wear supportive bra
3. Avoid decompression of the breasts by breastfeeding or breast pump
4. Rest during the acute phase
5. Continue to breastfeed if the breasts are not too sore.
Ans-21. 2, 4, and 5. Mastitis are an infection of the lactating breast. Client instructions include
resting during the acute phase, maintaining a fluid intake of at least 3 L a day, and taking
analgesics to relieve discomfort. Antibiotics may be prescribed and are taken until the complete
prescribed course is finished. They are not stopped when the soreness subsides. Additional
supportive measures include the use of moist heat or ice packs and wearing a supportive bra.
Continued decompression of the breast by breastfeeding or pumping is important to empty the
breast and prevent formation of an abscess.
22) Methergine or pitocin is prescribed for a woman to treat PP hemorrhage. Before

administration of these medications, the priority nursing assessment is to check the:
1. Amount of lochia
2. Blood pressure
3. Deep tendon reflexes
4. Uterine tone
Ans-22. 2. Methergine and pitocin are agents that are used to prevent or control postpartum
hemorrhage by contracting the uterus. They cause continuous uterine contractions and may
elevate blood pressure. A priority nursing intervention is to check blood pressure. The physician
should be notified if hypertension is present.
23) Methergine or pitocin are prescribed for a client with PP hemorrhage. Before
administering the medication(s), the nurse contacts the health provider who prescribed the
medication(s) in which of the following conditions is documented in the client’s medical
history?
1. Peripheral vascular disease

2. Hypothyroidism
3. Hypotension
4. Type 1 diabetes
Ans-23. 1. These medications are avoided in clients with significant cardiovascular disease,
peripheral disease, hypertension, eclampsia, or preeclampsia. These conditions are worsened by
the vasoconstriction effects of these medications.
24) Which of the following factors might result in a decreased supply of breast milk in a PP
mother?
1. Supplemental feedings with formula

2. Maternal diet high in vitamin C
3. An alcoholic drink
4. Frequent feedings
Ans-24. 1. Routine formula supplementation may interfere with establishing an adequate milk
volume because decreased stimulation to the mother’s nipples affects hormonal levels and milk
production.
25) Which of the following interventions would be helpful to a breastfeeding mother who is
experiencing engorged breasts?
1. Applying ice
2. Applying a breast binder
3. Teaching how to express her breasts in a warm shower
4. Administering bromocriptine (Parlodel)
Ans-25. 3. Teaching the client how to express her breasts in a warm shower aids with let-down
and will give temporary relief. Ice can promote comfort by vasoconstriction, numbing, and
discouraging further letdown of milk.
26) On completing a fundal assessment, the nurse notes the fundus is situated on the client’s
left abdomen. Which of the following actions is appropriate?
1. Ask the client to empty her bladder

2. Straight catheterize the client immediately
3. Call the client’s health provider for direction
4. Straight catheterize the client for half of her uterine volume
Ans-26. 1. A full bladder may displace the uterine fundus to the left or right side of the abdomen.
Catheterization is unnecessary invasive if the woman can void on her own.
27) The nurse is about the give a Type 2 diabetic her insulin before breakfast on her first day
postpartum. Which of the following answers best describes insulin requirements immediately
postpartum?
1. Lower than during her pregnancy

2. Higher than during her pregnancy
3. Lower than before she became pregnant
4. Higher than before she became pregnant
Ans-27. 3. PP insulin requirements are usually significantly lower than prepregnancy

requirements. Occasionally, clients may require little to no insulin during the first 24 to 48 hours
postpartum.
28) Which of the following findings would be expected when assessing the postpartum client?
1. Fundus 1 cm above the umbilicus 1 hour postpartum

2. Fundus 1 cm above the umbilicus on postpartum day 3
3. Fundus palpable in the abdomen at 2 weeks postpartum
4. Fundus slightly to the right; 2 cm above umbilicus on postpartum day 2
Ans-28. 1. Within the first 12 hours postpartum, the fundus usually is approximately 1 cm above
the umbilicus. The fundus should be below the umbilicus by PP day 3. The fundus shouldn’t be
palpated in the abdomen after day 10.
29) A client is complaining of painful contractions, or afterpains, on postpartum day 2.

Which of the following conditions could increase the severity of afterpains?
1. Bottle-feeding
2. Diabetes
3. Multiple gestation
4. Primiparity
Ans-29. 3. Multiple gestation, breastfeeding, multiparity, and conditions that cause

overdistention of the uterus will increase the intensity of after-pains. Bottle-feeding and diabetes
aren’t directly associated with increasing severity of afterpains unless the client has delivered a
macrosomic infant.
30) On which of the postpartum days can the client expect lochia serosa?
1. Days 3 and 4 PP
2. Days 3 to 10 PP
3. Days 10-14 PP
4. Days 14 to 42 PP
Ans-30. 2. On the third and fourth PP days, the lochia becomes a pale pink or brown and
contains old blood, serum, leukocytes, and tissue debris. This type of lochia usually lasts until PP
day 10. Lochia rubra usually last for the first 3 to 4 days PP. Lochia alba, which contain
leukocytes, decidua, epithelial cells, mucus, and bacteria, may continue for 2 to 6 weeks PP.
31) Which of the following behaviors characterizes the PP mother in the taking in phase?
1. Passive and dependant

2. Striving for independence and autonomy
3. Curious and interested in care of the baby
4. Exhibiting maximum readiness for new learning
Ans-31. 1. During the taking in phase, which usually lasts 1-3 days, the mother is passive and
dependent and expresses her own needs rather than the neonate’s needs. The taking hold phase
usually lasts from days 3-10 PP. During this stage, the mother strives for independence and
autonomy; she also becomes curious and interested in the care of the baby and is most ready to
learn.
32) Which of the following complications may be indicated by continuous seepage of blood
from the vagina of a PP client, when palpation of the uterus reveals a firm uterus 1 cm below
the umbilicus?
1. Retained placental fragments

2. Urinary tract infection
3. Cervical laceration
4. Uterine atony
Ans-32. 3. Continuous seepage of blood may be due to cervical or vaginal lacerations if the
uterus is firm and contracting. Retained placental fragments and uterine atony may cause
subinvolution of the uterus, making it soft, boggy, and larger than expected. UTI won’t cause
vaginal bleeding, although hematuria may be present.
33) What type of milk is present in the breasts 7 to 10 days PP?
1. Colostrum
2. Hind milk
3. Mature milk
4. Transitional milk
Ans-33. 4. Transitional milk comes after colostrum and usually lasts until 2 weeks PP.
34) Which of the following complications is most likely responsible for a delayed postpartum
hemorrhage?
1. Cervical laceration
2. Clotting deficiency
3. Perineal laceration
4. Uterine subinvolution
Ans-34. 4. Late postpartum bleeding is often the result of subinvolution of the uterus. Retained
products of conception or infection often cause subinvolution. Cervical or perineal lacerations
can cause an immediate postpartum hemorrhage. A client with a clotting deficiency may also
have an immediate PP hemorrhage if the deficiency isn’t corrected at the time of delivery.
35) Before giving a PP client the rubella vaccine, which of the following facts should the
nurse include in client teaching?
1. The vaccine is safe in clients with egg allergies

2. Breast-feeding isn’t compatible with the vaccine
3. Transient arthralgia and rash are common adverse effects
4. The client should avoid getting pregnant for 3 months after the vaccine because the vaccine
has teratogenic effects
Ans-35. 4. The client must understand that she must not become pregnant for 3 months after the
vaccination because of its potential teratogenic effects. The rubella vaccine is made from duck
eggs so an allergic reaction may occur in clients with egg allergies. The virus is not transmitted
into the breast milk, so clients may continue to breastfeed after the vaccination. Transient
arthralgia and rash are common adverse effects of the vaccine.
36) Which of the following changes best described the insulin needs of a client with type 1
diabetes who has just delivered an infant vaginally without complications?
1. Increase
2. Decrease
3. Remain the same as before pregnancy
4. Remain the same as during pregnancy
Ans-36. 2. The placenta produces the hormone human placental lactogen, an insulin antagonist.
After birth, the placenta, the major source of insulin resistance, is gone. Insulin needs decrease
and women with type 1 diabetes may only need one-half to two-thirds of the prenatal insulin
during the first few PP days.
37) Which of the following responses is most appropriate for a mother with diabetes who
wants to breastfeed her infant but is concerned about the effects of breastfeeding on her
health?
1. Mothers with diabetes who breast-feed have a hard time controlling their insulin needs
2. Mothers with diabetes shouldn’t breastfeed because of potential complications
3. Mothers with diabetes shouldn’t breastfeed; insulin requirements are doubled.
4. Mothers with diabetes may breastfeed; insulin requirements may decrease from
breastfeeding.
Ans-37. 4. Breastfeeding has an antidiabetogenic effect. Insulin needs are decreased because
carbohydrates are used in milk production. Breastfeeding mothers are at a higher risk of
hypoglycemia in the first PP days after birth because the glucose levels are lower. Mothers with
diabetes should be encouraged to breastfeed.
38) On the first PP night, a client requests that her baby be sent back to the nursery so she
can get some sleep. The client is most likely in which of the following phases?
1. Depression phase
2. Letting-go phase
3. Taking-hold phase
4. Taking-in phase
Ans-38. 4. The taking-in phase occurs in the first 24 hours after birth. The mother is concerned
with her own needs and requires support from staff and relatives. The taking-hold phase occurs
when the mother is ready to take responsibility for her care as well as the infants care. The
letting-go phase begins several weeks later, when the mother incorporates the new infant into the
family unit.
39) Which of the following physiological responses is considered normal in the early
postpartum period?
1. Urinary urgency and dysuria

2. Rapid diuresis
3. Decrease in blood pressure
4. Increase motility of the GI system
Ans-39. 2. In the early PP period, there’s an increase in the glomerular filtration rate and a drop
in the progesterone levels, which result in rapid diuresis. There should be no urinary urgency,
though a woman may feel anxious about voiding. There’s a minimal change in blood pressure
following childbirth, and a residual decrease in GI motility.
40) During the 3rd PP day, which of the following observations about the client would the
nurse be most likely to make?
1. The client appears interested in learning about neonatal care

2. The client talks a lot about her birth experience
3. The client sleeps whenever the neonate isn’t present
4. The client requests help in choosing a name for the neonate.
Ans-40. 1. The third to tenth days of PP care are the “taking-hold” phase, in which the new
mother strives for independence and is eager for her neonate. The other options describe the
phase in which the mother relives her birth experience.
41) Which of the following circumstances is most likely to cause uterine atony and lead to PP
hemorrhage?
1. Hypertension
2. Cervical and vaginal tears
3. Urine retention
4. Endometritis
Ans-41. 3. Urine retention causes a distended bladder to displace the uterus above the umbilicus
and to the side, which prevents the uterus from contracting. The uterus needs to remain
contracted if bleeding is to stay within normal limits. Cervical and vaginal tears can cause PP
hemorrhage but are less common occurrences in the PP period.
42) Which type of lochia should the nurse expect to find in a client 2 days PP?
1. Foul-smelling
2. Lochia serosa
3. Lochia alba
4. Lochia rubra
Ans-42. 4.
43) After expulsion of the placenta in a client who has six living children, an infusion of
lactated ringer’s solution with 10 units of pitocin is ordered. The nurse understands that this is
indicated for this client because:
1. She had a precipitate birth

2. This was an extramural birth
3. Retained placental fragments must be expelled
4. Multigravida’s are at increased risk for uterine atony.
Ans-43. 4. Multiple full-term pregnancies and deliveries result in overstretched uterine muscles
that do not contract efficiently and bleeding may ensue.
44) As part of the postpartum assessment, the nurse examines the breasts of a primiparous
breastfeeding woman who is one day postpartum. An expected finding would be:
1. Soft, non-tender; colostrum is present

2. Leakage of milk at let down
3. Swollen, warm, and tender upon palpation
4. A few blisters and a bruise on each areola
Ans-44. 1. Breasts are essentially unchanged for the first two to three days after birth. Colostrum
is present and may leak from the nipples.
45) Following the birth of her baby, a woman expresses concern about the weight she gained
during pregnancy and how quickly she can lose it now that the baby is born. The nurse, in
describing the expected pattern of weight loss, should begin by telling this woman that:
1. Return to prepregnant weight is usually achieved by the end of the postpartum period
2. Fluid loss from diuresis, diaphoresis, and bleeding accounts for about a 3 pound weight loss
3. The expected weight loss immediately after birth averages about 11 to 13 pounds
4. Lactation will inhibit weight loss since caloric intake must increase to support milk
production
1. Ans-45. 3. Prepregnant weight is usually achieved by 2 to 3 months after birth, not within the
6-week postpartum period. Weight loss from diuresis, diaphoresis, and bleeding is about 9
pounds. Weight loss continues during breastfeeding since fat stores developed during
pregnancy and extra calories consumed are used as part of the lactation process
46) Which of the following findings would be a source of concern if noted during the
assessment of a woman who is 12 hours postpartum?
1. Postural hypotension
2. Temperature of 100.4°F
3. Bradycardia — pulse rate of 55 BPM
4. Pain in left calf with dorsiflexion of left foot
Ans-46. 4. Responses 1 and 3 are expected related to circulatory changes after birth. A
temperature of 100.4°F in the first 24 hours is most likely indicative of dehydration which is
easily corrected by increasing oral fluid intake. The findings in response 4 indicate a positive
Homan sign and are suggestive of thrombophlebitis and should be investigated further.
47) The nurse examines a woman one hour after birth. The woman’s fundus is boggy,
midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots.
The nurse’s initial action would be to:
1. Place her on a bedpan to empty her bladder

2. Massage her fundus
4. Administer Methergine 0.2 mg IM which has been ordered prn
Ans-47. 2. A boggy or soft fundus indicates that uterine atony is present. This is confirmed by
the profuse lochia and passage of clots. The first action would be to massage the fundus until
firm, followed by 3 and 4, especially if the fundus does not become or remain firm with massage.
There is no indication of a distended bladder since the fundus is midline and below the
umbilicus.
48) When performing a postpartum check, the nurse should:
1. Assist the woman into a lateral position with upper leg flexed forward to facilitate the
examination of her perineum
2. Assist the woman into a supine position with her arms above her head and her legs extended
for the examination of her abdomen
3. Instruct the woman to avoid urinating just before the examination since a full bladder will
facilitate fundal palpation
4. Wash hands and put on sterile gloves before beginning the check
Ans-48. 1. While the supine position is best for examining the abdomen, the woman should keep
her arms at her sides and slightly flex her knees in order to relax abdominal muscles and
facilitate palpation of the fundus. The bladder should be emptied before the check. A full bladder
alters the position of the fundus and makes the findings inaccurate. Although hands are washed
before starting the check, clean (not sterile) gloves are put on just before the perineum and pad
are assessed to protect from contact with blood and secretions.
49) Perineal care is an important infection control measure. When evaluating a postpartum
woman’s perineal care technique, the nurse would recognize the need for further instruction if
the woman:
1. Uses soap and warm water to wash the vulva and perineum
2. Washes from symphysis pubis back to episiotomy
3. Changes her perineal pad every 2 – 3 hours
4. Uses the peribottle to rinse upward into her vagina
Ans-49. 4. Responses 1, 2, and 3 are all appropriate measures. The peribottle should be used in a
backward direction over the perineum. The flow should never be directed upward into the vagina
since debris would be forced upward into the uterus through the still-open cervix.
50) Which measure would be least effective in preventing postpartum hemorrhage?
1. Administer Methergine 0.2 mg every 6 hours for 4 doses as ordered

2. Encourage the woman to void every 2 hours
3. Massage the fundus every hour for the first 24 hours following birth
4. Teach the woman the importance of rest and nutrition to enhance healing
Ans-50. 3. The fundus should be massaged only when boggy or soft. Massaging a firm fundus
could cause it to relax. Responses 1, 2, and 4 are all effective measures to enhance and maintain
contraction of the uterus and to facilitate healing.
51) When making a visit to the home of a postpartum woman one week after birth, the nurse
should recognize that the woman would characteristically:
1. Express a strong need to review events and her behavior during the process of labor and birth
2. Exhibit a reduced attention span, limiting readiness to learn
3. Vacillate between the desire to have her own nurturing needs met and the need to take charge
of her own care and that of her newborn
4. Have reestablished her role as a spouse/partner
Ans-51. 3. One week after birth the woman should exhibit behaviors characteristic of the taking-
hold stage as described in response 3. This stage lasts for as long as 4 to 5 weeks after
birth. Responses 1 and 2 are characteristic of the taking-in stage, which lasts for the first few
days after birth. Response 4 reflects the letting-go stage, which indicates that psychosocial
recovery is complete.
52) Four hours after a difficult labor and birth, a primiparous woman refuses to feed her
baby, stating that she is too tired and just wants to sleep. The nurse should:
1. Tell the woman she can rest after she feeds her baby
2. Recognize this as a behavior of the taking-hold stage
3. Record the behavior as ineffective maternal-newborn attachment
4. Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time
Ans-52. 4. Response 1 does not take into consideration the need for the new mother to be
nurtured and have her needs met during the taking-in stage. The behavior described is typical of
this stage and not a reflection of ineffective attachment unless the behavior persists. Mothers
need to reestablish their own well-being in order to effectively care for their baby.
53) Parents can facilitate the adjustment of their other children to a new baby by:
1. Having the children choose or make a gift to give to the new baby upon its arrival home
2. Emphasizing activities that keep the new baby and other children together
3. Having the mother carry the new baby into the home so she can show the other children the
new baby
4. Reducing stress on other children by limiting their involvement in the care of the new baby
Ans-53. 1. Special time should be set aside just for the other children without interruption from
the newborn. Someone other than the mother should carry the baby into the home so she can
give full attention to greeting her other children. Children should be actively involved in the care
of the baby according to their ability without overwhelming them.
54) A primiparous woman is in the taking-in stage of psychosocial recovery and

adjustment following birth. The nurse, recognizing the needs of women during this stage,
should:
1. Foster an active role in the baby’s care

2. Provide time for the mother to reflect on the events of and her behavior during childbirth
3. Recognize the woman’s limited attention span by giving her written materials to read when
she gets home rather than doing a teaching session now
4. Promote maternal independence by encouraging her to meet her own hygiene and comfort
needs
Ans-54. 2. The focus of the taking-in stage is nurturing the new mother by meeting her
dependency needs for rest, comfort, hygiene, and nutrition. Once they are met, she is more able
to take an active role, not only in her own care but also the care of her newborn. Women express
a need to review their childbirth experience and evaluate their performance. Short teaching
sessions, using written materials to reinforce the content presented, are a more effective
approach.
Pharmacology
1. Morphine, Codeine, and Methadone have a high potential for abuse or physical or
psychological dependency. Which schedule of drugs do these belong in?
A. Schedule I
B. Schedule II
C. Schedule III
D. Schedule IV
Ans-1. B. Schedule II drugs are highly regulated.
2. In FDA pregnancy categories, what do most drugs fall under?
A. A
B. B
C. C
D. X
Ans-2. C. Uncertain risk. Most drugs fall under this category.
3. Where are most oral drugs absorbed?
A. Stomach
B. Tongue
C. Liver
D. Small intestine
Ans-3. D. Absorbed in small intestine to live to circulation.
4. True or false. In the first-pass effect, an oral medication is metabolized in the

kidneys before it gets into the blood stream.
Ans-4. False. It is metabolized in the liver. It is excreted through the kidneys.
5. Which medication administration method avoids the first-pass effect?
A. Suspensions
B. Troche
C. Elixirs
D. Sublingual
Ans-5. D. Sublingual and Buccal methods have a very fast absorption rate.
6. Kayexalate is given via which administration method?
A. Suppository
B. Retention enema
C. Topical
D. Inhalation
Ans-6. B. It is given to decrease Potassium levels in the body.

7. Topical creams and gels are based from what?
A. Oils
B. Water
C. Medication
D. Toothpaste
Ans-7. B. Topical corticosteroids are the most common.
8. True or false. Topical medications are absorbed into the skin slowly.
Ans-8. True.
9. NTG paste is measured in:
A. Not measured, it comes in a full patch

B. Inches
C. Centimeters
D. Feet
Ans-9. 2.
10. Which method of medication administration is considered the least safe?
1. Topical
2. Oral
3. Intravenous
4. Inhalation
Ans-10. C. ALWAYS double check order.
11. What does IVP stand for?
1. IV piggyback
2. Bolus
3. IV push
4. Both B and C
Ans-11. D. Bolus and IV push is the same thing.
12. Drug interactions at the cellular level between the drug and the receptor is:
1. Drug action
2. Drug effect
3. Lock and Key
4. Absorption
Ans-12. A.
13. Narcan is an example of:
1. Agonist
2. Antagonist
3. Noncompetitive
4. Beta-blocker
Ans-13. 4. It is a competitive antagonist. It cancels out the actions of morphine.
14. The process by which a drug gets from the dosage form into a biological substance that
can pass through or across tissues into blood is called:
1. Absorption
2. Distribution
3. Metabolism
4. Excretion
Ans-14. 1.
15. What is the main organ for metabolizing drugs? ___________________
Ans-15. Liver
16. What is the main organ for excreting drugs? _____________________
Ans-16. Kidneys
17. If the drug half-life is 6 hours, when would it be completely eliminated from the
bloodstream?
1. 12 hours
2. 18 hours
3. 24 hours
4. 30 hours
Ans-17. 4.
18. When is a maintained concentration typically reached?
1. 1 half-life
2. 2 half-lives
3. 4 half-lives
4. 5 half-lives
Ans-18. 3.
19. True or false: A loading dose can be given at once to reach a therapeutic level at once.
Ans-19. True
20. An adverse drug effect induced by the prescribed drug that may cause a pathological
disorder is called:
1. Iatrogenic drug effect

2. Unlabeled drug use
3. Anaphylaxis
4. Idiosyncratic reaction
Ans-20. 1.
21. What pages of the PDR (Physicians drug reference) book will have an index of drugs by
brand and alphabetized? (The pages the nurses would most often look)
1. White
2. Pink
3. Grey
4. Green
Ans-21. 2.
22. Which of these precautions should staff include in the care of a client who is receiving a
sealed source of radiation therapy for uterine cancer?
1. Limiting a staff member’s time with client to less than 30 minutes per shift.
2. Keeping a zinc-lined container and forceps in the client’s room
3. Instructing the visitors to maintain a distance of about 3 feet from the client
4. Reminding the client to flush the toilet several times after each use.
Ans-22. 1. To protect nurses and others from excessive radiation exposure, the principles of
distance, time, and shielding are important. It is recommended that a staff member limits direct
care to a client as described to 30 minutes per shift.
23. A client has pain because of cancer. The client’s pain management plan should include
one of these recommendations from the World Health Organization?
1. The potential problem of pain medications for cancer are overdose and addiction.
2. Medication and biofeedback should not be suggested because they have been proven
ineffective in pain relief.
3. Pain medications are best absorbed by the oral route.
4. The pain ladder concept should be used to decide what medications to use for cancer pain.
Ans-23. 4. Less than 1% of cancer clients in pain experience overdose or addiction problems.
24. A client who is about to undergo chemotherapy tells you that she is more terrified of
losing hair than of the drug. The client intends to take an herbal remedy to prevent baldness.
The most important nursing intervention is to:
1. Inform the client that herbal remedies will antagonize chemotherapy effects.
2. Tell the client that she must tell the physician, since herbs may or may not be harmful.
3. Encourage as many herbal remedies as possible, since chemotherapy is so toxic.
4. Tell the client that being bald and surviving is better than having hair and not being treated.
Ans-24. 2. The client must understand that the provider must be informed of all medications
(herbal, OTC, prescriptions) because they may not be safe.
25. An 11-year old client has been complaining of severe pain since surgery two days ago.
The client is currently in the play room, avidly playing video games, and shows no evidence of
pain. When the nurse has the client return to bed, the client begins complaining of severe pain
again. Which of the following is probably true about this pain?
1. The client is addicted to pain medication, so pain management must be carefully monitored.
2. Pain medications wore off as the client went to bed.
3. The client probably said there was no pain so bedrest wouldn’t be implicated.
4. The distraction of playing video games is an important adjunct to other pain-management
techniques.
Ans-25. 4. Nonpharmacologic interventions, including distractions, are an important component

of pain relief modalities.
26. Which of these steps in the administration of eye drops to a client is correct?
1. Warming the medication to body temperature

2. Having the client look downward as the head is tilted forward before administration
3. Placing the number of prescribed drops directly on the cornea.
4. Applying gentle finger pressure to the client’s inner canthus for one or two minutes after
administration.
Ans-26. 4. The major rationale for applying pressure to the inner canthus of the eye is to prevent
systemic absorption of the eye drops. In addition, absorption in the eye is promoted, and drainage
into the nose and throat is minimized.
27. When administering medications to a client, the nurse should:
1. Double check the medication orders before administering

2. Call the patient by name upon entering the room in order to verify the patient.
3. Check the patients armband before administering the medication
4. Prepare medications for all client’s first, and then administer by room in order to manage
time more efficiently.
Ans-27. C. Armband is the most accurate form of identifiably.
28. For which of the following activities is the nurse responsible during the evaluation phase
of drug administration?
1. Preparing and administering medication safely and as ordered.

2. Planning measurable outcomes for the patient related to drug therapy.
3. Monitoring the patient continuously for therapeutic as well as adverse effects
4. Gathering data in a drug and dietary history.
Ans-28. C. Ongoing monitoring of the patient evaluates the effect of the drug on the patient. All
of the other answers refer to the different steps in the nursing process.
29. Drugs can exert their action on the body by: (circle all that apply)
1. Interaction with receptors

2. Making the cell perform a new function
3. Inhibiting the action of a specific enzyme
4. Altering metabolic chemical processes.
Ans-29. A, C, D. Drugs cannot make the cell perform a new function; only alter the way it
performs its current function.
30. Another name for biotransformation of a drug is:
1. Absorption
2. Dilution
3. Excretion
4. Metabolism
Ans-30. 4. Metabolism connoted the breakdown of a product. Biotransformation is a more
accurate term because some drugs are actually changed into an active form in the liver in contrast
to being broken down for excretion.
31. Drugs given by which route is altered by the first-pass effect?
1. Sublingual
2. Subcutaneous
3. Oral
4. Intravenous
Ans-31. 3. Medications are absorbed in the stomach and small intestine travel through the portal
system and are metabolized by the liver before they reach the general circulation.
32. Drug half-life is defined as the amount of time required for 50% of the drug to:
1. Be absorbed by the body

2. Exert a response
3. Be eliminated by the body
4. Reach a therapeutic level
Ans-32. 3. Half-life refers to the time it takes to excrete a drug from the body.
33. Highly protein-bound drugs:
1. Increase the risk of drug-drug interactions

2. Typically provide a short duration of action
3. Must be administered with 8 ounces of water
4. Have a decreased effect in patients with low albumin levels.
Ans-33. 1. When administering 2 drugs that are protein bound, one of the drugs will have fewer
sites to which to bind and thus more drug available for the activity, thus increasing the risk for
toxicity.
34. Patients with renal failure would most likely have problems with drug:
1. Excretion
2. Absorption
3. Metabolism
4. Distribution
Ans-34. 1. The kidneys are responsible for the majority of drug secretion.
35. The ratio between drugs therapeutic effect and toxic effect is:
1. Tolerance
2. Cumulative effect
3. Therapeutic ratio
4. Affinity
Ans-35. 3.
36. When calculating pediatric doses, the nurse understands that:
1. Clark’s rules calculates dosage based on the client’s age and uses a nomogram to determine
body surface area.
2. Freid and Young’s rules calculate the dosage based on milligrams of drug per pound of body
weight.
3. Dosage calculation according to the body weight is the most accurate method because it takes
into account differences of maturational development.
4. Dosage calculation by body surface area is the most accurate method because it takes into the
account the differences in size of the child and/or neonate
Ans-36. 4.
37. The physiologic changes that normally occur in the older adult have which of the
following implications for the nurse who is assessing drug responses in this patient?
1. Drug half-life is lengthened.

2. Drug metabolism is faster
3. Drug elimination is faster
4. Protein binding is more efficient.
Ans-37. 1.
38. When assessing a client for adverse effects related to morphine, which of the following
would the nurse not expect?
1. Decreased peristalsis
2. Diarrhea
3. Delayed gastric emptying
4. Common bile duct spasm
Ans-38. 2. Morphine causes a decrease in GI mobility, leading to constipation, not diarrhea.
39. When assessing for the most serious adverse reaction to a narcotic, the nurse is careful to
monitor the patients:
1. Respiratory rate
2. Heart rate
3. Blood pressure
4. Mental status
Ans-39. 1. The most serious adverse effect would be respiratory depression.
Psych – Personality Disorders
1) The nursing diagnosis that would be most appropriate for a 22-year old client who uses
ritualistic behavior would be:
1. Ineffective coping
2. Impaired adjustment
3. personal identity disturbance
4. Sensory/perceptual alterations
Ans-1. 1. Ineffective coping is the impairment of a person’s adaptive behaviors and problem-
solving abilities in meeting life’s demands; ritualistic behavior fits under this category as a
defining characteristic.
2) A psychiatrist prescribes an anti-obsessional agent for a client who is using ritualistic
behavior. A common anti-anxiety medication used for this type of client would be:
1. Fluvoxamine (Luvox)
2. Benztropine (Cogentin)
3. Amantadine (Symmetrel)
4. Diphenhydramine (Benadryl)
Ans-2. 1. This drug blocks the uptake of serotonin.
3) A 20-year old college student has been brought to the psychiatric hospital by her parents.
Her admitting diagnosis is borderline personality disorder. When talking with the parents,
which information would the nurse expect to be included in the client’s history? Select all that
apply.
1. Impulsiveness
2. Lability of mood
3. Ritualistic behavior
4. psychomotor retardation
5. self-destructive behavior
Ans-3. 1, 2, 5.
4) A hospitalized client, diagnosed with a borderline personality disorder, consistently

breaks the unit’s rules. This behavior should be confronted because it will help the client:
1. Control anger
2. reduce anxiety
3. Set realistic goals
4. Become more self-aware
Ans-4. 4. Client’s must first become aware of their behavior before they can change it. (3)
Occurs after the client is aware of the behavior and has a desire to change the behavior.
5) When working with the nurse during the orientation phase of the relationship, a client
with a borderline personality disorder would probably have the most difficulty in:
1. Controlling anxiety
2. terminating the session on time
3. Accepting the psychiatric diagnosis
4. Setting mutual goals for the relationship
Ans-5. 4. Clients with borderline personality disorders frequently demonstrate a pattern of

unstable interpersonal relationships, impulsiveness, affective instability, and frantic efforts to
avoid abandonment; these behaviors usually create great difficulty in establishing mutual goals.
6) A client with a diagnosis of borderline personality disorder has negative feelings toward
the other clients on the unit and considers them all to be “bad.” The nurse understands this
defense is known as:
1. Splitting
2. Ambivalence
3. Passive aggression
4. Reaction formation
Ans-6. 1. Splitting is the compartmentalization of opposite-affect states and failure to integrate

the positive and negative aspects of self or others.
7) The client with antisocial personality disorder:
1. Suffers from a great deal of anxiety

2. Is generally unable to postpone gratification
3. Rapidly learns by experience and punishment
4. Has a great sense of responsibility toward others
Ans-7. 2. Individuals with this disorder tend to be self-centered and impulsive. They lack
judgment and self-control and do not profit from their mistakes.
8) A person with antisocial personality disorder has difficulty relating to others because of
never having learned to:
1. Count on others
2. Empathize with others
3. Be dependent on others
4. Communicate with others socially
Ans-8. 2. The lack of superego control allows the ego and the id to control the behavior. Self-
motivation and self-satisfaction are of paramount concern.
9) A young, handsome man with a diagnosis of antisocial personality disorder is being
discharged from the hospital next week. He asks the nurse for her phone number so that he
can call her for a date. The nurse’s best response would be:
1. “We are not permitted to date clients.”

2. “No, you are a client and I am a nurse.”
3. “I like you, but our relationship is professional.”
4. “It’s against my professional ethics to date clients.”
Ans-9. 3. This accepts the client as a person of worth rather than being cold or implying
rejection. However, the nurse maintains a professional rather than a social role.
10) When caring for a client with a diagnosis of schizotypal personality disorder, the nurse
should:
1. Set limits on manipulative behavior

2. encourage participation in group therapy
3. Respect the client’s needs for social isolation
4. Understand that seductive behavior is expected.
Ans-10. 3. These clients are withdrawn, aloof, and socially distant; allowing distance and
providing support may encourage the eventual development of a therapeutic alliance. Group
therapy would increase this client’s anxiety; cognitive or behavioral therapy would be more
appropriate.
11) A nurse is orienting a new client to the unit when another client rushes down the hallway
and asks the nurse to sit down and talk. The client requesting the nurse’s attention is
extremely manipulative and uses socially acting-out behaviors when demands are unmet. The
nurse should:
1. Suggest that the client requesting attention speak with another staff member
2. Leave the new client and talk with the other client to avoid precipitating acting out behavior
3. Tell the interrupting client to sit down and be patient, stating, “I’ll be back as soon as
possible.”
4. Introduce the two clients and suggest that the client join the new client and the nurse on the
tour
Ans-11. 3. This sets realistic limits on behavior without rejecting the client
12) A client with a diagnosis of narcissistic personality disorder has been given a day pass
from the psychiatric hospital. The client is due to return at 6pm. At 5pm the client telephones
the nurse in charge of the unit and says “6 o’clock is too early. I feel like coming back at
7:30.” The nurse would be most therapeutic by telling the client to:
1. Return immediately, to demonstrate control

2. Return on time or restrictions will be imposed
3. come back at 6:45, as a compromise to set limits
4. Come back as soon as possible or the police will be sent
Ans-12. 2. This sets limits, points out reality, and places responsibility for behavior on the client.
13) An adult client with a borderline personality disorder become nauseated and vomits
immediately after drinking after drinking 2 ounces of shampoo as a suicide gesture. The most
appropriate initial response by the nurse would be to:
1. Promptly notify the attending physician

2. Immediately initiate suicide precautions
3. Sit quietly with the client until nausea and vomiting subsides
4. Assess the client’s vital signs and administer syrup of ipecac
Ans-13. 3. This intervention demonstrates the nurse’s caring presence which is vital for this
client. (1) Although the treatment team does need to know about the event, notification is not the
immediate concern. (2) This is premature and it reinforces the client’s predisposition to
manipulative behavior. (4) This medication is inappropriate in this situation; vomiting would be
expected after the ingestion of shampoo
14) A nurse notices that a client is mistrustful and shows hostile behavior. Which of the
following types of personality disorder is associated with these characteristics?
1. Antisocial
2. Avoidant
3. Borderline
4. Paranoid
Ans-14. 4. Paranoid individuals have a need to constantly scan the environment for signs of
betrayal, deception, and ridicule, appearing mistrustful and hostile. They expect to be tricked or
deceived by others.
15) Which of the following statements is typical for a client diagnosed with a personality
disorder?
1. “I understand you’re the one to blame.”

2. “I must be seen first; it’s not negotiable.”
3. “I see nothing humorous in this situation.”
4. “I wish someone would select the outfit for me.”
Ans-15. 3. Clients with paranoid personality disorder tend to be extremely serious and lack a
sense of humor.
16) Which of the following characteristics is expected for a client with paranoid personality
disorder who receives bad news?
1. The client is overly dramatic after hearing the facts

2. The client focuses on self to not become over-anxious
3. The client responds from a rational, objective point of view
4. The client doesn’t spend time thinking about the information.
Ans-16. 3. Clients with paranoid personality disorder are affectively restricted, appear
unemotional, and appear rational and objective.
17) Which of the following types of behavior is expected from a client diagnosed with a
paranoid personality disorder?
1. Eccentric
2. exploitative
3. Hypersensitive
4. Seductive
Ans-17. 3. People with paranoid personality disorders are hypersensitive to perceived threats.
Schizotypal personalities appear eccentric and engage in activities others find perplexing. Clients
with narcissistic personality disorder are interpersonally exploitative to enhance themselves or
indulge in their own desires. A client with histrionic personality disorder can be extremely
seductive when in search of stimulation and approval.
18) Which of the following interventions is important for a client with paranoid personality
disorder taking olanzapine (Zyprexa)?
1. Explain effects of serotonin syndrome

2. Teach the client to watch for extrapyramidal adverse reactions
3. Explain that the drug is less effective if the client smokes
4. Discuss the need to report paradoxical effects such as euphoria.
Ans-18. 3. Olanzapine (Zyprexa) is less effective for clients who smoke cigarettes. Olanzapine
doesn’t cause euphoria (damn), and extrapyramidal side effects aren’t a problem. However, the
client should be aware of adverse effects such as tardive dyskinesia.
19) A client with antisocial personality is trying to convince a nurse that he deserves special
privileges and that an exception to the rules should be made for him. Which of the following
responses is the most appropriate?
1. “I believe we need to sit down and talk about this.”
2. “Don’t you know better than to try to bend the rules?”
3. “What you’re asking me to do is unacceptable.”
4. “Why don’t you bring this request to the community meeting?”
Ans-19. 3. These clients often try to manipulate the nurse to get special privileges or make
exceptions to the rules on their behalf. By informing the client directly when actions are
inappropriate, the nurse helps the client learn to control unacceptable behaviors by setting limits.
By sitting down to talk about the request, the nurse is telling the client there’s room for
negotiating when there is none.
20) A nurse notices other clients on the unit avoiding a client diagnosed with antisocial
personality disorder. When discussing appropriate behavior in group therapy, which of the
following comments is expected about this client by his peers?
1. Lack of honesty
2. Belief in superstitions
3. Show of temper tantrums
4. Constant need for attention
Ans-20. 1. Clients with antisocial personality disorder tend to engage in acts of dishonesty,
shown by lying.
21) Which of the following characteristics or client histories substantiates a diagnosis of

antisocial personality disorder?
1. Delusional thinking
2. Feelings of inferiority
3. Disorganized thinking
4. Multiple criminal charges
Ans-21. 4. Clients with antisocial personality disorder are often sent for treatment by the court
after multiple crimes or for the use of illegal substances.
22) A client with borderline personality disorder is admitted to the unit after slashing his
wrist. Which of the following goals is most important after promoting safety?
1. Establish a therapeutic relationship with the client

2. Identify whether splitting is present in the client’s thoughts
3. Talk about the client’s acting out and self-destructive tendencies.
4. Encourage the client to understand why he blames others
Ans-22. 1. After promoting safety, the nurse establishes a rapport with the client to facilitate
appropriate expression of feelings. At this time, the client isn’t ready to address unhealthy
behavior. A therapeutic relationship must be established before the nurse can effectively work
with the client on self-destructive tendencies and the issues of splitting.
23) Which of the following characteristics or situations is indicated when a client with
borderline personality disorder has a crisis?
1. Antisocial behavior
2. Suspicious behavior
3. Relationship problems
4. Auditory hallucinations
Ans-23. 3. Relationship problems can precipitate a crisis because they bring up issues of
abandonment. Clients with borderline personality disorder aren’t usually suspicious; they’re
more likely to be depressed or highly anxious.
24) Which of the following assessment findings is seen in a client diagnosed with borderline
personality disorder?
1. Abrasions in various healing stages

2. intermittent episodes of hypertension
3. Alternating tachycardia and bradycardia
4. Mild state of euphoria with disorientation
Ans-24. 1. Clients with borderline personality disorder tend to self-mutilate and have abrasions
in various stages of healing.
25) In planning care for a client with borderline personality disorder, a nurse must be aware
that this client is prone to develop which of the following conditions?
1. Binge eating
2. Memory loss
3. Cult membership
4. Delusional thinking
Ans-25. 1. Clients with borderline personality disorder are likely to develop dysfunctional coping
and act out in self-destructive ways such as binge eating.
26) Which of the following statements is expected from a client with borderline personality
disorder with a history of dysfunctional relationships?
1. “I won’t get involved in another relationship.”

2. “I’m determined to look for the perfect partner.”
3. “I’ve decided to use better communication skills.”
4. “I’m going to be an equal partner in a relationship.”
Ans-26. 2. Clients with borderline personality disorder would decide to look for a perfect
partner. This characteristic is a result of the dichotomous manner in which these clients view the
world. They go from relationship to relationship without taking responsibility for their behavior.
It’s unlikely that an unsuccessful relationship will cause clients to make a change. They tend to
be demanding and impulsive in relationships. There’s no thought given to what one wants or
needs from a relationship. Because they tend to blame others for problems, it’s unlikely they
would express a desire to learn communication skills.
27) Which of the following conditions is likely to coexist in clients with a diagnosis of
borderline personality disorder?
1. Avoidance
2. Delirium
3. Depression
4. Disorientation
Ans-27. 3. Chronic feelings of emptiness and sadness predispose a client to depression. About
40% of the clients with borderline struggle with depression.
28) Which of the following nursing interventions has priority for a client with borderline
personality disorder?
1. Maintain consistent and realistic limits

2. Give instructions for meeting basic self-care needs
3. Engage in daytime activities to stimulate wakefulness
4. Have the client attend group therapy on a daily basis
Ans-28. 1. Clients with borderline who are needy, dependent, and manipulative will benefit
greatly from maintaining consistent and realistic limits. They don’t tend to have difficulty
meeting their self-care needs. They enjoy attending group therapy because they often attempt to
use the opportunity to become the center of attention. They don’t tend to have sleeping
difficulties.
29) A nurse is assessing a client diagnosed with dependent personality disorder. Which of the
following characteristics is a major component to this disorder?
1. Abrasive to others
2. Indifferent to others
3. Manipulative of others
4. Overreliance on others
Ans-29. 4. Clients with dependent personality disorder are extremely overreliant on others; they
aren’t abrasive or assertive. They’re clinging and demanding of others; they don’t manipulate.
30) Which of the following information must be included for the family of a client diagnosed
with dependent personality disorder?
1. Address coping skills

2. Explore panic attacks
3. Promote exercise programs
4. Decrease aggressive outbursts
Ans-30. 1. The family needs information about coping skills to help the client learn to handle
stress. Clients with dependent personality disorder don’t have aggressive outbursts; they tend to
be passive and submit to others. They don’t tend to have panic attacks. Exercise is a health
promotion activity for all clients. Clients with dependent personality disorder wouldn’t need
exercise promoted more than other people
31) Which of the following behaviors by a client with dependent personality disorder shows
the client has made progress toward the goal of increasing problem solving skills?
1. The client is courteous

2. The client asks questions
3. The client stops acting out
4. The client controls emotions
Ans-31. 2. The client with dependent personality disorder is passive and tries to please others. By
asking questions, the client is beginning to gather information, the first step of decision making.
32) A client with schizotypal personality disorder is sitting in a puddle of urine. She’s playing
in it, smiling, and softly singing a child’s song. Which action would be best?
1. Admonish the client for not using the bathroom

2. Firmly tell the client that her behavior is unacceptable
3. Ask the client if she’s ready to get cleaned up now
4. Help the client to the shower, and change the bedclothes.
Ans-32. 4. A client with schizotypal personality disorder can experience high levels of anxiety
and regress to childlike behaviors. This client may require help needing self-care needs. The
client may not respond to the other options or those options may generate more anxiety.
33) A client with avoidant personality disorder says occupational therapy is boring and
doesn’t want to go. Which action would be best?
1. State firmly that you’ll escort him to OT.

2. Arrange with OT for the client to do a project on the unit.
3. Ask the client to talk about why OT is boring
4. Arrange for the client not to attend OT until he is feeling better
Ans-33. If given the chance, a client with avoidant personality disorder typically elects to remain
immobilized. The nurse should insist that the client participate in OT. Arranging for the client to
do a project on the unit validates and reinforces the client’s desire to avoid getting to OT.
Addressing an invalid issue such as the client’s perceived boredom avoids the real issue: the
client’s need for therapy.
34) A nurse discusses job possibilities with a client with schizoid personality disorder. Which
suggestion by the nurse would be helpful?
1. “You can work in a family restaurant part-time on the weekend and holidays.”
2. “Maybe your friend could get you that customer service job where you work only on the
weekends.”
3. “Your idea of applying for the position of filing and organizing records is worth pursuing.”
4. “Being an introvert limits the employment opportunities you can pursue.”
Ans-34. 3. Clients with schizoid personality disorder prefer solitary activities, such as filing, to
working with others. Working as a cashier or in customer service would involve interacting with
many people.
35) When assessing a client diagnosed with impulse control disorder, the nurse observes
violent, aggressive, and assaultive behavior. Which of the following assessment data is the
nurse also likely to find? Select all that apply.
1. The client functions well in other areas of his life.

2. The degree of aggressiveness is out of proportion to the stressor.
3. The violent behavior is most often justified by the stressor.
4. The client has a history of parental alcoholism and chaotic, abusive family life.
5. The client has no remorse about the inability to control his anger.
Ans-35. 1, 2, 4. A client with an impulse control disorder who displays violent, aggressive, and
assaultive behavior generally functions well in other areas of his life. The degree of
aggressiveness is typically out of proportion with the stressor. Such a client commonly has a
history of parental alcoholism and a chaotic family life, and often verbalizes sincere remorse and
guilt for the aggressive behavior.
Psych – Substance Abuse
1) The nurse is planning activities for a client who has bipolar disorder with aggressive
social behavior. Which of the following activities would be most appropriate for this client?
1. Ping pong
2. Writing
3. Chess
4. Basketball
Ans-1. 2. Solitary activities that require a short attention span with mild physical exertion are the
most appropriate activities for a client who is exhibiting aggressive behavior. Writing, walks
with staff, and finger painting are activities that minimize stimuli and provide a constructive
release for tension. Competitive games can stimulate aggression and increase psychomotor
activity.
2) A client is admitted to the hospital with a diagnosis of major depression, severe, single
episode. The nurse assesses the client and identifies a nursing diagnosis of imbalanced
nutrition related to poor nutritional intake. The most appropriate nursing intervention related
to this diagnosis is:
1. Explain to the client the importance of a good nutritional intake

2. Weight the client 3 times per week before breakfast
3. Report the nutritional concern to the psychiatrist and obtain a nutritional consultation as soon
as possible.
4. Consult with the nutritionist, offer the client several small meals per day, and schedule brief
nursing interactions with the client during these times.
Ans-2. 4. Change in appetite is one of the major symptoms of depression. Reporting to the
psychiatrist and nutritionist is to some degree correct but lacks the method as to how one would
increase food intake.
3) In planning activities for the depressed client, especially during the early stages of
hospitalization, which of the following plans is best?
1. Provide an activity that is quiet and solitary to avoid increased fatigue, such as working on a
puzzle or reading a book.
2. Plan nothing until the client asks to participate in milieu.
3. Offer the client a menu of daily activities and insist the client participate in all of them
4. Provide a structured daily program of activities and encourage the client to participate.
Ans-3. 4. A depressed person experiences a depressed mood and is often withdrawn. The person
also experiences difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and
feelings of worthlessness and poor self-esteem. The plan of care needs to provide successful
experiences in a stimulating yet structured environment. Option 3 is a forceful and absolute
approach.
4) The depressed client verbalizes feelings of low self-esteem and self-worth typified by
statements such as “I’m such a failure… I can’t do anything right!” The best nursing
response would be:
1. To tell the client this is not true; that we all have a purpose in life.
2. To remain with the client and sit in silence; this will encourage the client to verbalize feelings
3. To reassure the client that you know how the client is feeling and that things will get better
4. To identify recent behaviors or accomplishments that demonstrates skill ability.
Ans-4. 4. Feelings of low self-esteem and worthlessness are common symptoms of the depressed
client. An effective plan of care to enhance the client’s personal self-esteem is to provide
experiences for the client that are challenging but will not be met with failure. Reminders of the
client’s past accomplishments or personal successes are ways to interrupt the client’s negative
self-talk and distorted cognitive view of self. Silence may be interpreted as agreement. Options 1
and 3 give advice and devalue the client’s feelings.
5) A client with a diagnosis of major depression, recurrent with psychotic features is
admitted to the mental health unit. To create a safe environment for the client, the nurse most
importantly devises a plan of care that deals specifically with the client’s:
1. Disturbed thought processes

2. Imbalanced nutrition
3. Self-care deficit
4. Deficient knowledge
Ans-5. 1. Major depression, recurrent, with psychotic features alerts the nurse that in addition to
the criteria that designate the diagnosis of major depression, one also must deal with the client’s
psychosis. Psychosis is defined as a state in which a person’s mental capacity to recognize reality
and to communicate and relate to others is impaired, thus interfering with the person’s capacity
to deal with the demands of life. Altered thought processes generally indicate a state of increased
anxiety in which hallucinations and delusions prevail. Although all of the nursing diagnoses may
be appropriate because the client is experiencing psychosis, option 1 is correct.
6) A depressed client is ready for discharge. The nurse feels comfortable that the client
has a good understanding of the disease process when the client states:
1. “I’ll never let this happen to me again. I won’t let my boss or my job or my family get to
me!”
2. “It’s important for me to eat well, exercise, and to take my medication. If I begin to lose my
appetite or not sleep well, I’ve got to get in to see my doctor.”
3. “I’ve learned that I’m a good person and that I am worthy of giving and receiving love. I
don’t need anyone; I have myself to rely on!”
4. “I don’t know what happened to me. I’ve always been able to make decisions for myself and
for my business. I don’t ever want to feel so weak or vulnerable again!”
Ans-6. 2. The exact cause of depression is not known but is believed to be related to biochemical
disruption of neurotransmitters in the brain. Diet, exercise, and medication are recognized
treatment for the disease process.
7) The nurse assesses a client with the admitting diagnosis of bipolar affective disorder,
mania. The symptom presented by the client that requires the nurse’s immediate intervention
is the client’s:
1. Outlandish behaviors and inappropriate dress

2. Grandiose delusions of being a royal descendent of King Arthur.
3. Nonstop physical activity and poor nutritional intake
4. Constant, incessant talking that includes sexual innuendoes and teasing the staff
Ans-7. 3. Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive
energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of
thought. Mania is a period when the mood is predominately elevated, expansive, or irritable. All
options reflect a client’s possible symptomatology. Option 3, however, clearly presents a
problem that compromises one’s physiological integrity and needs to be addressed immediately.
8) The nurse reviews the activity schedule for the day and plans which activity for the
manic client?
1. Brown-bag luncheon and book review

2. Tetherball
3. Paint-by-number activity
4. Deep breathing and progressive relaxation group
Ans-8. 2. A person who is experiencing mania is overactive and full of energy, lacks
concentration, and has poor impulse control. The client needs an activity that will allow use of
excess energy yet not endanger others during the process. Options 1, 3, and 4 are relatively
sedate activities that require concentration, a quality that is lacking in the manic state. Such
activities lead to increased frustration and anxiety for the client. Tetherball is an exercise that
uses the large muscle groups of the body and is a great way to expend the increased energy that
the client is experiencing.
9) A hospitalized client is being considered for ECT. The client appears calm, but the
family is anxious. The client’s mother begins to cry and states “My son’s brain will be
destroyed. How can the doctor do this to him?” The nurse’s best response is:
1. “It sounds as though you need to speak with the psychiatrist”

2. “Your son has decided to have this treatment. You should be supportive to him.”
3. “Perhaps you’d like to see the ECT room and speak to the staff.”
4. “It sounds as though you have some concerns about the ECT procedure. Why don’t we sit
down together and discuss any concerns you may have.”
Ans-9. 4. The nurse encourages the client and the family to verbalize fears and concerns. The
other options avoid dealing with concerns and are blocks to communication.
10) The manic client announces to everyone in the dayroom that a stripper is coming to
perform this evening. When the nurse firmly states that this will not happen, the manic client
becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis
of this situation, the nurse determines that the most appropriate action would be to:
1. With assistance, escort the manic client to her room and administer Haldol as prescribed if
needed
2. Tell the client that smoking privileges are revoked for 24 hours
3. Orient the client to time, person, and place
4. Tell the client that the behavior is not appropriate.
Ans-10. 1. The client is at risk for injury to self and others and therefore should be escorted out
of the dayroom. Antipsychotic medications are useful to manage the manic client. Hyperactive
and agitated behavior usually responds to Haldol. Option 2 may increase the agitation that
already exists in this client. Orientation will not halt the behavior. Telling the client that the
behavior is not appropriate already has been attempted by the nurse.
11) Select all nursing interventions for a hospitalized client with mania who is exhibiting
manipulative behavior.
1. Communicate expected behaviors to the client

2. Enforce rules and inform the client the he or she will not be allowed to attend group therapy
sessions.
3. Ensure that the client knows that he or she is not in charge of the nursing unit
4. Be clear with the client regarding the consequences of exceeding limits set regarding
behavior.
5. Assist the client in testing out alternative behaviors for obtaining needs
Ans-11. 1, 4, and 5. Interventions for dealing with the client exhibiting manipulative behavior
include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear
with the client regarding the consequences of exceeding limits set; following through with the
consequences in a non-punishment manner; and assisting the client in identifying strengths and
in testing out alternative behaviors for obtaining needs. Enforcing rules and informing the client
that he or she will not be allowed to attend group therapy sessions is a violation of the client’s
rights. Ensuring the client knows that he or she is not in charge of the nursing unit is
inappropriate, power struggles need to be avoided.
12) A woman comes into the ER in a severe state of anxiety following a car accident. The
most appropriate nursing intervention is to:
1. Remain with the client

2. Put the client in a quiet room
3. Teach the client deep breathing
4. Encourage the client to talk about their feelings and concern.
Ans-12. 1. If a client with severe anxiety is left alone; the client may feel abandoned and become
overwhelmed. Placing the client in a quiet room is also important, but the nurse must stay with
the client. Teaching the client deep breathing or relaxation is not possible until the anxiety
decreases. Encouraging the client to discuss concerns and feelings would not take place until the
anxiety has decreased.
13) When planning the discharge of a client with chronic anxiety, the nurse directs the goals
at promoting a safe environment at home. The most appropriate maintenance goal should
focus on which of the following?
1. Continued contact with a crisis counselor

2. Identifying anxiety-producing situations
3. Ignoring feelings of anxiety
4. Eliminating all anxiety from daily situations
Ans-13. 2. Recognizing situations that produce anxiety allows the client to prepare to cope with
anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing
situations, and this option does not encourage the development of internal strengths. Ignoring
feelings will not resolve anxiety. Elimination anxiety from life is impossible.
14) The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal.
Which of the following would alert the nurse to the potential for delirium tremors?
1. Hypertension, changes in LOC, hallucinations

2. Hypotension, ataxia, hunger
3. Stupor, agitation, muscular rigidity
4. Hypotension, coarse hand tremors, agitation
Ans-14. 1. Some of the symptoms associated with delirium tremors typically are anxiety,
insomnia, anorexia, hypertension, disorientation, hallucinations, and changes in LOC, agitation,
fever, and delusions.
15) The spouse of a client admitted to the mental health unit for alcohol withdrawal says to
the nurse “I should get out of this bad situation.” The most helpful response by the nurse
would be:
1. “I agree with you. You should get out of this situation.”

2. “What do you find difficult about this situation?”
3. “Why don’t you tell your husband about this?”
4. “This is not the best time to make that decision.”
Ans-15. 2. The most helpful response is one that encourages the client to problem solve. Giving
advice implies that the nurse knows what is best and can foster dependency. The nurse should
not agree with the client, nor should the nurse request that the client provide explanations.
16) The nurse determines that the wife of an alcoholic client is benefiting from attending Al-
Anon group when she hears the wife say:
1. “My attendance at the meetings has helped me to see that I provoke my husband’s violence.”
2. “I no longer feel that I deserve the beatings my husband inflicts on me.”
3. “I can tolerate my husband’s destructive behavior now that I know they are common with
alcoholics.”
4. “I enjoy attending the meetings because they get me out of the house and away from my
husband.”
Ans-16. 2. Al-Anon support groups are protected, supportive opportunity for spouses and
significant others to learn what to expect and to obtain excellent pointers about successful
behavior changes. Option 2 is the healthiest response because is exemplifies and understanding
that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family
members for loss of control.
17) The client has been hospitalized and is participating in a substance abuse therapy group
sessions. On discharge, the client has consented to participate in AA community groups. The
nurse is monitoring the client’s response to the substance abuse sessions. Which statement by
the client best indicates that the client has developed effective coping response styles and has
processed information effectively for self-use?
1. “I know I’m ready to be discharged. I feel I can say ‘no’ and leave a group of friends if they
are drinking… ‘No Problem.’”
2. “This group has really helped a lot. I know it will be different when I go home. But I’m sure
that my family and friends will all help me like the people in this group have… They’ll all
help me… I know they will… They won’t let me go back to my old ways.”
3. “I’m looking forward to leaving here. I know that I will miss all of you. So, I’m happy and
I’m sad, I’m excited and I’m scared. I know that I have to work hard to be strong and that
everyone isn’t going to be as helpful as you people.”
4. “I’ll keep all my appointments; go to all my AA groups; I’ll do everything I’m supposed to…
Nothing will go wrong that way.”
Ans-17. 3. In the defense mechanism of denial the person denies reality. Option 1 identifies
denial. In option 2 the client is relying heavily on others, and the client’s focus of control is
external. In option 4 the client is concrete and procedure oriented; again the client identifies that
“Nothing will go wrong that way” if the client follows all the directions. In option 3 the client is
expressing real concern and ambivalence about discharge from the hospital. The client also
demonstrates reality in that statement.
18) A hospitalized client with a history of alcohol abuse tells the nurse, “I am leaving now. I
have to go. I don’t want any more treatment. I have things that I have to do right away.” The
client has not been discharged. In fact, the client is scheduled for an important diagnostic test
to be performed in 1 hour. After the nurse discusses the client’s concerns with the client, the
client dresses and begins to walk out of the hospital room. The most important nursing action
is to:
1. Restrain the client until the physician can be reached

2. Call security to block all areas
3. Tell the client that the client cannot return to this hospital again if the client leaves now.
4. Call the nursing supervisor.
Ans-18. 4. A nurse can be charged with false imprisonment if a client is made to believe
wrongfully that the client cannot leave the hospital. Most health care facilities have documents
that the client is asked to sign that relate to the client’s responsibilities when the client leaves
against medical advice. The client should be asked to sign this document before leaving. The
nurse should request that the client wait to speak to the physician before leaving, but if the client
refuses to do so, the nurse cannot hold him against his will. Restraining the client and calling
security to block exits constitutes false imprisonment. Any client has a right to health care and
cannot be told otherwise.
19) Select the appropriate interventions for caring for the client in alcohol withdrawal.
1. Monitor vital signs

2. Provide stimulation in the environment
3. Maintain NPO status
4. Provide reality orientation as appropriate
5. Address hallucinations therapeutically
Ans-19. 1, 4, and 5. When the client is experiencing withdrawal of alcohol, the priority of care is
to prevent the client from harming himself or others. The nurse would provide a low stimulating
environment to maintain the client in as calm a state as possible. The nurse would monitor vital
signs closely and report abnormal findings. The nurse would reorient the client to reality
frequently and would address hallucinations therapeutically. Adequate nutritional and fluid
intake needs to be maintained.
20) Which of the following nursing actions would be included in a care plan for a client with
PTSD who states the experience was “bad luck”?
1. Encourage the client to verbalize the experience

2. Assist the client in defining the experience
3. Work with the client to take steps to move on with his life
4. Help the client accept positive and negative feelings
Ans-20. 2. The client must define the experience as traumatic to realize the situation wasn’t
under his personal control. Encouraging the client to verbalize the experience without first
addressing the denial isn’t a useful strategy. The client can move on with life only after
acknowledging the trauma and processing the experience. Acknowledgement of the actual
trauma and verbalization of the event should come before the acceptance of feelings.
21) Which of the following psychological symptoms would the nurse expect to find in a
hospitalized client who is the only survivor of a train accident?
1. Denial
2. Indifference
3. Perfectionism
4. Trust
Ans-21. 1. Denial can act as a protective response. The client tends to be overwhelmed and
disorganized by the trauma, not indifferent to it. Perfectionism is more commonly seen in clients
with eating disorders, not in clients with PTSD. Clients who have had a severe trauma often
experience an inability to trust others.
22) Which of the following communication guidelines should the nurse use when talking with
a client experiencing mania?
1. Address the client in a light and joking manner

2. Focus and redirect the conversation as necessary
3. Allow the client to talk about several different topic
4. Ask only open ended questions to facilitate conversations
Ans-22. 2. To decrease stimulation, the nurse should attempt to redirect and focus the client’s
communication, not allow the client to talk about different topics. By addressing the client in a
light and joking manner, the conversation may contribute to the client’s feeling out of control.
For a manic client, it’s best to ask closed questions because open-minded questions may enable
the client to talk endlessly, again possibly contributing to the client’s feeling out of control.
23) What information is important to include in the nutritional counseling of a family with a
member who has bipolar disorder?
1. If sufficient roughage isn’t eaten while taking lithium, bowel problems will occur.
2. If the intake of carbohydrates increases, the lithium level increases.
3. If the intake of calories is reduced, the lithium level will increase
4. If the intake of sodium increases, the lithium level will decrease.
Ans-23. 4. Any time the level of sodium increases, such as with a change in the dietary intake,
the levels of lithium will decrease.
24) In conferring with the treatment team, the nurse should make which of the following
recommendations for a client who tells the nurse that everyday thoughts of suicide are
present?
1. A no-suicide contract
2. Weekly outpatient therapy
3. A second psychiatric opinion
4. Intensive inpatient treatment
Ans-24. 4. For a client thinking about suicide on a daily basis, inpatient care would be the best
intervention. Although a no-suicide contract is an important strategy, this client needs additional
care. The client needs a more intensive level of care than weekly outpatient therapy. Immediate
intervention is paramount, not a second psychiatric opinion.
25) Which of the following short term goals is most appropriate for a client with bipolar
disorder who is having difficulty sleeping?
1. Obtain medication for sleep

2. Work on solving a problem
3. Exercise before bedtime
4. Develop a sleep ritual
Ans-25. 4. A sleep ritual or nighttime routine helps the client to relax and prepare for sleep.
Obtaining sleep medication is a temporary solution. Working on problem solving may excite the
client rather than tire him. Exercise before retiring is inappropriate.
Renal
1. Which of the following symptoms do you expect to see in a patient diagnosed with acute
pyelonephritis?
A. Jaundice and flank pain

B. Costovertebral angle tenderness and chills
C. Burning sensation on urination
D. Polyuria and nocturia
Ans-1. B. Costovertebral angle tenderness, flank pain, and chills are symptoms of acute
pyelonephritis. Jaundice indicates gallbladder or liver obstruction. A burning sensation on
urination is a sign of lower urinary tract infection.
2. You have a patient that might have a urinary tract infection (UTI). Which statement by the
patient suggests that a UTI is likely?
A. “I pee a lot.”
B. “It burns when I pee.”
C. “I go hours without the urge to pee.”
D. “My pee smells sweet.”
Ans-2. B. A common symptom of a UTI is dysuria. A patient with a UTI often reports frequent
voiding of small amounts and the urgency to void. Urine that smells sweet is often associated
with diabetic ketoacidosis.
3. Which instructions do you include in the teaching care plan for a patient with cystitis
receiving phenazopyridine (Pyridium).
A. If the urine turns orange-red, call the doctor.

B. Take phenazopyridine just before urination to relieve pain.
C. Once painful urination is relieved, discontinue prescribed antibiotics.
D. After painful urination is relieved, stop taking phenazopyridine.
Ans-3. D. Pyridium is taken to relieve dysuria because is provides an analgesic and anesthetic
effect on the urinary tract mucosa. The patient can stop taking it after the dysuria is relieved. The
urine may temporarily turn red or orange due to the dye in the drug. The drug isn’t taken before
voiding, and is usually taken 3 times a day for 2 days.
4. Which patient is at greatest risk for developing a urinary tract infection (UTI)?
A. A 35 y.o. woman with a fractured wrist
B. A 20 y.o. woman with asthma
C. A 50 y.o. postmenopausal woman
D. A 28 y.o. with angina
Ans-4 C. Women are more prone to UTI’s after menopause due to reduced estrogen levels.
Reduced estrogen levels lead to reduced levels of vaginal Lactobacilli bacteria, which protect
against infection. Angina, asthma and fractures don’t increase the risk of UTI.
5. You have a patient that is receiving peritoneal dialysis. What should you do when you
notice the return fluid is slowly draining?
A. Check for kinks in the outflow tubing.

B. Raise the drainage bag above the level of the abdomen.
C. Place the patient in a reverse Trendelenburg position.
D. Ask the patient to cough.
Ans-5. A. 1. Tubing problems are a common cause of outflow difficulties, check the tubing for
kinks and ensure that all clamps are open. Other measures include having the patient change
positions (moving side to side or sitting up), applying gentle pressure over the abdomen, or
having a bowel movement.
6. What is the appropriate infusion time for the dialysate in your 38 y.o. patient with chronic
renal failure?
A. 15 minutes
B. 30 minutes
C. 1 hour
D. 2 to 3 hours
Ans-6. A. Dialysate should be infused quickly. The dialysate should be infused over 15 minutes
or less when performing peritoneal dialysis. The fluid exchange takes place over a period
ranging from 30 minutes to several hours.
7. A 30 y.o. female patient is undergoing hemodialysis with an internal arteriovenous fistula

in place. What do you do to prevent complications associated with this device?
A. Insert I.V. lines above the fistula.

B. Avoid taking blood pressures in the arm with the fistula.
C. Palpate pulses above the fistula.
D. Report a bruit or thrill over the fistula to the doctor.
Ans-7. B. Don’t take blood pressure readings in the arm with the fistula because the
compression could damage the fistula. IV lines shouldn’t be inserted in the arm used for
hemodialysis. Palpate pulses below the fistula. Lack of bruit or thrill should be reported to the
doctor.
8. Your patient becomes restless and tells you she has a headache and feels nauseous during
hemodialysis. Which complication do you suspect?
A. Infection
B. Disequilibrium syndrome
C. Air embolus
D. Acute hemolysis
Ans-8. B Disequilibrium syndrome is caused by a rapid reduction in urea, sodium, and other
solutes from the blood. This can lead to cerebral edema and increased intracranial pressure (ICP).
Signs and symptoms include headache, nausea, restlessness, vomiting, confusion, twitching, and
seizures.

9. Your patient is complaining of muscle cramps while undergoing hemodialysis. Which
intervention is effective in relieving muscle cramps?
1. Increase the rate of dialysis

2. Infuse normal saline solution
3. Administer a 5% dextrose solution
4. Encourage active ROM exercises
Ans-9. B. 2. Treatment includes administering normal saline or hypertonic normal saline solution
because muscle cramps can occur when the sodium and water are removed to quickly during
dialysis. Reducing the rate of dialysis, not increasing it, may alleviate muscle cramps.
10. Your patient with chronic renal failure reports pruritus. Which instruction should you
include in this patient’s teaching plan?
1. Rub the skin vigorously with a towel

2. Take frequent baths
3. Apply alcohol-based emollients to the skin
4. Keep fingernails short and clean
Ans-10. 4. Calcium-phosphate deposits in the skin may cause pruritus. Scratching leads to
excoriation and breaks in the skin that increase the patient’s risk of infection. Keeping fingernails
short and clean helps reduce the risk of infection.
11. Which intervention do you plan to include with a patient who has renal calculi?
1. Maintain bed rest

2. Increase dietary purines
3. Restrict fluids
4. Strain all urine
Ans-11. 4. All urine should be strained through gauze or a urine strainer to catch stones that are
passed. The stones are then analyzed for composition. Ambulation may help the movement of
the stone down the urinary tract. Encourage fluid to help flush the stones out.
12. An 18 y.o. student is admitted with dark urine, fever, and flank pain and is diagnosed with
acute glomerulonephritis. Which would most likely be in this student’s health history?
1. Renal calculi
2. Renal trauma
3. Recent sore throat
4. Family history of acute glomerulonephritis
Ans-12. 3. The most common form of acute glomerulonephritis is caused by group A beta-
hemolytic streptococcal infection elsewhere in the body.
13. Which drug is indicated for pain related to acute renal calculi?
1. Narcotic analgesics
2. Nonsteroidal anti-inflammatory drugs (NSAIDS)
3. Muscle relaxants
4. Salicylates
Ans-13. 1. Narcotic analgesics are usually needed to relieve the severe pain of renal calculi.
Muscle relaxants are typically used to treat skeletal muscle spasms. NSAIDS and salicylates are
used for their anti-inflammatory and antipyretic properties and to treat less severe pain.
14. Which of the following causes the majority of UTI’s in hospitalized patients?
1. Lack of fluid intake

2. Inadequate perineal care
3. Invasive procedures
4. Immunosuppression
Ans-14. 3. Invasive procedures such as catheterization can introduce bacteria into the urinary
tract. A lack of fluid intake could cause concentration of urine, but wouldn’t necessarily cause
infection
19. Clinical manifestations of acute glomerulonephritis include which of the following?
1. Chills and flank pain

2. Oliguria and generalized edema
3. Hematuria and proteinuria
4. Dysuria and hypotension
Ans-15. 3. Hematuria and proteinuria indicate acute glomerulonephritis. These finding result
from increased permeability of the glomerular membrane due to the antigen-antibody reaction.
Generalized edema is seen most often in nephrosis.
16. You expect a patient in the oliguric phase of renal failure to have a 24 hour urine output
less than:
1. 200ml
2. 400ml
3. 800ml
4. 1000ml
Ans-16. 2. Oliguria is defined as urine output of less than 400ml/24hours.
17. The most common early sign of kidney disease is:
1. Sodium retention
2. Elevated BUN level
3. Development of metabolic acidosis
4. Inability to dilute or concentrate urine
Ans-17. 2. Increased BUN is usually an early indicator of decreased renal function.
18. A patient is experiencing which type of incontinence if she experiences leaking urine
when she coughs, sneezes, or lifts heavy objects?
1. Overflow
2. Reflex
3. Stress
4. Urge
Ans-18. 3. Stress incontinence is an involuntary loss of a small amount of urine due to sudden
increased intra-abdominal pressure, such as with coughing or sneezing.
19. Immediately post-op after a prostatectomy, which complications requires priority

assessment of your patient?
1. Pneumonia
2. Hemorrhage
3. Urine retention
4. Deep vein thrombosis
Ans-19. 2. Hemorrhage is a potential complication. Urine retention isn’t a problem soon after
surgery because a catheter is in place. Pneumonia may occur if the patient doesn’t cough and
deep breathe. Thrombosis may occur later if the patient doesn’t ambulate.
20. The most indicative test for prostate cancer is:
1. A thorough digital rectal examination

2. Magnetic resonance imaging (MRI)
3. Excretory urography
4. Prostate-specific antigen
Ans-20. 4. An elevated prostate-specific antigen level indicates prostate cancer, but it can be
falsely elevated if done after the prostate gland is manipulated. A digital rectal examination
should be done as part of the yearly screening, and then the antigen test is done if the digital
exam suggests cancer. MRI is used in staging the cancer.
21. A 22 y.o. patient with diabetic nephropathy says, “I have two kidneys and I’m still young.
If I stick to my insulin schedule, I don’t have to worry about kidney damage, right?” Which of
the following statements is the best response?
1. “You have little to worry about as long as your kidneys keep making urine.”
2. “You should talk to your doctor because statistics show that you’re being unrealistic.”
3. “You would be correct if your diabetes could be managed with insulin.”
4. “Even with insulin, kidney damage is still a concern.”
Ans-21. 4. Kidney damage is still a concern. Microavascular changes occur in both of the
patient’s kidneys as a complication of the diabetes. Diabetic nephropathy is the leading cause of
end-stage renal disease. The kidneys continue to produce urine until the end stage. Nephropathy
occurs even with insulin management.
22. A patient diagnosed with sepsis from a UTI is being discharged. What do you plan to
include in her discharge teaching?
1. Take cool baths

2. Avoid tampon use
3. Avoid sexual activity
4. Drink 8 to 10 eight-oz glasses of water daily
Ans-22. 4. Drinking 2-3L of water daily inhibits bacterial growth in the bladder and helps flush
the bacteria from the bladder. The patient should be instructed to void after sexual activity.
23. You’re planning your medication teaching for your patient with a UTI prescribed
phenazopyridine (Pyridium). What do you include?
1. “Your urine might turn bright orange.”

2. “You need to take this antibiotic for 7 days.”
3. “Take this drug between meals and at bedtime.”
4. “Don’t take this drug if you’re allergic to penicillin.”
Ans-23. 1. The drug turns the urine orange. It may be prescribed for longer than 7 days and is
usually ordered three times a day after meals. Phenazopyridine is an azo (nitrogenous) analgesic;
not an antibiotic.
24. Which finding leads you to suspect acute glomerulonephritis in your 32 y.o. patient?
1. Dysuria, frequency, and urgency

2. Back pain, nausea, and vomiting
3. Hypertension, oliguria, and fatigue
4. Fever, chills, and right upper quadrant pain radiating to the back
Ans-24. 3. Mild to moderate HTN may result from sodium or water retention and inappropriate
rennin release from the kidneys. Oliguria and fatigue also may be seen. Other signs are
proteinuria and azotemia.
25. What is the priority nursing diagnosis with your patient diagnosed with end-stage renal
disease?
1. Activity intolerance
2. Fluid volume excess
3. Knowledge deficit
4. Pain
Ans-25. 2. Fluid volume excess because the kidneys aren’t removing fluid and wastes. The other
diagnoses may apply, but they don’t take priority.
26. A patient with ESRD has an arteriovenous fistula in the left arm for hemodialysis. Which
intervention do you include in his plan of care?
1. Apply pressure to the needle site upon discontinuing hemodialysis

2. Keep the ehad of the bed elevated 45 degrees
3. Place the left arm on an arm board for at least 30 minutes
4. Keep the left arm dry
Ans-26. 1. Apply pressure when discontinuing hemodialysis and after removing the
venipuncture needle until all the bleeding has stopped. Bleeding may continue for 10 minutes in
some patients
27. Your 60 y.o. patient with pyelonephritis and possible septicemia has had five UTIs over
the past two years. She is fatigued from lack of sleep, has lost weight, and urinates frequently
even in the night. Her labs show: sodium, 154 mEq/L; osmolarity 340 mOsm/L; glucose, 127
mg/dl; and potassium, 3.9 mEq/L. Which nursing diagnosis is priority?
1. Fluid volume deficit related to osmotic diuresis induced by hyponatremia

2. Fluid volume deficit related to inability to conserve water
3. Altered nutrition: Less than body requirements related to hypermetabolic state
4. Altered nutrition: Less than body requirements related to catabolic effects of insulin
deficiency
Ans-27. 2.
28. Which sign indicated the second phase of acute renal failure?
1. Daily doubling of urine output (4 to 5 L/day)

2. Urine output less than 400 ml/day
3. Urine output less than 100 ml/day
4. Stabilization of renal function
Ans-28. 1. Daily doubling of the urine output indicates that the nephrons are healing. This
means the patient is passing into the second phase (dieresis) of acute renal failure.
29. Your patient had surgery to form an arteriovenous fistula for hemodialysis. Which
information is important for providing care for the patient?
1. The patient shouldn’t feel pain during initiation of dialysis

2. The patient feels best immediately after the dialysis treatment
3. Using a stethoscope for auscultating the fistula is contraindicated
4. Taking a blood pressure reading on the affected arm can cause clotting of the fistula
Ans-29. 4. Pressure on the fistula or the extremity can decrease blood flow and precipitate
clotting, so avoid taking blood pressure on the affected arm.
30. A patient with diabetes mellitus and renal failure begins hemodialysis. Which diet is best
on days between dialysis treatments?
1. Low-protein diet with unlimited amounts of water

2. Low-protein diet with a prescribed amount of water
3. No protein in the diet and use of a salt substitute
4. No restrictions
Ans-30. 2. The patient should follow a low-protein diet with a prescribed amount of water. The
patient requires some protein to meet metabolic needs. Salt substitutes shouldn’t be used without
a doctor’s order because it may contain potassium, which could make the patient hyperkalemic.
Fluid and protein restrictions are needed.
31. After the first hemodialysis treatment, your patient develops a headache, hypertension,
restlessness, mental confusion, nausea, and vomiting. Which condition is indicated?
1. Disequilibrium syndrome
2. Respiratory distress
3. Hypervolemia
4. Peritonitis
Ans-31. 1. Disequilibrium occurs when excess solutes are cleared from the blood more rapidly
than they can diffuse from the body’s cells into the vascular system.
32. Which action is most important during bladder training in a patient with a neurogenic
bladder?
1. Encourage the use of an indwelling urinary catheter

2. Set up specific times to empty the bladder
3. Encourage Kegel exercises
4. Force fluids
Ans-32. 2. Instruct the patient with neurogenic bladder to write down his voiding pattern and
empty the bladder at the same times each day.
33. A patient with diabetes has had many renal calculi over the past 20 years and now has
chronic renal failure. Which substance must be reduced in this patient’s diet?
1. Carbohydrates
2. Fats
3. Protein
4. Vitamin C
Ans-33. 3. Because of damage to the nephrons, the kidney can’t excrete all the metabolic wastes
of protein, so this patient’s protein intake must be restricted. A higher intake of carbs, fats, and
vitamin supplements is needed to ensure the growth and maintenance of the patient’s tissues.
34. What is the best way to check for patency of the arteriovenous fistula for hemodialysis?
1. Pinch the fistula and note the speed of filling on release

2. Use a needle and syringe to aspirate blood from the fistula
3. Check for capillary refill of the nail beds on that extremity
4. Palpate the fistula throughout its length to assess for a thrill
Ans-34. 4. The vibration or thrill felt during palpation ensures that the fistula has the desired
turbulent blood flow. Pinching the fistula could cause damage. Aspirating blood is a needless
invasive procedure.
35. You have a paraplegic patient with renal calculi. Which factor contributes to the
development of calculi?
1. Increased calcium loss from the bones

2. Decreased kidney function
3. Decreased calcium intake
4. High fluid intake
Ans-35. 1. Bones lose calcium when a patient can no longer bear weight. The calcium lost from
bones form calculi, a concentration of mineral salts also known as a stone, in the renal system.
36. What is the most important nursing diagnosis for a patient in end-stage renal disease?
1. Risk for injury

3. Altered nutrition: less than body requirements
4. Activity intolerance
Ans-36. 2. Kidneys are unable to rid the body of excess fluids which results in fluid volume
excess during ESRD.
37. Frequent PVCs are noted on the cardiac monitor of a patient with end-stage renal disease.
The priority intervention is:
1. Call the doctor immediately

2. Give the patient IV lidocaine (Xylocaine)
3. Prepare to defibrillate the patient
4. Check the patient’s latest potassium level
Ans-37. 4. The patient with ESRD may develop arrhythmias caused by hypokalemi. Call the
doctor after checking the patient’s potassium values. Lidocaine may be ordered if the PVCs are
frequent and the patient is symptomatic.
38. A patient who received a kidney transplant returns for a follow-up visit to the outpatient
clinic and reports a lump in her breast. Transplant recipients are:
1. At increased risk for cancer due to immunosuppression caused by cyclosporine (Neoral)

2. Consumed with fear after the life-threatening experience of having a transplant
3. At increased risk for tumors because of the kidney transplant
4. At decreased risk for cancer, so the lump is most likely benign
Ans-38. 1. Cyclosporine suppresses the immune response to prevent rejection of the

transplanted kidney. The use of cyclosporine places the patient at risk for tumors.
39. You’re developing a care plan with the nursing diagnosis risk for infection for your
patient that received a kidney transplant. A goal for this patient is to:
1. Remain afebrile and have negative cultures

2. Resume normal fluid intake within 2 to 3 days
3. Resume the patient’s normal job within 2 to 3 weeks
4. Try to discontinue cyclosporine (Neoral) as quickly as possible
Ans-39. 1. The immunosuppressive activity of cyclosporine places the patient at risk for
infection, and steroids can mask the signs of infection. The patient may not be able to resume
normal fluid intake or return to work for an extended period of time and the patient may need
cyclosporine therapy for life.
40. You suspect kidney transplant rejection when the patient shows which symptoms?
1. Pain in the incision, general malaise, and hypotension

2. Pain in the incision, general malaise, and depression
3. Fever, weight gain, and diminished urine output
4. Diminished urine output and hypotension
Ans-40. 3. Symptoms of rejection include fever, rapid weight gain, hypertension, pain over the
graft site, peripheral edema, and diminished urine output.
41. Your patient returns from the operating room after abdominal aortic aneurysm repair.
Which symptom is a sign of acute renal failure?
1. Anuria
2. Diarrhea
3. Oliguria
4. Vomiting
Ans-41. 3. Urine output less than 50ml in 24 hours signifies oliguria, an early sign of renal
failure. Anuria is uncommon except in obstructive renal disorders.
42. Which cause of hypertension is the most common in acute renal failure?
1. Pulmonary edema
2. Hypervolemia
3. Hypovolemia
4. Anemia
Ans-42. 2. Acute renal failure causes hypervolemia as a result of overexpansion of extracellular

fluid and plasma volume with the hypersecretion of rennin. Therefore, hypervolemia causes
hypertension.
43. A patient returns from surgery with an indwelling urinary catheter in place and empty.
Six hours later, the volume is 120ml. The drainage system has no obstructions. Which
intervention has priority?
1. Give a 500ml bolus of isotonic saline

2. Evaluate the patient’s circulation and vital signs
3. Flush the urinary catheter with sterile water or saline
4. Place the patient in the shock position, and notify the surgeon
Ans-43. 2. A total UO of 120ml is too low. Assess the patient’s circulation and hemodynamic
stability for signs of hypovolemia. A fluid bolus may be required, but only after further nursing
assessment and a doctor’s order.
44. You’re preparing for urinary catheterization of a trauma patient and you observe bleeding
at the urethral meatus. Which action has priority?
1. Irrigate and clean the meatus before catheterization

2. Check the discharge for occult blood before catheterization
3. Heavily lubricate the catheter before insertion
4. Delay catheterization and notify the doctor
Ans-44. 4. Bleeding at the urethral meatus is evidence that the urethra is injured. Because
catheterization can cause further harm, consult with the doctor.
45. What change indicates recovery in a patient with nephritic syndrome?
1. Disappearance of protein from the urine

2. Decrease in blood pressure to normal
3. Increase in serum lipid levels
4. Gain in body weight
Ans-45. 1. With nephrotic syndrome, the glomerular basement membrane of the kidney
becomes more porous, leading to loss of protein in the urine. As the patient recovers, less protein
is found in the urine.
46. Which statement correctly distinguishes renal failure from prerenal failure?
1. With prerenal failure, vasoactive substances such as dopamine (Intropin) increase blood
pressure
2. With prerenal failure, there is less response to such diuretics as furosemide (Lasix)
3. With prerenal failure, an IV isotonic saline infusion increases urine output
4. With prerenal failure, hemodialysis reduces the BUN level
Ans-46. 3. Prerenal failure is caused by such conditions as hypovolemia that impairs kidney
perfusion; giving isotonic fluids improves urine output. Vasoactive substances can increase
blood pressure in both conditions.
47. Which criterion is required before a patient can be considered for continuous peritoneal
dialysis?
1. The patient must be hemodynamically stable

2. The vascular access must have healed
3. The patient must be in a home setting
4. Hemodialysis must have failed
Ans-47. 1. Hemodynamic stability must be established before continuous peritoneal dialysis can
be started.
48. Polystyrene sulfonate (Kayexalate) is used in renal failure to:
1. Correct acidosis
2. Reduce serum phosphate levels
3. Exchange potassium for sodium
4. Prevent constipation from sorbitol use
Ans-48. 3. In renal failure, patients become hyperkalemic because they can’t excrete potassium
in the urine. Polystyrene sulfonate acts to excrete potassium by pulling potassium into the bowels
and exchanging it for sodium.
49. Your patient has complaints of severe right-sided flank pain, nausea, vomiting and
restlessness. He appears slightly pale and is diaphoretic. Vital signs are BP 140/90 mmHg,
Pulse 118 beats/min., respirations 33 breaths/minute, and temperature, 98.0F. Which
subjective data supports a diagnosis of renal calculi?
1. Pain radiating to the right upper quadrant

2. History of mild flu symptoms last week
3. Dark-colored coffee-ground emesis
4. Dark, scant urine output
Ans-49. 4. Patients with renal calculi commonly have blood in the urine caused by the stone’s
passage through the urinary tract. The urine appears dark, tests positive for blood, and is
typically scant.
Kidney stones, bladder cancer, prostate issues
1. A client is complaining of severe flank and abdominal pain. A flat plate of the abdomen
shows urolithiasis. Which of the following interventions is important?
1. Strain all urine

2. Limit fluid intake
3. Enforce strict bed rest
4. Encourage a high calcium diet
Ans-1. 1. Urine should be strained for calculi and sent to the lab for analysis. Fluid intake of 3 to
4 L is encouraged to flush the urinary tract and prevent further calculi formation. A low-calcium
diet is recommended to help prevent the formation of calcium calculi. Ambulation is encouraged
to help pass the calculi through gravity.
2. A client is receiving a radiation implant for the treatment of bladder cancer. Which of the
following interventions is appropriate?
1. Flush all urine down the toilet

2. Restrict the client’s fluid intake
3. Place the client in a semi-private room
4. Monitor the client for signs and symptoms of cystitis
Ans-2. 4. Cystitis is the most common adverse reaction of clients undergoing radiation therapy;
symptoms include dysuria, frequency, urgency, and nocturia. Clients with radiation implants
require a private room. Urine of clients with radiation implants for bladder cancer should be sent
to the radioisotopes lab for monitoring. It is recommended that fluid intake be increased.
3. A client has just received a renal transplant and has started cyclosporine therapy to
prevent graft rejection. Which of the following conditions is a major complication of this drug
therapy?
1. Depression
2. Hemorrhage
3. Infection
Ans-3. 3. Infections is the major complication to watch for in clients on cyclosporine therapy
because it’s an immunosuppressive drug. Depression may occur post transplantation but not
because of cyclosporine. Hemorrhage is a complication associated with anticoagulant therapy.
Peptic ulcer disease is a complication of steroid therapy.
4. A client received a kidney transplant 2 months ago. He’s admitted to the hospital with the
diagnosis of acute rejection. Which of the following assessment findings would be expected?
1. Hypotension
2. Normal body temperature
3. Decreased WBC count
4. Elevated BUN and creatinine levels
Ans-4. 4. In a client with acute renal graft rejection, evidence of deteriorating renal function is
expected. The nurse would see elevated WBC counts and fever because the body is recognizing
the graft as foreign and is attempting to fight it. The client would most likely have acute
hypertension.
5. The client is to undergo kidney transplantation with a living donor. Which of the
following preoperative assessments is important?
1. Urine output
2. Signs of graft rejection
3. Signs and symptoms of rejection
4. Client’s support system and understanding of lifestyle changes.
Ans-5. 4. The client undergoing a renal transplantation will need vigilant follow-up care and
must adhere to the medical regimen. The client is most likely anuric or oliguric preoperatively,
but postoperatively will require close monitoring of urine output to make sure the transplanted
kidney is functioning optimally. While the client will always need to be monitored for signs and
symptoms of infection, it’s most important post-op will require close monitoring of urine output
to make sure the transplanted kidney is functioning optimally. While the client will always need
to be monitored for signs and symptoms of infection, it’s most important postoperatively due to
the immunosuppressant therapy. Rejection can occur postoperatively.
6. A client had a transurethral prostatectomy for benign prostatic hypertrophy. He’s
currently being treated with a continuous bladder irrigation and is complaining of an increase
in severity of bladder spasms. Which of the interventions should be done first?
1. Administer an oral analgesic

2. Stop the irrigation and call the physician
3. Administer a belladonna and opium suppository as ordered by the physician.
4. Check for the presence of clots, and make sure the catheter is draining properly.
Ans-6. 4. Blood clots and blocked outflow if the urine can increase spasms. The irrigation
shouldn’t be stopped as long as the catheter is draining because clots will form. A belladonna
and opium suppository should be given to relieve spasms but only after assessment of the
drainage. Oral analgesics should be given if the spasms are unrelieved by the belladonna and
opium suppository
7. A client is admitted with a diagnosis of hydronephrosis secondary to calculi. The calculi
have been removed and post obstructive diuresis is occurring. Which of the following
interventions should be done?
1. Take vital signs every 8 hours

2. Weigh the client every other day
3. Assess for urine output every shift
4. Monitor the client’s electrolyte levels.
Ans-7. 4. Postobstructive diuresis seen in hydronephrosis can cause electrolyte imbalances; lab
values must be checked so electrolytes can be replaced as needed. VS should initially be taken
every 30 minutes for the first 4 hours and then every 2 hours. Urine output needs to be assessed
hourly. The client’s weight should be taken daily to assess fluid status more closely.
8. A client has passed a renal calculus. The nurse sends the specimen to the laboratory so it
can be analyzed for which of the following factors?
1. Antibodies
2. Type of infection
3. Composition of calculus
4. Size and number of calculi
Ans-8. 3. The calculus should be analyzed for composition to determine appropriate

interventions such as dietary restrictions. Calculi don’t result in infections. The size and number
of calculi aren’t relevant, and they don’t contain antibodies.
9. Which of the following symptoms indicate acute rejection of a transplanted kidney?
1. Edema, nausea
2. Fever, anorexia
3. Weight gain, pain at graft site
4. Increased WBC count, pain with voiding
Ans-9. 3. Pain at the graft site and weight gain indicates the transplanted kidney isn’t functioning
and possibly is being rejected. Transplant clients usually have edema, anorexia, fever, and
nausea before transplantation, so those symptoms may not indicate rejection.
10. Adverse reactions of prednisone therapy include which of the following conditions?
1. Acne and bleeding gums
2. Sodium retention and constipation
3. Mood swings and increased temperature
4. Increased blood glucose levels and decreased wound healing.
Ans-10. 4. Steroid use tends to increase blood glucose levels, particularly in clients with
diabetes and borderline diabetes. Steroids also contribute to poor wound healing and may cause
acne, mood swings, and sodium and water retention. Steroids don’t affect thermoregulation,
bleeding tendencies, or constipation.
11. The nurse suspects that a client with polyuria is experiencing water diuresis. Which
laboratory value suggests water diuresis?
1. High urine specific gravity

2. High urine osmolarity
3. Normal to low urine specific gravity
4. Elevated urine pH
Ans-11. 3. Water diuresis causes low urine specific gravity, low urine osmolarity, and a normal
to elevated serum sodium level. High specific gravity indicates dehydration. Hypernatremia
signals acidosis and shock. Elevated urine pH can result from potassium deficiency, a high-
protein diet, or uncontrolled diabetes.
12. A client is diagnosed with prostate cancer. Which test is used to monitor progression of
this disease?
1. Serum creatinine
2. Complete blood cell count (CBC)
3. Prostate specific antigen (PSA)
4. Serum potassium
Ans-12. 3. The PSA test is used to monitor prostate cancer progression; higher PSA levels
indicate a greater tumor burden. Serum creatinine levels may suggest blockage from an enlarged
prostate. CBC is used to diagnose anemia and polycythemia. Serum potassium levels identify
hypokalemia and hyperkalemia.
13. A 27-year old client, who became paraplegic after a swimming accident, is experiencing
autonomic dysreflexia. Which condition is the most common cause of autonomic dysrelexia?
1. Upper respiratory infection

2. Incontinence
3. Bladder distention
4. Diarrhea
Ans-13. 3. Autonomic dysreflexia is a potentially life-threatening complication of spinal cord

injury, occurring from obstruction of the urinary system or bowel. Incontinence and diarrhea
don’t result in obstruction of the urinary system or bowel, respectively. An URI could obstruct
the respiratory system, but not the urinary or bowel system.
14. When providing discharge teaching for a client with uric acid calculi, the nurse should an
instruction to avoid which type of diet?
1. Low-calcium
2. Low-oxalate
3. High-oxalate
4. High-purine
Ans-14. 4. To control uric acid calculi, the client should follow a low-purine diet, which
excludes high-purine foods such as organ meats. A low-calcium diet decreases the risk for
oxalate renal calculi. Oxalate is an essential amino acid and must be included in the diet. A low-
oxalate diet is used to control calcium or oxalate calculi.
15. The client with urolithiasis has a history of chronic urinary tract infections. The nurse
concludes that this client most likely has which of the following types of urinary stones?
1. Calcium oxalate
2. Uric acid
3. Struvite
4. Cystine
Ans-15. 3. Struvite stones commonly are referred to as infection stones because they form in
urine that is alkaline and rich in ammonia, such as with a urinary tract infection. Calcium oxalate
stones result from increased calcium intake or conditions that raise serum calcium
concentrations. Uric acid stones occur in clients with gout. Cystine stones are rare and occur in
clients with a genetic defect that results in decreased renal absorption of the amino acid cystine.
16. The nurse is receiving in transfer from the postanesthesia care unit a client who has had a
percutaneous ultrasonic lithrotripsy for calculuses in the renal pelvis. The nurse anticipates
that the client’s care will involve monitoring which of the following?
1. Suprapubic tube
2. Urethral stent
3. Nephrostomy tube
4. Jackson-Pratt drain
Ans-16. 3. A nephrostomy tube is put in place after a percutaneous ultrasonic lithotripsy to treat
calculuses in the renal pelvis. The client may also have a foley catheter to drain urine produced
by the other kidney. The nurse monitors the drainage from each of these tubes and strains the
urine to detect elimination of the calculus fragments.
17. The client is admitted to the ER following a MVA. The client was wearing a lap seat belt
when the accident occurred. The client has hematuria and lower abdominal pain. To
determine further whether the pain is due to bladder trauma, the nurse asks the client if the
pain is referred to which of the following areas?
1. Shoulder
2. Umbilicus
3. Costovertebral angle
4. Hip
Ans-17. 1. Bladder trauma or injury is characterized by lower abdominal pain that may radiate
to one of the shoulders. Bladder injury pain does not radiate to the umbilicus, CV angle, or hip.
18. The client complains of fever, perineal pain, and urinary urgency, frequency, and dysuria.
To assess whether the client’s problem is related to bacterial prostatitis, the nurse would look
at the results of the prostate examination, which should reveal that the prostate gland is:
1. Tender, indurated, and warm to the touch

2. Soft and swollen
3. Tender and edematous with ecchymosis
4. Reddened, swollen, and boggy.
Ans-18. 1. The client with prostatitis has a prostate gland that is swollen and tender but that is
also warm to the touch, firm, and indurated. Systemic symptoms include fever with chills,
perineal and low back pain, and signs of urinary tract infection (which often accompany the
disorder).
19. The nurse is taking the history of a client who has had benign prostatic hyperplasia in the
past. To determine whether the client currently is experiencing difficulty, the nurse asks the
client about the presence of which of the following early symptoms?
1. Urge incontinence
2. Nocturia
3. Decreased force in the stream of urine
4. Urinary retention
Ans-19. 3. Decreased force in the stream of urine is an early sign of BPH. The stream later
becomes weak and dribbling. The client then may develop hematuria, frequency, urgency, urge
incontinence, and nocturia. If untreated, complete obstruction and urinary retention can occur.
20. The client who has a cold is seen in the emergency room with inability to void. Because
the client has a history of BPH, the nurse determines that the client should be questioned
about the use of which of the following medications?
1. Diuretics
2. Antibiotics
3. Antitussives
4. Decongestants
Ans-20. 4. In the client with BPH, episodes of urinary retention can be triggered by certain
medications, such as decongestants, anticholinergics, and antidepressants. The client should be
questioned about the use of these medications if the client has urinary retention. Retention can
also be precipitated by other factors, such as alcoholic beverages, infection, bedrest, and
becoming chilled.
21. The nurse is preparing to care for the client following a renal scan. Which of the
following would the nurse include in the plan of care?
1. Place the client on radiation precautions for 18 hours

2. Save all urine in a radiation safe container for 18 hours
3. Limit contact with the client to 20 minutes per hour.
4. No special precautions except to wear gloves if in contact with the client’s urine.
Ans-21. 4. No specific precautions are necessary following a renal scan. Urination into a
commode is acceptable without risk from the small amount of radioactive material to be
excreted. The nurse wears gloves to maintain body secretion precautions.
22. The client passes a urinary stone, and lab analysis of the stone indicates that it is
composed of calcium oxalate. Based on this analysis, which of the following would the nurse
specifically include in the dietary instructions?
1. Increase intake of meat, fish, plums, and cranberries

2. Avoid citrus fruits and citrus juices
3. Avoid green, leafy vegetables such as spinach.
4. Increase intake of dairy products.
Ans-22. 3. Oxalate is found in dark green foods such as spinach. Other foods that raise urinary
oxalate are rhubarb, strawberries, chocolate, wheat bran, nuts, beets, and tea.
23. The client returns to the nursing unit following a pyelolithotomy for removal of a kidney
stone. A Penrose drain is in place. Which of the following would the nurse include on the
client’s postoperative care?
1. Sterile irrigation of the Penrose drain

2. Frequent dressing changes around the Penrose drain
3. Weighing the dressings
4. Maintaining the client’s position on the affected side
Ans-23. 2. Frequent dressing changes around the Penrose drain is required to protect the skin
against breakdown from urinary drainage. If urinary drainage is excessive, an ostomy pouch may
be placed over the drain to protect the skin. A Penrose drain is not irrigated. Weighing the
dressings is not necessary. Placing the client on the affected side will prevent a free flow of urine
through the drain.
24. The nurse is caring for a client following a kidney transplant. The client develops
oliguria. Which of the following would the nurse anticipate to be prescribed as the treatment
of oliguria?
1. Encourage fluid intake

2. Administration of diuretics
3. Irrigation of Foley catheter
4. Restricting fluids
Ans-24. 2. To increase urinary output, diuretics and osmotic agents are considered. The client
should be monitored closely because fluid overload can cause hypertension, congestive heart
failure, and pulmonary edema. Fluid intake would not be encouraged or restricted. Irrigation of
the Foley catheter will not assist in alleviating this oliguria.
25. A week after kidney transplantation the client develops a temperature of 101, the blood
pressure is elevated, and the kidney is tender. The x-ray results the transplanted kidney is
enlarged. Based on these assessment findings, the nurse would suspect which of the
following?
1. Acute rejection
2. Chronic rejection
3. Kidney infection
4. Kidney obstruction
Ans-25. 1. Acute rejection most often occurs in the first 2 weeks after transplant. Clinical
manifestations include fever, malaise, elevated WBC count, acute hypertension, graft tenderness,
and manifestations of deteriorating renal function. Chronic rejection occurs gradually during a
period of months to years. Although kidney infection or obstruction can occur, the symptoms
presented in the question do not relate specifically to these disorders.
26. The client with BPH undergoes a transurethral resection of the prostate.
Postoperatively, the client is receiving continuous bladder irrigations. The nurse assesses the
client for signs of transurethral resection syndrome. Which of the following assessment data
would indicate the onset of this syndrome?
1. Bradycardia and confusion

2. Tachycardia and diarrhea
3. Decreased urinary output and bladder spasms
4. Increased urinary output and anemia
Ans-26. 1. Transurethral resection syndrome is caused by increased absorption of nonelectrolyte

irrigating fluid used during surgery. The client may show signs of cerebral edema and increased
intracranial pressure such as increased blood pressure, bradycardia, confusion, disorientation,
muscle twitching, visual disturbances, and nausea and vomiting.
27. The client is admitted to the hospital with BPH, and a transurethral resection of the
prostate is performed. Four hours after surgery the nurse takes the client’s VS and empties the
urinary drainage bag. Which of the following assessment findings would indicate the need to
notify the physician?
1. Red bloody urine

2. Urinary output of 200 ml greater than intake
3. Blood pressure of 100/50 and pulse 130.
4. Pain related to bladder spasms.
Ans-27. 3. Frank bleeding (arterial or venous) may occur during the first few days after surgery.
Some hematuria is usual for several days after surgery. A urinary output of 200 ml of greater
than intake is adequate. Bladder spasms are expected to occur after surgery. A rapid pulse with a
low blood pressure is a potential sign of excessive blood loss. The physician should be notified.
28. Which of the following symptoms is the most common clinical finding associated with
bladder cancer?
1. Suprapubic pain
2. Dysuria
3. Painless hematuria
4. Urinary retention
Ans-28. 3. Painless hematuria is the most common clinical finding in bladder cancer. Other
symptoms include frequency, dysuria, and urgency, but these are not as common as the
hematuria. Suprapubic pain and urinary retention do not occur in bladder cancer.
29. A client who has been diagnosed with bladder cancer is scheduled for an ileal conduit.
Preoperatively, the nurse reinforces the client’s understanding of the surgical procedure by
explaining that an ileal conduit:
1. Is a temporary procedure that can be reversed later.

2. Diverts urine into the sigmoid colon, where it is expelled through the rectum.
3. Conveys urine from the ureters to a stoma opening in the abdomen.
4. Creates an opening in the bladder that allows urine to drain into an external pouch.
Ans-29. 3. An ileal conduit is a permanent urinary diversion in which a portion of the ileum is
surgically resected and one end of the segment is closed. The ureters are surgically attached to
this segment of the ileum, and the open end of the ileum is brought to the skin surface on the
abdomen to form the stoma. The client must wear a pouch to collect the urine that continually
flows through the conduit. The bladder is removed during the surgical procedure and the ileal
conduit is not reversible. Diversion of the urine to the sigmoid colon is called
a ureteroileosigmoidostomy. An opening in the bladder that allows urine to drain externally is
called a cystostomy.
30. After surgery for an ileal conduit, the nurse should closely evaluate the client for the
occurrence of which of the following complications related to pelvic surgery?
1. Peritonitis
2. Thrombophlebitis
3. Ascites
4. Inguinal hernia
Ans-30. 2. After pelvic surgery, there is an increased chance of thrombophlebitis owing to the
pelvic manipulation that can interfere with circulation and promote venous stasis. Peritonitis is a
potential complication of any abdominal surgery, not just pelvic surgery. Ascites is most
frequently an indication of liver disease. Inguinal hernia may be caused by an increase in
abdominal pressure or a congenital weakness of the abdominal wall; ventral hernia occurs at the
site of a previous abdominal surgery.
31. The nurse is assessing the urine of a client who has had an ileal conduit and notes that
the urine is yellow with a moderate amount of mucus. Based on the assessment data, which of
the following nursing interventions would be most appropriate at this time?
1. Change the appliance bag
3. Obtain a urine specimen for culture
4. Encourage a high fluid intake
Ans-31. 4. Mucus is secreted by the intestinal segment used to create the conduit and is a normal
occurrence. The client should be encouraged to maintain a large fluid intake to help flush the
mucus out of the conduit. Because mucus in the urine is expected, it is not necessary to change
the appliance bag or notify the physician. The mucus is not an indication of an infection, so a
urine culture is not necessary.
32. When teaching the client to care for an ileal conduit, the nurse instructs the client to
empty the appliance frequently, primarily to prevent which of the following problems?
1. Rupture of the ileal conduit

2. Interruption of urine production
3. Development of odor
4. Separation of the appliance from the skin
Ans-32. 4. If the appliance becomes too full, it is likely to pull away from the skin completely or
to leak urine onto the skin. A full appliance will not rupture the ileal conduit or interrupt urine
production. Odor formation has numerous causes.
33. The client with an ileal conduit will be using a reusable appliance at home. The nurse
should teach the client to clean the appliance routinely with what product?
1. Baking soda
2. Soap
3. Hydrogen peroxide
4. Alcohol
Ans-33. 2. A reusable appliance should be routinely cleaned with soap and water.
34. The nurse is evaluating the discharge teaching for a client who has an ileal conduit.
Which of the following statements indicates that the client has correctly understood the
teaching? Select all that apply.
1. “If I limit my fluid intake I will not have to empty my ostomy pouch as often.”
2. “I can place an aspirin tablet in my pouch to decrease odor.”
3. “I can usually keep my ostomy pouch on for 3 to 7 days before changing it.”
4. “I must use a skin barrier to protect my skin from urine.”
5. “I should empty my ostomy pouch of urine when it is full.”
Ans-34. 3, 4. The client with an ileal conduit must learn self-care activities related to care of the
stoma and ostomy appliances. The client should be taught to increase fluid intake to about 3,000
ml per day and should not limit intake. Adequate fluid intake helps to flush mucus from the ileal
conduit. The ostomy appliance should be changed approximately every 3 to 7 days and whenever
a leak develops. A skin barrier is essential to protecting the skin from the irritation of the urine.
An aspirin should not be used as a method of odor control because it can be an irritant to the
stoma and lead to ulceration. The ostomy pouch should be emptied when it is one-third to one-
half full to prevent the weight from pulling the appliance away from the skin.
35. A female client with a urinary diversion tells the nurse, “This urinary pouch is
embarrassing. Everyone will know that I’m not normal. I don’t see how I can go out in public
anymore.” The most appropriate nursing diagnosis for this patient is:
1. Anxiety related to the presence of urinary diversion.

2. Deficient Knowledge about how to care for the urinary diversion.
3. Low Self-Esteem related to feelings of worthlessness
4. Disturbed Body Image related to creation of a urinary diversion.
Ans-35. 4. It is normal for clients to express fears and concerns about the body changes
associated with a urinary diversion. Allowing the client time to verbalize concerns in a
supportive environment and suggest that she discuss these concerns with people who have
successfully adjusted to ostomy surgery can help her begin coping with these changes in a
positive manner. Although the client may be anxious about this situation and self-esteem may be
diminished, the underlying problem is disturbance in body image. There are no data to support a
diagnosis of Deficient Knowledge.
36. The nurse teaches the client with a urinary diversion to attach the appliance to a standard
urine collection bag at night. The most important reason for doing this is to prevent:
1. Urine reflux into the stoma

2. Appliance separation
3. Urine leakage
4. The need to restrict fluids
Ans-36. 1. The most important reason for attaching the appliance to a standard urine collection
bag at night is to prevent reflux into the stoma and ureters, which can result in infection. Use of a
standard collection bag also keeps the appliance from separating from the skin and helps prevent
urine leakage from an overly full bag, but the primary purpose is to prevent reflux of urine. A
client with a urinary diversion should drink 2000-3000 ml of fluid each day; it would be
inappropriate to suggest decreasing fluid intake.
37. The nurse teaches the client with an ileal conduit measures to prevent a UTI. Which of
the following measures would be most effective?
1. Avoid people with respiratory tract infections

2. Maintain a daily fluid intake of 2,000 to 3,000 ml
3. Use sterile technique to change the appliance
4. Irrigate the stoma daily.
Ans-37. 2. Maintaining a fluid intake of 2,000 to 3,000 ml/day is likely to be effective in

preventing UTI. A high fluid intake results in high urine output, which prevents urinary stasis
and bacterial growth. Avoiding people with respiratory tract infections will not prevent urinary
tract infections. Clean, not sterile, technique is used to change the appliance. An ileal conduit
stoma is not irrigated.
38. A client who has been diagnosed with calculi reports that the pain is intermittent and less
colicky. Which of the following nursing actions is most important at this time?
1. Report hematuria to the physician

2. Strain the urine carefully
3. Administer meperidine (Demerol) every 3 hours
4. Apply warm compresses to the flank area
Ans-38. 2. Intermittent pain that is less colicky indicates that the calculi may be moving along
the urinary tract. Fluids should be encouraged to promote movement, and the urine should be
strained to detect passage of the stone. Hematuria is to be expected from the irritation of the
stone. Analgesics should be administered when the client needs them, not routinely. Moist heat
to the flank area is helpful when renal colic occurs, but it is less necessary as pain is lessoned.
39. A client has a ureteral catheter in place after renal surgery. A priority nursing action for
care of the ureteral catheter would be to:
1. Irrigate the catheter with 30 ml of normal saline every 8 hours

2. Ensure that the catheter is draining freely
3. Clamp the catheter every 2 hours for 30 minutes.
4. Ensure that the catheter drains at least 30 ml an hour
Ans-39. 2. The ureteral catheter should drain freely without bleeding at the site. The catheter is
rarely irrigated, and any irrigation would be done by the physician. The catheter is never
clamped. The client’s total urine output (ureteral catheter plus voiding or foley catheter output)
should be 30 ml/hour.
40. Which of the following interventions would be most appropriate for preventing the
development of a paralytic ileus in a client who has undergone renal surgery?
1. Encourage the client to ambulate every 2 to 4 hours

2. Offer 3 to 4 ounces of a carbonated beverage periodically.
3. Encourage use of a stool softener
4. Continue intravenous fluid therapy
Ans-40. 1. Ambulation stimulates peristalsis. A client with paralytic ileus is kept NPO until
peristalsis returns. Intravenous fluid infusion is a routine postoperative order that does not have
any effect on preventing paralytic ileus. A stool softener will not stimulate peristalsis.
41. The nurse is conducting a postoperative assessment of a client on the first day after renal
surgery. Which of the following findings would be most important for the nurse to report to
the physician?
1. Temperature, 99.8
2. Urine output, 20 ml/hour
3. Absence of bowel sounds
4. A 2×2 inch area of serous sanguineous drainage on the flank dressing.
Ans-41. 2. The decrease in urinary output may indicate inadequate renal perfusion and should be
reported immediately. Urine output of 30 ml/hour or greater is considered acceptable. A slight
elevation in temperature is expected after surgery. Peristalsis returns gradually, usually the
second or third day after surgery. Bowel sounds will be absent until then. A small amount of
serous sanguineous drainage is to be expected.
42. Because a client’s renal stone was found to be composed to uric acid, a low-purine,
alkaline-ash diet was ordered. Incorporation of which of the following food items into the
home diet would indicate that the client understands the necessary diet modifications?
1. Milk, apples, tomatoes, and corn

2. Eggs, spinach, dried peas, and gravy.
3. Salmon, chicken, caviar, and asparagus
4. Grapes, corn, cereals, and liver.
Ans-42. 1. Because a high-purine diet contributes to the formation of uric acid, a low-purine diet
is advocated. An alkaline-ash diet is also advocated, because uric acid crystals are more likely to
develop in acid urine. Foods that may be eaten as desired in a low-purine diet include milk, all
fruits, tomatoes, cereals, and corn. Food allowed on an alkaline-ash diet include milk, fruits
(except cranberries, plums, and prunes), and vegetables (especially legumes and green
vegetables). Gravy, chicken, and liver are high in purine.
43. Allopurinol (Zyloprim), 200 mg/day, is prescribed for the client with renal calculi to take
home. The nurse should teach the client about which of the following side effects of this
medication?
1. Retinopathy
2. Maculopapular rash
3. Nasal congestion
4. Dizziness
Ans-43. 2. Allopurinol is used to treat renal calculi composed of uric acid. Side effects of
allopurinol include drowsiness, maculopapular rash, anemia, abdominal pain, nausea, vomiting,
and bone marrow depression. Clients should be instructed to report skin rashes and any unusual
bleeding or bruising. Retinopathy, nasal congestion, and dizziness are not side effects of
allopurinol.
44. The client has a clinic appointment scheduled 10 days after discharge. Which laboratory
finding at that time would indicate that allopurinol (Zyloprim) has had a therapeutic effect?
1. Decreased urinary alkaline phosphatase level

2. Increased urinary calcium excretion
3. Increased serum calcium level
4. Decreased serum uric acid level
Ans-44. 4. By inhibiting uric acid synthesis, allopurinol decreases its excretion. The drug’s
effectiveness is assessed by evaluating for a decreased serum uric acid concentration.
Allopurinol does not alter the level of alkaline phosphatase, not does it affect urinary calcium
excretion or the serum calcium level.
45. When developing a plan of care for the client with stress incontinence, the nurse should
take into consideration that stress incontinence is best defined as the involuntary loss of urine
associated with:
1. A strong urge to urinate

2. Overdistention of the bladder
3. Activities that increase abdominal pressure
4. Obstruction of the urethra
Ans-45. 3. Stress incontinence is the involuntary loss of urine during such activities as coughing,
sneezing, laughing, or physical exertion. These activities increase abdominal and detruser
pressure. A strong urge to urinate is associated with urge incontinence. Overdistention of the
bladder can lead to overflow incontinence. Obstruction of the urethra can lead to urinary
retention.
46. Which of the following assessment data would most likely be related to a client’s current
complaint of stress incontinence?
1. The client’s intake of 2 to 3 L of fluid per day.

2. The client’s history of three full-term pregnancies
3. The client’s age of 45 years
4. The client’s history of competitive swimming
Ans-46. 2. The history of three pregnancies is most likely the cause of the client’s current
episodes of stress incontinence. The client’s fluid intake, age, or history of swimming would not
create an increase in intra-abdominal pressure.
47. The nurse is developing a teaching plan for a client with stress incontinence. Which of the
following instructions should be included?
1. Avoid activities that are stressful and upsetting

2. Avoid caffeine and alcohol
3. Do not wear a girdle
4. Limit physical exertion
Ans-47. 2. Client’s with stress incontinence are encouraged to avoid substances such as caffeine
and alcohol which are bladder irritants. Emotional stressors do not cause stress incontinence. It is
caused most commonly be relaxed pelvic musculature. Wearing girdles is not contraindicated.
Although clients may be inclined to limit physical exertion to avoid incontinence episodes, they
should be encouraged to seek treatment instead of limiting their activities.
48. A client has urge incontinence. Which of the following signs and symptoms would the
nurse expect to find in this client?
1. Inability to empty the bladder

2. Loss of urine when coughing
3. Involuntary urination with minimal warning
4. Frequent dribbling of urine
Ans-48. 3. A characteristic of urge incontinence is involuntary urination with little or no

warning. The inability to empty the bladder is urinary retention. Loss of urine when coughing
occurs with stress incontinence. Frequent dribbling of urine is common in male clients after
some types of prostate surgery or may occur in women after the development of vesicovaginal or
urethrovaginal fistula.
49. A 72-year old male client is brought to the emergency room by his son. The client is
extremely uncomfortable and has been unable to void for the past 12 hours. He has known for
some time that he has an enlarged prostate but has wanted to avoid surgery. The best method
for the nurse to use when assessing for bladder distention in a male client is to check for:
1. A rounded swelling above the pubis.

2. Dullness in the lower left quadrant
3. Rebound tenderness below the symphysis
4. Urine discharge from the urethral meatus
Ans-49. 1. The best way to assess for a distended bladder in either a male or female client is to
check for a rounded swelling above the pubis. The swelling represents the distended bladder
rising above the pubis into the abdominal cavity. Dullness does not indicate a distended bladder.
The client might experience tenderness or pressure above the symphysis. No urine discharge is
expected; the urine flow is blocked by the enlarged prostate.
50. During a client’s urinary bladder catherization, the bladder is emptied gradually. The best
rationale for the nurse’s action is that completely emptying an over-distended bladder at one
time tends to cause:
1. Renal failure
3. Possible shock
4. Atrophy of bladder musculature
Ans-50. 3. Rapid emptying of an overdistended bladder may cause hypotension and shock due
to the sudden change of pressure within the abdominal viscera. Previously, removing no more
than 1,000 ml at one time was the standard of practice, but this is no longer thought to be
necessary as long as the overdistended bladder is emptied slowly.
51. The primary reason for taping an indwelling catheter laterally to the thigh of a male client
is to:
1. Eliminate pressure at the penoscrotal angle

2. Prevent the catheter from kinking in the urethra
3. Prevent accidental catheter removal
4. Allow the client to turn without kinking the catheter
Ans-51. 1. The primary reason for taping an indwelling catheter to a male client soothe penis is
held in a lateral position to prevent pressure at the penoscrotal angle. Prolonged pressure at the
penoscrotal angle can cause an ureterocutaneous fistula.
52. The primary function of the prostate gland is:
1. To store underdeveloped sperm before ejaculation

2. To regulate the acidity and alkalinity of the environment for proper sperm development.
3. To produce a secretion that aids in the nourishment and passage of sperm
4. To secrete a hormone that stimulates the production and maturation of sperm
Ans-52. 3. The prostate gland is located below the bladder and surrounds the urethra. It serves
one primary purpose: to produce a secretion that aids in the nourishment and passage of sperm.
53. The nurse is reviewing a medication history of a client with BPH. Which medication
should be recognized as likely to aggravate BPH?
1. Metformin (Glucophage)
2. Buspirone (BuSpar)
3. Inhaled ipratropium (Atrovent)
4. Ophthalmic timolol (Timoptic)
Ans-53. 3. Atrovent is a bronchodilator, and its anticholinergic effects can aggravate urinary
retention. Glucophage and BuSpar do not affect the urinary system; timolol does not have a
systemic effect.
54. A client is scheduled to undergo a transurethral resection of the prostate gland (TURP).
The procedure is to be done under spinal anesthesia. Postoperatively, the nurse should be
particularly alert for early signs of:
1. Convulsions
2. Cardiac arrest
3. Renal shutdown
4. Respiratory paralysis
Ans-54. 4. If paralysis of vasomotor nerves in the upper spinal cord occurs when spinal
anesthesia is used, the client is likely to develop respiratory paralysis. Artificial ventilation is
required until the effects of the anesthesia subside. Convulsions, cardiac arrest, and renal
shutdown are not likely results of spinal anesthesia.
55. A client with BPH is being treated with terazosin (Hytrin) 2mg at bedtime. The nurse
should monitor the client’s:
1. Urinary nitrites
2. White blood cell count
3. Blood pressure
4. Pulse
Ans-55. 3. Terazosin (Hytrin) is an antihypertensive drug that is also used in the treatment of
BPH. Blood pressure must be monitored to ensure that the client does not develop hypotension,
syncope, or postural hypotension. The client should be instructed to change positions slowly.
Urinary nitrites, white blood cell count, and pulse rate are not affected by terazosin.
56. A client underwent a TURP, and a large three way catheter was inserted in the bladder
with continuous bladder irrigation. In which of the following circumstances would the nurse
increase the flow rate of the continuous bladder irrigation?
1. When the drainage is continuous but slow

2. When the drainage appears cloudy and dark yellow
3. When the drainage becomes bright red
4. When there is no drainage of urine and irrigating solution
Ans-56. 3. The decision made by the surgeon to insert a catheter after a TURP or prostatectomy
depends on the amount of bleeding that is expected after the procedure. During continuous
bladder irrigation after a TURP or prostatectomy, the rate at which the solution enters the bladder
should be increased when the drainage becomes brighter red. The color indicates the presence of
blood. Increasing the flow of irrigating solution helps flush the catheter well so clots do not plug
it. There would be no reason to increase the flow rate when the return is continuous or when the
return appears cloudy and dark yellow. Increasing the flow would be contraindicated when there
is no return of urine and irrigating solution.
57. A priority nursing diagnosis for the client who is being discharged t home 3 days after a
TURP would be:
1. Deficient fluid volume

2. Imbalanced Nutrition: Less than Body Requirements
3. Impaired Tissue Integrity
4. Ineffective Airway Clearance
Ans-57. 1. Deficient Fluid Volume is a priority diagnosis, because the client needs to drink a
large amount of fluid to keep the urine clear. The urine should be almost without color. About 2
weeks after a TURP, when desiccated tissue is sloughed out, a secondary hemorrhage could
occur. The client should be instructed to call the surgeon or go to the ED if at any time the urine
turns bright red. The client is not specifically at risk for nutritional problems after a TURP. The
client is not specifically at risk for nutritional problems after a TURP. The client is not
specifically at risk for impaired tissue integrity because there is no external incision, and the
client is not specifically at risk for airway problems because the procedure is done after spinal
anesthesia.
58. If a client’s prostate enlargement is caused by a malignancy, which of the following blood
examinations should the nurse anticipate to assess whether metastasis has occurred?
1. Serum creatinine level

2. Serum acid phosphatase level
3. Total nonprotein nitrogen level
4. Endogenous creatinine clearance time
Ans-58. 2. The most specific examination to determine whether a malignancy extends outside of
the prostatic capsule is a study of the serum acid phosphatase level. The level increases when a
malignancy has metastasized. The prostate specific antigen (PSA) determination and a digital
rectal examination are done when screening for prostate cancer. Serum creatinine level, total
nonprotein nitrogen level, and endogenous creatinine clearance time give information about
kidney function, not prostate malignancy.
Renal failure, dialysis
1. Dialysis allows for the exchange of particles across a semipermeable membrane by which
of the following actions?
1. Osmosis and diffusion
2. Passage of fluid toward a solution with a lower solute concentration
3. Allowing the passage of blood cells and protein molecules through it.
4. Passage of solute particles toward a solution with a higher concentration.
Ans-1. 1. Osmosis allows for the removal of fluid from the blood by allowing it to pass through
the semipermeable membrane to an area of high concentrate (dialysate), and diffusion allows for
passage of particles (electrolytes, urea, and creatinine) from an area of higher concentration to an
area of lower concentration. Fluid passes to an area with a higher solute concentration. The pores
of a semipermeable membrane are small, thus preventing the flow of blood cells and protein
molecules through it.
2. A client is diagnosed with chronic renal failure and told she must start hemodialysis.
Client teaching would include which of the following instructions?
1. Follow a high potassium diet

2. Strictly follow the hemodialysis schedule
3. There will be a few changes in your lifestyle.
4. Use alcohol on the skin and clean it due to integumentary changes.
Ans-2. 2. To prevent life-threatening complications, the client must follow the dialysis schedule.
Alcohol would further dry the client’s skin more than it already is. The client should follow a
low-potassium diet because potassium levels increase in chronic renal failure. The client should
know hemodialysis is time-consuming and will definitely cause a change in current lifestyle.
3. A client is undergoing peritoneal dialysis. The dialysate dwell time is completed, and the
dwell clamp is opened to allow the dialysate to drain. The nurse notes that the drainage has
stopped and only 500 ml has drained; the amount the dialysate instilled was 1,500 ml. Which
of the following interventions would be done first?
1. Change the client’s position.

2. Call the physician.
3. Check the catheter for kinks or obstruction.
4. Clamp the catheter and instill more dialysate at the next exchange time.
Ans-3. 3. The first intervention should be to check for kinks and obstructions because that could
be preventing drainage. After checking for kinks, have the client change position to promote
drainage. Don’t give the next scheduled exchange until the dialysate is drained because
abdominal distention will occur, unless the output is within parameters set by the physician. If
unable to get more output despite checking for kinks and changing the client’s position, the nurse
should then call the physician to determine the proper intervention.
4. A client receiving hemodialysis treatment arrives at the hospital with a blood pressure of
200/100, a heart rate of 110, and a respiratory rate of 36. Oxygen saturation on room air is
89%. He complains of shortness of breath, and +2 pedal edema is noted. His last hemodialysis
treatment was yesterday. Which of the following interventions should be done first?
2. Elevate the foot of the bed
3. Restrict the client’s fluids
4. Prepare the client for hemodialysis.
Ans-4. 1. Airway and oxygenation are always the first priority. Because the client is
complaining of shortness of breath and his oxygen saturation is only 89%, the nurse needs to try
to increase his levels by administering oxygen. The client is in pulmonary edema from fluid
overload and will need to be dialyzed and have his fluids restricted, but the first interventions
should be aimed at the immediate treatment of hypoxia. The foot of the bed may be elevated to
reduce edema, but this isn’t the priority.
5. A client has a history of chronic renal failure and received hemodialysis treatments three
times per week through an arteriovenous (AV) fistula in the left arm. Which of the following
interventions is included in this client’s plan of care?
1. Keep the AV fistula site dry.

2. Keep the AV fistula wrapped in gauze.
3. Take the blood pressure in the left arm
4. Assess the AV fistula for a bruit and thrill
Ans-5. 4. Assessment of the AV fistula for bruit and thrill is important because, if not present, it
indicates a non-functioning fistula. No blood pressures or venipunctures should be taken in the
arm with the AV fistula. When not being dialyzed, the AV fistula site may get wet. Immediately
after a dialysis treatment, the access site is covered with adhesive bandages.
6. Which of the following factors causes the nausea associated with renal failure?
1. Oliguria
2. Gastric ulcers
3. Electrolyte imbalances
4. Accumulation of waste products
Ans-6. 4. Although clients with renal failure can develop stress ulcers, the nausea is usually
related to the poisons of metabolic wastes that accumulate when the kidneys are unable to
eliminate them. The client has electrolyte imbalances and oliguria, but these don’t directly cause
nausea.
7. Which of the following clients is at greatest risk for developing acute renal failure?
1. A dialysis client who gets influenza

2. A teenager who has an appendectomy
3. A pregnant woman who has a fractured femur
4. A client with diabetes who has a heart catherization
Ans-7. 4. Clients with diabetes are prone to renal insufficiency and renal failure. The contrast
used for heart catherization must be eliminated by the kidneys, which further stresses them and
may produce acute renal failure. A teenager who has an appendectomy and a pregnant woman
with a fractured femur isn’t at increased risk for renal failure. A dialysis client already has end-
stage renal disease and wouldn’t develop acute renal failure.
8. In a client in renal failure, which assessment finding may indicate hypocalcemia?
1. Headache
2. Serum calcium level of 5 mEq/L
3. Increased blood coagulation
4. Diarrhea
Ans-8. 4. In renal failure, calcium absorption from the intestine declines, leading to increased
smooth muscle contractions, causing diarrhea. CNS changes in renal failure rarely include
headache. A serum calcium level of 5 mEq/L indicates hypercalcemia. As renal failure
progresses, bleeding tendencies increase.
9. A nurse is assessing the patency of an arteriovenous fistula in the left arm of a client
who is receiving hemodialysis for the treatment of chronic renal failure. Which finding
indicates that the fistula is patent?
1. Absence of bruit on auscultation of the fistula.

2. Palpation of a thrill over the fistula
3. Presence of a radial pulse in the left wrist
4. Capillary refill time less than 3 seconds in the nail beds of the fingers on the left hand.
Ans-9. 2. The nurse assesses the patency of the fistula by palpating for the presence of a thrill or
auscultating for a bruit. The presence of a thrill and bruit indicate patency of the fistula.
Although the presence of a radial pulse in the left wrist and capillary refill time less than 3
seconds in the nail beds of the fingers on the left hand are normal findings, they do not assess
fistula patency.
10. The client with chronic renal failure is at risk of developing dementia related to excessive
absorption of aluminum. The nurse teaches that this is the reason that the client is being
prescribed which of the following phosphate binding agents?
1. Alu-cap (aluminum hydroxide)

2. Tums (calcium carbonate)
3. Amphojel (aluminum hydroxide)
4. Basaljel (aluminum hydroxide)
Ans-10. 2. Phosphate binding agents that contain aluminum include Alu-caps, Basaljel, and
Amphojel. These products are made from aluminum hydroxide. Tums are made from calcium
carbonate and also bind phosphorus. Tums are prescribed to avoid the occurrence of dementia
related to high intake of aluminum. Phosphate binding agents are needed by the client in renal
failure because the kidneys cannot eliminate phosphorus.
11. The client newly diagnosed with chronic renal failure recently has begun hemodialysis.
Knowing that the client is at risk for disequilibrium syndrome, the nurse assesses the client
during dialysis for:
1. Hypertension, tachycardia, and fever

2. Hypotension, bradycardia, and hypothermia
3. restlessness, irritability, and generalized weakness
4. Headache, deteriorating level of consciousness, and twitching.
Ans-11. 4. Disequilibrium syndrome is characterized by headache, mental confusion, decreasing

level of consciousness, nausea, and vomiting, twitching, and possible seizure activity.
Disequilibrium syndrome is caused by rapid removal of solutes from the body during
hemodialysis. At the same time, the blood-brain barrier interferes with the efficient removal of
wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic
gradient, causing brain swelling and onset of symptoms. The syndrome most often occurs in
clients who are new to dialysis and is prevented by dialyzing for shorter times or at reduced
blood flow rates.
12. A client with chronic renal failure has completed a hemodialysis treatment. The nurse
would use which of the following standard indicators to evaluate the client’s status after
dialysis?
1. Potassium level and weight

2. BUN and creatinine levels
3. VS and BUN
4. VS and weight.
Ans-12. 4. Following dialysis, the client’s vital signs are monitored to determine whether the
client is remaining hemodynamically stable. Weight is measured and compared with the client’s
predialysis weight to determine effectiveness of fluid extraction. Laboratory studies are done as
per protocol but are not necessarily done after the hemodialysis treatment has ended.
13. The hemodialysis client with a left arm fistula is at risk for steal syndrome. The nurse
assesses this client for which of the following clinical manifestations?
1. Warmth, redness, and pain in the left hand.

2. Pallor, diminished pulse, and pain in the left hand.
3. Edema and reddish discoloration of the left arm
4. Aching pain, pallor, and edema in the left arm.
Ans-13. 2. Steal syndrome results from vascular insufficiency after creation of a fistula. The
client exhibits pallor and a diminished pulse distal to the fistula. The client also complains of
pain distal to the fistula, which is due to tissue ischemia. Warmth, redness, and pain more likely
would characterize a problem with infection.
14. A client is admitted to the hospital and has a diagnosis of early stage chronic renal failure.
Which of the following would the nurse expect to note on assessment of the client?
1. Polyuria
2. Polydipsia
3. Oliguria
4. Anuria
Ans-14. 1. Polyuria occurs early in chronic renal failure and if untreated can cause severe
dehydration. Polyuria progresses to anuria, and the client loses all normal functions of the
kidney. Oliguria and anuria are not early signs, and polydipsia is unrelated to chronic renal
failure.
15. The client with chronic renal failure returns to the nursing unit following a hemodialysis
treatment. On assessment the nurse notes that the client’s temperature is 100.2. Which of the
following is the most appropriate nursing action?
1. Encourage fluids
3. Monitor the site of the shunt for infection
4. Continue to monitor vital signs
Ans-15. 4. The client may have an elevated temperature following dialysis because the dialysis
machine warms the blood slightly. If the temperature is elevated excessively and remains
elevated, sepsis would be suspected and a blood sample would be obtained as prescribed for
culture and sensitivity purposes.
16. The nurse is performing an assessment on a client who has returned from the dialysis unit
following hemodialysis. The client is complaining of a headache and nausea and is extremely
restless. Which of the following is the most appropriate nursing action?

2. Monitor the client
3. Elevate the head of the bed
4. Medicate the client for nausea
Ans-16. 1. Disequilibrium syndrome may be due to the rapid decrease in BUN levels during
dialysis. These changes can cause cerebral edema that leads to increased intracranial pressure.
The client is exhibiting early signs of disequilibrium syndrome and appropriate treatments with
anticonvulsant medications and barbiturates may be necessary to prevent a life-threatening
situation. The physician must be notified.
17. The nurse is assisting a client on a low-potassium diet to select food items from the menu.
Which of the following food items, if selected by the client, would indicate an understanding of
this dietary restriction?
1. Cantaloupe
2. Spinach
3. Lima beans
4. Strawberries
Ans-17. 4. Cantaloupe (1/4 small), spinach (1/2 cooked) and strawberries (1 ¼ cups) are high
potassium foods and average 7 mEq per serving. Lima beans (1/3 c) averages 3 mEq per
serving.
18. The nurse is reviewing a list of components contained in the peritoneal dialysis solution
with the client. The client asks the nurse about the purpose of the glucose contained in the
solution. The nurse bases the response knowing that the glucose:
1. Prevents excess glucose from being removed from the client.

2. Decreases risk of peritonitis.
3. Prevents disequilibrium syndrome
4. Increases osmotic pressure to produce ultrafiltration.
Ans-18. 4. Increasing the glucose concentration makes the solution increasingly more
hypertonic. The more hypertonic the solution, the greater the osmotic pressure for ultrafiltration
and thus the greater amount of fluid removed from the client during an exchange.
19. The nurse is preparing to care for a client receiving peritoneal dialysis. Which of the
following would be included in the nursing plan of care to prevent the major complication
associated with peritoneal dialysis?
1. Monitor the clients level of consciousness

2. Maintain strict aseptic technique
3. Add heparin to the dialysate solution
4. Change the catheter site dressing daily
Ans-19. 2. The major complication of peritoneal dialysis is peritonitis. Strict aseptic technique is
required in caring for the client receiving this treatment. Although option 4 may assist in
preventing infection, this option relates to an external site.
20. A client newly diagnosed with renal failure is receiving peritoneal dialysis. During the
infusion of the dialysate the client complains of abdominal pain. Which action by the nurse is
most appropriate?
1. Slow the infusion

2. Decrease the amount to be infused
3. Explain that the pain will subside after the first few exchanges
4. Stop the dialysis
Ans-20. 3. Pain during the inflow of dialysate is common during the first few exchanges because
of peritoneal irritation; however, the pain usually disappears after 1 to 2 weeks of treatment. The
infusion amount should not be decreased, and the infusion should not be slowed or stopped.
21. The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The
nurse tells the client that it is important to maintain the dwell time for the dialysis at the
prescribed time because of the risk of:
1. Infection
2. Hyperglycemia
3. Fluid overload
4. Disequilibrium syndrome
Ans-21. 2. An extended dwell time increases the risk of hyperglycemia in the client with
diabetes mellitus as a result of absorption of glucose from the dialysate and electrolyte changes.
Diabetic clients may require extra insulin when receiving peritoneal dialysis.
22. The client with acute renal failure has a serum potassium level of 5.8 mEq/L. The nurse
would plan which of the following as a priority action?
1. Allow an extra 500 ml of fluid intake to dilute the electrolyte concentration.

2. Encourage increased vegetables in the diet
3. Place the client on a cardiac monitor
4. Check the sodium level
Ans-22. 3. The client with hyperkalemia is at risk for developing cardiac dysrhythmias and
cardiac arrest. Because of this the client should be placed on a cardiac monitor. Fluid intake is
not increased because it contributes to fluid overload and would not affect the serum potassium
level significantly. Vegetables are a natural source of potassium in the diet, and their use would
not be increased. The nurse may also assess the sodium level because sodium is another
electrolyte commonly measured with the potassium level. However, this is not a priority action at
this time.
23. The client with chronic renal failure who is scheduled for hemodialysis this morning is
due to receive a daily dose of enalapril (Vasotec). The nurse should plan to administer this
medication:
1. Just before dialysis

2. During dialysis
3. On return from dialysis
4. The day after dialysis
Ans-23. 3. Antihypertensive medications such as enalapril are given to the client following
hemodialysis. This prevents the client from becoming hypotensive during dialysis and also from
having the medication removed from the bloodstream by dialysis. No rationale exists for waiting
a full day to resume the medication. This would lead to ineffective control of the blood pressure.
24. The client with chronic renal failure has an indwelling catheter for peritoneal dialysis in
the abdomen. The client spills water on the catheter dressing while bathing. The nurse should
immediately:
1. Reinforce the dressing

2. Change the dressing
3. Flush the peritoneal dialysis catheter
4. Scrub the catheter with providone-iodine
Ans-24. 2. Clients with peritoneal dialysis catheters are at high risk for infection. A dressing that
is wet is a conduit for bacteria for bacteria to reach the catheter insertion site. The nurse assures
that the dressing is kept dry at all times. Reinforcing the dressing is not a safe practice to prevent
infection in this circumstance. Flushing the catheter is not indicated. Scrubbing the catheter with
povidone-iodine is done at the time of connection or disconnecting of peritoneal dialysis.
25. The client being hemodialyzed suddenly becomes short of breath and complains of chest
pain. The client is tachycardic, pale, and anxious. The nurse suspects air embolism. The nurse
should:
1. Continue the dialysis at a slower rate after checking the lines for air
2. Discontinue dialysis and notify the physician
3. Monitor vital signs every 15 minutes for the next hour
4. Bolus the client with 500 ml of normal saline to break up the air embolism.
Ans-25. 2. If the client experiences air embolus during hemodialysis, the nurse should terminate
dialysis immediately, notify the physician, and administer oxygen as needed.
26. The nurse has completed client teaching with the hemodialysis client about self-
monitoring between hemodialysis treatments. The nurse determines that the client best
understands the information given if the client states to record the daily:
1. Pulse and respiratory rate

2. Intake, output, and weight
3. BUN and creatinine levels
4. Activity log
Ans-26. 2. The client on hemodialysis should monitor fluid status between hemodialysis
treatments by recording intake and output and measuring weight daily. Ideally, the hemodialysis
client should not gain more than 0.5 kg of weight per day.
27. The client with an arteriovenous shunt in place for hemodialysis is at risk for bleeding.
The nurse would do which of the following as a priority action to prevent this complication
from occurring?
1. Check the results of the PT time as they are ordered.

2. Observe the site once per shift
3. Check the shunt for the presence of a bruit and thrill
4. Ensure that small clamps are attached to the AV shunt dressing.
Ans-27. 4. An AV shunt is a less common form of access site but carries a risk for bleeding
when it is used because two ends of an external cannula are tunneled subcutaneously into an
artery and a vein, and the ends of the cannula are joined. If accidental connection occurs, the
client could lose blood rapidly. For this reason, small clamps are attached to the dressing that
covers the insertion site to use if needed. The shunt site should be assessed at least every four
hours.
28. The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a
client’s outflow is less than the inflow. Select actions that the nurse should take.
1. Place the client in good body alignment

2. Check the level of the drainage bag
4. Check the peritoneal dialysis system for kinks
5. Reposition the client to his or her side.
Ans-28. 1, 2, 4, 5. If outflow drainage is inadequate, the nurse attempts to stimulate outflow by

changing the client’s position. Turning the client to the other side or making sure that the client is
in good body alignment may assist with outflow drainage. The drainage bag needs to be lower
than the client’s abdomen to enhance gravity drainage. The connecting tubing and the peritoneal
dialysis system is also checked for kinks or twisting and the clamps on the system are checked to
ensure that they are open. There is no reason to contact the physician.
29. The nurse assesses the client who has chronic renal failure and notes the following:
crackles in the lung bases, elevated blood pressure, and weight gain of 2 pounds in one day.
Based on these data, which of the following nursing diagnoses is appropriate?
1. Excess fluid volume related to the kidney’s inability to maintain fluid balance.
2. Increased cardiac output related to fluid overload.
3. Ineffective tissue perfusion related to interrupted arterial blood flow.
4. Ineffective therapeutic Regimen Management related to lack of knowledge about
Ans-29. 1. Crackles in the lungs, weight gain, and elevated blood pressure are indicators of
excess fluid volume, a common complication in chronic renal failure. The client’s fluid status
should be monitored carefully for imbalances on an ongoing basis.
30. The nurse is caring for a hospitalized client who has chronic renal failure. Which of the
following nursing diagnoses are most appropriate for this client? Select all that apply.
1. Excess Fluid Volume

2. Imbalanced Nutrition; Less than Body Requirements
3. Activity Intolerance
4. Impaired Gas Exchange
5. Pain.
Ans-30. 1, 2, 3. Appropriate nursing diagnoses for clients with chronic renal failure include
excess fluid volume related to fluid and sodium retention; imbalanced nutrition, less than body
requirements related to anorexia, nausea, and vomiting; and activity intolerance related to
fatigue. The nursing diagnoses of impaired gas exchange and pain are not commonly related to
chronic renal failure.
31. What is the primary disadvantage of using peritoneal dialysis for long term management
of chronic renal failure?
1. The danger of hemorrhage is high.

2. It cannot correct severe imbalances.
3. It is a time consuming method of treatment.
4. The risk of contracting hepatitis is high.
Ans-31. 3. The disadvantages of peritoneal dialysis in long-term management of chronic renal

failure is that is requires large blocks of time. The risk of hemorrhage or hepatitis is not high
with PD. PD is effective in maintaining a client’s fluid and electrolyte balance.
32. The dialysis solution is warmed before use in peritoneal dialysis primarily to:
1. Encourage the removal of serum urea.

2. Force potassium back into the cells.
3. Add extra warmth into the body.
4. Promote abdominal muscle relaxation.
Ans-32. 1. The main reason for warming the peritoneal dialysis solution is that the warm
solution helps dilate peritoneal vessels, which increases urea clearance. Warmed dialyzing
solution also contributes to client comfort by preventing chilly sensations, but this is a secondary
reason for warming the solution. The warmed solution does not force potassium into the cells or
promote abdominal muscle relaxation.
33. During the client’s dialysis, the nurse observes that the solution draining from the
abdomen is consistently blood tinged. The client has a permanent peritoneal catheter in place.
Which interpretation of this observation would be correct?
1. Bleeding is expected with a permanent peritoneal catheter
2. Bleeding indicates abdominal blood vessel damage
3. Bleeding can indicate kidney damage.
4. Bleeding is caused by too-rapid infusion of the dialysate.
Ans-33. 2. Because the client has a permanent catheter in place, blood tinged drainage should
not occur. Persistent blood tinged drainage could indicate damage to the abdominal vessels, and
the physician should be notified. The bleeding is originating in the peritoneal cavity, not the
kidneys. Too rapid infusion of the dialysate can cause pain.
34. Which of the following nursing interventions should be included in the client’s care plan
during dialysis therapy?
1. Limit the client’s visitors

2. Monitor the client’s blood pressure
3. Pad the side rails of the bed
4. Keep the client NPO.
Ans-34. 2. Because hypotension is a complication of peritoneal dialysis, the nurse records intake
and output, monitors VS, and observes the client’s behavior. The nurse also encourages visiting
and other diversional activities. A client on PD does not need to be placed in bed with padded
side rails or kept NPO.
35. Aluminum hydroxide gel (Amphojel) is prescribed for the client with chronic renal failure to
take at home. What is the purpose of giving this drug to a client with chronic renal failure?
1. To relieve the pain of gastric hyperacidity

2. To prevent Curling’s stress ulcers
3. To bind phosphorus in the intestine
4. To reverse metabolic acidosis.
Ans-35. 3. A client in renal failure develops hyperphosphatemia that causes a corresponding

excretion of the body’s calcium stores, leading to renal osteodystrophy. To decrease this loss,
aluminum hydroxide gel is prescribed to bind phosphates in the intestine and facilitate their
excretion. Gastric hyperacidity is not necessarily a problem associated with chronic renal failure.
Antacids will not prevent Curling’s stress ulcers and do not affect metabolic acidosis.
36. The nurse teaches the client with chronic renal failure when to take the aluminum
hydroxide gel. Which of the following statements would indicate that the client understands
the teaching?
1. “I’ll take it every 4 hours around the clock.”

2. “I’ll take it between meals and at bedtime.”
3. “I’ll take it when I have a sour stomach.”
4. “I’ll take it with meals and bedtime snacks.”
Ans-36. 3. Aluminum hydroxide gel is administered to bind the phosphates in ingested foods
and must be given with or immediately after meals and snacks. There is no need for the client to
take it on a 24-hour schedule. It is not administered to treat hyperacidity in clients with CRF and
therefore is not prescribed between meals.
37. The client with chronic renal failure tells the nurse he takes magnesium hydroxide (milk
of magnesium) at home for constipation. The nurse suggests that the client switch to psyllium
hydrophilic mucilloid (Metamucil) because:
1. MOM can cause magnesium toxicity

2. MOM is too harsh on the bowel
3. Metamucil is more palatable
4. MOM is high in sodium
Ans-37. 1. Magnesium is normally excreted by the kidneys. When the kidneys fail, magnesium
can accumulate and cause severe neurologic problems. MOM is harsher than Metamucil, but
magnesium toxicity is a more serious problem. A client may find both MOM and Metamucil
unpalatable. MOM is not high in sodium.
38. In planning teaching strategies for the client with chronic renal failure, the nurse must
keep in mind the neurologic impact of uremia. Which teaching strategy would be most
appropriate?
1. Providing all needed teaching in one extended session.

2. Validating frequently the client’s understanding of the material.
3. Conducting a one-on-one session with the client.
4. Using videotapes to reinforce the material as needed.
Ans-38. 2. Uremia can cause decreased alertness, so the nurse needs to validate the client’s
comprehension frequently. Because the client’s ability to concentrate is limited, short lesions are
most effective. If family members are present at the sessions, they can reinforce the material.
Written materials that the client can review are superior to videotapes, because the clients may
not be able to maintain alertness during the viewing of the videotape.
39. The nurse helps the client with chronic renal failure develop a home diet plan with the
goal of helping the client maintain adequate nutritional intake. Which of the following diets
would be most appropriate for a client with chronic renal failure?
1. High carbohydrate, high protein

2. High calcium, high potassium, high protein
3. Low protein, low sodium, low potassium
4. Low protein, high potassium
Ans-39. 3. Dietary management for clients with chronic renal failure is usually designed to
restrict protein, sodium, and potassium intake. Protein intake is reduced because the kidney can
no longer excrete the byproducts of protein metabolism. The degree of dietary restriction
depends on the degree of renal impairment. The client should also receive a high carbohydrate
diet along with appropriate vitamin and mineral supplements. Calcium requirements remain
1,000 to 2,000 mg/day.
40. A client with chronic renal failure has asked to be evaluated for a home continuous
ambulatory peritoneal dialysis (CAPD) program. The nurse should explain that the major
advantage of this approach is that it:
1. Is relatively low in cost

2. Allows the client to be more independent
3. Is faster and more efficient than standard peritoneal dialysis
4. Has fewer potential complications than standard peritoneal dialysis
Ans-40. 2. The major benefit of CAPD is that it frees the client from daily dependence on
dialysis centers, home health care personnel, and machines for life-sustaining treatment. The
independence is a valuable outcome for some people. CAPD is costly and must be done daily.
Side effects and complications are similar to those of standard peritoneal dialysis.
41. The client asks whether her diet would change on CAPD. Which of the following would
be the nurse’s best response?
1. “Diet restrictions are more rigid with CAPD because standard peritoneal dialysis is a more
effective technique.”
2. “Diet restrictions are the same for both CAPD and standard peritoneal dialysis.”
3. “Diet restrictions with CAPD are fewer than with standard peritoneal dialysis because
dialysis is constant.”
4. “Diet restrictions with CAPD are fewer than with standard peritoneal dialysis because
CAPD works more quickly.”
Ans-41. 3. Dietary restrictions with CAPD are fewer than those with standard peritoneal dialysis
because dialysis is constant, not intermittent. The constant slow diffusion of CAPD helps prevent
accumulation of toxins and allows for a more liberal diet. CAPD does not work more quickly,
but more consistently. Both types of peritoneal dialysis are effective.
42. Which of the following is the most significant sign of peritoneal infection?
1. Cloudy dialysate fluid

2. Swelling in the legs
3. Poor drainage of the dialysate fluid
4. Redness at the catheter insertion site
Ans-42. 1. Cloudy drainage indicates bacterial activity in the peritoneum. Other signs and
symptoms of infection are fever, hyperactive bowel sounds, and abdominal pain. Swollen legs
may be indicative of congestive heart failure. Poor drainage of dialysate fluid is probably the
result of a kinked catheter. Redness at the insertion site indicates local infection, not peritonitis.
However, a local infection that is left untreated can progress to the peritoneum.
Sleep
1. To validate the suspicion that a married male client has sleep apnea the nurse first:
A. asks the client if he experiences apnea in the middle of the night

B. Questions the spouse if she is awakened by her husband’s snoring
C. Places the client on a continuous positive airway pressure (CPAP) device
D. Schedules the client for a sleep test
Ans-1. 4. (2- Although this is a diagnostic tool, the first thing the nurse would do is question the
spouse. This may lead to determining whether more tests are needed).
2. When analgesics are ordered for a client with obstructive sleep apnea (OSA) following
surgery, the nurse is most concerned about:
1. Nonsteroidal antiinflammatory drugs (NSAIDs)

2. Opioids
3. Anticonvulsants
4. Antidepressants
5. Adjuvants
Ans-2. 2. Clients with obstructive sleep apnea are particularly sensitive to opioids. Thus the risk
of respiratory depression is increased. The nurse must recognize that clients with OSA should
start out receiving very low doses of opioids.
3. The nurse finds a client sleep walking down the unit hallway. An appropriate
intervention the nurse implements is:
1. Asking the client what he or she is doing and call for help
2. Quietly approaching the client and then loudly calling his or her name
3. Lightly tapping the client on the shoulder and leading him or her back to bed
4. Blocking the hallway with chairs and seating the client
Ans-3. 3. The nurse should not startle the client but should gently awaken the client and lead him
or her back to bed.
4. The nurse is sure to implement strategies to reduce noise on the unit particularly on the
______ night of admission, when the client is especially sensitive to hospital noises.
1. 1st
2. 2nd
3. 3rd
4. 4th
Ans-4. 1. The client is most sensitive to noise in the hospital setting the first night because
everything is new. This represents sensory overload, which interferes with sleep and decreases
rapid eye movement (REM) as well as total sleep time.
5. Which of the following medications are the safest to administer to adults needing
assistance in falling asleep?
1. Sedatives
2. Hypnotics
3. Benzodiazepines
4. Anti-anxiety agents
Ans-5. 3. The group of drugs that are the safest are the benzodiazepines. They facilitate the
action of the neurons in the central nervous system (CNS) that suppress responsiveness to
stimulation, therefore decreasing levels of arousal.
6. To assist an adult client to sleep better the nurse recommends which of the following?
(Select all that apply.)
1. Drinking a glass of wine just before retiring to bed

2. Eating a large meal 1 hour before bedtime
3. Consuming a small glass of warm milk at bedtime
4. Performing mild exercises 30 minutes before going to bed
Ans-6. 3. A small glass of milk relaxes the body and promotes sleep.
7. The nurse recognizes that a client is experiencing insomnia when the client reports (select
all that apply):
1. Extended time to fall asleep

2. Falling asleep at inappropriate times
3. Difficulty staying asleep
4. Feeling tired after a night’s sleep
Ans-7. 1, 3, and 4. These symptoms are often reported by clients with insomnia. Clients report
nonrestorative sleep. Arising once at night to urinate (nocturia) is not in and of itself insomnia.
8. The nurse teaches the mother of a newborn that in order to prevent sudden infant death
syndrome (SIDS) the best position to place the baby after nursing is (select all that apply):
1. Prone
2. Side-lying
3. Supine
4. Fowler’s
Ans-8. 2 and 3. Research demonstrate that the occurrence of SIDS is reduced with these two
positions.
9. When assessing a client for obstructive sleep apnea (OSA), the nurse understands the
most common symptom is:
1. Headache
2. Early awakening
3. Impaired reasoning
4. Excessive daytime sleepiness
Ans-9. 4. Excessive daytime sleepiness is the most common complaint of people with OSA.
Persons with severe OSA may report taking daytime naps and experiencing a disruption in their
daily activities because of sleepiness.
10. The nurse understands that the most vivid dreaming occurs during:
1. REM sleep
2. Stage 1 NREM
3. Stage 4 NREM
4. Transition period from NREM to REM sleep
Ans-10. 1. Although dreams occur during both NREM and REM sleep, the dreams of REM sleep
are more vivid and elaborate and are believed to be functionally important to learning, memory
processing, and adaptation to stress.
11. A client taking a beta adrenergic blockers for HTN can experience interference with sleep
patterns such as:
1. Nocturia
2. Increased daytime sleepiness
3. Increased awakening from sleep
4. Increased difficulty falling asleep
Ans-11. 2. Beta Blockers can cause nightmares, insomnia, and awakenings from sleep.
12. Narcolepsy can be best explained as:
1. A sudden muscle weakness during exercise

2. Stopping breathing for short intervals during sleep
3. Frequent awakenings during the night
4. An overwhelming wave of sleepiness and falling asleep
Ans-12. 4. Narcolepsy is a dysfunction of mechanisms that regulate the sleep and wake states.
Excessive daytime sleepiness is the most common complaint associated with this disorder.
During the day a person may suddenly feel an overwhelming wave of sleepiness and fall asleep;
REM sleep can occur within 15 minutes of falling asleep.
13. A nursing measure to promote sleep in school-age children is to:
1. Make sure the room is dark and quiet

2. Encourage evening exercise
3. Encourage television watching
4. Encourage quiet activities prior to bed time.
Ans-13. 4. The amount of sleep needed during the school years is individualized because of
varying states of activities and levels of health. A 6-year old averages 11-12 hours of sleep
nightly, whereas an 11-year old sleeps about 9-10 hours. The 6- or 7-year old can usually be
persuaded to go to bed by encouraging quiet activities

14. A female client verbalizes that she has been having trouble sleeping and feels wide awake
as soon as getting into bed. The nurse recognizes that there are many interventions the
promote sleep. Check all that apply.
1. Eat a heavy snack before bedtime

2. Read in bed before shutting out the light
3. Leave the bedroom if you are unable to sleep
4. Drink a cup of warm tea with milk at bedtime
5. Exercise in the afternoon rather than the evening
6. Count backwards from 100 to 0 when your mind is racing.
Ans-14. 3, 5, and 6. Lying in bed when one is unable to sleep increases frustration and anxiety
which further impede sleep; other activities, such as reading or watching television, should not
be conducted in bed. Counting backwards requires minimal concentration but it is enough to
interfere with thoughts that distract a person from falling asleep.
15. A client has a diagnosis of primary insomnia. Before assessing this client, the nurse
recalls the numerous causes of this disorder. Select all that apply:
1. Chronic stress
2. Severe anxiety
3. Generalized pain
4. Excessive caffeine
5. Chronic depression
6. Environmental noise
Ans-15. 1, 4, and 6. Acute or primary insomnia is caused by emotional or physical discomfort
not caused by the direct physiologic effects of a substance or a medical condition. Excessive
caffeine intake is an example of disruptive sleep hygiene; caffeine is a stimulant that inhibits
sleep. Environmental noise causes physical and/or emotional and therefore is related to primary
insomnia.
16. A hospitalized client is prescribed chloral hydrate (Noctec). The nurse includes which
action in the plan of care?
1. Monitor apical heart rate every 2 hours

2. Monitor blood pressure every 4 hours
3. Instruct the client to call for ambulation assistance
4. Clear a path to the bathroom at bedtime.
Ans-16. 3. Chloral hydrate is a sedative. This medication does not affect cardiac function. Blood
pressure changes are not significant with the use of this medication. A client should call for
assistance to the bathroom at night. Additionally, the client may experience residual daytime
sedation; therefore, the nurse should instruct the client to call for ambulation assistance during
the daytime hours.
17. Select all that apply to the use of barbiturates in treating insomnia:
1. Barbiturates deprive people of NREM sleep

2. Barbiturates deprive people of REM sleep
3. When the barbiturates are discontinued, the NREM sleep increases.
4. When the barbiturates are discontinued, the REM sleep increases.
5. Nightmares are often an adverse effect when discontinuing barbiturates.
Ans-17. 2, 4, and 5. Barbiturates deprive people of REM sleep. When the barbiturate is stopped
and REM sleep once again occurs, a rebound phenomenon occurs. During this phenomenon, the
persons dream time constitutes a larger percentage of the total sleep pattern, and the dreams are
often nightmares.
18. Select all that apply that is appropriate when there is a benzodiazepine overdose:
1. Administration of syrup of ipecac

2. Gastric lavage
3. Activated charcoal and a saline cathartic
4. Hemodialysis
5. Administration of Flumazenil
Ans-18. 2, 3, and 5. If ingestion is recent, decontamination of the GI system is indicated. The

administration of syrup of ipecac is contraindicated because of aspiration risks related to
sedation. Gastric lavage is generally the best and most effective means of gastric
decontamination. Activated charcoal and a saline cathartic may be administered to remove any
remaining drug. Hemodialysis is not useful in the treatment of benzodiazepine overdose.
Flumazenil can be used to acutely reverse the sedative effects of benzodiazepines, though this is
normally done only in cases of extreme overdose or sedation.
19. A patient is admitted to the emergency department with an overdose of a benzodiazepine.

The nurse immediately prepares to administer which of the following antidotes from the
emergency drug cart?
1. naloxone (Narcan)
2. naltrexone (ReVia)
3. nalmefene (Revex)
4. flumazenil (Romazicon)
Ans-19. 4. Flumazenil is the antidote for benzodiazepine overdoses.
20. Older adults who take long-acting sedatives or hypnotics are likely to experience:
1. Hallucinations
2. Ataxia
3. Alertness
4. Dyspnea
Ans-20. 2. If longer-acting barbiturates are used in older adults, these clients may experience
daytime sedation, ataxia, and memory deficits.
21. Which nursing diagnosis is appropriate for a patient who has received a sedative-hypnotic
agent?
1. Alteration in tissue perfusion

3. Risk for injury
4. Risk for infection
Ans-21. 3. Sedative-hypnotics cause CNS depression, putting the patient at risk for injury.
22. A patient is admitted to the emergency department with an overdose of a barbiturate. The
nurse immediately prepares to administer which of the following from the emergency drug
cart?
1. naloxone HCl (Narcan

2. activated charcoal
3. flumazenil (Romazicon)
4. ipecac syrup
Ans-22. 2. There is no antidote for barbiturates. The use of activated charcoal absorbs any drug
in the GI tract, preventing absorption.
23. During patient teaching, the nurse explains the difference between a sedative and
hypnotic by stating:
1. “Sedatives are much stronger than hypnotic drugs and should only be used for short periods
of time.”
2. “Sedative drugs induce sleep, whereas hypnotic drugs induce a state of hypnosis.”
3. “Most drugs produce sedation at low doses and sleep (the hypnotic effect) at higher doses.”
4. “There really is no difference; the terms are used interchangeably.”
Ans-23. 3. Many drugs have both sedative and hypnotic properties, with the sedative properties
evident at low doses and the hypnotic properties demonstrated at larger doses.
24. The patient’s chart notes the administration of dantrolene (Dantrium) immediately
postoperatively. The nurse suspects that the patient experienced:
1. Delirium tremens
2. Malignant hyperthermia
3. A tonic-clonic seizure
4. Respiratory arrest
Ans-24. 2. Dantrolene is a direct-acting musculoskeletal muscle relaxant and is the drug of

choice to treat malignant hyperthermia, a complication of generalized anesthesia (remember
intraoperative nursing???)
25. Which of the following is an important nursing action for the administration of a
benzodiazepine as a sedative-hypnotic agent?
1. Use IM dosage forms for longer duration

2. Administer safely with other CNS depressants for insomnia
3. Monitor geriatric patients for the common occurrence of paradoxical reactions.
4. Evaluate for physical dependence that occurs within 48 hours of beginning the drug.
Ans-25. 3.
26. Pediatric and geriatric patients often react with more sensitivity to CNS depressants. This
type of sensitivity manifests itself in the development of which type of reaction?
1. Idiopathic
2. Teratogenic
3. Paradoxical
4. Psychogenic
Ans-26. 3.
27. Which of the following is an appropriate nursing intervention for patients who are
receiving CNS depressants?
1. Prevent any activity within the hospital setting while on oral muscle relaxants
2. Make sure that the patient knows that sedation should be minimal with these agents.
3. Cardiovascular stimulation, a common side effect, would lead to hytertension
4. Make sure the patient’s call light is close by in case of the need for assistance with activities.
Ans-27. 4.
28. Which of the following conditions characterizes rapid eye movement (REM) sleep?
1. Disorientation and disorganized thinking

2. Jerky limb movements and position changes
3. Pulse rate slowed by 5 to 10 beats/minute
4. Highly active brain and physiological activity levels.
Ans-28. 4. Highly active brain and physiological activity levels characterize REM stage. Stages 3
and 4 of NREM sleep are characterized by disorientation and disorganization, During REM
sleep, the body movement ceases except for the eyes. The pulse rate slows by 5-10 beats/minute
during NREM sleep, not REM sleep
29. Which of the following sleep disorders is the most prevalent?
1. Hypersomnia
2. Insomnia
3. Parasomnia
4. Sleep-awake schedule disturbance.
Ans-29. 2. Approximately 1/3 of American adults have some type of sleep disorder, and
insomnia is the most common.
30. Which of the following substances is a natural hormone produced by the pineal gland that
induces sleep?
1. Amphetamine
2. Melatonin
3. Methylphenidate
4. Pemoline
Ans-30. 2. Melatonin is a natural hormone that induces sleep. All the others are medications
classified as stimulants.
Vascular – PVD
1. The most important factor in regulating the caliber of blood vessels, which determines
resistance to flow, is:
A. Hormonal secretion
B. Independent arterial wall activity.
C. The influence of circulating chemicals
D. The sympathetic nervous system
Ans-1. D.
2 With peripheral arterial insufficiency, leg pain during rest can be reduced by:
1. Elevating the limb above heart level

2. Lowering the limb so it is dependent
3. Massaging the limb after application of cold compresses
4. Placing the limb in a plane horizontal to the body
Ans-2. 2
3. Buerger’s disease is characterized by all of the following except:
1. Arterial thrombosis formation and occlusion

2. Lipid deposits in the arteries
3. Redness or cyanosis in the limb when it is dependent
4. Venous inflammation and occlusion
Ans-3. 2
4. A significant cause of venous thrombosis is:
1. Altered blood coagulation

2. Stasis of blood
3. Vessel wall injury
4. All of the above
Ans-4. 4
5. When caring for a patient who has started anticoagulant therapy with warfarin
(Coumadin), the nurse knows not to expect therapeutic benefits for:
1. At least 12 hours
2. The first 24 hours
3. 2-3 days
4. 1 week
Ans-5. 3
6. Mike, a 43-year old construction worker, has a history of hypertension. He smokes two
packs of cigarettes a day, is nervous about the possibility of being unemployed, and has
difficulty coping with stress. His current concern is calf pain during minimal exercise that
decreased with rest. The nurse assesses Mike’s symptoms as being associated with peripheral
arterial occlusive disease. The nursing diagnosis is probably:
1. Alteration in tissue perfusion related to compromised circulation

2. Dysfunctional use of extremities related to muscle spasms
3. Impaired mobility related to stress associated with pain
4. Impairment in muscle use associated with pain on exertion.
Ans-6. 1
7. A 24-year old man seeks medical attention for complaints of claudication in the arch of
the foot. A nurse also notes superficial thrombophlebitis of the lower leg. The nurse would
next assess the client for:
1. Familial tendency toward peripheral vascular disease

2. Smoking history
3. Recent exposures to allergens
4. History of insect bites
Ans-7. 2. The mixture of arterial and venous manifestations (claudication and phlebitis,
respectively) in the young male client suggests Buerger’s disease. This is an uncommon disorder
characterized by inflammation and thrombosis of smaller arteries and veins. This disorder
typically is found in young adult males who smoke. The cause is not known precisely but is
suspected to have an autoimmune component.
8. Intravenous heparin therapy is ordered for a client. While implementing this order, a
nurse ensures that which of the following medications is available on the nursing unit?
1. Vitamin K
2. Aminocaproic acid
Ans-8. 4. The antidote to heparin is protamine sulfate and should be readily available for use if
excessive bleeding or hemorrhage should occur
9. A client who has been receiving heparin therapy also is started on warfarin sodium
(coumadin). The client asks the nurse why both medications are being administered. In
formulating a response, the nurse incorporates the understanding that warfarin sodium:
1. Stimulates the breakdown of specific clotting factors by the liver, and it takes 2-3 days for
this is exhibit an anticoagulant effect.
2. Inhibits synthesis of specific clotting factors in the liver, and it takes 3 to 4 days for this
medication to exert an anticoagulation effect.
3. Stimulates production of the body’s own thrombolytic substances, but it takes 2-4 days for it
to begin.
4. Has the same mechanism action of heparin, and the crossover time is needed for the serum
level of warfarin sodium to be therapeutic.
Ans-9. 2. Warfarin sodium works in the liver and inhibits synthesis of four vitamin K-dependent
clotting factors (X, IX, VII, and II), but it takes 3 to 4 days before the therapeutic effect of
warfarin is exhibited.
10. A nurse has an order to begin administering warfarin sodium (coumadin) to a client.
While implementing this order, the nurse ensures that which of the following medications is
available on the nursing unit as the antidote for Coumadin?
1. Vitamin K
2. Aminocaproic acid
Ans-10. 1. The antidote to warfarin (Coumadin) is Vitamin K and should be readily available for
use if excessive bleeding or hemorrhage should occur.
11. A nurse is assessing the neurovascular status of a client who returned to the surgical
nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm,
and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from
admission. The nurse interprets that the neurovascular status is:
1. Normal because of the increased blood flow through the leg

2. Slightly deteriorating and should be monitored for another hour
3. Moderately impaired, and the surgeon should be called.
4. Adequate from the arterial approach, but venous complications are arising
Ans-11. 1. An expected outcome of surgery is warmth, redness, and edema in the surgical
extremity because of increased blood flow. Options 2, 3, and 4 are incorrect interpretations.
12. A client is admitted with a venous stasis leg ulcer. A nurse assesses the ulcer, expecting
to note that the ulcer:
1. Has a pale colored base

2. Is deep, with even edges
3. Has little granulation tissue
4. Has brown pigmentation around it.
Ans-12. 4. Venous leg ulcers, also called stasis ulcers, tend to be more superficial than arterial
ulcers, and the ulcer bed is pink. The edges of the ulcer are uneven, and granulation tissue is
evident. The skin has a brown pigmentation from accumulation of metabolic waste products
resulting from venous stasis. The client also exhibits peripheral edema. (options 1, 2, and 3 is due
to tissue malnutrition; and thus us an arterial problem)
13. In preparation for discharge of a client with arterial insufficiency and Raynaud’s
disease, client teaching instructions should include:
1. Walking several times each day as an exercise program.

2. Keeping the heat up so that the environment is warm
3. Wearing TED hose during the day
4. Using hydrotherapy for increasing oxygenation
Ans13. 2. The client’s instructions should include keeping the environment warm to prevent
vasoconstriction. Wearing gloves, warm clothes, and socks will also be useful when preventing
vasoconstriction, but TED hose would not be therapeutic. Walking would most likely increase
pain.
14. A client comes to the outpatient clinic and tells the nurse that he has had legs pains that
begin when he walks but cease when he stops walking. Which of the following conditions
would the nurse assess for?
1. An acute obstruction in the vessels of the legs

2. Peripheral vascular problems in both legs
3. Diabetes
4. Calcium deficiency
Ans-14. 2. Intermittent claudication is a condition that indicates vascular deficiencies in the

peripheral vascular system. If an obstruction were present, the leg pain would persist when the
client stops walking. Low calcium levels may cause leg cramps but would not necessarily be
related to walking.
15. Which of the following characteristics is typical of the pain associated with DVT?
1. Dull ache
2. No pain
3. Sudden onset
4. Tingling
Ans-15. 3. DVT is associated with deep leg pain of sudden onset, which occurs secondary to the
occlusion. A dull ache is more commonly associated with varicose veins. A tingling sensation is
associated with an alteration in arterial blood flow. If the thrombus is large enough, it will cause
pain.
16. Cancer can cause changes in what component of Virchow’s triad?
1. Blood coagulability
2. Vessel walls
3. Blood flow
4. Blood viscosity
Ans-16. 1.

17. Varicose veins can cause changes in what component of Virchow’s triad?
1. Blood coagulability
2. Vessel walls
3. Blood flow
4. Blood viscosity
Ans-17. 3.
18. Which technique is considered the gold standard for diagnosing DVT?
1. Ultrasound imaging
2. Venography
3. MRI
4. Doppler flow study
Ans-18. 2.
19. A nurse is assessing a client with an abdominal aortic aneurysm. Which of the following
assessment findings by the nurse is probably unrelated to the aneurysm?
1. Pulsatile abdominal mass

2. Hyperactive bowel sounds in that area
3. Systolic bruit over the area of the mass
4. Subjective sensation of “heart beating” in the abdomen.
Ans-19. 2. Not all clients with abdominal aortic aneurysms exhibit symptoms. Those who do
describe a feeling of the “heart beating” in the abdomen when supine or be able to feel the mass
throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit
may be auscultated over the mass. Hyperactive bowel sounds are not related specifically to an
abdominal aortic aneurysm.
20. A nurse is caring for a client who had a percutaneous insertion of an inferior vena cava
filter and was on heparin therapy before surgery. The nurse would inspect the surgical site
most closely for signs of:
1. Thrombosis and infection

2. Bleeding and infection
3. Bleeding and wound dehiscence.
4. Wound dehiscence and evisceration.
Ans-20. 2. After inferior vena cava insertion, the nurse inspects the surgical site for bleeding and
signs and symptoms of infection. Otherwise, care is the same as for any post-op client.
Assessment Documentation Examples

Assessment Thursday Friday
General Appearance
Affect, facial expression,

posture, gait
Affect and facial expression
Speech appropriate to situation. Patient
not observed OOB. Speech clear.
Skin mostly warm and dry.
Braden score- 20. Catheter
insertion site found with dried
Skin sanguineous urine around
meatus. Area cleaned
Color, texture, hygiene, thoroughly. R midline dressing
moisture covered with Telfa cloth adhesive
dressing soaked with dried blood
Braden score inferior to incision, gauze
covering changed, JP drain intact.
Midline and 2 groin incisions at
Intactness, lesions, top of each leg clean, dry and well
breakdown approximated with derma bond.
No other skin lesions or
breakdown
Room and equipment D51/2 NS + 20 mEq KCl at 125

ml/hr in 18 gauge LFA PIV. R
IV fluids, IV access wrist PIV medlocked. Foley
catheter. JP drain from R midline
Tube feedings incision drained 19 ml
sanguineous fluid, drain
reactivated. (Drain later removed
Drains, Foley by MD, incision left clean, dry
and intact).
Neuro
LOC, pupils
Hand grips
Feet – flexion, extension Oriented x4. Grips, flexion,

extension strong bilaterally.
S1, S2 auscultated over aortic,
pulmonic, erb’s point, tricuspid
and mitral areas. Pulse rate 70.
C-V: pulses Heart: rhythm, Radial 3+, R dorsalis pedis 2+.
S1, S2, extra sounds
Capillary refill JVD, bruits Cap refill sec. No JVD. Or
Edema bruit. No edema.
Resp: rate, rhythm, depth, Rate 20, even, unlabored
effort Accessory muscle use respirations. No accessory
Chest expansion Breath muscles used. Breath sounds
sounds clear in all areas.
GI: abdominal shape, Abdomen round and soft. Bowel
appearance bowel sounds x sounds x 4.Tenderness only in
4 tenderness last BM, usual compromised areas. No BM since
pattern the day before operation (3/4/08).
G-U: voiding
pattern Amount, color, 180 ml clear amber urine drained
clarity, Urgency, frequency, from Foley catheter. No pain or
pain on voiding Bladder bladder tenderness reported. No
tenderness or distention distention.
Psy/ Soc Lives with wife, who will be

Family/ support systems caregiver as needed upon
discharge
Pain
Intensity (specify tool)
Location, character
Associated signs/ symptoms

Pain noted at 6 on the number
Pain interventions and scale. Pain medication
effectiveness administered and pain noted at 3
on same scale 30 minutes later.
Rest/ Sleep
Usual pattern/ changes since

hospitalized
Pt reported no sleep problems
Sleeping aids used other than hospital required
interruptions.
Other: specific to your
patient, incl. Dressings/
treatments
General Appearance
Affect, facial
expression, posture,
gait
Affect and facial
Flat affect. Posture expression appropriate to
Speech stupped. Gait unsteady situation. Posture erect.
and weak. Speech clear. Gait weak. Speech clear.
Skin Skin pink, cool and dry. Skin pink, cool and dry.
Braden score- 18. Braden score- 17.
Color, texture, Abdominal sagittal Abdominal sagittal
hygiene, moisture midline well midline well approximated
approximated incision incision with packed
with packed wound at wound at inferior and
inferior and superior ends, superior ends, both approx
both approx 1 cm in
circumference and 11-12 1 cm in circumference and
mm in depth, no site 11-12 mm in depth, no site
redness or swelling, scant redness or swelling, scant
sanguiness drainage. serosanguiness drainage.
Three puncture wounds Three puncture wounds
from laparoscopic from laparoscopic
nephrectomy, well nephrectomy, well
approximated, covered approximated, covered
with steri-strips located with steri-strips located
Braden score right medial midline, right medial midline,
inferior and superior left inferior and superior left
lateral abdominal area, no lateral abdominal area, no
Intactness, lesions, site swelling or redness. site swelling or redness.
breakdown No other skin lesions or No other skin lesions or
breakdown found. breakdown found.
Room and equipment
IV fluids, IV access NS at 50 ml/hr in 22

gauge LFA IVAD, 22 gauge LFA S/L,
Tube feedings insertion date 6/1/08. insertion date 6/1/08.
Dressing clean, dry, and Dressing clean, dry intact,
intact and reinforced and reinforced with. No
Drains, Foley with. No other tubes, other tubes, drains, or
drains, or Foley. Foley.
Neuro
LOC, pupils
Hand grips
Feet – flexion, Oriented x4. Grips, Oriented x4. PERRL.

extension flexion, extension strong Grips, flexion, extension
bilaterally. strong bilaterally.
C-V: pulses Heart: S1, S2 auscultated over S1, S2 auscultated over
rhythm, S1, S2, extra aortic, pulmonic, erb’s aortic, pulmonic, erb’s
sounds Capillary refill point, tricuspid and mitral point, tricuspid and mitral
JVD, bruits areas. Pulse rate 72. areas. Pulse rate 76.
Radial pulse 2+, dorsalis Radial pulse 2+, dorsalis
Edema pedis and posterior tibial pedis and posterior tibial
pulses 1+ bilaterally. Cap pulses 1+ bilaterally. Cap
refill <2 sec. No JVD or refill <2 sec. No JVD or
bruit. Non-pitting edema
in hands and feet
bilaterally. bruit.
Resp: rate, rhythm,
depth, effort Rate 20, even, unlabored Rate 20, even, unlabored
Accessory muscle use respirations. No respirations. No
Chest expansion accessory muscles used. accessory muscles used.
Breath sounds RLL wet, all other breath Breath sounds clear in all
sounds clear. areas.
Abdomen firm and
GI: abdominal shape, round. Bowel sounds x 4. Abdomen firm and round.
appearance bowel General abdominal Bowel sounds hyperactive
sounds x 4 tenderness tenderness reported. x 4. Soft stool at approx
last BM, usual pattern Reported last BM was 10:00 after administration
formed 5/31/08. of Ducolax suppository.
G-U: voiding
pattern Amount, color,
clarity, Urgency, 230 ml clear, yellow Reported voiding x 2 this
frequency, pain on urine. No pain, urgency, morning. No pain,
voiding frequency or tenderness urgency, frequency or
Bladder tenderness or with voiding reported. No tenderness with voiding
distention bladder distention reported. No bladder
reported. distention reported.
Psy/ Soc Pt transferred from rehab Daughter (who is able to

facility and expects to go give some support for pt
Feelings or concerns back to another facility and caregiver) and wife
r/t hospitalization, prior to going back home are arranging placement
illness. Recent where wife is caregiver. for pt into a rehab facility
stressors, anxiety or Wife has arthritis and upon expected discharge
depression. Family/ back problems, so in- today. Pt is please that he
support systems home assistance may be has been able to self-
needed for a period of ambulate today, but has
time. Pt concerned about concern of repeated
pet (Beauty) and not being evisceration.
able to take her on long
walks which they both
enjoy. Not being able to
do this and anticipating
never being able to do this
along with unrelieved
pain and lack of sleep
caused pt to say “if I had a
gun, I would shoot
myself”.
Pain noted at 5 on the
Pain number scale at incision
site and radiating to right
Intensity (specify tool) side. PRN Oxycodone
pain medication
Location, character administered with no
relief within 30 minutes. Pain noted at 5 on the
Associated signs/ PRN acetaminophen number scale at incision
symptoms administered with pain site and radiating to right
decreased to a 3 with 30 side. PRN Oxycodone
minutes. Patients’ report pain medication
Pain interventions and of consistent lack of pain administered with pain
effectiveness relief reported to his decrease to 3 within 30
nurse. minutes.
Rest/ Sleep
Usual pattern/ changes

since hospitalized
Pt reported not being able Pt reported reduced pain
Sleeping aids used to get any sleep due to and was able to get rest
unrelieved pain. during the night.
Abdominal incision site Abdominal incision site
packed with NuGauze, dressed with approx. 4
covered with (2) 4×4, left inches NuGauze (both
untapped, then covered superiorly and inferiorly),
with binder. Two covered with (2) 4×4,
abdominal pads placed tapped, then covered with
underneath top edge on binder. Two abdominal
binder to prevent pads placed underneath
chaffing. Dressing top edge on binder to
changed by Dr. during prevent chaffing.
rounds this morning. Dressing changed 11:00
Dressing found clean and and found scant amt of
intact with scant amount serosanguiness drainage
Other: specific to your of sanguiness drainage on the both pieces of
patient, incl. during assessment. Order NuGauze. Order for
Dressings/ treatments for dressing change TID. dressing change TID.
Acidosis or Alkalosis
Sleuthing: Using Blood Values to determine the Cause of Acidosis or Alkalosis

1. Note the pH. This tells you whether the person is in acidosis (pH < 7.35) or alkalosis (pH >
7.45); but it does not tell you the cause.
2. Next, check the PCO2 to see if this is the cause of the acid-base imbalance. Because the
respiratory system is a fast-acting system, an excessively high or low PCO2 may indicate either
that the condition is respiratory system—caused or that the respiratory system is
compensating. For example, if the pH indicates acidosis and:
A. The PCO2 is over 45 mm Hg, the respiratory system is the cause of the problem and the
condition is a respiratory acidosis.
B. The PCO2 is below normal limits (below 35 mmHg), the respiratory system is not the cause
but is compensating.
C. The PCO2 is within normal limits; the condition is neither caused nor compensated by the
respiratory system.
3. Check the bicarbonate level. If step 2 proves that the respiratory system is not responsible for
the imbalance, then the condition is metabolic and should be reflected in increased or
decreased bicarbonate levels. Metabolic acidosis is indicated by HCO3–values below 22
mEq/L, and metabolic alkalosis by values over 26 mEq/L. Notice that whereas PCO2 vary
inversely with blood pH (PCO2 rises as blood pH falls), HCO3– levels vary directly with blood
pH (increased HCO3– results in increased pH). Beyond this bare-bones approach there is
something else to consider when you are assessing acid-base problems. If an imbalance
is fully compensated, the pH may be normal even when the pH is normal, carefully scrutinize
the PCO2 or HCO3– values for clues to what imbalance may be occurring.

Causes and Consequences of Acid-Base imbalances

Metabolic acidosis:
 Uncompensated (uncorrected) HCO3– < 22 mEq/L; pH < 7.4
 Severe diarrhea: Bicarbonate-rich intestinal (and pancreatic) secretions rushed through

digestive tract before their solutes can be reabsorbed; bicarbonate ions are replaced by
renal mechanisms that generate new bicarbonate ions.
 Renal disease: failure of the kidneys to rid body of acids formed by normal metabolic
processes.
 Untreated diabetes mellitus: lack of insulin or inability of tissue cells to respond to
insulin, resulting in inability to use glucose; fats are used as primary energy fuel, and
ketoacidosis occurs.
 Starvation: Lack of dietary nutrients for cellular fuels, body proteins and fat reserves are
used for energy—both yield acidic metabolites as they are broken down for energy.
 High ECF potassium concentrations: Potassium ions compete with H+ for secretion in

renal tubules; when ECF levels of K+ are high, H+ secretion is inhibited.
Metabolic alkalosis:
 Uncompensated (HCO3– >26 mEq/L; pH > 7.4)
 Vomiting or gastric suctioning: loss of stomach HCl requires that H+ be withdrawn from
blood to replace stomach acids; thus H+ decreases and HCO3– proportionally.
 Selected diuretics: cause K+ depletion and H2O loss. Low K+ directly stimulates the tubule
cells to secrete H+. Reduced blood volume elicits the renin-angiotensin mechanism, which
stimulates Na+ reabsorption and H+ secretion.
 Ingestion of excessive sodium bicarbonate (antacid): bicarbonate moves easily into

ECF, where it enhances natural alkaline reserve.
 Constipation: prolonged retention of feces, resulting in increased amounts of

HCO3– being reabsorbed.
 Excessive aldosterone: (adrenal tumors) promotes excessive reabsorption of Na+, which

pulls increased amount of H+ into urine. Hypovolemia promotes the same relative effect
because aldosterone secretion is increased to enhance Na+ (and H2O) reabsorption.

Respiratory acidosis:
 Uncompensated (PCO2 >45 mm Hg; pH <7.4)
 Impaired gas exchange or lung ventilation (chronic bronchitis, cystic fibrosis,
emphysema): Increased airway resistance and decreased expiratory air flow, leading to
retention of carbon dioxide.
 Rapid, shallow breathing: Tidal volume markedly reduced.
 Narcotic or barbiturate overdose or injury to the brain stem: depression of respiratory
centers, resulting in hypoventilation and respiratory arrest.

Respiratory alkalosis:
 Uncompensated (PCO2 < 35 mm Hg; pH > 7.4)
 Direct cause is always hyperventilation: hyperventilation is pain/anxiety, asthma,
pneumonia, and at high altitude represents effort to raise PO2 at the expense of excessive
carbon dioxide excretion.
 Brain injury or tumor: abnormality of respiratory controls.

Meds for Neuro
Mannitol (Osmitrol)
 Is used to decrease cerebral edema during increased ICP.
 It is an osmotic diuretic, which means the blood will be drawn from interstitial areas to
vascular space and then be eliminated in the urine excretion.
 Electrolytes are also drawn into blood and excreted, so monitor for electrolyte imbalance
 Hyponatremia is a life threatening side effect, causes seizures and death.
 Maintain strict I&O.
 Can have rebound ICP’s about 12 hours after drug administration
Dobutamine (Dubutrex) and Norepinephrine (Levophed) – cardiac stimulants used to

maintain cerebral perfusion during increased ICP.
Dexamethasone (Decadron)
 Corticosteroid used to decrease inflammation surrounding a brain tumor
 Used in medical management of meningitis.
 Used post craniotomy for cerebral edema
 Administer IV q 6 hours for 24-72 hours, change to oral a.s.a.p., taper dosage over 5-7 days
 As with any steroid, fluid retention, increased sugar, lowed immune system
 Common side effect nasal irritation, cardiovascular edema, hyperglycemia, cataract, oral
candidiasis, impaired would healing
 If using with Mannitol (makes electrolytes be excreted) (by the way the two together are
contraindicated according to the book) add potassium-rich foods or supplement to diet.
 Use good oral hygiene to prevent oral candidiasis
Phenytion (Dilantin)
 Anticonvulsant – to reduce risk of seizures
 Especially after supratentorial neurosurgical procedure (prone to seizures)
 Used to prevent grand mal and complex partial seizures
 During Ictal phase of seizure give ativan (lorazepam), then start dilantin
 Life threatening side effects are cardiovascular collapse, Agranulocytosis, aplastic anemias,
dermatitis (bullous, exfoliative, or purpuric), and Steven-Johnson syndrome.
 Common side effects gingival hyperplasia (swollen gums), give good mouth care. Self-care
pt should brush, floss and massage gums after each meal.
 Other side effect in power point; headache, dizziness, confusion, ataxia, slurred speech,
depression, bleeding gums
 Decreases the effects of oral anticoagulants, corticosteroids, antihistamines, and oral
contraceptive
 Therapeutic level is narrow; therapeutic level is 10-20 mcg/ml, toxic level is 30-50 mcg/ml,
lethal level is 100 mcg/ml. Therapeutic levels not reached for at least 7-10 days
 Do not stop drug abruptly, may precipitate status epilepticus.
 Tell patients to inform all healthcare providers they are on this med.
Diazepam (Valium)
 To reduce anxiety
Antiseizure medications
 Tegretol
 Klonopin
 Keppra
 Luminal
 Dilantin-Phenytoin
 Topamax
 Depakote
Abortive meds for migraines
 Triptans
 Lilitrex
 amerge
 maxalt
 ergotamine
 cafergot-combo of ergotamine and caffeine
Preventive meds for migraines
 Inderal
 Lopressor
 elavil
 valproate
 flunarzine
 serotonin antagonists
 Ca antagonists
Apresoline
 Give for autonomic dysreflexia
To give for bladder spasticity with spinal cord injury
 Baclofen, valium, Dantrium

For encephalitis caused by Herpes Simplex Virus
 Acyclovir
For encephalitis caused by fungal infections
 Amphotericin
For complications of vasospasms after hemorrhagic stroke
 Calcium channel blockers – Nimotop, Verapamil, Nifedipine

 OR triple H-therapy hemodilution, hypertension, hypervolemia (fluid volume expanders)
Methylpredinisolone (Solu medoral)

 Give high doses of this steroid within 8 hours of spinal cord injury.
 Has shown to improve outcomes at 6 weeks, 6 months, and 1 year
For shoulder pain after a stroke give:
 Lamictal
 Amitriptyline
Neuromuscular and Skeletal diseases and conditions

MS – multiple sclerosis,
 autoimmune, progressive, permanent myelin destroyed and nerve fiber breakdown, 20-40,

environmental factors, relapsing/remitting most common type
 FATIGUE, weakness, vision, spas. & trem., pain w/ parasthesia, no 2 patients alike
 MRI & imunoglobin G bonded
 Mobility, no heat, urinary and bowel – embarrassing young, eye dr. often, sex dysfunction
 MEDS: Rebif, Betasteron SQqod / Avonex IMqwk / Copaxone SQqd / ßflulike
symptoms / Methylprednisone for exacerbations, Mitoxarone IVq3mos (all to slow
progression & reduce relapses
MG – Myasthenia Gravis
 Autoimmune, myoneural junction, antibodies get in ACH receptors, 20-40W – 60-70M, face,
throat (bulbar) swallow, voice, big thymus may hold antibodies
 Tensilon test – bradycardia – Atropine
 MG crisis ¯ or late meds (respir failure) , ACH crisis meds (respir failure), always have
suction available hospital and home, no sedative (hypoxia), conserve energy, energy for
eating timed meds, sit to eat
 MEDS: ACHsterase inhib – Mestinon / immuno mod (¯antibodies) Prednisone, Imuron,
Cyclosporin, Cytoxan / Plasmaphoresis for exacerbations / Thymectomy
GBS – Guillain Barre Syndrome

 Acute fixable myelin problem, after virus (CMV, pneum, flu) 16-25, 45-60, ASCENDING,
fast
 Respiratory failure, pulmonary embolis, , autonomic dysfunction, CV instability
 In ICU, CSF will have protein, Plasmaphoresis, IVIG
 Have intubation close by, early detection, support limbs, temp pacemaker, TPN,
communications before can’t talk, positive atmosphere, G-tube risk for aspiration
Parkinson
 Progressive, basal ganglia, substantial nigra, dopamine ¯ – symptoms only after 80%
decrease
 ? cause – 2 out of 4 (trem, ridg, bradykensia, posture)
 tremors, dementia, micrography, suffling gait
 thalamotomy, Pallidotomy, stem cells
 exercise, rest periods, assistive devices, no rugs, OT
 MEDS: Antiparkinson –Levadopa, Carbidopa / AntiACH – Cogentin (Æ see pee spit shit) /
Antiviral (¯ tremors) Symmetrel / Dopa-agonist – Parlodel, Permax, Requip,Mirapex / MAOI
– Elderpryl / COMT inhibitors ( dopa) – Comtan, Tasmar / Antidepressant
– Wellbutrin, Prozac Elavil
Huntington
 Chronic progressive, premature cell death basil ganglia & cortex / no treatment stops or ¯
 Intellect, emotional and mobile decline
 MEDS: Haldol, Navane – reduces involuntary movement
ALS – Lou Gerig’s

 2 yrs to life / loss of motor neurons in anterior horn and brain stem
 Atrophy in extremities, trunk and bulbar
 No cause, no cure / death by infection, aspiration, respiratory failure
Osteoporosis
 Loss of bone mass, altered bone turnover, in small white women
 DEXA
 Diet in calcium and Vit D, walking, watch for fractures
 MEDS: biphosphonates: Fosamax, Actonel, Boniva / Calcitonin / SERMS
– Evista /Forteo / Reclasp IV 1 q yr
Osteomalacia
 Deformity in long bones (bowing), low serium calcium and phosphate / due to GI, renal, -
thyroidism
 Treat cause / fix with lots of calcium and Vit D / watch for hypercalcemia
Osteomyelitis
 Infection of bone / due to soft tissue infection, direct bone contamination, spread from
another site, mostly staphylococcus aureus
 Bloodborne – signs of sepsis, tissue – no signs of sepsis – pulsing pain, swelling, tenderness
 Round the clock IV antibiotics (lot of teaching), then oral 3 mos. / debridement
 Diet protein & vit C, hydration
RA – Rheumatoid Arthritis
 Autoimmune, synovial tissue, collagen breakdown, edema, joint pain
 Stages: Early – edu, balance exer & rest, NSAID, COX 2 – Viox, Celebrex,
smmethotrexate / Moderate erosive – OT, PT, re-eval meds, cyclosporine (increases metho) /
Persistent erosive – reconstructive surgery – synovectomy, arthroplasty, corticosteroids /
Advanced unremitting – high methotrexate, cyclphosphamide,Imuran
Osteoarthritis
 Articular cartiledge, subcondral bone, synovium / pain in morning, relieved with moving
around
 Conservative ¯ weight, TENS/ surgical – osteotomy, arthroplasty, tidal irrigation
 MEDS: Tylenol, NSAID, COX 2, opiod, steroid, glucosamine and condroiton
Gout
 uric acid in blood/ cause by purines (shellfish, organ meats, asparagus, dried beans, oatmeal,
alcohol), stress, illness / or secondary can be genetic
 Tophi – red and inflamed great toe, hands, ears / kidney stones
 MEDS: Colchicine, NSAID, corticosteroids, Benemid, Allopurinal – renal problems for
kidney stones
Bone injuries
 Contusion – soft tissue (fall) / strain – pulled muscle (over use) / sprain – ligaments, etc
(twist) / dislocation – out of joint ¬ is a medical emergency (blood flow and nerve conduction
– necrosis)
 Treat with RICE – rest, ice, compression, elevation / dislocation – treatment,
immobilized, closed reduction
 Fractures: incomplete-greenstick – complete: comminuted (shattered), open
(compound/complex), closed (simple)
 Treat with: internal fixators or external fixators
 Pin care – don’t pick scabs, no weights on floor
 Buck can unhook and move up in bed, Thomas (balanced) cannot unhook
Bone injury complications

 Compartment syndrome
 Increased pressure within a fascia compartment, cuts of blood supply and nerve
conduction, muscle death, happens under cast or dressing often
 5 p’s – pain, paralysis, parasthesia, pallor, pulselessness – relentless pain unrelieved by
pain meds
 Medical emergency
 Remove cast, elevate, call dr, surgical decompression, stays open until swelling resolved
 Shock – caused by blood loss, replace fluid
 Fat embolism
 Often from break in upper thigh, finger/ travels and clots major organ
 S&S: hypoxic, tachycardia, Tachypnea, crackles, wheezes, fever, chest pain, coughing up
yuck, ¯ BP, change in mental status
 Prevent by immobilization at accident, give oxygen,
CHILDREN
CP – Cerebral Palsy
 Most common permanent physical disability / non-progressive / extremely or very low birth
weight – hypoxia during birth – kerniterous –
 no sitting by 8-12 mos – may not be diagnosed until 2 yo
 Can be: hypotonic, spastic/hypertonic, dyskinetic/athetoid, ataxic, mixed
 Goal is optimum development / AFO, orthopedic surgery / align with bolsters, pillows
 MEDS: Baclofen, Diazepam, Dantrolene (for spas), Botox (prevent contractures),Baclofen
pump (intrathecal), Tegretol, Depokote (antiseizure)
MD – Muscular Distrophy
 Largest group of muscle diseases / progressive / Duchenne most common / wkness, wasting,
contractures / calf & thigh / loss of ambulation by 12 y/o / progress to resp. or card. failure
 Gower sign, muscle biopsy shows fat replacing muscle fiber, creatine kinase
 Maintain indep. & function / nutrition & hydration / avoid obesity / home s/b
 wheelchair accessible
Downs Syndrome
 Most common chromosomal abnormality / extra chromosome, trisomy 21 / whites
 Karyotyping / congenital heart – mostly septal / URI (due to depressed nasal bridge) / dys-
thyroid / risk leuk
 Otitis media / atlantoaxinal instability (C1&2) / parents greive loss / ragdoll-like infant /
swaddling / infection prone-handwashing
Fragile X
 Most common cause of inherited mental impairment / males-all races / karyotyping-
abnormality on x chrom / big ears, long face, prom. chin, big balls / aggressive / need
routine / no cure / normal life span / MEDS: Tegretol, Prozac (for aggressiveness),Catapres (
for hyperactivity)
Gestational Hypertensive Disorders
Pregnancy Induced hypertension or PIH

 Mom is not hypertensive before pregnancy
 Hypertension and other symptoms that occur due to pregnancy
 Disappear with birth of fetus and placenta

High risk factors

 Chronic renal disease
 Chronic hypertension
 Family history
 Primagravidas (a woman who is pregnant for the 1st time)
 Twins
 Mom <19 and >40
 Diabetes
 Rh incompatibility
 Obesity
 Hydatidiform mole

Pathophysiology
 Can progress from mild to severe
 Aterial venospasms decrease diameter of blood flow, which results in:
 Decreased blood flow
 Increased BP

Classifications
 Transcient Hypertension
 Preeclampsia
 Mild
 severe
 Eclampsia
 HELLP syndrome

Transcient Hypertension
 BP > 140/90
 Develops during pregnancy
 No proteinuria
 No edema (other than “normal” places like ankles)
 BP returns to normal by 10th day postpartum

Mild Preeclampsia
 BP > 140/90 x 2 at least 4-6 hours apart
 Weight gain (due to 3rd spacing)
 +2 pounds/wk in 2nd trimester, or
 +1 pound/wk in 3rd trimester, or
 sudden weight gain of 4 pounds/week anytime
 Norms –
 1st trimester: 1 lb/month
 2nd and 3rd trimester: 1 lb/week
 Dependant edema
 Eyes, face, fingers (above the waist)
 Proteinuria
 Urine output > 30ml/hr

Nursing care for Mild Preeclampsia

 Patient at home
 Bedrest (with BR privileges); side-lying position
 Mom and family will be taught to monitor:
 Daily weight
 Urine dipstick
 BP
 Fetal movements
 Diet: Regular with no salt restrictions
 If symptoms progress to severe Preeclampsia à Hospital!

Severe Preeclampsia
 Presence of any of the following in a woman diagnosed with Preeclampsia:
 BP > 160/110 (x2) 4-6 hours apart
 Proteinuria > 2+ dipstick x2 4 hrs apart
 Urine output < 500ml/24 hr
 Pulmonary edema (Crackles heard in lungs)
 Cerebral changes
 Headache (Tylenol will not alleviate)
 visual changes (blurred vision or scotomata [blind spot or tunnel vision])
 Decreased LOC
 Liver involvement (epigastric pain)
 May develop into HELLP
 Thrombocytopenia, platelet count < 100,000/mm3
 Hyperreflexia >3+
 clonis, DTR [deep tendon reflex] – biceps and patellar
 Fetus growth severely shunted [IUGR]
 Due to decrease placental profusion

Care of patient with severe Preeclampsia

 Hospitalized until baby is delivered
 Bedrest on side
 Bed near nurse’s station with code cart nearby
 Quiet, calm, low light environment
 Siderails up, padded
 Frequent assessments to include:
 BP, P, R q 5/10 min
 Daily weight
 Assess edema
 Deep tendon reflexes
 Assess for headache, visual disturbances,
 Epigastric pain (liver is getting involved)
 Insert foley (to best assess for oliguria)
 Strict I and O
 Evaluate urine for protein
 Monitor fetal well-being
 Assess labs; platelets, liver enzymes

Medical management
 Prevent seizuresà MAGNESIUM SULFATE
 Decreases neuromuscular irritability
 Decreases CNS irritability (anticonvulsant effect)
 Promotes maternal vasodilation, better tissue perfusion
 Watch for magnesium toxicity
 Loss of knee-jerk reflexes
 Respirations <12 p/min
 Urine output <30ml/hr
 Cardiac or respiratory arrest
 Toxic serum levels >9.6mg/dl
 Sign of fetal distress
 Calcium Gluconate is the antidote
 Control hypertension
 BP meds via IV
 Continue observations 24-48 hrs after birth
 Symptoms usually resolve within 48 hours after birth

Eclampsia
 Onset of seizure activity or coma in person with PIH
 Assessment findings
 Increased hypertension precedes seizures followed by hypotension and collapse
 Coma may occur
 Labor may begin, putting fetus in great jeopardy
 Treat with magnesium sulfate and above measures for severe Preeclampsia

HELLP syndrome
 Hemolysis (destruction of RBC’s) H
 Elevated liver enzymes EL
 Low platelets LP
 Occurs in 4-12% of patients with PIH; life-threatening situation to mom and/or baby. No
known cause.
 Treatment:
 Give platelets
 Deliver infant ASAP
 All usually returns to normal after the delivery

DIC Disseminated Intravascular Coagulopathy

 A complication of preeclampsia
 Can occur with or without HELLP
 Occurs in other conditions as well
 Abruption placentae, stillbirth, amniotic fluid embolus syndrome, c-section, miscarriage
 Sepsis, metastic carcinoma, transfusion reactions, hemolytic conditions, malignant
hypertension, snake bite
 Pathophysiology
 Overreaction of clotting cascade
 Overreaction of fibrinolytic (clot break down) system
 Resulting in bleeding and clotting at the same time
 Microclots form and go everywhere including microcirculation
 Resulting in decrease profusion
 Physical findings
 Bleeding of gums, nose, puncture sites
 Hematuria (may bleed at foley insertion site)
 Petechiae or eccymosis at B/P cuff and monitor placement
 Gastrointestinal bleeding
 Tachycardia
 Diaphoresis
 s/s of shock
 bleeding, light-headed, nausea, ashen or grayish skin, cool and clammy skin, pulse
increases, BP decreases
 Lab findings
 Fibrinogen less than 100
 Platelets less than 50,000
 Fibrin split products greater than 40
 PT decreased – 11 seconds
 PTT decreased – 26-39 sec
 Clotting time increased 4-12 minutes

Normal labs – nonpregnant

Hemoglobin 12-16 g/dl
Hematocrit 37-47%
Platelets 150,000-400,000/mm3
PT 12-14 sec
PTT 60-70 sec
Fibrinogen 200-400 mg/dl
Fibrin split products < 10 mcg/ml

BUN 10-20 mg/dl
Creatinine .5 to 1.1 mg/dl
Lactate dehydrogenase LDT 45-40 units/l

Aspertate aminotransferase AST 4-20 units/l
Alanine aminotransferase ALT 3-21 units/l
Creatinine clearance 80-125 ml/min
Burr cells 0
Uric acid 2-6.6 mg/dl
Bilirubin (total) 0.1-1 mg/dl
High Risk Pregnancies

High Risk Pregnancies

A high risk pregnancy is one in which the life or health of the mother or fetus is jeopardized by a
disorder coincidental with or unique to pregnancy.
Risk assessment:
Biophysical -factors that originate within the mother or fetus and affect the development or
functioning of either one or both.
Examples: genetic disorders, nutritional and general health status, and medical or obstetric-
related emergencies
Psychosocial -maternal behaviors and adverse lifestyles that have a negative effect on the health
of the mother or fetus.
Ex: emotional distress and disturbed interpersonal relationships, inadequate social support,
unsafe cultural practices, substance use, abuse
Sociodemographic -arise from the mother and her family. These risks may place the mother and
fetus at risk.
Ex: lack of prenatal care, age, low income, marital status, and ethnicity.
Environmental– hazards in the workplace and the woman’s general environment. May include
environmental chemicals (ie: pesticides, lead, and mercury), radiation, and pollutants.

Risk factors are interrelated and cumulative in their effects.
Morning Sickness Hyperemesis Gravidarum

Begins at 4-6 weeks gestation- peaks at 8-
12 weeks Begins during the first 10 weeks gestation
Confined to first trimester (ends at 16-20
weeks) Continues throughout pregnancy
Excessive- causes a weight loss of at least
More common when HCG is higher (ie: 5% of prepregnancy weight.–> significant
multiples) weight loss
Normal- may be histamine response or Accompanied by dehydration, electrolyte
psychological. imbalance, ketosis, and acetonuria
Able to keep down small meals and clear Unable to keep down anything, even clear
liquids liquids
Decreased BP, increased pulse rate, poor
skin turgor
Tx: IV therapy for correction of fluid and
electrolyte imbalance, NPO status until
dehydration has resolved and for at least
48 hours after vomiting has stopped
– Meds may be needed for uncontrolled
Tx: Small meals, crackers before arising, n/v
etc
If not resolved, TPN may be used as last
resort.

First Trimester Bleeding

Miscarriage– a pregnancy that ends before 20 weeks of gestation.
– 20 weeks is considered the point of viability- or when the fetus is able to survive in an extra
uterine environment.
– A fetal weight of <500g may also be used to define miscarriage.
Spontaneous Abortions/Miscarriages
(1) Threatened– include spotting of blood but with the cervical os closed. Mild uterine cramping
may be present.
(2) Inevitable– involves a heavy amount of bleeding with an open cervical os. Tissue may be
present with the bleeding. May involve rupture of membranes and cervical dilation. Passage of
the products of conception may occur.
(3) Incomplete– Involves expulsion of the fetus with retention of the placenta.
(4) Complete– all fetal tissue is passed, the cervix is closed and there may be slight bleeding.
(5) Missed– a pregnancy in which the fetus has died but the products of conception are retained
in utero for several weeks.

Causes:
– Early miscarriage (under 12 weeks) - causes include endocrine imbalance, immunologic

factors, systemic disorders (ie: lupus), and genetic factors.
-A late miscarriage/abortion (12-20 weeks) usually results from maternal causes, such as
advancing maternal age and parity, chronic infections, premature dilation of the cervix and other
anomalies of the reproductive tract, chronic debilitating diseases, poor nutrition, and recreational
drug use.
Diagnosis: Assess pain, bleeding, LMP (to determine gestational age), pain (type, location,
duration, precipitating and palliative factors), vital signs, previous pregnancies (incl. losses),
emotional status
– HCG levels: low levels of HCG are characteristic of miscarriage (HCG should double q48 hr in
normal preg).
– Draw 2 levels 48 hours apart- levels should double.
– Ultrasound
Treatment: Threatened- bed rest and supportive care.
Others- treat hemorrhage and infection. (IV, blood type and crossmatch, H&H, u/s
– Dilation and Curetage (D&C) - surgical procedure in which the cervix is dilated and a curette
is inserted to scrape the uterine walls and remove uterine contents. Used to tx inevitable and
incomplete miscarriages.

Ectopic Pregnancy- the fertilized ovum is implanted outside the uterine cavity.

– leading pregnancy-related cause of 1st trimester maternal deaths and is responsible for 9% of all
maternal deaths.
– Implants within 1st week, as it grows, baby can rupture tube and cause fullness.

S/S: abnormal vaginal bleeding, adnexal fullness and pain are classic sx. Abdominal pain is
usually the primary presenting sx at approx 5-6 weeks of gestataion.
– Infection (gonorrhea, chlaymia, STDs) can cause ectopic preg...
– If implants on intestines, will very rarely grow to term
– The tenderness can progress from a dull pain to a colicky pain when the tube stretches, to sharp
stabbing pain.
– Pain may be unilateral, bilateral, or diffuse over the abdomen.
– If ectopic pregnancy ruptures, pain increases.
– Referred shoulder pain if internal bleeding.
– Ecchymotic blueness around the umbilicus (Cullen’s sign) indicating hematoperitoneum.
– Other presenting sx include dizziness, fainting, and pregnancy sx
DES Daughter- have reproductive issues d/t mother taking med for preterm labor.
Treatment:
– Vaginal exam should be performed only once, and then great caution.
– Removal of the ectopic preg. is possible when the pregnancy is <2cm in length.
– Methotrexate (chemo drug) can be given to attack rapidly growing cells.
– Advanced ectopic preg, requires laparotomy

– Both tubes are often affected, so future fertility is often an issue.
Gestational Trophoblastic Disease (Hydatidiform Mole)

 Persistent trophblastic tissue presumed to be malignant.
 Women at higher risk for mole formation: Teens, over 40, from Far East or tropics.
 Mole looks like a bunch of white grapes.
 Fluid-filled vesicles grow rapidly, causing uterus to be larger than expected for the
duration of the pregnancy.
 Bleeding into uterine cavity and vaginal bleeding occur.
 Anemia from blood loss, hyperemesis gravidarum, abdominal cramps caused by uterine
distension common.
 Diagnosis made by HCG levels (100’s-1000x normal) and ultrasound (snowstorm pattern)
 Treatment: dilation and evacuation
 Then weekly HCG levels are drawn until normal- then monthly for 1 year.
 Need to avoid pregnancies for this 1-year because of close monitoring of HCG levels.
 Need birth control counseling.
 Termination of pregnancy.
 Most cases benign- but can be cancer.
 If cancerous, highly metastatic to brain and lungs
 Can cause PIH in 1st trimester

Incompetent Cervix
 Passive and painless dilation without labor or contractions
 Occurs late 2nd or early 3rd trimester.
Risk Factors:
 Previous cervical trauma, threatened abortions, biopsy, congenital problem (DES Daughter).
Diagnosis:
 Ultrasound- short cervix and effacement of internal os (Cervical funneling)

Treatment:
 Bedrest, hydration, progesterone, anti-inflammatories, antibiotics

 Cerclage– ‘purse string’ closure of the cervix
 Prophylactic cerclage- closure at 11-15 weeks-> pelvic rest, no heavy lifting, no prolonged
(>90min) standing.
 Needs to be taught- if contractions start- need to come to hospital immediately to have
cerclage removed (risk for cervical tearing).
 Risk for self-esteem, grieving
 Risk for preterm labor r/t procedure, hemorrhage, fever

Anemia
 Hemoglobin = 11 or less (normal non-preg 37-47%, pregnant = >33%)
 Have s/s if Hgb <6-7
 Results in decrease of O2 carrying capacity of the blood- heart tries to compensate by
increasing the cardiac output.
 Anemia that occurs with any other complication (ie: preeclampsia) may result in CHF
 Increased risk of puerperal complications.
 Iron deficiency anemia= most common
Treatment:
 Ask about PICA

 Women who eat balanced diet are encouraged to take multivitamin with iron.
 Increase iron dosage (60-120 mg/day)
 Watch GI side effects
 Vitamin C helps with iron absorption.

Folate Deficiency
 Poor diet and increased alcohol intake may contribute
 Malabsorption may play a part in development of anemia
 S/S: Pallor, fatigue, lethargy
 More common in multiple gestation
 Recommended intake during pregnancy= 400 mcg
 Should consume legumes, green/leafy vegetables.

Sickle Cell
 Stress of pregnancy can active it- causing sickle cell crisis
 Risk for UTI’s, iron deficiency, and hematuria.
 Fetal complications= SGA, IUGR, Skeletal changes

Thalassemia
 Hemoglobin problem- premature RBC death
 2 types: Major and minor
 Minor= trait- minor persistent anemia during pregnancy but RBC’s normal or elevated
 Major= disease

Thromboembolic Disease
 SVT’s and DVT’s
 Deep Vein Thrombosis= more prevalent in pregnancy
 s/s: unilateral leg pain, calf tenderness, swelling
 Fibrogenin increases-> blood is hyperclottable
 Venous stasis- hard for blood to come up body
 Tx: Heparin-> doesn’t cross placenta.
 Can use subq heparin at home
 No oral contraceptives- increases risk of DVT’s
 Okay to breastfeed- avoid cracked nipples
 SVT= more common in postpartum
 s/s: warmth, tenderness, enlarged hardened vein over site.

Substance Abuse
 Marijuana and cocaine most commonly used
 Cocaine= causes severe muscle contractions, abruption of placenta
 Methadone (heroin) = every effort is made to get mom on methodone. More controlled
source
 Alcohol= no safe limit- fetal alcohol syndrome-
– mental, physical and behavioral effects.
Cardiac Disease
Risk greatest in 2nd trimester and immediately after delivery
All extra circulating volume that was in placenta, etc has to go back into mom’s circulation=
massive overload
Degree of disability divided into classes:
Class I: asymptomatic- without limitation of physical activity
Class II: Symptomatic- with slight limitation of activity
Class III: Symptomatic with marked limitation of activity (ie: can’t go up 2 stairs without
getting winded)
Class IV: Symptoms at rest (Can’t sit in chair without getting winded)
Classes I and II = will do close monitoring during pregnancy
Classes III and IV= Major difficulties in pregnancy- should be in specialized hospital.
Usually admitted at approx. 20 weeks on telemetry floor

Tx: Rest, avoid infections, low salt diet, avoid anemia, O2, avoid constipation, monitor for
thrombophlebitis, decrease stress
Avoid beta blockers (Inderal) - can interfere with uterine perfusion.
Values, Morals, Ethics and Advocacy

VALUES, ETHICS, AND ADVOCACY

Values
Values – something of worth; enduring beliefs or attitudes about the worth of a person, object,
idea, or action. They are important because they influence decisions, actions, even nurse’s
ethical decision making.
Value set all the values (eg, personal, professional, and religous) that a person holds
Value system the organization of a person’s values along a continuum of relative importance;

basic to a way of life, give direction to life, form basis of behavior
Beliefs interpretations or conclusions that one accepts as true (based more on faith than fact)
 Judged by others as correct or incorrect
 Beliefs do not necessarily involve attitude. Example: “I believe if I study hard I will make
good grades.” Belief and value would be “Good grades are important to me and I believe I
can make good grades if I study very hard.”
Attitudes mental stance that is composed of many different beliefs; usually involving a positive
or negative judgment toward a person, object, or idea
 Judged by others as being bad or good, positive or negative
 They vary greatly among individuals. Example: some clients may feel strongly about their
need for privacy, whereas others may dismiss it as important.
Values Transmission
Values are learned through observation and experience. Therefore, they are influenced greatly by
cultural, ethnic, and religious groups and by family and peer groups. Example: a parent
consistently demonstrates honesty in dealing with others, the child will probably value honesty.
Our health beliefs are also learned this way.
American Association of
Colleges of Nursing’s 5 Values
Essential for the Nursing
Professional
 Altruism – doing good,
concern for others
 Autonomy – right to self-
determination
 Human dignity – respect for
the uniqueness of individuals
and populations
 Integrity – honesty; acting
in accordance with the code
of ethics and standards of
practice
 Social justice – working to
ensure equal treatment under
the law and equal access to
quality health care
Personal Values
Personal values values internalized from the society or culture in which one lives. People need
societal values to feel accepted, and they need personal values to have a sense of individuality.

Professional Values
Professional values values acquired during socialization into nursing from codes of ethics,
nursing experiences, teachers, and peers

Values Clarification
Values clarification a process by which individuals identify, examine and develop their own
value
Raths, Harmin and Simon described a “valuing process”
 Choosing (cognitive) – beliefs are chosen freely from alternative and reflection and
consideration of consequences
 Prizing (affective) – beliefs are prized and cherished
 Acting (behavior) – chosen beliefs are confirmed to others, incorporated into behavior
consistently in one’s life
Behaviors that May Indicate Unclear Values
 Ignoring a health professional’s advice.
 Inconsistent communication or behavior
 Numerous admissions to a health agency for the
same problem
 Confusion or uncertainty about which course of
action to take
 Clarifying the Nurse’s Values
 The student nurse needs to examine the values they hold about life, death, health, and
illness. It is important for the nurse to be aware of their own values so if helping a client
they are not imposed on the client.
 Clarifying Client Values
 To plan effective care, the nurse needs to identify the client’s values as they relate to
health problems. If the client is unclear or has conflicting values the nurse can help guide
the patient to clarify the client’s values by using the seven following steps:
 1. List alternatives. Are you considering other courses of action? Tell me about them.
 2. Examine possible consequences of choices. What do you think you will gain from
doing that? What benefits do you foresee from doing that?
 3. Choose freely. Did you have any say in that decision? Do you have a choice?
 4. Feel good about the choice. Some people feel good after a decision is made, others
feel bad. How do you feel?
 5. Affirm the choice. How will you discuss his with others (family, friends)?
 6. Act on the choice. Will it be difficult to tell your wife about this?
 7. Act with a pattern. How many times have you done that before? Would you act that
way again?
 * The nurse rarely if ever offers an opinion, and then only with great care or when they have
expertise in a certain area. The situation for the client will be different from the nurse’s
situation.
ANA Standards of Professional
PerformanceStandard 12: Ethics
Measurement Criteria
 Uses the code for nurses with Interpretive
Statements to guide practice
 Delivers care in a manner that preserves
patient autonomy, dignity, and rights
 Maintains patient confidentiality within
legal and regulatory parameters.
 Serves as a patient advocate assisting
patients in developing skills for self-
advocacy.
 Maintains a therapeutic and professional
patient-nurse relationship with appropriate
professional role boundaries
 Demonstrates a commitment to practicing
self-care, managing stress, and connecting
with self and others.
 Contributes to resolving ethical issues of
patients, colleagues, or systems as
evidenced in such activities as
participating on ethics committees
 Reports illegal, incompetent, or impaired
practices.

Morality and Ethics

Ethics the rules or principles that govern right conduct *** 2005 Gallop pole found that
nurses have been viewed as the most ethical profession ***
Bioethics ethical rules or principles that govern right conduct concerning human life or health
Nursing ethics ethical issues that occur in nursing practice

Morality a doctrine or system denoting what is right and wrong in conduct, character, or
attitude
Law A rule made by humans that regulate social conduct in a formally prescribed and binding
manner
¬ Nurses should distinguish between law and morality.
 An action can be legal but not moral: An order for full resuscitation of a dying client is legal,
but one could still question whether the act is moral.
 An action can be moral but not legal: If a child at home stops breathing, it is moral but not
legal to exceed the speed limit when driving to the hospital.
¬ Nurses should distinguish between morality and religion.
 Example: some religions think it is acceptable to circumcise women, others think the ritual
to be a violation of human rights

Moral Development
Moral development process of learning to tell the difference between right and wrong and of
learning what ought and ought not to be done; the pattern of change in moral behavior with age
The moral development theorists are:
¬ Koberg – emphasizes rights and formal reasoning ¬Gilligan – emphasizes care and
responsibility
Moral Frameworks
Moral theories provide different frameworks through with nurses can view and clarify disturbing
client situations. The following three frameworks are widely used:
1. Consequence-based (teleological) theories the ethics of judging whether an action is

moral
A. Utilitarianism a specific, consequence-based, ethical theory that judges as right the
action that does the most good and least amount of harm for the greatest number of
persons; often used in making decisions about the funding and delivery of health care
B. Utility the principle of utilitarianism

C. Principle-based (deontological) theories emphasize individual rights, duties, and
obligations
D. Relationships-based (caring) theories stress courage, generosity, commitment, and the

need to nurture and maintain relationships

Moral Principles
Moral Principles are statements about broad, general philosophical concepts. They provide the
foundation for forming Moral rules – specific prescriptions for actions. Examples:
 Moral principle – respect other people
 Moral rule – do not lie
Moral Principles that a nurse should follow:
Autonomy right to make one’s own decisions because each person is unique. People have
“inward autonomy” if they have the ability to make choices; they have “outward autonomy” if
their choices are not limited or imposed by others.
 Do not disregard a client’s statement about subjective symptoms they may be having
 Be sure the client gives “informed” consent
Nonmaleficence the duty to do no harm

 Their is sometimes unintentional harm, such as; an adverse reaction to a medication, bruising
a client that you held to tightly in order to keep him from falling, breaking a rib doing CPR
Beneficence the moral obligation to do good or to implement actions that benefit clients and
their support persons
 Doing good can also cause harm, such as; advising a client to do strenuous exercise, but he
should for risk of a heart attack
Justice fairness. This is not always easy considering time constraints

 A home healthcare nurse must decide to stay with the current client, who is depressed, 30
more minutes, and have to reduce her time with the next client
Fidelity a moral principle that obligates the individual to be faithful to agreements and
responsibilities one has undertaken
 If a nurse says “I’ll be right back with pain medication”, she should do so or find an
alternative for relief of the client’s pain
Veracity a moral principle that holds that one should tell the truth and not lie
 Does a nurse tell a lie when it is known that the lie will relieve anxiety and fear? The loss of
trust in the nurse rarely justifies any benefits gained from lying.
Nurses should also have the following according to the Code of Ethics for Nurses by the ANA
Accountability being responsible for one’s actions and accepting the consequences of one’s
behavior
Responsibility the specific accountability or liability associated with the performance of duties
of a particular role or an obligation to complete a task.
 Thus, the ethical nurse is able to explain the rationale behind every action and recognizes the
standards to which she will be held.

Nursing Ethics
JCAHO mandates the health care institutions provide multidisciplinary ethics committees (or
like structures) to provide education, counseling and support on ethical issues. These
committees ensure:
 That relevant facts of a case are brought out ¬ Provide a forum in which diverse views can
be expressed ¬ Provide support for caregivers ¬ Can reduce the institution’s legal risks

Nursing Codes of Ethics
Code of ethics a formal statement of a group’s ideals and values; a set of ethical principles
shared by members of a group, reflecting their moral judgments and serving as a standard for
professional actions
ANA Code of Ethic for Nurses (approved July 2001)
1. The nurse, in all professional relationships, practices with
compassion and respect for the inherent dignity, worth, and
uniqueness of every individual, unrestricted by considerations of
social or economic status, personal attributes, or the nature of
health problems
2. The nurse’s primary commitment is to the patient, whether an
individual, family, group, or community.
3. The nurse promotes, advocates for, and strives to protect the
health, safety, and rights of the patient.
4. The nurse is responsible and accountable for individual nursing
practice and determines the appropriate delegation of tasks
consistent with the nurse’s obligation to provide optimum patient
care.
5. The nurse owes the same duties to self as to others, including the
responsibility to preserve integrity and safety, to maintain
competence, and to continue personal and professional growth
6. The nurse participates in establishing, maintaining, and improving
healthcare environments and conditions of employment conducive
to the provision of quality healthcare and consistent with the values
of the profession through individual and collective action
7. The nurse participates in the advancement of the profession
through contributions to practice, education, administration, and
knowledge development
8. The nurse collaborates with the other health professional and the
public in promoting community, national, and international efforts
to meet health needs
9. The profession of nursing, as represented by associations and their
members, is responsible for articulating nursing values, for
maintaining the integrity of the profession and its practice, and for
shaping social policy.
A. Inform the public about the minimum
The International Council of Nurses (ICN) and the ANA both have nursing codes of ethics.
They have the following purpose:
Standards of the profession and help them understand professional nursing conduct.
1. Provide a sign of the profession’s commitment to the public it serves.

2. Outline the major ethical considerations of the profession.
3. Provide ethical standards for professional behavior.
4. Guide the profession in self-regulation.
5. Remind nurses of the special responsibility they assume when caring for the sick.
Origins of Ethical Problems in Nursing
 Social and Technological Changes


 Social – growing consumerism, women’s movement, large number of people without
health insurance, workplaces redesigned under managed healthcare, issues of fairness and
allocation of resources
 Technology – extending life with monitors, respirators, and parenteral feedings, saving
extreme premature babies, definition of death associated with organ transplants, cloning,
stem cell research
 Conflicting Loyalties and Obligations
 Loyalties and obligations may be conflicted between; * the client, * the client’s

families, * the physician, * the employing institution, and * licensing bodies. Nursing
code of ethics states that the nurse’s loyalty must always lie with the client, but it is the
determination of which action best serves the needs of the client that is sometime difficult
 Example – should the nurse tell her client that marijuana can help with nausea
 Example – should the nurse honor a picket line

Making Ethical Decisions
Many nursing problems are not ethical problems at all, but simply questions of good nursing
practice. Therefore, you should decide if an ethical situation exists. The following criteria may
be used:
 I A difficult choice exists between actions that conflict with the needs of one or more
persons.
 I Moral principles or frameworks exist that can be used to provide some justification for the
action.
 I The choice is guided by a process of weighing reasons.
 I The decision must be freely and consciously chosen.
 I The choice is affected by personal feelings and by the particular context of the situation.
If the problem is an ethical one, then, remember that responsible ethical reasoning is rational and
systematic. A good decision is one that is in the client’s best interest and at the same time
preserves the integrity of all involved. Two ethical decision-making models follow:
Thompson and Thompson Model (1985)

 Review the situation to determine health problems,
decision needs, ethical components, and key individuals
 Gather additional information to clarify the situation.
 Identify the ethical issues in the situation.
 Define personal and professional moral positions.
 Identify moral positions of key individuals involved.
 Determine who should make the decision.
 Identify range of actions with anticipated outcomes.
 Decide on a course of action and carry it out.
 Evaluate/review results of decision/action.
Cassells and Redman Model (1989)

 Identify the moral aspects of nursing care.
 Gather relevant facts related to moral issue.
 Clarify and apply personal values.
 Understand ethical theories and principles.
 Utilize competent interdisciplinary resources.
 Propose alternative actions.
 Apply nursing codes of ethics to help guide actions.
 Choose and implement resolutive action.
 Participate actively in resolving the issue. Apply state and
federal laws governing nursing practice.
 Evaluate the resolutive action taken.
Being involved in ethical problems and dilemmas is stressful for the nurse. A good support
system should be established such as team conferences and use of counseling professionals to
allow expressing of their feelings.
Strategies to Enhance Ethical Decision and Practice

The following strategies should be taken by a nurse to overcome the moral distress on the job:
 Become aware of your own values and ethical aspects of nursing.

 Be familiar with nursing codes of ethics.
 Seek continuing education opportunities to stay knowledgeable about ethical issues in
nursing.
 Respect the values, opinions, and responsibilities of other health care professional that may
be different from your own.
 Serve on institutional ethics committees.
 Strive for collaborative practice in which nurses’ function effectively in cooperation with
other health care professionals.
Specific Ethical Issues
Acquired Immune Deficiency Syndrome (AIDS)

 The ANA’s position on AIDS – the moral obligation to care for HIV-infected client cannot
be set aside unless the risk exceeds the responsibility.
 Should health care providers and clients be mandatory? If so, should the results be released
to insurance companies, sexual partners, or caregivers?
Abortion
 The debate continues between the sanctity of life and the right for a woman to control her
own body.
 Conscience clauses give the caregiver the right to refuse to participate in abortions, but they
cannot impose their values on the client. The client has a right to be educated about all
choices
Organ Transplantation
 Who deserves to be on the lists for possible transplants? Should organs be sold? Should
parents have children just to harvest an organ for another child? What is the clear definition
of death pertaining organ donators? Is there a conflict of interest between the potential donor
and recipients? There are religious conflicts with both donating and receiving of organs.
End-of-Life Issues
 Advance Directives
 All 40 states have enacted advance directive legislation. Having the client complete these
saves many moral and ethical decisions.
 Euthanasia and Assisted Suicide

 Euthanasia, a Greek word meaning “good death”
 Active euthanasia – actions that directly bring about the client’s death with or without
consent. This is forbidden by law (especially for the caregiver).
 Assisted suicide – a form of active euthanasia in which clients are given the means to kill
themselves. This is legal in Oregon.
 The ANA states that both active euthanasia and assisted suicide are in violation of
the Code for Nurses.
 Passive euthanasia allowing a person to die by withholding or withdrawing measures
to maintain life (aka withdrawing or withholding life-sustaining therapy [WWLST]).
This is both legally and ethically more acceptable to most persons than assisted suicide.
 Termination of Life-Sustaining Treatment

 Nurses must understand that a decision to withdraw treatment is not a decision to
withdraw care. As the primary caregivers, nurses must ensure that sensitive care and
comfort measures are given as the client’s illness progresses.
 Withdrawing or Withholding Food and Fluids

 A nurse is morally obligate to withhold food and fluids (or any treatment) if it is
determined to be more harmful to administer then than to withhold them. The nurse must
ablos honor competent and informed clients’ refusal of food and fluids.
Allocation of Scarce Health Resources

 The moral principle of autonomy cannot be applied if it is not possible to give each client
what he or she chooses. In this situation, health care providers may use the principle of
justice – attempting to choose what is most fair to all.
 Some nurses are concerned that staffing in their institutions is not adequate to give the level
of care they value. California is the first state to enact legislation mandating specific nurse-
to-client ratios.
Management of Personal Health Information

 Keeping the client’s privacy is both a legal and moral mandate. The client must be able to
trust that the nurses will reveal details of their situations only as appropriate for the health
care. Nurses should help develop and follow security measures and policies.
Advocacy
Advocate individual who pleads the cause of another or argues or plead for a cause or proposal
Values Basic to Client Advocacy
 The client is a holistic, autonomous being who has
the right to make choices and decisions.
 Clients have the right to expect a nurse-client
relationship that is based on shared respect, trust,
collaboration in solving problems related to
health and health care needs, and consideration
of their thoughts and feelings.
 It is the nurse’s responsibility to ensure the client
has access to health care services that meet health
needs.
Patient’s Bill of Rights Act of 2004 – guarantee of
certain rights under their health insurance plans
 Basic standards for access to care, including
clinical trails.
 The ability to gain access to their own doctor, and
doctor’s ability to communicate with the client
without fear of insurance company retaliation.
 The assurance that medical decisions about the
client care will be made by doctors according to
sound medical principles.
 A fair, independent external review process if
needed care is denied by their insurance company.
 The right to hold their health plan accountable if a
negligent medical decision resulted in injury or
harm.
The Advocate’s Role

The overall goal of the client advocate is to protect client’s rights. She does this by:
 Informing clients of their rights

 Providing them with the information they need to make informed decisions
 Supports client’s in their decision giving the responsibility in the decision making when
capable
 Remains objective and does not convey approval or disapproval of client’s choices
 Is accepting and respectful of the client’s decision, even if the nurse believes the decision to
be wrong
 Intervenes on the client’s behalf, often influencing others
Advocacy in Home Care

 The client reverting to own personal values at home must, nevertheless, still have his
autonomy respected.
 Financial considerations can limit the availability of services and materials, making it
difficult to ensure the client needs are met.
Professional and Public Advocacy

 Gains made in developing and improving health policy at the institutional and government
levels help to achieve better health care for the public.
Being an effective advocate involves:
 Being assertive
 Recognizing that the rights and values of client and families must take precedence when they
conflict with those of the health care providers
 Being aware that conflicts may arise over issues that require consultation, confrontation, or
negotiation between the nurse and administrative personnel or between the nurse and primary
care provider
 Knowing that advocacy may require political action – communicating a client’s health care
needs to government and other officials who have authority to do something about these
needs.
Values and Markers
Hematology Values
 HEMATOCRIT (HCT)
 Normal Adult Female Range: 37 – 47%
Optimal Adult Female Reading: 42%
Normal Adult Male Range 40 – 54%
Optimal Adult Male Reading: 47
Normal Newborn Range: 50 – 62%
Optimal Newborn Reading: 56
 HEMOGLOBIN (HGB)
 Normal Adult Female Range: 12 – 16 g/dl
Optimal Adult Female Reading: 14 g/dl
Normal Adult Male Range: 14 – 18 g/dl
Optimal Adult Male Reading: 16 g/dl
Normal Newborn Range: 14 – 20 g/dl
Optimal Newborn Reading: 17 g/dl
 MCH (Mean Corpuscular Hemoglobin)

 Normal Adult Range: 27 – 33 pg
Optimal Adult Reading: 30
 MCV (Mean Corpuscular Volume)

 Normal Adult Range: 80 – 100 fl
Higher ranges are found in newborns and infants
 MCHC (Mean Corpuscular Hemoglobin Concentration)

 Normal Adult Range: 32 – 36 %
Higher ranges are found in newborns and infants
R.B.C. (Red Blood Cell Count)

 Normal Adult Female Range: 3.9 – 5.2 mill/mcl
Optimal Adult Female Reading: 4.55
Normal Adult Male Range: 4.2 – 5.6 mill/mcl
Optimal Adult Male Reading: 4.9
Lower ranges are found in Children, newborns and infants
 W.B.C. (White Blood Cell Count)

 Normal Adult Range: 3.8 – 10.8 thous/mcl
Optimal Adult Reading: 7.3
higher ranges are found in children, newborns and infants.

 PLATELET COUNT
 Normal Adult Range: 130 – 400 thous/mcl
Higher ranges are found in children, newborns and infants
 NEUTROPHILS and NEUTROPHIL COUNT – this is the main defender of the body

against infection and antigens. High levels may indicate an active infection.
Normal Children’s Range: 30 – 60 %
Optimal Children’s Reading: 45
 LYMPHOCYTES and LYMPHOCYTE COUNT – Elevated levels may indicate an

active viral infections such as measles, rubella, chickenpox, or infectious mononucleosis.
Normal Children’s Range: 25 – 50 %
Optimal Children’s Reading: 37.5
 MONOCYTES and MONOCYTE COUNT – Elevated levels are seen in tissue

breakdown or chronic infections, carcinomas, leukemia (monocytic) or lymphomas.
 EOSINOPHILS and EOSINOPHIL COUNT – Elevated levels may indicate an allergic

reactions or parasites.
 BASOPHILS and BASOPHIL COUNT – Basophilic activity is not fully understood but it

is known to carry histamine, heparin and serotonin. High levels are found in allergic
reactions.
Electrolyte Values
 SODIUM – Sodium is the most abundant cation in the blood and its chief base. It
functions in the body to maintain osmotic pressure, acid-base balance and to transmit
nerve impulses. Very Low value: seizure and Neurologic Sx.
 Normal Adult Range: 135-146 mEq/L

 POTASSIUM – Potassium is the major intracellular cation. Very low value: Cardiac

arythemia.
 Normal Range: 3.5 – 5.5 mEq/L

 CHLORIDE – Elevated levels are related to acidosis as well as too much water crossing
the cell membrane. Decreased levels with decreased serum albumin may indicate water
deficiency crossing the cell membrane (edema).
 CO2 (Carbon Dioxide) – The CO2 level is related to the respiratory exchange of carbon
dioxide in the lungs and is part of the bodies buffering system. Generally when used with
the other electrolytes, it is a good indicator of acidosis and alkalinity.
Normal Childrens Range – 20 – 28 mEq/L
Optimal Childrens Reading: 24
 CALCIUM – involved in bone metabolism, protein absorption, and fat transfer muscular

contraction, transmission of nerve impulses, blood clotting and cardiac function.
Regulated by parathyroid.
 Normal Adult Range: 8.5-10.3 mEq/dl
 PHOSPHORUS – Generally inverse with Calcium.

 Normal Adult Range: 2.5 – 4.5 mEq/dl
Normal Childrens Range: 3 – 6 mEq/dl
Optimal Childrens Range: 4.5
 ANION GAP (Sodium + Potassium – CO2 + Chloride) – An increased measurement is

associated with metabolic acidosis due to the overproduction of acids (a state of alkalinity
is in effect). Decreased levels may indicate metabolic alkalosis due to the overproduction of
alkaloids (a state of acidosis is in effect).
 Normal Adult Range: 4 – 14 (calculated)
 CALCIUM/PHOSPHORUS Ratio
 Normal Adult Range: 2.3 – 3.3 (calculated)
Normal Children’s range: 1.3 – 3.3 (calculated)
Optimal Children’s Reading: 2.3
 SODIUM/POTASSIUM
 Normal Adult Range: 26 – 38 (calculated)
Hepatic Enzymes
 AST (Serum Glutamic-Oxalocetic Transaminase – SGOT ) – found primarily in the
liver, heart, kidney, pancreas, and muscles. Seen in tissue damage, especially heart and
live
 Normal Adult Range: 0 – 42 U/L
Normal Children’s Range: 40 – 400 U/L
Optimal Children’s Reading: 220
 Normal Adult Female Range: 0 – 45 U/L
Optimal Female Reading: 22.5
Normal Adult Male Range: 0 – 65 U/L
Optimal Male Reading: 32.5
 Normal Adult Range 0 – 1.3 mg/dl
Optimal Adult Reading: .65
 ALT (Serum Glutamic-Pyruvic Transaminase – SGPT) – Decreased SGPT in

combination with increased cholesterol levels is seen in cases of a congested liver. We also
see increased levels in mononucleosis, alcoholism, liver damage, kidney infection,
chemical pollutants or myocardial infarction
 ALKALINE PHOSPHATASE – Used extensively as a tumor marker it is also present in

bone injury, pregnancy, or skeletal growth (elevated readings. Low levels are sometimes
found in hypoadrenia, protein deficiency, malnutrition and a number of vitamin
deficiencies
 GGT (Gamma-Glutamyl Transpeptidase) – Elevated levels may be found in liver disease,

alcoholism, bile-duct obstruction, cholangitis, drug abuse, and in some cases excessive
magnesium ingestion. Decreased levels can be found in hypothyroidism, hypothalamic
malfunction and low levels of magnesium.
 LDH (Lactic Acid Dehydrogenase) – Increases are usually found in cellular death and/or
leakage from the cell or in some cases it can be useful in confirming myocardial or
pulmonary infarction (only in relation to other tests). Decreased levels of the enzyme may
be seen in cases of malnutrition, hypoglycemia, adrenal exhaustion or low tissue or organ
activity.
 BILIRUBIN, TOTAL – Elevated in liver disease, mononucleosis, hemolytic anemia, low

levels of exposure to the sun, and toxic effects to some drugs, decreased levels are seen in
people with an inefficient liver, excessive fat digestion, and possibly a diet low in nitrogen
bearing foods
Renal Related
 B.U.N. (Blood Urea Nitrogen) – Increases can be caused by excessive protein intake,
kidney damage, certain drugs, low fluid intake, intestinal bleeding, exercise or heart
failure. Decreased levels may be due to a poor diet, malabsorption, liver damage or low
nitrogen intake.
 Normal Adult Range: 7 – 25 mg/dl
 Normal Adult Range: .7 – 1.4 mg/dl
 Normal Adult Female Range: 2.5 – 7.5 mg/dl
Optimal Adult Female Reading: 5.0
Normal Adult Male Range: 3.5 – 7.5 mg/dl
Optimal Adult Male Reading:5.5
 Normal Adult Range: 6 -25 (calculated)
 CREATININE – Low levels are sometimes seen in kidney damage, protein starvation,

liver disease or pregnancy. Elevated levels are sometimes seen in kidney disease due to the
kidneys job of excreting creatinine, muscle degeneration, and some drugs involved in
impairment of kidney function.
 URIC ACID – High levels are noted in gout, infections, kidney disease, alcoholism, high
protein diets, and with toxemia in pregnancy. Low levels may be indicative of kidney
disease, malabsorption, poor diet, liver damage or an overly acid kidney.
 BUN/CREATININE – This calculation is a good measurement of kidney and liver

function.
Protein
 PROTEIN, TOTAL – Decreased levels may be due to poor nutrition, liver disease,
malabsorption, diarrhea, or severe burns. Increased levels are seen in lupus, liver disease,
chronic infections, alcoholism, leukemia, tuberculosis amongst many others.
 Normal Adult Range: 6.0 -8.5 g/dl
 Normal Adult Range: 3.2 – 5.0 g/dl
 Normal Adult Range: 2.2 – 4.2 g/dl (calculated)
 Normal Adult Range: 0.8 – 2.0 (calculated)
 ALBUMIN – major constituent of serum protein (usually over 50%). High levels are seen
in liver disease (rarely), shock, dehydration, or multiple myeloma. Lower levels are seen in
poor diets, diarrhea, fever, infection, liver disease, inadequate iron intake, third-degree
burns and edemas or hypocalcemia
 GLOBULIN – Globulins have many diverse functions such as, the carrier of
 Some hormones, lipids, metals, and antibodies (IgA, IgG, IgM, and IgE). Elevated levels
are seen with chronic infections, liver disease, rheumatoid arthritis, myelomas, and lupus
are present. Lower levels in immune compromised patients, poor dietary habits,
malabsorption and liver or kidney disease.
 A/G RATIO (Albumin/Globulin Ratio)

Lipids
 CHOLESTEROL – High density lipoproteins (HDL) is desired as opposed to the low

density lipoproteins (LDL), two types of cholesterol. Elevated cholesterol has been seen in
artherosclerosis, diabetes, hypothyroidism and pregnancy. Low levels are seen in
depression, malnutrition, liver insufficiency, malignancies, anemia and infection.
Optimal Adult Reading: 81 mg/dl
Optimal Adult Reading: +85 mg/dl
 Normal Adult Range: 1 – 6
 LDL (Low Density Lipoprotein) – studies correlate the association between high levels of
LDL and arterial arterosclerosis
 HDL (High Density Lipoprotein) – A high level of HDL is an indication of a healthy

metabolic system if there is no sign of liver disease or intoxication.
 TRIGLYCERIDES – Increased levels may be present in atherosclerosis, hypothyroidism,
liver disease, pancreatitis, myocardial infarction, metabolic disorders, toxemia, and
nephrotic syndrome. Decreased levels may be present in chronic obstructive pulmonary
disease, brain infarction, hyperthyroidism, malnutrition, and malabsorption.
 CHOLESTEROL/LDL RATIO
Thyroid
 THYROXINE (T4) – Increased levels are found in hyperthyroidism, acute thyroiditis, and

hepatitis. Low levels can be found in Cretinism, hypothyroidism, cirrhosis, malnutrition,
and chronic thyroiditis.
 Normal Adult Range: 4 – 12 ug/dl
Optimal Adult Reading: 8 ug/dl
 Normal Adult Range: 27 – 47%
Optimal Adult Reading: 37 %
 Normal Adult Range: 4 – 12
 Normal Adult Range: .5 – 6 milU/L
 AACE (2003) target level: 0.3 to 3.04

 T3-UPTAKE – Increased levels are found in hyperthyroidism, severe liver disease,
metastatic malignancy, and pulmonary insufficiency. Decreased levels are found in
hypothyroidism, normal pregnancy, and hyperestrogenis status.
 FREE T4 INDEX (T7)

 THYROID-STIMULATING HORMONE (TSH) – produced by the anterior pituitary
gland, causes the release and distribution of stored thyroid hormones. When T4 and T3
are too high, TSH secretion decreases, when T4 and T3 are low, TSH secretion increases.
Cardiac
 Creatine phosphokinase (CK) – Levels rise 4 to 8 hours after an acute MI, peaking at 16
to 30 hours and returning to baseline within 4 days
 25-200 U/L
 32-150 U/L
 < 12 IU/L if total CK is <400 IU/L
 .5% of total CK if total CK is >400 IU/L

 140-280 U/L
 LDH-1 18%-33%
 LDH-2 28%-40%
 10-42 U/L
 <1
 < 0.4
 CK-MB CK isoenzyme – It begins to increase 6 to 10 hours after an acute MI, peaks in
24 hours, and remains elevated for up to 72 hours.
 (LDH) Lactate dehydrogenase – Total LDH will begin to rise 2 to 5 days after an MI;
the elevation can last 10 days.
 LDH-1 and LDH-2 LDH isoenzymes – Compare LDH 1 and LDH 2 levels. Normally, the
LDH-1 value will be less than the LDH-2. In the acute MI, however, the LDH 2 remains
constant, while LDH 1 rises. When the LDH 1 is higher than LDH 2, the LDH is said to
be flipped, which is highly suggestive of an MI. A flipped pattern appears 12-24 hours post
MI and persists for 48 hours.
 SGOT – will begin to rise in 8-12 hours and peak in 18-30 hours
 Myoglobin – early and sensitive diagnosis of myocardial infarction in the emergency

department this small heme protein becomes abnormal within 1 to 2 hours of necrosis,
peaks in 4-8 hours, and drops to normal in about 12 hours.
 Troponin Complex – Peaks in 10-24 hours, begins to fall off after 1-2 weeks.
Table of Cardiac markers
Serum Markers of
Myocardial Injury
Detected Peak Falls
Myoglobin 1-3 1-8 12-18
CK/CK-MB 3-8 12-16 24-48
MB Isoforms 1-6 4-8 12-48
cTnI: 5-9 days
Troponin Complex 3-6 10-24 cTnT: 7-14 days
Renal – NUR 220
Renal Failure Bullet Notes

 Oligura– urine output less than 400ml/day

 Anuria– Urine output less than 50ml/day
 Higher specific gravity= MORE concentrated urine
 Lower specific gravity= Dilute- more ‘watery’
 Acute Renal Failure– Reversable- Sudden and almost complete loss of kidney fxn over
hours to days.
 Increase in serum creatnine and BUN

 3 Types ARF:
 Pre-Renal– This is everything before the kidneys-ex. Hypovolemia/dehydration,

hemorrhage, renal losses-diuretics, vomiting, diarrhea, prolonged fever (sepsis), n/v,
hypotension, decreased c.o., MI, diabetes type 1 and type 2. Is the result of impaired
blood flow that leads to hypoperfusion of the kidney and a decrease in the GFR.

 Intra-renal– Also called ARF or ATN-this is when there is damage to the kidney that
causes a nephritic infection. Ex. Medications such as nephrotoxic episodes,
(gentimyacin, NSAIDS), transfusion reaction, hypercalcemia, and trauma.
 Post-renal– This is after the kidneys and is usually the result of an obstruction
somewhere distal to the kidney. Pressure rises in the kidney tubules and eventually,
the GFR decreases. Ex: infection in the ureters or bladder such as stones, obstruction,
tumor or stricture, BPH, or a blood clot.
 Phases of ARF:
 Initiation phase– (onset) - Begins with the initial insult and ends when oliguria
develops.
 Increase in BUN and Creatinine that can last hours to days.
 Urine output is 30 ml or less per hour- 50% of the pts. Are noted to be oliguric
 Oliguric phase– Decrease in urine output approx. 100-400 ml/24 hours. It doesn’t
respond to fluid challenges and diuretics.
 Increase in creatinine, BUN, Potassium, and Magnesium.
 Decrease in bicarb and calcium, and GFR.
 F&E abnormalities, and metabolic acidosis.
 Can last from 1-2 weeks.
 Uremic symptoms first appear and life-threatening conditions such as
hyperkalemia develop.
 Diuretic phase-Occurs when the source of the obstruction has been removed but
there is residual scarring and edema of the renal tubules remains.
 A gradual increase in u.o. which signal that GFR has started to recover. The pt.
will have a lot of urine in this phase-about 4 L in 24 hours. pt. just can’t
concentrate their urine (Increased Specific gravity).
 Gradual onset-(2-6 weeks) after the oliguric phase.
 Electrolyte losses because they are putting out so much urine.
 Monitor them for dehydration-administer crystalloids (D5W or NS) to prevent
dehydration.
 Monitor their BUN and creatinine levels-these will level off at a lower level and
plateau up and plateau down.
 GFR will be increased (this increase contributes to the passive loss of electrolytes
which requires the admin of IV crystalloids), u.o. will be 2-4 L per day, and the
 Recovery period phase-This phase can last up to a year.

 Edema decreases
 Renal tubules begin to function adequately
 F&E balance are restored.
 GFR has returned to 70% to *0% of normal.
 Non-oliguirc phase- May take the place of oliguric phase.

 Urine output remains near normal. The pt. still puts out urine but their kidneys are
just not working.
 Decreased renal function with increasing nitrogen retention, yet actually excrete
normal amounts of urine.
 This occurs predominantly after exposure of the pt. to nephrotoxic agents.
 Prevention ARF
 Assess S&S- fever, dehydration, and sustained hypotension.
 Always monitor pt’s labs-if there is a decrease in urine-check specific gravity-the

kidney loses the ability to concentrate urine.
 Monitor the pt’s fluid status–the best way to monitor this is taking the pt’s
weight!! Also take accurate I&O’s
 Nephrotoxic meds- such as gentomyacin and tobimyocin, immunoglycosides,

contrast dyes. Dr. will take baseline BUN and Creatnine before giving med- will
recheck weekly.
 Assessment/ Dx of ARF:
 History: Ask about voiding (color, clarity, problems, etc.). Surgeries or trauma,

blood transfusions, HTN or diabetes, meds (otc and prescribed), allergies.
 **One of the earliest manifestations of tubular damage is the inability to
concentrate urine.
 Flat plate of abdomen x-ray – Renal Scan
 Renal ultrasound – Renal Angiogram
 CT and MAG3 – Renal Biopsy
 Lab Values
 Creatnine (0.6-1.2)- gradual increase over hours
 BUN- (10-20)- value may reach as high as 80-100 within one week
 Serum Sodium- pre-renal= low serum Na; intra-renal= high; post-renal= high or
normal serum Na.
 Serum Potassium– increased
 Serum Phosphorous–increased **Everything high
 Serum Calcium–decreased except for calcium
 Serum Magnesium–increased and gasses**
 Arterial Ph–decreased-è metabolic acidosis
 arterial bicarbonate–decreased
 arterial blood PaCO2-decreased
 specific gravity–lower
 glomerular damage–protein in urine
 glucose in urine–ph of 5 or 6
 Medications:
 Cation Exchange Resins: Kayexalate and Sorbitol-
 Both can be given PO or rectally as an enema-the pt. needs to hold onto it as long
as possible.
 If hemodynamically unstable (low BP, changes in mental status, and

dysrrythmias) – give IV D50, insulin, and calcium replacements may be
administered to shift potassium back into the cells. They will give pt. 50%
dextrose and insulin IV-this pushes the K back into the cells.
 Vitamins and minerals– Folic acid and iron. Kidneys produce erythropoietin
(hormone that regulates RBC production)-if kidneys are not producing this-pt. will
need iron supp-pt. may be anemic.
 Biological Response Modifiers–Epogen and procrit-both of these will increase the

RBC’s.
 Phosphate binders–Amphojel, Renegel and Tums-these meds are absorbed in the GI

tract-they don’t cause diarrhea like K. They absorb Phosphate-so Ca levels will rise.
 Stool softeners/laxatives–Colace and Dulcolax
 Diuretics–Lasix-this is given to improve the renal blood flow-if the pt. is oliguric
they should not use it.
 Nutrition: No protein- High-carb meals, because carbs have a protein sparing effect;
Restricted potassium and phosphorus
 Foods containing potassium: Bananas, avacados, cantaloupe
 Foods containing phosphorus: Bran cereal, whole-wheat bread, almonds, nuts, beans
 Nutrition in diuretic phase: High-protein and High-calorie
 Chronic Renal Failure (ESRD) – Progressive, irreversible kidney injury where kidney fxn
DOES NOT recover.
 Body’s ability to maintain metabolic F&E balance fails, resulting in uremia or azotemia.
 Slow progression that it takes years before the pt. will have any S&S.
 S/S CRF:
 HTN-due to Na and H2O retention /Renin-angiotensin process (fluid overload)
 hyperlipidemia-the body doesn’t metabolize fats as it should
 heart failure- because renal failure puts extra work on the heart-anemia and fluid overload
 pulmonary edema-d/t fluid overload
 uremic pericarditis-due to the irritation of the pericardial lining by uremic toxins-causes

severe chest pain, SOB, increased HR, increased temp, dysrythmias, and friction rub
 dermatologic-severe itching and uremic frost-deposit of uremic crystals on the skin, Skin
will be yellow/gray topical color. Decreased skin turgor and bruising. Give good skin
care!!
 GI-ulcers, bleeding, anorexia, n/v and hiccups, breath has odor of urine (uremic
halitosis)-if pt, has this may be the result of ineffective dialysis.
 Altered LOC, muscle twitching, confusion, seizures, decreased attention span.
 Polyuria or alluric-urine will be dark and straw colored.
 Azotemia– the buildup of nitrogenous wastes in the blood
 Uremia- excess urea: s/s: metallic taste/ change in taste, itching, muscle cramps, edema, sob.
 *****#1 cause of CRF= diabetes**********
 Other causes include HTN, glomerular nephritis, certain meds over a long time
 There has to be 95% damage to the millions of nephrons to be dx with CRF.
 Normal GFR is 125 ml/min
 Stages in CRF:
 Stage 1-GFR > 90 ml/min-normal renal function
 Stage 2-GFR 60-89 ml/min- mild decrease in GFR. No buildup of waste but nephrons are
still working overtime, may have an increase in BP which causes an increase in
glomerular pressure on healthy nephrons. There is no S&S of renal failure in this phase.
 Stage 3-GFR 30-59 ml/min- moderate decrease in GFR. Will see a buildup of waste- Not
enough healthy nephrons to prevent it. There is an increase in BUN, creatinine, uric acid
and phosphorous. An increase managing fluid volume and an increase in BP and edema.
There are F&E changes. **If the pt. can manage their BP and diet, they can slow down
the progression.
 Stage 4-GFR 15-29 ml/min-there is a severe decrease in GFR.
 Stage 5-the GFR is less than 15 ml/min. Will see S&S and kidney failure. ESRF
will result from severe F&E imbalances.
 Diagnostic findings of CRF:
 GFR– The lower the GFR, the more kidney damage is done.
 Electrolytes-Na and K-early chronic renal failure-hyponatremic. In the later stages, pt’s
are hypernatremic and K will go up.
 Acid-base balance-as nephrons die-acid builds up and the pt. gets metabolic acidosis.
 Hematological-the pt. is anemic because of a decrease in erythropoietin and RBC

 Calcium and phosphorous-these lab values go hand in hand. The lower the Ca values,
the more at risk the pt. is for sucking Ca out of the bone and increasing the serum Ca
 Effects on phosphate:
 Phosphate retention hyperphosphatemia.
 Binding of phosphate with calcium. This decreases the serum calcium. The pt. is not
making good ca because of low Vitamin D. (High phosphate levels=low Ca levels.)
 The parathyroid gland releases PTH-the parathyroid gland controls the amount of
phosphate excreted. In CRF, the parathyroid gland is not doing its job. So, the more the
body secretes PTH, the more Ca is released from the bones. So this gives you an
increased serum Ca level which will cause binding of phosphate with calcium and cause
metastatic calcification. With increased serum ca levels-crystals can lodge in your heart,
brain etc., so it puts you at risk for metastatic calcification (crystal like clots-detrimental
to pt’s.)
 Effects on calcium
 There is a decreased production of vitamin D leads to a decreased absorption of calcium

from the GI tract decreased serum calcium level causes a release of PTH from the
parathyroid gland-which controls the amount of phosphorous excreted which causes a
release of calcium stored in the bones leads to an increased serum calcium level So there
is binding of phosphorous with calcium
 Meds for CRF ***KNOW***
 Calcium and phosphate binders: **Give both with food**
 If calcium is LOW- give Oscal (calcium carbonate) and Phos-lo

 If calcium is HIGH – give Renegel
 Antihypertensive and CV agents
 Lanoxin, Dobutamine, and diuretics

 These prevent heart failure and pulmonary edema and control BP
 Antiseizure agents
 Valium and Dilantin
 Give to patient in ESRF
 Watch if patient’s sodium is low
 Erythropoietin
 Epogen- give 3x a week- SQ or IV
 Nutrition with CRF
 Protein-restricted; complete proteins only (dairy products, eggs, meats only)

 Fluids – 500-600ml more than the previous days 24-hour urine output
 No potassium
 No sodium
 Vitamin supplements

 Nursing Interventions with CRF
 Accurate I&O
 Daily weight- assess for manifestations of volume excess-assess by pt. weight. 1 kg of
extra weight=1 liter of fluid. Weigh the pt. at the same time, with the same clothes on the
same scale.
 Fluid restriction-assess the pt. for fluid excess-crackles-they will start at the base of the
lungs. The more fluid the pt. retains the more the crackles will move up the lung. S/S
include restlessness, agitation, anxious- feels like pt. can’t breathe.
 When pt. goes to dialysis hold all meds. Will get meds when they get back from
dialysis...
 Meticulous/ preventative skin care- due to uremic frost and itching (keep nails cut short)
 Inspection of vascular access site
 Monitoring of v/s- pt’s temp and heart rate will increase after dialysis.
 Cardiac monitor- look at T-waves- cardiac issues- biggest cause of death in pt’s
 Assess electrolytes
DIALYSIS
 Pt’s go to dialysis 3x/week.
 Works by using passive transfer of toxins by diffusion. Some use anticoagulation (Heparin) -
newer machines don’t.
 Arteriovenous fistula- the preferred method of permanent access that is created surgically.

 Join an artery to a vein usually an anastomosis between the radial artery and cephalic
vein.
 Most of the time, they will start the pt’s off with a fistula.
 Arteriovenous graft- Can be created subcutaneously interposing a biologic (silicone tube)

graft material between an artery and vein.
 Usually created when the patient’s vessels are not suitable for creation of a fistula.
 Acute dialysis- used for QUICK fluid changes

 High potassium – Increasing acidosis
 Fluid overload – Pericarditis
 Pulmonary Edema – Severe confusion
 Chronic or Maintenance dialysis

 ESRD – fluid overload not responsive to diauretics and fluid
restrictions
 Presence of uremic S/S affecting all body systems (N/V)
 Hyperkalemia – pericardial friction rub
 Hemodialysis– Used to extract toxic nitrogenous substances from the blood and to remove
excess water.
 Used for pt’s not responding to tx.
 If the K+ is 7 and not responding to tx such as kayexelate and they can’t get the K+
down, they will start the pt. on dialysis.
 If the BUN is too high they will also start dialysis.
 If pt. has ARF- this dialysis tx will be short-term
 Cath. will be in subclavian or jugular with an inflow/outflow lumen
 If pt. only has dialysis 1 or 2 times, will put cath. in femoral artery- not used longterm d/t
risk for infection and kinking.
 Peritoneal Dialysis– used to remove toxic substances and metabolic wastes and to re-
establish normal F&E balance.
 May be used for pt’s with renal failure who are unable to undergo hemodialysis or renal
x-plant.
 Will put dialysate into the abdomen- let it sit and well- then the drainage tube is
unclamped and fluid drains from the peritoneal cavity. Uses a Tenkoff catheter
 Usually takes 36 to 48 hours to achieve what Hemodialysis accomplishes in 6-8 hours.
 High risk for peritonitis- infection comes from insertion site- STERILE technique is used.
 Dialysate is warmed prior to administration to prevent discomfort and abdominal pain
and to dilate the vessels of the peritoneum to decrease urea clearance.
 3 Phases of peritoneal dialysis:

 Infusion: 2-3 Liters – takes 5-20 minutes. The docs can add different things to dialysate
(ex: insulin, antibiotics, or dextrose- 4.25à the higher the dextrose concentration, the
more water will be removed.
 Dwell– solution sits in the abd. Cavity for 20-30 mins
 Drain– should look colorless, pale, straw with a little blood.
 Don’t want to see cloudy fluid- Indicates infection **exam**
 Two types of peritoneal dialysis:
 Continuous ambulatory PD: 5 different exchanges per day.

 Can be done at home-it allows more flexibility and remains in the ab for 4 to 5 hours.
 Less extreme fluctuations in the pt’s lab values occur because dialysis is constantly in
progress.
 Because of protein loss with CAPD, the pt. needs to eat high protein, and increase
daily fiber to help prevent constipation, which can impede the flow of dialysate into
or out of the peritoneal cavity.
 May be asked to limit their carb intake to avoid excessive wt. gain. Potassium,
sodium, and fluid restrictions are not normally needed
 Continuous cycle PD: This combines overnight intermittent peritoneal dialysis with a

prolonged dwell time during the day
 Need a very stable pt. to do this.
 The peritoneal cath is connected to a cycler machine every evening and the pt
receives 3 to 5 exchanges during the night. In the morning the pt. caps off the catch
after infusing 2 to 3 L of fresh dialysate. This dialysate remains in the abs cavity until
the tubing is reattached to the cycler machine at bedtime
 Complications of Peritoneal Dialysis:
 Peritonitis/ Infection-this is the most common-due to connection contamination.

Characterized by cloudy dialysate, drainage, diffuse abdominal pain, and rebound
tenderness. Can treat this by using dextrose alone to clear system and then add ATBX if
not helping take out TEEKOFF catch and get rid of catheter.
 Pain– usually goes away with time. Heat/warm dialysate-wrap in heating pad and then
infuse it.
 Poor dialysate flow-make sure bag is lower, no kinks or blocks in tubing. Constipation
can also cause this. Have a good bowel regimen and stool softener. Also have pt. turn
from side to side. The catheter should never be pushed further into the peritoneal cavity.
 Dialysate leakage-this is common at the beginning of dialysis. 1 to 3 L exchange. Body

has a hard time adapting to large amounts of volume. Leakage can be avoided by using
small volumes (500 ml) of dialysate and then gradually increasing the volume.
 Blood tinged drainage is common-if yellow like urine color-pt. could have bladder
perforation; if brown-pt. could have bowel perforation.
 Nursing Interventions during PD

 Always evaluate baseline vs., weight and lab values before and after treating the pt.
 continue to monitor the pt for resp distress, pain and discomfort
 always monitor prescribed dwell time and initiate outflow
 Observe the outflow for amount and pattern of fluid.-document I&O, pt’s response to tx,
how long it took the fluid to go in, color that came out, how much fluid came out.
 Want to see more fluid come out than you instill (ex: if you put in 3L- you want to see 4L
come out). Can use a stronger dextrose solution if you need to pull more fluid off.
 Treatment of choice in pt’s with ARF:
 Continuous venovenous hemofiltration (CVH)-

 don’t have arterial access-
 only removes fluid – very slowly
 is tolerated better by the patient
 It is done in the ICU setting. It is used to manage acute renal failure.
 This provides continuous slow fluid removal. Therefore hemodynamic effects are
mild and better tolerated by pt’s with unstable conditions.
 Continuous Venovenous Hemodialysis ***EXAM***

 You will see this used in ******UNSTABLE PATIENTS****
 It removes fluid and uremic waste.
 Blood is pumped from a double-lumen venous catheter through a hemofilter and
returned to the patient through the same catheter.
 In addition to the benefits of filtration, CVVHD uses a concentration gradient to
facilitate the removal of uremic toxins and fluid. No arterial access is required.
 Short term catheters are placed at the bedside and are used for 1-week because of infection.
Veins used are subclavian, internal jugular or femoral vein.
 Perm caths can last longer. There is a notch/cuff which is used for infection. This helps
micro-organisms from entering the wound. Want the notch to be inside the pt.
 Complications of dialysis ***EXAM***

 atherosclerotic cardiovascular disease-caused by disturbances of lipid metabolism
 heart failure
 coronary artery disease
 anginal pain/chest pain-occur in pt’s with anemia or arteriosclerotic heart disease
 stroke
 peripheral vascular insufficiency
 hypotension-n/v, diaphoresis, tachycardia, dizziness-all S&S of hypotension
 painful muscle cramping-this occurs usually late in dialysis as F&E rapidly leave the
extra-cellular space
 exsanguinations- occurs if blood lines separate or dialysis needle become dislodged
 air embolism
 ****Dialysis disequilibrium-cerebral fluid shifts-this can cause cerebral edema. S&S
include headache, n/v, restlessness, LOC changes (1st symptom), seizures, and death. Can
prevent this by having shorter dialysis treatment with lower blood volume shifts. Can
cause Increased ICP.
 Complications of having a vascular access device, fistula or graft?***EXAM***

 Thrombus- **most common** Due to reduced blood flow- due to the muscles in the vein
thickening up. They will use decreased doses of TPA to treat.
 Infection-usually cause by staph aurus-use sterile technique when accessing a graft.
 Aneurysms-repeated needle sticks can weaken the vein/fistula
 Ischemia-this is a rarer complication. There is decreased arterial blood flow. See
diminished pulses, discoloration, cool skin-this can progress to gangrene if you don’t
catch it in time.
 Safety measures when a pt. undergoes dialysis

 No BP, no blood draws, no IV fluids through fistula
 No tight dressings, restraints, or jewelry
 Assess bruit or thrill over the site at least every 8 hours-absence may indicate clot or
blockage
 Assess site for infection-pts with renal disease are more prone to infection-they have low
WBC counts, low RBC counts, and impaired platelet function.
 Weight is taken before and after dialysis- it’s is a good indication of how dialysis worked.
 Drop in weight and drop in blood pressure is good sign- showed it worked.

 Glomerulonephritis– inflammation of the capillaries of the glomerulus
 2 types:
 Acute: –see more in children
 If severe it can progress to acute renal failure.
 Most common cause is strep throat. You see this about 2-3 weeks after the infection.
 The kidney becomes large, edematous, and congested.
 Can also see this after viral infections but not as common.
 S/S: hematuria-blood in urine-coca cola urine, proteinuria-protein in urine, edema-
will see this in orbital area, face and hands-watch out for fluid overload and SOB,
HTN, Azotemia-this is the buildup of urea and nitrogenous waste
 Labs: Decreased GFR, blood and protein in urine, increased BUN and creatinine,
hypoalbumin-pt. losing all protein, urine output will decrease-may do renal biopsy to
make a definitive diagnosis, anemia may be present
 Tx: infection management-treat the pt. with ANTBX-penicillin, arythromycin,
zithromycin-use good hygiene to prevent spread of this. May also use steroids and
immunosuppressants. Prevent complications with diuretics(get rid of protein-prevent
fluid overload-also helps with HTN and edema); Na, H2O, K and protein
restrictions(pt. needs a diet high in carbs-give energy and decrease the catabolism
(break down) of protein; dialysis and plasmapheresis(usually if pt. has fluid overload
and uremic symptoms-take off fluid and antibodies if immunosuppressive
component);pt. education-teach diet and nutrition-teach that if the pt. has a sore throat
then he needs to take an ANTBX.
 Chronic-This will progress to renal failure.

 The cause includes repeated episodes of acute glomerular nephritis, hypertensive
nephrosclerosis (hardening of renal arteries) hyperlipidemia and other causes of
glomerular damage.
 The pt. may be without symptoms for years.
 S/S: first symptoms-sudden nose bleed, stroke or seizure, swollen feet at night,
gradual weight loss, decreased strength, increased irritability, confusion, nocturis-
getting up more at night to go to the bathroom, complain of HA and dizziness, will
look poorly nourished, skin-yellow. Grayish color, orbital edema, s&s of heart (or
renal) failure
 Labs: decreased urine output, protein and RBC’s in urine, increased K and
phosphorous, decreased GFR, increased BUN and creatinine, may be anemic because
of epotien, metabolic acidosis, decreased serum calcium
 NI’s- slow the progression of the disease, prevent complications through management
of symptoms-if pt has hypertension-reduce BP with sodium and water restrictions,
high carbs and good complete proteins (eggs and dairy products), restrict K and Na,
have pt. limit fluid intake-monitor it along with weight daily, the pt. may or may not
use diuretics as drug therapy. Will be on anti-HTN meds, dialysis and transplant is
needed for the pt. to survive.
 Nephrotic Syndrome: Increased glomerular permeability that allows larger

 Molecules to pass through the membrane into the urine and be removed from the blood.
 An immune or inflammatory response (ex. Lupus, multiple myloma).
 Cluster of findings r/t this syndrome including proteinuria (severe loss of protein in
urine), hypoalbumemia, edema and hyperlipidemia.
 Without treatment this will lead to ESRD
 S/S: massive proteinuria, hypoalbuminia, lipiduria-protein and lipids in urine, edema-
periorbital and in dependent areas
 Tx: use immunosuppressive agents-steroids. ACE inhib and loop diuretics to decrease
proteinuria-takes about 6 weeks to be effective. Heparin-.this reduces protein in urine and
reduces the risk of renal insufficiency. Diet changes-if the pt. is not hyperkalemic-
decrease Na and increase K in diet. This helps get rid of Na and help edema-use ONLY if
K is not high! The pt. should be on a low protein diet. Mild diuretics.
 Teach Importance of following all medication and dietary regimens so that their
condition can remain stable as long as possible.

Kidney Transplant
 Treatment of choice for pt’s with ESRD
 Live /related donor-pt. will have good urine output after surgery.
 If kidney from cadaver-may take 2 weeks for kidney to wake up. If kidney does not
produce urine output after surgery, pt may need to go on dialysis until the kidney wakes
up.
 Make sure pt is free from infection before transplant. Meds are prescribed after surgery to
immunosuppress the pt’s immune system so that transplant rejection will not occur.
 Pt’s are tx for dental cavities and gingival infections as well (make sure you look in pt’s
mouth).
 It is preferred to avoid dialysis before transplant.
 Meds after transplant:

 Cyclosporine (immunosuppressive agent) are used with other medications to prevent
transplant rejection
 Pt’s receiving cyclosporine may not exhibit the ususal signs and symptoms of acute
rejection.
 The pt. is closely monitored for infection because of susceptibility to impaired
healing and infection r/t immunosuppressive therapy and complications of renal
failure.
 Tacrolimus (Prograf) similar to cyclosporine and about 100 times more potent. Given in
smaller doses than cyclosporine.
 Mycophenolate (CellCept) - immunosuppressive. Don’t want to open if pregnant.


 Sirolimus (Rapamune)
 Doses are gradually reduced- but the pt is required to take immunosuppressives for the
rest of their life.
 Risks of meds: *nephrotoxicity*, HTN, hyperlipidemia, hirsutism-excessive hair, tremor,
several types of cancer
 S/S transplant rejection: fever (one of the first signs), oliguria, edema, increasing BP, weight
gain, swelling or tenderness over the transplanted kidney
 S/S Infection: shaking chills, fever, rapid heartbeat, tachypnea, increase or decrease in
WBC’s-leukocytosis or leucopenia need freq. urine cultures.
 Chase Urine: ***EXAM*** the pts. will need a lot of IV fluids. Need to adjust the IV fluids
based on what the pt’s urine output is. Check urine output every 1 to 2 hours and follow
protocol. Keep the kidney good and hydrated!!!
Newborn Assessment
Immediate Care of the Newborn

Simultaneous activities:
– Assess and stabilize
– Evaluate if cardiac/respiratory help needed for baby to initiate breathing
S/S respiratory distress:
– Grunting- noise on exhalation Retractions
– Nasal flaring Cyanosis
– Lack of respiratory effort

– Respiratory- suction secretions from the airway.
– Cardiac: Always take apical pulse for 1 minute- 4th intercostals space a little left of the
midclavicular line
– <100= bad. Normal= 120-160
– Dry and wrap in blanket-
– Newborns can’t shiver- problem regulating/ maintaining temperature.
– Heat loss and cold stress can cause hypoglycemia in newborn
– Apgar at 1 and 5 minutes
– Visual inspection:
– Posture, muscle tone of extremities, state, color, gross abnormalities (congenital
malformations)
– Take and record time of birth
Apgar

SIGN Score 0 Score 1 Score 2
Below 100 Above 100
Heart Rate Absent per minute per minute
Weak,
Respiratory irregular, or
Effort Absent gasping Good, crying
Some Well flexed,
flexion of or active
arms and movements
Muscle Tone Flaccid legs of extremities
Reflex/Irritability No Grimace or Good cry
response weak cry
Blue all Body pink,
over, or hands and
Color pale feet blue Pink all over

If <5 resuscitative measures may be necessary.
Vital Signs
Temperature: 36.5 (97.7) to 37.2 (98.9)
Pulse: 100-180 à checked at 5th intercostals space- midclavicular line

Respirations: 30-60/minute
Other nursing responsibilities in L & D

– Identify baby (ID band on child before leaving labor room) and footprints
– “Eyes and Thighs”- 2 medications need to be given: Put in Vastus Lateralis muscle
1- Vitamin K- 25 gauge 5/8 inch needle- given for clotting
2- Erythromycin Ophthalmic- put in eyes – for Chlamydia and gonorrhea in birth canal.
Benefits of skin to skin contact:

– temperature regulation- babies who have skin to skin contact immediately after birth can better
regulate their temp at 1 hour
– Decreased crying
– Enhanced breastfeeding
– Increased milk supply
- can put baby on mother’s abdomen to do assessment
Newborn Skin Issues

Milia– little white ‘dots’ on nose, forehead and chin or mouth. Caused by blocked sebaceous
glands. Will go away completely- totally benign
Newborn Rash– will spontaneously go away by 3 weeks

Vernix– is the waxy or “cheesy” white substance found coating the skin. It is very good for the
newborn skin- rub it in- will absorb naturally. Don’t put products on it.
Mongolian Spots– dark spots- collection of capillaries. Looks like a bruise. Completely benign.
Most common on dark-skinned babies (black, Asian).
Lanugo– fine hair most commonly found on preterm neonates. Tends to be most on back and
chest. More premature=more lanugo.
Acrocyanosis– cyanosis in hands and feet. Takes a few days to go away.

Nevi– “stork bite”- will blanch when touched- will fade by 2 y/o. Collection of immature blood
vessels.
Strawberry Hemangioma- will be textured (rough, raised, and bumpy). Will appear later- after
birth and will fade by 9 y/o.
Port-Wine Stain– Most often on head and neck. Will not change colors when touched. Tx most
often laser surgery.

Make sure fontanels aren’t sunken (dehydration) or bulging (increased ICP).
Molding – reassure parents head will go back to ‘round’ shortly after birth. Sign to pay special
attention to neuro exam.
Common Problems
Caput Succedaneum– swelling in a diffuse area
– Edema – appears at birth, disappears in several days
– Vague, poorly defined outline -***Crosses suture lines***
Cephalhematoma– more significant

– Blood between skull and periosteum – Appears several hours after birth, size
increases
– Well defined outline – **Never crosses suture lines- will follow
lines**
– Risk for jaundice, skull fracture, and intracranial bleeds
Newborn
Vital Signs:
Temp- 36.5- 37.2 C (97.7-98.9) normal- Take axillary- will stabilize in 8-12 hr.
Pulse- 120-160 (100-180 may be normal depending on activity level)

4th intercostal space, midclavicular line
Respirations- 30-60
Blood Pressure- 60-80/ 40-50
Thermoregulation:
Evaporation: When wet surface on the baby is exposed to air – need to dry the infant after birth
and after baths, especially the head.
Conduction: When the newborn comes into direct contact with something colder than them – Do
not place them on a cold surface. Warm objects first that will touch the baby. Skin to skin contact
prevents this loss.
Convection: Heat transfers to air around the infant such as AC or people walking around creating
currents – Need to keep the newborn out of drafts, maintain a warm environment, warm oxygen
before administering.
Radiation: Transferring of heat to cooler objects not in contact with the newborn – newborns lose
their heat by being placed near a cold window. Place crib or play area away from windows.
***Test***Weight- Newborns lose 5-10% in the first 5 days- should regain birth weight by 2
weeks
If lose 7% this is a red flag that should be evaluated.
Renal- newborn should void within 24 hours
Urine output scant during first few days as baby adjusts to feedings
Once in 1st 24 hours, Twice in 2nd 24 hours, 3x in 3rd 24 hours

Increases on day 3-4 when milk comes in, then 6-8 voids/24 hours
Stools- Meconium at first progressive changes in appearance and pattern
Indication of adequate nutritional intake:
1st stool at 48 hours of age; 3 stools per 24 hours once milk comes in

Jaundice: Cephalocaudal pattern
Total Bilirubin-

Conjugated (direct) - attached to albumin- can be excreted
Unconjugated (indirect) - causes problems- isn’t attached to protein (free floating)- could go into
the brain.
Measured in lab with a heel stick
Physiologic Jaundice or Hyperbilirubinemia– onset after 24 hours of age

Peaks around day 4; subsides at 4-6 days
Benign in normal- healthy term newborn
Indirect bilirubin (normal) equal to or less than 12mg/dl by day 3
15-17 in preemie
Early (within 1 hour) and frequent feedings may help
Breastfeeding Jaundice– Early onset (within first few days) due to lack of adequate intake.
Counsel mother to put baby to breast every 3 hours – even if sleeping. This stimulates stool to
excrete excess bilirubin.
Breast milk Jaundice– Late onset- Hyperbilirubinemia beyond 1st week- peaks at 2 weeks.
Pathologic Jaundice– Jaundice <24 hours. Usually caused by ABO incompatibility. Increases
>0.5 mg/dl/hr. Peaks at >13 mg/dl/hr in term infant.
Associated with anemia and enlarged liver and spleen. If it persists past day 7- it can progress to
kernicterus or bilirubin encephalophy (usually at bilirubin level >25). s/s= lethargy, hypotonic,
poor suck.
Tx: Phototherapy
Monitor Temp Eye patches
Turning q2 hours Monitor I & O
Shield Genitals (boys) Observe skin color
Risk factors for Hyperbilirubinemia:
ABO Incompatibility Preterm

Postterm Traumatic birth (bruising will cause RBC’s to lyse)
Immunology:
– Infant retains passive immunity for approx 3 months; longer if breastfeeding.
IgG- only immunoglobin that crosses placenta
IgM- 1st immunogloubin newborn makes

IgA- Secreted in colostrum – immunity to GI and respiratory infections if breastfed
Reflexes:
Rooting and Sucking Stepping or Walking
Grasp – Palmar and plantar Moro
Babinski- on sole of foot, beginning at heel, stroke upward alongside of sole then move finger
across ball of foot- All toes hyperextend- with dorsiflexion of big toe.
Tonic Neck

Sleep-Wake States
Sleep States
Deep Sleep- Regular breathing
Light Sleep- REM, body movement, variable breathing
Wake States
Drowsy- intermediate, state before waking
Quiet alert- optimal state of arousal- Easiest to interact- highly receptive
Active alert- high movement, fussy state
Crying- communication state

Behavioral Adaptation after birth
First period of reactivity: Transitions to extrauterine life. Very alert, irregular respiratory effort,
irregular CV, etc. promote bonding, encourage breastfeeding.
Period of inactivity- Deep sleep- lasts 1 to 1 ½ hours. Cannot breastfeed during this time.
Second Period of reactivity- alert, responsive. Lasts a few minutes to hours.
PKU- Causes Mental retardation- test done on day 2-3. Tx: diet low in Phenylamine.
Danger Signs:
Abnormal fontanel size- or bulging or sunken fontanel
Respiratory system signs:
Tachypnea (TTN- transient tachypnea of the newborn)- when newborn takes too long to
transition to extrauterine life- will go away, but needs care until then.
Nasal Flaring Expiratory grunting
Retractions Rales and Rhonchi
Asynchronous breathing movements Cyanosis
Decreased/absent breath sounds Acidosis
Hypotension and shock Hypercapnia
Preterm- before 37 weeks
Immaturity in all systems
Risks: Excessive heat loss- thin skin, decreased subq fat, increased BSA
Vulnerability to hyperoxic injury (too high O2 level can damage retina causing blindness).
Immature lungs and diminished respiratory drive
Immature brain that is prone to bleeding

Vulnerability to infection
Necrotizing enterocolitis- part of intestine dies- most serious problem of preterm infant. s/s- not
passing stool, increased vomiting, increasing abd. Distension, no bowel sounds.
Nursing: Monitor and control blood sugar
Monitor for apnea, tachycardia, bradycardia, or O2 desaturations- intervene promptly.
Monitor and control oxygenation and ventilation
Consider delaying feeding if perinatal compromise is significant
Increased suspicion for infection
Control noise and light (cover isolette, decrease noise level)
Small For Gestational Age (SGA) - 2 types
Intrauterine growth retardation (IUGR) - wt. below 10th percentile

1- Symmetric- caused by an early insult to the fetus during pregnancy (ie: drug use, rubella)
Deficiency in cell numbers
Head circumference below 10th percentile

Small brain- child never catches up- mental retardation
2- Asymmetric- Caused by an insult late in the pregnancy
Atrophy in cells that are already formed by this time
Diminished cell size but cell numbers are normal
Large head (disproportionately)
Long body with little fat, looks emaciated
Postnatal growth and development rapid- can catch up if caught early.
Large for Gestational Age (LGA) - wt above 90th percentile or over 8lb14oz

Risk factors: Genetics, maternal weight gain, gestational diabetes
Potential for trauma (shoulder dystocia, clavicle fx, palsies, skull fx, facial nerve damage) if
delievered vaginally-> may necessitate c-section.
Also at risk for hypoglycemia
Other GYN stuff

GYN Stuff

Health Screening Recommendations= Early Detection
Blood Pressure Every visit- but at least every 2 years
Cholesterol Test Every 5 years- but more often if high-risk
Start at age 65; younger women with risk
for osteoperosis may need periodic
Bone mineral density screens
Annually with fmly hx of diabetes or
gestational diabetes or if significantly
obese Every 3-5 years for all women
Fasting Blood Glucose test older than 45.
Annually q 1-2 years starting at age 40
unless family hx.If mother, sister or
daughter was dx, should start
mammograms 10 years before age at
which they were diagnosed. (Ex: mother
dx at 45- should start mammograms at
Breast Cancer Screening (mammogram) 35).
Breast self-exam Done monthly at end of menses.
Pap Test Every 1-3 years starting at age 21
Annually from start of sexual activity
Pelvic Exam until age 70
Chlamydia As needed yearly until age 25
Fecal occult blood test annually starting at
age 50.Flexible sigmoidoscopy q5 years
Colorectal Health starting at age 50.
Thyroid screening Every 5 years, starting age 35
Mole exam Monthly self-exam; by a doctor q 3 years
Influenza Annually after age 65
Tetanus-Diphtheria booster Every 5-10 years after primary series
Eye exam, hearing test, dental checks Every 1-2 years
Risk Groups= FBS, STI, TD
Breast Cancer Screening

Triad of screening techniques:
1- Breast self-exam
– Should be done AFTER menses (some lumpiness normal during period)
– If no period, should be done at same time every month
– BSE should be done starting at midadolescence on.
– Should include looking and feeling.
– Looking for any dimpling, discharge, skin rash, mottling, etc
– Feeling for lumps.
– Cysts- fluid-filled, painful to palpate- usually benign
– Fibroadenomas- firm- fiber-filled masses- not assoc. with cancer. Caffeine, chocolate, coffee,
sodas will exacerbate.
– Self exams will usually pick up nodules 1cm or larger
2- Clinical exam
3- Mammography
– Can pick up lumps <1cm
– Start at age 40- every 1-2 years.
Papanicolaou Smear (Pap smear)

 Used for early detection of cellular changes associated with premalignant or malignant
conditions
 Also used to identify fungal and viral infections and to monitor effects of hormonal therapy
 If hysterectomy- she still needs to have Pap smear annually.
 Done annually when woman becomes sexually active or turns 21
 More often in high risk group
 Make sure she has not douched, used vaginal medications, or had sexual intercourse for 24-
48 hours before procedure.
Menopause
 The actual permanent cessation of menstrual cycles; so diagnosed after 1 year without
menses
 Declining estrogen levels
 Average age= 35-60
 Effects seen in breasts (atrophy, soft/pendulous), bone (increased risk for osteoporosis d/t
decreased calcium), mucous membranes (increased risk for UTI’s d/t stress incontinence),
heart (increased risk for heart disease d/t loss of estrogen), neuroendocrine system (hot
flashes), reproductive organs (uterus and ovaries decrease in size).
 If woman is having a hard time coping with sx, she may be put on estrogen therapy.
 Perimenopause– Time before cessation of menses- period before menopause. Ovarian
function declines, ova slowly diminish, and menstrual cycles are non-ovulatory- resulting in
irregular, regular, or heavy bleeding.
 Usually lasts 5-10 years
Self-care:
 Weight-bearing exercises- adequate calcium intake

 Teaching about Sexual relations – lubrication
 Hormone replacement therapy if indicated

 Reduces incidence and severity of vasomotor disturbance
 Health promotion

 Breast self-exams, mammography
 Bone mineral density testing
 Yearly physical exam
 Screening for colon cancer, cholesterol, diabetes
Contraception
Is the intentional prevention of pregnancy during sexual intercourse.
Assessment:
Frequency of coitus Current health practices
Number of sexual partners Religious and cultural factors
Level of contraceptive involvement Partner’s objections to any methods

Willingness and ability to use methods correctly and consistently
Discuss: Dependence of method on health care system Method cost
Effect of method on partner Information and help with second

method
Teaching in regard to STI’s
Intrapartum Unit Outcomes

Intrapartum Period Unit Outcomes
1. Describe methods of determining gestational age

EDB and EDC stands for estimated date of birth and estimated date of confinement. This is used
to figure out due date.
Nagele’s Rule is used to figure out baby’s due date.
First step is to figure out first day of last period. Add 7 days, subtract 3 months, and add 1 year.
Ex. Aug 20th last menstrual cycle-add 7 to make Aug 27th and subtract 3 months-May 27thand
then add 1 year-due date is May 27th, 2008. This is accurate within +/- 2 weeks of date.
LMP-stands for first day of last period
What are different reasons that a due date may not be accurate?
the pill
Endometriosis-irregular cycle
To have an US is becoming the norm-to have an US in the 1st or 2nd trimester. If US detects due
date within 7 days then will keep calculated due date. But if US is not within 7 days, will go with
US due date. The US will detect a more accurate gestational age of the fetus.

An US measures crown to rump length and measures head and femur length.
All fetus’s growth is the same up until 20 weeks, after 20 weeks, growth differs and depends on
genetics.
1. Differentiate between gravida and para.
Gravity equals the total number of pregnancies a female has had. This includes abortions and
miscarriages. Ex-Primigravida and multigravida.
Parity-This is the number of past viable births (20 weeks)
Way to remember what numbers stand for-
Florida Light and power
1. Florida=all full term births

2. Power=before 37 weeks-number of pre-term deliveries
3. And=Abortions/Miscarriages-losses-Before 20 weeks
4. Light=living children-outcome of pregnancies
Ex. Mother lost all 3 pregnancies and is pregnant now
G4
P0030
This info tells you the mother will have a lot of anxiety!
1. Describe how to perform Leopold’s maneuver.

This procedure is performed with the woman briefly lying on her back. These maneuvers help ID
the number of fetuses, the presenting part, fetal lie, and fetal attitude; the degree of the presenting
part’s descent into the pelvis, and the expected location of the PMI of the FHR on the woman’s
ab.
Ask woman to empty bladder and position woman supine with towel rolled under hip-this offsets
pressure off inf. vena cava.
1. ID fetal part that occupies the fundus-this maneuver ID’s fetal lie (longitudinal or transverse)
and presentation (cephalic or breech)
2. Locate and palpate the smooth contour of fetal back and small parts-ID’s fetal presentation
3. Determine which fetal part is presenting over inlet to pelvis. If head is presenting and not
engaged-determine the attitude of the head-flexed or extended
4. If the cephalic prominence is found on the same side as the small parts, this means that the
head must be flexed and the vertex is presenting. If cephalic prominence is on the same side
as the back, this indicates that the presenting head is extended and the face is presenting.

1. Identify nursing responsibilities in caring for a woman who is Group B strep positive.
It is normal vaginal flora, but in the NB it can cause pneumonia. 10% of NB will get SIDS and
die. Treat with antibiotics while in labor. The woman gets 2 doses-IV penicillin-4 hours apart.
They will observe NB for longer if don’t get penicillin and mom is positive. Once you test
positive for group B strep will always be positive.

1. ID nursing responsibilities in caring for a woman who is rubella negative.

All pregnant women should have a rubella titre. If woman gets rubella in the first 3 weeks of
pregnancy-she will miscarry. If she gets rubella within 3-8 weeks of pregnancy-baby will have
cardiac/neurologic defects. If gets rubella within 8 weeks of pregnancy-structure of baby is
formed but may cause IUGR.
This is a live vaccine that’s given-GIVE ONLY WHEN NOT PREGNANT!!
It is a minor disease for the mom but for fetus it is devastating.
If mom is infected with Rubella then she is at more risk for choria amnionites-infection on the
chorion and endometritis. Immune sytem is more vulnerable. Inflammation reaction in the
amniotic membranes caused by bacteria
1. Define supine hypotension and nursing measures to prevent it’s occurance

In the supine pregnant woman at or near term, maternal hypotension; maternal hypotension is
due to obstruction by the gravid uterus of the inferior vena cava with
resulting decrease in venous return to the heart; foetal hypoxia is due to maternal hypotension
and obstruction of the maternal aorta by the gravid uterus with resulting decrease
in placental perfusion.
Signs and symptoms
Pallor
Dizziness, faintness, breathlessness

Tachycardia
Nausea
Clammy (damp, cool) skin; sweating
Nursing Interventions
Position woman on her side until her s+s subside and v.s. stabilize within normal limits.
Describe the four stages of labor and related maternal behavioral changes.

1. Review factors involved in the initial assessment of the woman in labor.

Assessment begins at the first contact with the woman, whether by telephone or in person. The
nurse should ask the woman for a description of what she is experiencing that signals to her that
she is in labor. These s+s can include recurrent or nonrecurrent pain, watery or blood stained
fluid from the vagina, GI symptoms (vomiting, stomachache, and diarrhea) emotional upheaval
(anxiety) and sleep disturbances.

Asses btw true and false labor-regular/irregular contractions
This is the physiological process by which REGULARLY OCCURING uterine contractions

result in PROGRESSIVE effacement and dilation of the cervix.
If a woman is 2/100/0 and came back after walking and is still 2/100/0-she is not in labor-maybe
early labor. But since she is not progressing, it would not be considered active labor.
Contractions begin irregular and short and then become more regular and stringer-every 20 min.
Mother will get Braxton-Hicks contractions during last tri mester
Active labor is contractions every 2-3 minutes lasting 1 minute long.
Encourage mother in early labor to eat light food, resting and walking. Take shower and rest then
walk. If mother is in true labor-with walking contractions will progress.
Woman should be informed that she will not be admitted is she is 3 cm or less dilated.
Assess time and onset of contractions and progress in terms of frequency, duration and intensity
Location and character of discomfort from contractions (e.g. back pain, suprapubic discomfort)
Persistence of contractions despite changes in maternal position and activity (walking or lying
down)
Presence and character of vaginal discharge and show
Status of membranes-ROM?
Bloody show-mucousy/bloody
Admission asses-anything not found in prenatal record
Birth plan
1. ID beliefs/practices of selected cultures about labor and birth

Mexico-woman may be stoic about discomfort until second stage, then may request pain relief;
fathers and female relatives may be present
China-stoic response to pain; fathers usually not present; side lying position preferred for labor
and birth-because this position thought to reduce infant trauma.
Japan-natural childbirth methods-may labor in silent may eat during labor; father may be
present
India-natural childbirth preferred; father is usually not present female relatives usually present.
Iran-father not present; female support

1. Describe the nursing responsibilities for a woman receiving analgesia or anesthesia

during labor.

Marked hypotension, impaired placental perfusion, and an ineffective breathing pattern may
occur during spinal anesthesia. Before induction of the spinal anesthetic (block), the woman’s
fluid balance is assessed, and IV fluid usually is administered to decrease the potential for
hypotension caused by sympathetic blockade (vasodilation with pooling of blood in the lower
extremities decreases cardiac output).

After induction of the anesthetic maternal BP, pulse, resp and FHR and pattern must be checked
and documented Q 5-10 min. If s+s of maternal hypotension or fetal distress develop, turn
woman to lateral position or place pillow or wedge under hip to displace uterus
Maintain IV infusion or increase as needed.
Administer O2 by face mask at 10-12 L/min

Elevate woman’s legs
1. ID methods of labor induction.

Both chemical and mechanical methods are used to induce labor. IV oxytocin and amniotomy
are the most common. Prostaglandins are used as well. Less common methods are stripping
membranes, nipple stimulation, and acupuncture.
Chemical agents-
Prostaglandin E1 and E2 can be used before induction to “ripen” (soften and thin) the cervix
Oxytocin-a hormaone naturally produced by the posterior pituitary gland; it stimulates uterine
contractions. It may be used either to induce labor or to augment a labor that is progressing
slowly because of inadequate uterine contractions.
Mechanical methods-
Mechanical dilators ripen the cervix by stimulating the release of endogenous prostaglandins
Balloon catheters can be inserted into the cervical canal to ripen and dilate the cervix.
Amniotomy- AROM
Common augmentation methods include oxytocin infusion, amniotomy, and nipple stimulation.
Noninvasive methods such as emptying the bladder, ambulation, and position changes, relaxation
measures, nourishment and hydration, and hydrotherapy should be attempted before invasive
interventions are initiated.
1. Describe nursing management of the woman whose labor is being induced.

Encourage woman to void before beginning protocol to prevent discomfort and remove a barrier
to labor progress
Obtain a 15-20 min baseline FHR strip to ensure adequate assessment of FHR and pattern and
contractions
Position woman in side lying position and administer oxytocin using IV
Regulate oxytocin to evaluate woman’s response and to prevent hyperstimulation and fetal
hypoxia-if hypertonicity or signs of fetal distress are detected, d/c oxytocin immed! Turn woman
on her side to increase placental blood flow.
Monitor maternal v.s. Q 30-60 min to assess for oxytocin induced hypertension
Monitor FHR and contractility pattern Q 15 min.
Monitor I+O-to assess for urinary retention and prevent water intox.
Monitor progress of labor-dilation, effacement, and station
Prepare mother for increase in contractions once oxytocin is started
Review relaxation techniques, breathing, massage
Ask if wants anything for pain.
1. Discuss the actions, side effects and precautions in the use of oxytocin to induce labor
See above
1. Describe the reasons for the use of forceps and the vacuum extractor and possible
maternal and fetal complications.
Reasons-forceps
Used to assist in the birth of the fetal head.
Maternal indications for forceps assisted birth include the need to shorten the second stage of
labor in the event of dystocia or to compensate for the woman’s deficient expulsive efforts (if she
has been given an epidural) or to prevent worsening a dangerous condition (cardia
decompensation)
Fetal indications include birth of a fetus in distress or in certain abnormal presentations; arrest of
rotation; or delivery of the head in a breech presentation.
Complications-forceps
The mother is assessed for vaginal and cervical lacerations; urine retention, which may result
from bladder or urethral injuries; and hematoma formation in the pelvic soft tissues which may
result from b.v. damage.
The infant should be assessed for bruising or abrasions as the site of the blade applications, facial
palsy resulting from pressure of the blades on the facial nerve and subdural hematoma.
Reasons-vacuum
A birth method involving the attachment of a vacuum cup to the fetal head and using negative
pressure to assist in the birth of the head.
Indications for use are similar to those for forceps.
Complications-vacuum
Maternal complications are uncommon but can include perineal, vaginal, or cervical lacerations
and soft-tissue hematomas
Fetal complications include cephalhematoma, scalp lacerations, and subdural hematoma.
1. ID the components of routine preoperative, intraoperative, and postoperative nursing

care for a cesarean delivery.
1. Discuss the nurse’s responsibility when caring for the client undergoing VBAC

1. ID the most common causes of dystocia as they relate to the mechanics of labor.
Dystocia is defined as long, difficult, or abnormal labor. It is suspected when there is an
alteration in the characteristics of uterine contractions, a lack of progress in the rate of cervical
dilation, or lack of progress in fetal descent or expulsion.
1. ineffective uterine contractions or maternal bearing down efforts-most common cause of

dystocia
2. alterations in pelvic structure
3. abnormal presentation, position, anomalies, excessive size, and number of fetus’s
4. maternal position during labor and birth
5. psychologic responses of mother to labor
1. ID three primary clinical characteristics of amniotic fluid embolism

1. ID factors that influence the course of labor.
1. passenger-fetus
2. passageway-birth canal
3. powers-contractions
4. position of the mother
5. psychological response
1. Describe the anatomical structure of the pelvis.

The true pelvis is the most significant part in L&D. It consists of the inlet, midpelvis, and outlet.
1. The inlet is where the baby has engaged. If the baby engages in the inlet we have a good
sense that the baby will fit through the pelvis. The inlet is the smallest diameter anterior and
posterior.
2. The outlet is the ischeal spine-it is the smallest diameter. When the baby reaches this part of
the pelvis it is at 0 station.
The pelvis is measured when the woman comes into the office in the first trimester. It is
measured again before delivery. The measurements will be larger in labor because the joints are
relaxed.
The Gynecoid pelvis is the most ideal pelvis for child bearing-50% of women have this pelvis.
1. Describe the internal pelvic measurements.

Inlet-12.5-13 cm
Midplane-10.5 cm-the largest plane and the one of the greatest diameter
Outlet->8cm-the outlet presents the smallest plane of the pelvic canal.

1. Differentiate between fetal lie, attitude, presentation, and position.
Attitude
This is the relationship of fetal parts to each other.
Is the head:
1. flexed-chin to neck-ideal position

2. deflexed (military)-straight
3. Extended (mentum)-neck back.
Lie
The relationship of the long axis of the fetus to the long axis of the mother. The baby is born at
longitudinal lie. Breech would be considered longitudinal lie as well. Transverse is another lie-
when transverse the presenting part is the babies shoulder.
Presentation
This is the part of the fetus that enters the pelvis first.
Can either be:
1. vertex of cephalic-forehead, face, chin/mentum

2. breech
3. shoulder
LOA (Left occipital anterior) is the easiest delivery. This is when the back of the baby’s head is
facing the left part of the pelvis. The landmark on the baby’s head is the posterior fontanel-find
out if it is on the left or right side of the mother’s pelvis.
LOP (Left occipital posterior) this position is not ideal-birth will be harder. The baby will be
born face up. The nurse can facilitate helping the baby change positions by changing the
mother’s position.
For both the LOA and LOP-will find the FHR in different places on the mother’s abdomen.
When baby is in LOA, the fetal tones will be below the umbilicus toward the umbilicus. When
the baby is in ROP, the fetal tones will be below the umbilicus but rotated out to the side. This is
a red flag that baby is posterior.
The letters mean Left or Right side of pelvis; scapula, occiput (head is in flexed position),
mentum (extension position), breech; anterior/posterior/transverse-more ideal to be anterior.
24. ID the major bones, fontanels, sutures, and diameters of the fetal skull
The fetal skull is composed of two parietal bones, two temporal bones, the frontal bone and the
occipital bone. These bones are united by the membranous sutures; sagittal, lamboidal, coronal,
and frontal. The membrane filled spaces called fontanels are located where the sutures intersect.
The two most important fontanels are the anterior and posterior ones. The larger of these, the
anterior fontanel, is diamond shaped, is about 3 cm by 2 cm, and lies at the junction of the
sagittal, coronal, and frontal sutures. The posterior fontanel lies at the junction of the sutures of
the two parietal bones and the occipital bone, is triangular and is about 1 cm by 2 cm.
25. Summarize theories proposed to explain the onset of labor.

1. changes in the maternal uterus
2. changes in cervix
3. pituitary gland
4. hormones produced by the normal fetal hypothalamus, pituitary, and adrenal cortex
5. progressive uterine distension
6. increasing intrauterine pressure
7. aging of the placenta
8. increasing myometrial irritability- this is a result of increased concentration of estrogen and
prostaglandins as well as decreasing progesterone levels.-the coordination of these factors
result in occurrence of strong, regular, rhythmic contractions

1. ID premonitory signs of labor.
1. Uterine contractions occurring Q 10 min or more frequently persisting for 1 hour or more
2. uterine contractions may be painful or painless
3. Lower ab cramping similar to gas pains may be accompanied by diarrhea
4. dull intermittent low back pain
5. painful menstrual like cramps
6. suprapubic pain or pressure
7. pelvic pressure or heaviness-feeling that baby is pushing down
8. urinary freq
9. change in amount of discharge-
10. ROM

1. Differentiate the signs of true versus false labor.
True Labor
Contractions-occur regularly, lasting longer, and occurring closer together.
Contractions become more intense with walking
Usually felt in the lower back and radiate to lower part of ab.
Cervix shows progressive change-softening, effacement and dilation-bloody show
The presenting part of the fetus becomes engaged in the pelvis

False Labor
Contractions occur irregularly
Contractions stop with walking or position change
Contractions can be felt in the back or abdomen above the navel
Contractions stopped by use of comfort measures
Cervix may be soft, but no sig change in effacement or dilation or evidence of bloody show
Fetus presenting part is not engaged in pelvis

1. Discuss the cardinal movements that are involved in the process of labor and birth.
1. engagement and descent-LOA
2. Flexion-forces head to flex even more chin into neck-this flexion permits the smaller
subocipitobregmatic diameter (9.5 cm) rather than the larger diameters to present to the
outlet.
3. Internal rotation to occipitoanterior position OA- the maternal pelvic inlet is widest in the
transverse diameter; therefore the fetal head passes the inlet into the true pelvis in the
occipitotransverse position. The outlet is widest in the anteroposterior diameter; for the fetus
to exit, the head must rotate. Internal rotation begins at the level of the ischial spines but is
not completed until the presenting part reaches the lower pelvis. As the occiput rotates
anteriorly, the face rotates posteriorly.
4. Extension-as baby comes-lower head extends-when the fetal head reaches the perineum for
birth, it is deflected anteriorly by the perineum. The occiput passes under the lower border of
the symphosis pubis first and then the head emerges by extension; first the occiput, then the
face and finally the chin
5. External rotation-beginning-because babies’ shoulders turn, the head turns too. The head will
turn in position. After the head is born, it rotates briefly to the position it occupied when it
was engaged in the inlet. The 45 degree turn realigns the infant’s head with her back and
shoulders.
Hot
 44 °C (111.2 °F) or more – Almost certainly death will occur; however, people have been
known to survive up to 46.5 °C (115.7 °F).

 43 °C (109.4 °F) – Normally death, or there may be serious brain damage, continuous
convulsions and shock. Cardio-respiratory collapse will likely occur.
 42 °C (107.6 °F) – Subject may turn pale or remain flushed and red. They may become
comatose, be in severe delirium, vomiting, and convulsions can occur. Blood pressure may
be high or low and heart rate will be very fast.
 41 °C (105.8 °F) – (Medical emergency) – Fainting, vomiting, severe headache, dizziness,
confusion, hallucinations, delirium and drowsiness can occur. There may also be palpitations
and breathlessness.
 40 °C (104.0 °F) – Fainting, dehydration, weakness, vomiting, headache, breathlessness and
dizziness may occur as well as profuse sweating. Starts to be life-threatening.
 39 °C (102.2 °F) – Severe sweating, flushed and red. Fast heart rate and breathlessness.
There may be exhaustion accompanying this. Children and people with epilepsy may be very
likely to get convulsions at this point.
 38 °C (100.4 °F) – (this is classed as hyperthermia if not caused by a fever) Feeling hot,
sweating, feeling thirsty, feeling very uncomfortable, slightly hungry. If this is caused
by fever, there may also be chills.
Normal
 37 °C (98.6 °F) – Normal internal body temperature (which varies between about 36.12–
37.8 °C (97.02–100.04 °F)
Cold
 36 °C (97 °F) – Feeling cold, mild to moderate shivering (body temperature may drop this
low during sleep). May be a normal body temperature.
 35 °C (95 °F) – (Hypothermia is less than 35 °C (95 °F)) – Intense shivering, numbness and
bluish/grayness of the skin. There is the possibility of heart irritability.
 34 °C (93 °F) – Severe shivering, loss of movement of fingers, blueness and confusion.
Some behavioral changes may take place.
 33 °C (91 °F) – Moderate to severe confusion, sleepiness, depressed reflexes, progressive
loss of shivering, slow heartbeat, shallow breathing. Shivering may stop. Subject may be
unresponsive to certain stimuli.
 32 °C (90 °F) – (Medical emergency) Hallucinations, delirium, complete confusion, extreme
sleepiness that is progressively becoming comatose. Shivering is absent (subject may even
think they are hot). Reflex may be absent or very slight.
 31 °C (88 °F) – Comatose, very rarely conscious. No or slight reflexes. Very shallow
breathing and slow heart rate. Possibility of serious heart rhythm problems.
 28 °C (82 °F) – Severe heart rhythm disturbances are likely and breathing may stop at any
time. Patient may appear to be dead.
 24–26 °C (75–79 °F) or less – Death usually occurs due to irregular heart beat or respiratory
arrest; however, some patients have been known to survive with body temperatures as low as
14.2 °C (57.5 °F).[17]

Airway - Obstruction and Asthma

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Airway – Obstruction and

1. Take a full medication history

1. Adult respiratory distress syndrome (ARDS)

1. Adult respiratory distress syndrome (ARDS)

1. All clients are recommended to have these vaccines

1. It enhances cardiovascular fitness.

1. Reducing fluid volume reduces oxygen demand.

1. The client doesn’t notice he needs to breathe.

1. Inhaled beta-adrenergic agents

Ans-20. 1. Inhaled beta-adrenergic agents help promote bronchodilation, which improves

1. Arterial blood gas (ABG) and breath sounds

24. A client is in danger of respiratory arrest following the administration of a narcotic

26. Emergency treatment for a client with impending anaphylaxis secondary to

1. Administer beta-adrenergic blockers

Ans-29. 1. Respiratory acidosis is most often due to hypoventilation. Chronic respiratory

1. Sodium level of 145 mEq/L

Ans-30. 2. Clinical manifestations of respiratory alkalosis include headache, tachypnea,

1. Metabolic acidosis, compensated.

1. Respirations that are abnormally deep, regular, and increased in rate.

Ans-36. 4. Increases in base components occur as a result of oral or parenteral intake of

1. Sodium level of 145 mEq/L

Ans-37. 3. Clinical manifestations of metabolic acidosis include hyperpnea with Kussmaul’s

1. Ask the client to open and close the hand repeatedly.

Ans-38. 5, 2, 1, 4, and then 3.

43. An unconscious client is admitted to an emergency room. Arterial blood gas

1. Increased oxygen saturation with exercise

Ans-44. 3. Clinical manifestations of COPD include hypoxemia, hypercapnia, dyspnea on

1. Promote oxygen intake

1. Respiratory acidosis uncompensated

1. “Is there any possibility that you could be pregnant?”

1. Encouraging additional fluids for the next 24 hours

1. Chronic obstructive bronchitis

1. Decreased anxiety level

Ans-58. 4. Benzonatate is a locally acting antitussive the effectiveness of which is measured by

1. Maintain a fluid intake of 800ml every 24 hours.

1. A 60-year-old man with a hiatal hernia

1. It is likely that the client is developing a secondary bacterial pneumonia.

Ans-64. 4. Side effects of pseudoephedrine are experienced primarily in the cardiovascular

1. Altered nutrition: Less than body requirements related to fatigue.

1. Develop infections easily

1. Promises to do pursed lip breathing at home.

Ans-68. 1. Increased anteroposterior chest diameter is characteristic of advanced COPD. Air is

1. To promote oxygen intake

1. Maintaining functional ability

1. While inhaling through an open mouth.

1. Clubbing of nail beds

Ans-73. 3. Right-sided heart failure is a complication of COPD that occurs because of

1. Normal breath sounds

Ans-74. 4. Exacerbations of COPD are frequently caused by respiratory infections. Coarse

1. Low fat, low cholesterol

1. Initiate oxygen therapy and reassess the client in 10 minutes.

1. Decreased PaCO2, increased PaO2, and decreased pH.

1. Corticosteroids promote bronchodilation

1. The inhaler is held upright.

1. “This is an anticipated side-effect of your medication. It should go away in a couple of

1. Incorporate physical exercise as tolerated into the treatment plan.

1. Occupational exposure to toxins

1. Begin mechanical ventilation

1. Caused by the sudden opening of alveoli

1. Wait until the client’s lab work is done.

89. Immediately following a thoeacentesis, which clinical manifestations indicate that a

1. Serosanguineous drainage from the puncture site

1. Observe the chest rising and falling