PNLE 3 – CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL Blood pressure is decreased from 160/90 to 110/70.

ALTERATIONS Pulse is increased from 87 to 95, with an occasional skipped beat.

The client is oriented when aroused from sleep, and goes back
1. Nurse Michelle should know that the drainage is normal 4 days to sleep immediately.
after a sigmoid colostomy when the stool is: The client refuses dinner because of anorexia.
Green liquid 11.Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of
Solid formed the following symptoms may appear first?
Loose, bloody Altered mental status and dehydration
Semiformed Fever and chills
2. Where would nurse Kristine place the call light for a male client Hemoptysis and Dyspnea
with a right-sided brain attack and left homonymous hemianopsia? Pleuritic chest pain and cough
On the client’s right side 12. A male client has active tuberculosis (TB). Which of the following
On the client’s left side symptoms will be exhibit?
Directly in front of the client Chest and lower back pain
Where the client like Chills, fever, night sweats, and hemoptysis
3. A male client is admitted to the emergency department following Fever of more than 104°F (40°C) and nausea
an accident. What are the first nursing actions of the nurse? Headache and photophobia
Check respiration, circulation, neurological response. 13. Mark, a 7-year-old client is brought to the emergency
Align the spine, check pupils, and check for hemorrhage. department. He’s tachypneic and afebrile and has a respiratory rate
Check respirations, stabilize spine, and check circulation. of 36 breaths/minute and has a nonproductive cough. He recently
Assess level of consciousness and circulation. had a cold. Form this history; the client may have which of the
4. In evaluating the effect of nitroglycerin, Nurse Arthur should know following conditions?
that it reduces preload and relieves angina by: Acute asthma
Increasing contractility and slowing heart rate. Bronchial pneumonia
Increasing AV conduction and heart rate. Chronic obstructive pulmonary disease (COPD)
Decreasing contractility and oxygen consumption. Emphysema
Decreasing venous return through vasodilation. 14. Marichu was given morphine sulfate for pain. She is sleeping and
5. Nurse Patricia finds a female client who is post-myocardial her respiratory rate is 4 breaths/minute. If action isn’t taken quickly,
infarction (MI) slumped on the side rails of the bed and she might have which of the following reactions?
unresponsive to shaking or shouting. Which is the nurse next action? Asthma attack
Call for help and note the time. Respiratory arrest
Clear the airway Seizure
Give two sharp thumps to the precordium, and check the pulse. Wake up on his own
Administer two quick blows. 15. A 77-year-old male client is admitted for elective knee surgery.
6. Nurse Monett is caring for a client recovering from gastro- Physical examination reveals shallow respirations but no sign of
intestinal bleeding. The nurse should: respiratory distress. Which of the following is a normal physiologic
Plan care so the client can receive 8 hours of uninterrupted change related to aging?
sleep each night. Increased elastic recoil of the lungs
Monitor vital signs every 2 hours. Increased number of functional capillaries in the alveoli
Make sure that the client takes food and medications at Decreased residual volume
prescribed intervals. Decreased vital capacity
Provide milk every 2 to 3 hours. 16. Nurse John is caring for a male client receiving lidocaine I.V.
7. A male client was on warfarin (Coumadin) before admission, and Which factor is the most relevant to administration of this
has been receiving heparin I.V. for 2 days. The partial medication?
thromboplastin time (PTT) is 68 seconds. What should Nurse Carla Decrease in arterial oxygen saturation (SaO2) when measured with
do? a pulse oximeter.
Stop the I.V. infusion of heparin and notify the physician. Increase in systemic blood pressure.
Continue treatment as ordered. Presence of premature ventricular contractions (PVCs) on a
Expect the warfarin to increase the PTT. cardiac monitor.
Increase the dosage, because the level is lower than normal. Increase in intracranial pressure (ICP).
8. A client undergone ileostomy, when should the drainage 17. Nurse Ron is caring for a male client taking an anticoagulant. The
appliance be applied to the stoma? nurse should teach the client to:
24 hours later, when edema has subsided. Report incidents of diarrhea.
In the operating room. Avoid foods high in vitamin K
After the ileostomy begin to function. Use a straight razor when shaving.
When the client is able to begin self-care procedures. Take aspirin to pain relief.
9. A client undergone spinal anesthetic, it will be important that the 18. Nurse Lhynnette is preparing a site for the insertion of an I.V.
nurse immediately position the client in: catheter. The nurse should treat excess hair at the site by:
On the side, to prevent obstruction of airway by tongue. Leaving the hair intact
Flat on back. Shaving the area
On the back, with knees flexed 15 degrees. Clipping the hair in the area
Flat on the stomach, with the head turned to the side. Removing the hair with a depilatory.
10.While monitoring a male client several hours after a motor 19. Nurse Michelle is caring for an elderly female with osteoporosis.
vehicle accident, which assessment data suggest increasing When teaching the client, the nurse should include information
intracranial pressure? about which major complication:
Bone fracture Friction rubs
Loss of estrogen 29. The nurse is caring for Kenneth experiencing an acute asthma
Negative calcium balance attack. The client stops wheezing and breath sounds aren’t audible.
Dowager’s hump The reason for this change is that:
20. Nurse Len is teaching a group of women to perform BSE. The The attack is over.
nurse should explain that the purpose of performing the The airways are so swollen that no air cannot get through.
examination is to discover: The swelling has decreased.
Cancerous lumps Crackles have replaced wheezes.
Areas of thickness or fullness 30. Mike with epilepsy is having a seizure. During the active seizure
Changes from previous examinations. phase, the nurse should:
Fibrocystic masses Place the client on his back remove dangerous objects, and insert
21. When caring for a female client who is being treated for a bite block.
hyperthyroidism, it is important to: Place the client on his side, remove dangerous objects, and insert
Provide extra blankets and clothing to keep the client warm. a bite block.
Monitor the client for signs of restlessness, sweating, and Place the client o his back, remove dangerous objects, and hold
excessive weight loss during thyroid replacement therapy. down his arms.
Balance the client’s periods of activity and rest. Place the client on his side, remove dangerous objects, and protect
Encourage the client to be active to prevent constipation. his head.
22. Nurse Kris is teaching a client with history of atherosclerosis. To 31. After insertion of a cheat tube for a pneumothorax, a client
decrease the risk of atherosclerosis, the nurse should encourage the becomes hypotensive with neck vein distention, tracheal shift,
client to: absent breath sounds, and diaphoresis. Nurse Amanda suspects a
Avoid focusing on his weight. tension pneumothorax has occurred. What cause of tension
Increase his activity level. pneumothorax should the nurse check for?
Follow a regular diet. Infection of the lung.
Continue leading a high-stress lifestyle. Kinked or obstructed chest tube
23. Nurse Greta is working on a surgical floor. Nurse Greta must Excessive water in the water-seal chamber
logroll a client following a: Excessive chest tube drainage
Laminectomy 32. Nurse Maureen is talking to a male client, the client begins
Thoracotomy choking on his lunch. He’s coughing forcefully. The nurse should:
Hemorrhoidectomy Stand him up and perform the abdominal thrust maneuver from
Cystectomy. behind.
24. A 55-year old client underwent cataract removal with intraocular Lay him down, straddle him, and perform the abdominal
lens implant. Nurse Oliver is giving the client discharge instructions. thrust maneuver.
These instructions should include which of the following? Leave him to get assistance
Avoid lifting objects weighing more than 5 lb (2.25 kg). Stay with him but not intervene at this time.
Lie on your abdomen when in bed 33. Nurse Ron is taking a health history of an 84 year old client.
Keep rooms brightly lit. Which information will be most useful to the nurse for planning
Avoiding straining during bowel movement or bending at the waist. care?
25. George should be taught about testicular examinations during: General health for the last 10 years.
when sexual activity starts Current health promotion activities.
After age 69 Family history of diseases.
After age 40 Marital status.
Before age 20. 34. When performing oral care on a comatose client, Nurse Krina
26. A male client undergone a colon resection. While turning him, should:
wound dehiscence with evisceration occurs. Nurse Trish first Apply lemon glycerin to the client’s lips at least every 2 hours.
response is to: Brush the teeth with client lying supine.
Call the physician Place the client in a side lying position, with the head of the
Place a saline-soaked sterile dressing on the wound. bed lowered.
Take a blood pressure and pulse. Clean the client’s mouth with hydrogen peroxide.
Pull the dehiscence closed. 35. A 77-year-old male client is admitted with a diagnosis of
27. Nurse Audrey is caring for a client who has suffered a dehydration and change in mental status. He’s being hydrated with
severe cerebrovascular accident. During routine assessment, the L.V. fluids. When the nurse takes his vital signs, she notes he has a
nurse notices Cheyne- Strokes respirations. Cheyne-strokes fever of 103°F (39.4°C) a cough producing yellow sputum and
respirations are: pleuritic chest pain. The nurse suspects this client may have which of
A progressively deeper breaths followed by shallower breaths the following conditions?
with apneic periods. Adult respiratory distress syndrome (ARDS)
Rapid, deep breathing with abrupt pauses between each breath. Myocardial infarction (MI)
Rapid, deep breathing and irregular breathing without pauses. Pneumonia
Shallow breathing with an increased respiratory rate. Tuberculosis
28. Nurse Bea is assessing a male client with heart failure. The 36. Nurse Oliver is working in a out patient clinic. He has been
breath sounds commonly auscultated in clients with heart failure alerted that there is an outbreak of tuberculosis (TB). Which of the
are: following clients entering the clinic today most likely to have TB?
Tracheal A 16-year-old female high school student
Fine crackles A 33-year-old day-care worker
Coarse crackles A 43-yesr-old homeless man with a history of alcoholism
A 54-year-old businessman
37. Virgie with a positive Mantoux test result will be sent for a chest
X-ray. The nurse is aware that which of the following reasons this is
done?
To confirm the diagnosis
To determine if a repeat skin test is needed
To determine the extent of lesions
To determine if this is a primary or secondary infection
38. Kennedy with acute asthma showing inspiratory and expiratory
wheezes and a decreased forced expiratory volume should be
treated with which of the following classes of medication right
away?
Beta-adrenergic blockers
Bronchodilators
Inhaled steroids
Oral steroids
39. Mr. Vasquez 56-year-old client with a 40-year history of smoking
one to two packs of cigarettes per 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?
Adult respiratory distress syndrome (ARDS)
Asthma
Chronic obstructive bronchitis
Emphysema
Situation: Francis, age 46 is admitted to the hospital with diagnosis
of Chronic Lymphocytic Leukemia.
40. The treatment for patients with leukemia is bone marrow
transplantation. Which statement about bone marrow
transplantation is not correct?
The patient is under local anesthesia during the procedure
The aspirated bone marrow is mixed with heparin.
The aspiration site is the posterior or anterior iliac crest.
The recipient receives cyclophosphamide (Cytoxan) for 4
consecutive days before the procedure.
41. After several days of admission, Francis becomes disoriented and
complains of frequent headaches. The nurse in-charge first action
would be:
Call the physician
Document the patient’s status in his charts.
Prepare oxygen treatment
Raise the side rails
42. During routine care, Francis asks the nurse, “How can I be
anemic if this disease causes increased my white blood cell
production?” The nurse in-charge best response would be that the
increased number of white blood cells (WBC) is:
Crowd red blood cells
Are not responsible for the anemia.
Uses nutrients from other cells
Have an abnormally short life span of cells.
43. Diagnostic assessment of Francis would probably not reveal:
Predominance of lymhoblasts
Leukocytosis
Abnormal blast cells in the bone marrow
Elevated thrombocyte counts
44. Robert, a 57-year-old client with acute arterial occlusion of the
left leg undergoes an emergency embolectomy. Six hours later, the
nurse isn’t able to obtain pulses in his left foot using Doppler
ultrasound. The nurse immediately notifies the physician, and asks
her to prepare the client for surgery. As the nurse enters the client’s
room to prepare him, he states that he won’t have any
more surgery. Which of the following is the best initial response by
the nurse?
Explain the risks of not having the surgery
Notifying the physician immediately
Notifying the nursing supervisor
Recording the client’s refusal in the nurses’ notes
45. During the endorsement, which of the following clients should
the on-duty nurse assess first?
The 58-year-old client who was admitted 2 days ago with heart
failure, blood pressure of 126/76 mm Hg, and a respiratory rate of
22 breaths/minute.
The 89-year-old client with end-stage right-sided heart failure,
blood pressure of 78/50 mm Hg, and a “do not resuscitate” order
The 62-year-old client who was admitted 1 day ago
with thrombophlebitis and is receiving L.V. heparin
The 75-year-old client who was admitted 1 hour ago with new-
onset atrial fibrillation and is receiving L.V. dilitiazem (Cardizem)
46. Honey, a 23-year old client complains of substernal chest pain
and states that her heart feels like “it’s racing out of the chest”. She
reports no history of cardiac disorders. The nurse attaches her to a
cardiac monitor and notes sinus tachycardia with a rate of
136beats/minutes. Breath sounds are clear and the respiratory rate
is 26 breaths/minutes. Which of the following drugs should
the nurse question the client about using?
Barbiturates
Opioids
Cocaine
Benzodiazepines
47. A 51-year-old female client tells the nurse in-charge that she has
found a painless lump in her right breast during her monthly self-
examination. Which assessment finding would strongly suggest that
this client’s lump is cancerous?
Eversion of the right nipple and mobile mass
Nonmobile mass with irregular edges
Mobile mass that is soft and easily delineated
Nonpalpable right axillary lymph nodes
48. A 35-year-old client with vaginal cancer asks the nurse, “What is
the usual treatment for this type of cancer?” Which treatment
should the nurse name?
Surgery
Chemotherapy
Radiation
Immunotherapy
49. Cristina undergoes a biopsy of a suspicious lesion. The biopsy
report classifies the lesion according to the TNM staging system as
follows: TIS, N0, M0. What does this classification mean?
No evidence of primary tumor, no abnormal regional lymph nodes,
and no evidence of distant metastasis
Carcinoma in situ, no abnormal regional lymph nodes, and
no evidence of distant metastasis
Can’t assess tumor or regional lymph nodes and no evidence
of metastasis
Carcinoma in situ, no demonstrable metastasis of the regional
lymph nodes, and ascending degrees of distant metastasis
50. Lydia undergoes a laryngectomy to treat laryngeal cancer. When
teaching the client how to care for the neck stoma, the nurse should
include which instruction?
“Keep the stoma uncovered.”
“Keep the stoma dry.”
“Have a family member perform stoma care initially until you get
used to the procedure.”
“Keep the stoma moist.”
51. A 37-year-old client with uterine cancer asks the nurse, “Which is
the most common type of cancer in women?” The nurse replies that
it’s breast cancer. Which type of cancer causes the most deaths in
women?
Breast cancer
Lung cancer
Brain cancer
Colon and rectal cancer
52. Antonio with lung cancer develops Horner’s syndrome when the
tumor invades the ribs and affects the sympathetic nerve ganglia.
When assessing for signs and symptoms of this syndrome, the nurse
should note:
miosis, partial eyelid ptosis, and anhidrosis on the affected side of
the face.
chest pain, dyspnea, cough, weight loss, and fever.
arm and shoulder pain and atrophy of arm and hand muscles, both
on the affected side.
hoarseness and dysphagia.
53. Vic asks the nurse what PSA is. The nurse should reply that it
stands for:
prostate-specific antigen, which is used to screen for prostate
cancer.
protein serum antigen, which is used to determine protein levels.
pneumococcal strep antigen, which is a bacteria that
causes pneumonia.
Papanicolaou-specific antigen, which is used to screen for
cervical cancer.
54. What is the most important postoperative instruction that nurse
Kate must give a client who has just returned from the operating
room after receiving a subarachnoid block?
“Avoid drinking liquids until the gag reflex returns.”
“Avoid eating milk products for 24 hours.”
“Notify a nurse if you experience blood in your urine.”
“Remain supine for the time specified by the physician.”
55. A male client suspected of having colorectal cancer will require
which diagnostic study to confirm the diagnosis?
Stool Hematest
Carcinoembryonic antigen (CEA)
Sigmoidoscopy
Abdominal computed tomography (CT) scan
56. During a breast examination, which finding most strongly
suggests that the Luz has breast cancer?
Slight asymmetry of the breasts.
A fixed nodular mass with dimpling of the overlying skin
Bloody discharge from the nipple
Multiple firm, round, freely movable masses that change with
the menstrual cycle
57. A female client with cancer is being evaluated for possible
metastasis. Which of the following is one of the most common
metastasis sites for cancer cells?
Liver
Colon
Reproductive tract
White blood cells (WBCs)
58. Nurse Mandy is preparing a client for magnetic resonance
imaging (MRI) to confirm or rule out a spinal cord lesion. During the
MRI scan, which of the following would pose a threat to the client?
The client lies still.
The client asks questions.
The client hears thumping sounds.
The client wears a watch and wedding band.
59. Nurse Cecile is teaching a female client about preventing
osteoporosis. Which of the following teaching points is correct?
Obtaining an X-ray of the bones every 3 years is recommended
to detect bone loss.
To avoid fractures, the client should avoid strenuous exercise.
The recommended daily allowance of calcium may be found in a
wide variety of foods.
Obtaining the recommended daily allowance of calcium requires
taking a calcium supplement.
60. Before Jacob undergoes arthroscopy, the nurse reviews the
assessment findings for contraindications for this procedure. Which
finding is a contraindication?
Joint pain
Joint deformity
Joint flexion of less than 50%
Joint stiffness
61. Mr. Rodriguez is admitted with severe pain in the knees. Which
form of arthritis is characterized by urate deposits and joint pain,
usually in the feet and legs, and occurs primarily in men over age
30?
Septic arthritis
Traumatic arthritis
Intermittent arthritis
Gouty arthritis
62. A heparin infusion at 1,500 unit/hour is ordered for a 64-year-old
client with stroke in evolution. The infusion contains 25,000 units of
heparin in 500 ml of saline solution. How many milliliters per hour
should be given?
15 ml/hour
30 ml/hour
45 ml/hour
50 ml/hour
63. A 76-year-old male client had a thromboembolic right stroke; his
left arm is swollen. Which of the following conditions may cause
swelling after a stroke?
Elbow contracture secondary to spasticity
Loss of muscle contraction decreasing venous return
Deep vein thrombosis (DVT) due to immobility of the ipsilateral side
Hypoalbuminemia due to protein escaping from an
inflamed glomerulus
64. Heberden’s nodes are a common sign of osteoarthritis. Which of
the following statement is correct about this deformity?
It appears only in men
It appears on the distal interphalangeal joint
It appears on the proximal interphalangeal joint
It appears on the dorsolateral aspect of the interphalangeal joint.
65. Which of the following statements explains the main difference
between rheumatoid arthritis and osteoarthritis?
Osteoarthritis is gender-specific, rheumatoid arthritis isn’t
Osteoarthritis is a localized disease rheumatoid arthritis is systemic
Osteoarthritis is a systemic disease, rheumatoid arthritis is localized
Osteoarthritis has dislocations and subluxations, rheumatoid
arthritis doesn’t
66. Mrs. Cruz uses a cane for assistance in walking. Which of the
following statements is true about a cane or other assistive devices?
A walker is a better choice than a cane.
The cane should be used on the affected side
The cane should be used on the unaffected side
A client with osteoarthritis should be encouraged to ambulate
without the cane
67. A male client with type 1 diabetes is scheduled to receive 30 U of
70/30 insulin. There is no 70/30 insulin available. As a substitution,
the nurse may give the client:
9 U regular insulin and 21 U neutral protamine Hagedorn (NPH).
21 U regular insulin and 9 U NPH.
10 U regular insulin and 20 U NPH.
20 U regular insulin and 10 U NPH.
68. Nurse Len should expect to administer which medication to a
client with gout?
aspirin
furosemide (Lasix)
colchicines
calcium gluconate (Kalcinate)
69. Mr. Domingo with a history of hypertension is diagnosed with Acid phosphatase level
primary hyperaldosteronism. This diagnosis indicates that the Serum calcitonin level
client’s hypertension is caused by excessive hormone secretion from Alkaline phosphatase level
which of the following glands? Carcinoembryonic antigen level
Adrenal cortex 78. Francis with anemia has been admitted to the medical-surgical
Pancreas unit. Which assessment findings are characteristic of iron-deficiency
Adrenal medulla anemia?
Parathyroid Nights sweats, weight loss, and diarrhea
70. For a diabetic male client with a foot ulcer, the doctor orders bed Dyspnea, tachycardia, and pallor
rest, a wetto- dry dressing change every shift, and blood glucose Nausea, vomiting, and anorexia
monitoring before meals and bedtime. Why are wet-to-dry dressings Itching, rash, and jaundice
used for this client? 79. In teaching a female client who is HIV-positive about pregnancy,
They contain exudate and provide a moist wound environment. the nurse would know more teaching is necessary when the client
They protect the wound from mechanical trauma and promote says:
healing. The baby can get the virus from my placenta.”
They debride the wound and promote healing by secondary “I’m planning on starting on birth control pills.”
intention. “Not everyone who has the virus gives birth to a baby who has
They prevent the entrance of microorganisms and minimize the virus.”
wound discomfort. “I’ll need to have a C-section if I become pregnant and have a baby.”
71. Nurse Zeny is caring for a client in acute addisonian crisis. Which 80. When preparing Judy with acquired immunodeficiency syndrome
laboratory data would the nurse expect to find? (AIDS) for discharge to the home, the nurse should be sure to
Hyperkalemia include which instruction?
Reduced blood urea nitrogen (BUN) “Put on disposable gloves before bathing.”
Hypernatremia “Sterilize all plates and utensils in boiling water.”
Hyperglycemia “Avoid sharing such articles as toothbrushes and razors.”
72. A client is admitted for treatment of the syndrome of “Avoid eating foods from serving dishes shared by other
inappropriate antidiuretic hormone (SIADH). Which nursing family members.”
intervention is appropriate? 81. Nurse Marie is caring for a 32-year-old client admitted with
Infusing I.V. fluids rapidly as ordered pernicious anemia. Which set of findings should the nurse expect
Encouraging increased oral intake when assessing the
Restricting fluids client?
Administering glucose-containing I.V. fluids as ordered Pallor, bradycardia, and reduced pulse pressure
73. A female client tells nurse Nikki that she has been working hard Pallor, tachycardia, and a sore tongue
for the last 3 months to control her type 2 diabetes mellitus with Sore tongue, dyspnea, and weight gain
diet and exercise. To determine the effectiveness of the client’s Angina, double vision, and anorexia
efforts, the nurse should check: 82. After receiving a dose of penicillin, a client develops dyspnea
urine glucose level. and hypotension. Nurse Celestina suspects the client is experiencing
fasting blood glucose level. anaphylactic shock. What should the nurse do first?
serum fructosamine level. Page an anesthesiologist immediately and prepare to intubate
glycosylated hemoglobin level. the client.
74. Nurse Trinity administered neutral protamine Hagedorn (NPH) Administer epinephrine, as prescribed, and prepare to intubate
insulin to a diabetic client at 7 a.m. At what time would the nurse the client if necessary.
expect the client to be most at risk for a hypoglycemic reaction? Administer the antidote for penicillin, as prescribed, and continue
10:00 am to monitor the client’s vital signs.
Noon Insert an indwelling urinary catheter and begin to infuse I.V. fluids
4:00 pm as ordered.
10:00 pm 83. Mr. Marquez with rheumatoid arthritis is about to begin aspirin
75. The adrenal cortex is responsible for producing which therapy to reduce inflammation. When teaching the client about
substances? aspirin, the nurse discusses adverse reactions to prolonged aspirin
Glucocorticoids and androgens therapy. These include:
Catecholamines and epinephrine weight gain.
Mineralocorticoids and catecholamines fine motor tremors.
Norepinephrine and epinephrine respiratory acidosis.
76. On the third day after a partial thyroidectomy, Proserfina bilateral hearing loss.
exhibits muscle twitching and hyperirritability of the nervous 84. A 23-year-old client is diagnosed with human immunodeficiency
system. When questioned, the client reports numbness and tingling virus (HIV). After recovering from the initial shock of the diagnosis,
of the mouth and fingertips. Suspecting a lifethreatening electrolyte the client expresses a desire to learn as much as possible about HIV
disturbance, the nurse notifies the surgeon immediately. Which and acquired immunodeficiency syndrome (AIDS). When teaching
electrolyte disturbance most commonly follows thyroid surgery? the client about the immune system, the nurse states that adaptive
Hypocalcemia immunity is provided by which type of white blood cell?
Hyponatremia Neutrophil
Hyperkalemia Basophil
Hypermagnesemia Monocyte
77. Which laboratory test value is elevated in clients who smoke and Lymphocyte
can’t be used as a general indicator of cancer?
85. In an individual with Sjögren’s syndrome, nursing care should
focus on:
moisture replacement.
electrolyte balance.
nutritional supplementation.
arrhythmia management.
86. During chemotherapy for lymphocytic leukemia, Mathew
develops abdominal pain, fever, and “horse barn” smelling diarrhea.
It would be most important for the nurse to advise the physician to
order:
enzyme-linked immunosuppressant assay (ELISA) test.
electrolyte panel and hemogram.
stool for Clostridium difficile test.
flat plate X-ray of the abdomen.
87. A male client seeks medical evaluation for fatigue, night sweats,
and a 20-lb weight loss in 6 weeks. To confirm that the client has
been infected with the human immunodeficiency virus (HIV), the
nurse expects the physician to order:
E-rosette immunofluorescence.
quantification of T-lymphocytes.
enzyme-linked immunosorbent assay (ELISA).
Western blot test with ELISA.
88. A complete blood count is commonly performed before a Joe
goes into surgery. What does this test seek to identify?
Potential hepatic dysfunction indicated by decreased blood
urea nitrogen (BUN) and creatinine levels
Low levels of urine constituents normally excreted in the urine
Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
Electrolyte imbalance that could affect the blood’s ability to
coagulate properly
89. While monitoring a client for the development of disseminated
intravascular coagulation (DIC), the nurse should take note of what
assessment parameters?
Platelet count, prothrombin time, and partial thromboplastin time
Platelet count, blood glucose levels, and white blood cell (WBC)
count
Thrombin time, calcium levels, and potassium levels
Fibrinogen level, WBC, and platelet count
90. When taking a dietary history from a newly admitted female
client, Nurse Len should remember that which of the following foods
is a common allergen?
Bread
Carrots
Orange
Strawberries
91. Nurse John is caring for clients in the outpatient clinic. Which of
the following phone calls should the nurse return first?
A client with hepatitis A who states, “My arms and legs are itching.”
A client with cast on the right leg who states, “I have a funny feeling
in my right leg.”
A client with osteomyelitis of the spine who states, “I am so
nauseous that I can’t eat.”
A client with rheumatoid arthritis who states, “I am having
trouble sleeping.”
92. Nurse Sarah is caring for clients on the surgical floor and has just
received report from the previous shift. Which of the following
clients should the nurse see first?
A 35-year-old admitted three hours ago with a gunshot wound; 1.5
cm area of dark drainage noted on the dressing.
A 43-year-old who had a mastectomy two days ago; 23 ml
of serosanguinous fluid noted in the Jackson-Pratt drain.
A 59-year-old with a collapsed lung due to an accident; no
drainage noted in the previous eight hours.
A 62-year-old who had an abdominal-perineal resection three
days ago; client complaints of chills.
93. Nurse Eve is caring for a client who had a thyroidectomy 12
hours ago for treatment of Grave’s disease. The nurse would be
most concerned if which of the following was observed?
Blood pressure 138/82, respirations 16, oral temperature 99
degrees Fahrenheit.
The client supports his head and neck when turning his head to
the right.
The client spontaneously flexes his wrist when the blood pressure
is obtained.
The client is drowsy and complains of sore throat.
94. Julius is admitted with complaints of severe pain in the lower
right quadrant of the abdomen. To assist with pain relief, the nurse
should take which of the following actions?
Encourage the client to change positions frequently in bed.
Administer Demerol 50 mg IM q 4 hours and PRN.
Apply warmth to the abdomen with a heating pad.
Use comfort measures and pillows to position the client.
95. Nurse Tina prepares a client for peritoneal dialysis. Which of the
following actions should the nurse take first?
Assess for a bruit and a thrill.
Warm the dialysate solution.
Position the client on the left side.
Insert a Foley catheter
96. Nurse Jannah teaches an elderly client with right-sided weakness
how to use cane. Which of the following behaviors, if demonstrated
by the client to the nurse, indicates that the teaching was effective?
The client holds the cane with his right hand, moves the can
forward followed by the right leg, and then moves the left leg.
The client holds the cane with his right hand, moves the cane
forward followed by his left leg, and then moves the right leg.
The client holds the cane with his left hand, moves the cane
forward followed by the right leg, and then moves the left leg.
The client holds the cane with his left hand, moves the cane
forward followed by his left leg, and then moves the right leg.
97. An elderly client is admitted to the nursing home setting. The
client is occasionally confused and her gait is often unsteady. Which
of the following actions, if taken by the nurse, is most appropriate?
Ask the woman’s family to provide personal items such as photos
or mementos.
Select a room with a bed by the door so the woman can look down
the hall.
Suggest the woman eat her meals in the room with her roommate.
Encourage the woman to ambulate in the halls twice a day.
98. Nurse Evangeline teaches an elderly client how to use a standard
aluminum walker. Which of the following behaviors, if demonstrated
by the client, indicates that the nurse’s teaching was effective?
The client slowly pushes the walker forward 12 inches, then
takes small steps forward while leaning on the walker.
The client lifts the walker, moves it forward 10 inches, and then
takes several small steps forward.
The client supports his weight on the walker while advancing it
forward, then takes small steps while balancing on the walker.
The client slides the walker 18 inches forward, then takes small
steps while holding onto the walker for balance.
99. Nurse Deric is supervising a group of elderly clients in a
residential home setting. The nurse knows that the elderly are at
greater risk of developing sensory deprivation for what reason?
Increased sensitivity to the side effects of medications.
Decreased visual, auditory, and gustatory abilities.
Isolation from their families and familiar surroundings.
Decrease musculoskeletal function and mobility.
100. A male client with emphysema becomes restless and confused.
What step should nurse Jasmine take next?
Encourage the client to perform pursed lip breathing.
Check the client’s temperature.
Assess the client’s potassium level.
Increase the client’s oxygen flow rate.
Answers and Rationales
Answer: (C) Loose, bloody. Normal bowel function and soft-formed
stool usually do not occur until around the seventh day following
surgery. The stool consistency is related to how much water is being
absorbed.
Answer: (A) On the client’s right side. The client has left visual field
blindness. The client will see only from the right side.
Answer: (C) Check respirations, stabilize spine, and check
circulation. Checking the airway would be priority, and a neck injury
should be suspected.
Answer: (D) Decreasing venous return through vasodilation. The
significant effect of nitroglycerin is vasodilation and decreased
venous return, so the heart does not have to work hard.
Answer: (A) Call for help and note the time. Having established, by
stimulating the client, that the client is unconscious rather than
sleep, the nurse should immediately call for help. This may be done
by dialing the operator from the client’s phone and giving the
hospital code for cardiac arrest and the client’s room number to the
operator, of if the phone is not available, by pulling the emergency
call button. Noting the time is important baseline information for
cardiac arrest procedure.
Answer: (C) Make sure that the client takes food and medications
at prescribed intervals. Food and drug therapy will prevent the
accumulation of hydrochloric acid, or will neutralize and buffer the
acid that does accumulate.
Answer: (B) Continue treatment as ordered. The effects of heparin
are monitored by the PTT is normally 30 to 45 seconds; the
therapeutic level is 1.5 to 2 times the normal level.
Answer: (B) In the operating room. The stoma drainage bag is
applied in the operating room. Drainage from the ileostomy contains
secretions that are rich in digestive enzymes and highly irritating to
the skin. Protection of the skin from the effects of these enzymes is
begun at once. Skin exposed to these enzymes even for a short time
becomes reddened, painful, and excoriated.
Answer: (B) Flat on back. To avoid the complication of a painful
spinal headache that can last for several days, the client is kept in
flat in a supine position for approximately 4 to 12 hours
postoperatively. Headaches are believed to be causes by the
seepage of cerebral spinal fluid from the puncture site. By keeping
the client flat, cerebral spinal fluid pressures are equalized, which
avoids trauma to the neurons.
Answer: (C) The client is oriented when aroused from sleep, and
goes back to sleep immediately. This finding suggest that the level
of consciousness is decreasing.
Answer: (A) Altered mental status and dehydration. Fever, chills,
hemortysis, dyspnea, cough, and pleuritic chest pain are the
common symptoms of pneumonia, but elderly clients may
first appear with only an altered lentil status and dehydration due to
a blunted immune response.
Answer: (B) Chills, fever, night sweats, and hemoptysis. 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
(38.9°C). Nausea, headache, and photophobia aren’t usual
TB symptoms.
Answer:(A) Acute asthma. 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) and emphysema.
Answer: (B) Respiratory arrest. Narcotics can cause respiratory
arrest if given in large quantities. It’s unlikely the client will have
asthma attack or a seizure or wake up on his own.
Answer: (D) Decreased vital capacity.  Reduction in vital capacity is
a normal physiologic changes include decreased elastic recoil of the
lungs, fewer functional capillaries in the alveoli, and an increased in
residual volume.
Answer: (C) Presence of premature ventricular contractions (PVCs)
on a cardiac monitor. Lidocaine drips are commonly used to treat
clients whose arrhythmias haven’t been controlled with oral
medication and who are having PVCs that are visible on the cardiac
monitor. SaO2, blood pressure, and ICP are important factors but
aren’t as significant as PVCs in the situation.
Answer: (B) Avoid foods high in vitamin K. The client should avoid
consuming large amounts of vitamin K because vitamin K can
interfere with anticoagulation. The client may need to report
diarrhea, but isn’t effect of taking an anticoagulant. An
electric razor-not a straight razor-should be used to prevent cuts
that cause bleeding. Aspirin may increase the risk of bleeding;
acetaminophen should be used to pain relief.
Answer: (C) Clipping the hair in the area. Hair can be a source of
infection and should be removed by clipping. Shaving the area can
cause skin abrasions and depilatories can irritate the skin.
Answer: (A) Bone fracture. Bone fracture is a major complication of
osteoporosis that results when loss of calcium and phosphate
increased the fragility of bones. Estrogen deficiencies result from
menopause-not osteoporosis. Calcium and vitamin D supplements
may be used to support normal bone metabolism, But a negative
calcium balance isn’t a complication of osteoporosis. Dowager’s
hump results from bone fractures. It develops when repeated
vertebral fractures increase spinal curvature.
Answer: (C) Changes from previous examinations. Women are
instructed to examine themselves to discover changes that have
occurred in the breast. Only a physician can diagnose lumps that are
cancerous, areas of thickness or fullness that signal the presence of
a malignancy, or masses that are fibrocystic as opposed
to malignant.
Answer: (C) Balance the client’s periods of activity and rest. A client
with hyperthyroidism needs to be encouraged to balance periods of
activity and rest. Many clients with hyperthyroidism are hyperactive
and complain of feeling very warm.
Answer: (B) Increase his activity level. The client should be
encouraged to increase his activity level. Maintaining an ideal
weight; following a low-cholesterol, low sodium diet; and avoiding
stress are all important factors in decreasing the risk
of atherosclerosis.
Answer: (A) Laminectomy. The client who has had spinal surgery,
such as laminectomy, must be log rolled to keep the spinal column
straight when turning. Thoracotomy and cystectomy may turn
themselves or may be assisted into a comfortable position. Under
normal circumstances, hemorrhoidectomy is an outpatient
procedure, and the client may resume normal activities immediately
after surgery.
Answer: (D) Avoiding straining during bowel movement or bending
at the waist. The client should avoid straining, lifting heavy objects,
and coughing harshly because these activities increase intraocular
pressure. Typically, the client is instructed to avoid lifting objects
weighing more than 15 lb (7kg) – not 5lb. instruct the client when
lying in bed to lie on either the side or back. The client should avoid
bright light by wearing sunglasses.
Answer: (D) Before age 20. Testicular cancer commonly occurs in
men between ages 20 and 30. A male client should be taught how to
perform testicular selfexamination before age 20, preferably when
he enters his teens.
Answer: (B) Place a saline-soaked sterile dressing on the
wound. The nurse should first place saline-soaked sterile dressings
on the open wound to prevent tissue drying and possible infection.
Then the nurse should call the physician and take the client’s vital
signs. The dehiscence needs to be surgically closed, so the nurse
should never try to close it.
Answer: (A) A progressively deeper breaths followed by
shallower breaths with apneic periods. Cheyne-Strokes respirations
are breaths that become progressively deeper fallowed by shallower
respirations with apneas periods. Biot’s respirations are rapid, deep
breathing with abrupt pauses between each breath, and equal depth
between each breath. Kussmaul’s respirations are rapid, deep
breathing without pauses. Tachypnea is shallow breathing with
increased respiratory rate.
Answer: (B) Fine crackles. Fine crackles are caused by fluid in the
alveoli and commonly occur in clients with heart failure. Tracheal
breath sounds are auscultated over the trachea. Coarse crackles are
caused by secretion accumulation in the airways. Friction rubs occur
with pleural inflammation.
Answer: (B) The airways are so swollen that no air cannot get
through. During an acute attack, wheezing may stop and breath
sounds become inaudible because the airways are so swollen that
air can’t get through. If the attack is over and swelling has
decreased, there would be no more wheezing and less emergent
concern. Crackles do not replace wheezes during an acute asthma
attack.
Answer: (D) Place the client on his side, remove dangerous objects,
and protect his head. During the active seizure phase, initiate
precautions by placing the client on his side, removing dangerous
objects, and protecting his head from injury. A bite block should
never be inserted during the active seizure phase. Insertion can
break the teeth and lead to aspiration.
Answer: (B) Kinked or obstructed chest tube. Kinking and blockage
of the chest tube is a common cause of a tension pneumothorax.
Infection and excessive drainage won’t cause a tension
pneumothorax. Excessive water won’t affect the chest
tube drainage.
Answer: (D) Stay with him but not intervene at this time. If the
client is coughing, he should be able to dislodge the object or cause
a complete obstruction. If complete obstruction occurs, the nurse
should perform the abdominal thrust maneuver with the
client standing. If the client is unconscious, she should lay him down.
A nurse should never leave a choking client alone.
Answer: (B) Current health promotion activities. Recognizing an
individual’s positive health measures is very useful. General health in
the previous 10 years is important, however, the current activities of
an 84 year old client are most significant in planning care. Family
history of disease for a client in later years is of minor significance.
Marital status information may be important for discharge planning
but is not as significant for addressing the immediate
medical problem.
Answer: (C) Place the client in a side lying position, with the head
of the bed lowered.  The client should be positioned in a side-lying
position with the head of the bed lowered to prevent aspiration. A
small amount of toothpaste should be used and the mouth swabbed
or suctioned to remove pooled secretions. Lemon glycerin can be
drying if used for extended periods. Brushing the teeth with the
client lying supine may lead to aspiration. Hydrogen peroxide is
caustic to tissues and should not be used.
Answer: (C) Pneumonia. Fever productive cough and pleuritic chest
pain are common signs and symptoms of pneumonia. The client with
ARDS has dyspnea and hypoxia with worsening hypoxia over time, if
not treated aggressively. Pleuritic chest pain varies with respiration,
unlike the constant chest pain during an MI; so this client most likely
isn’t having an MI. the client with TB typically has a cough producing
blood-tinged sputum. A sputum culture should be obtained to
confirm the nurse’s suspicions.
Answer: (C) A 43-yesr-old homeless man with a history of
alcoholism. Clients who are economically disadvantaged,
malnourished, and have reduced immunity, such as a client with a
history of alcoholism,  are at extremely high risk for developing TB. A
high school student, daycare worker, and businessman probably
have a much low risk of contracting TB.
Answer: (C ) To determine the extent of lesions. 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.
Answer: (B) Bronchodilators. Bronchodilators are the first line of
treatment for asthma because broncho-constriction is the cause of
reduced airflow. Beta adrenergic blockers aren’t used to treat
asthma and can cause bronchoconstriction. Inhaled oral steroids
may be given to reduce the inflammation but aren’t used for
emergency relief.
Answer: (C) Chronic obstructive bronchitis. Because of this
extensive smoking history and symptoms the client most likely has
chronic obstructive bronchitis. Client with ARDS have acute
symptoms of hypoxia and typically need large amounts of oxygen.
Clients with asthma and emphysema tend not to have chronic cough
or peripheral edema.
Answer: (A) The patient is under local anesthesia during the
procedure. Before the procedure, the patient is administered with
drugs that would help to prevent infection and rejection of the
transplanted cells such as antibiotics, cytotoxic, and corticosteroids.
During the transplant, the patient is placed under general
anesthesia.
Answer: (D) Raise the side rails. A patient who is disoriented is at
risk of falling out of bed. The initial action of the nurse should be
raising the side rails to ensure patients safety.
Answer: (A) Crowd red blood cells. The excessive production of
white blood cells crowd out red blood cells production which causes
anemia to occur.
Answer: (B) Leukocytosis. Chronic Lymphocytic leukemia (CLL) is
characterized by increased production of leukocytes and
lymphocytes resulting in leukocytosis, and proliferation of these cells
within the bone marrow, spleen and liver.
Answer: (A) Explain the risks of not having the surgery. The best
initial response is to explain the risks of not having the surgery. If the
client understands the risks but still refuses the nurse should notify
the physician and the nurse supervisor and then record the client’s
refusal in the nurses’ notes.
Answer: (D) The 75-year-old client who was admitted 1 hour ago
with new-onset atrial fibrillation and is receiving L.V. dilitiazem
(Cardizem). The client with atrial fibrillation has the greatest
potential to become unstable and is on L.V. 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 the 58- year-old client admitted 2 days ago with heart
failure (his signs and symptoms 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.
Answer: (C) Cocaine. Because of the client’s age and negative
medical history, the nurse should question her about cocaine use.
Cocaine increases myocardial oxygen consumption and can cause
coronary artery spasm, leading to tachycardia, ventricular
fibrillation, myocardial ischemia, and myocardial infarction.
Barbiturate overdose may trigger respiratory depression and slow
pulse. Opioids can cause marked respiratory depression, while
benzodiazepines can cause drowsiness and confusion.
Answer: (B) Nonmobile mass with irregular edges. Breast cancer
tumors are fixed, hard, and poorly delineated with irregular edges. A
mobile mass that is soft and easily delineated is most often a fluid-
filled benign cyst. Axillary lymph nodes may or may not be palpable
on initial detection of a cancerous mass. Nipple retraction — not
eversion — may be a sign of cancer.
Answer: (C) Radiation. The usual treatment for vaginal cancer is
external or intravaginal radiation therapy. Less often, surgery is
performed. Chemotherapy typically is prescribed only if vaginal
cancer is diagnosed in an early stage, which is rare. Immunotherapy
isn’t used to treat vaginal cancer.
Answer: (B) Carcinoma in situ, no abnormal regional lymph nodes,
and no evidence of distant metastasis. TIS, N0, M0 denotes
carcinoma in situ, no abnormal regional lymph nodes, and no
evidence of distant metastasis. No evidence of primary tumor, no
abnormal regional lymph nodes, and no evidence of distant
metastasis is classified as T0, N0, M0. If the tumor and
regional lymph nodes can’t be assessed and no evidence of
metastasis exists, the lesion is classified as TX, NX, M0. A progressive
increase in tumor size, no demonstrable metastasis of the regional
lymph nodes, and ascending degrees of distant metastasis is
classified as T1, T2, T3, or T4; N0; and M1, M2, or M3.
Answer: (D) “Keep the stoma moist.” The nurse should instruct the
client to keep the stoma moist, such as by applying a thin layer of
petroleum jelly around the edges, because a dry stoma may become
irritated. The nurse should recommend placing a stoma bib over the
stoma to filter and warm air before it enters the stoma. The client
should begin performing stoma care without assistance as soon as
possible to gain independence in self-care activities.
Answer: (B) Lung cancer.  Lung cancer is the most deadly type of
cancer in both women and men. Breast cancer ranks second in
women, followed (in descending order) by colon and rectal cancer,
pancreatic cancer, ovarian cancer, uterine cancer, lymphoma,
leukemia, liver cancer, brain cancer, stomach cancer, and multiple
myeloma.
Answer: (A) miosis, partial eyelid ptosis, and anhidrosis on the
affected side of the face. Horner’s syndrome, which occurs when a
lung tumor invades the ribs and affects the sympathetic nerve
ganglia, is characterized by miosis, partial eyelid ptosis, and
anhidrosis on the affected side of the face. Chest pain, dyspnea,
cough, weight loss, and fever are associated with pleural tumors.
Arm and shoulder pain and atrophy of the arm and hand muscles on
the affected side suggest Pancoast’s tumor, a lung tumor involving
the first thoracic and eighth cervical nerves within the brachial
plexus. Hoarseness in a client with lung cancer suggests that
the tumor has extended to the recurrent laryngeal nerve; dysphagia
suggests that the lung tumor is compressing the esophagus.
Answer: (A) prostate-specific antigen, which is used to screen for
prostate cancer. PSA stands for prostate-specific antigen, which is
used to screen for prostate cancer. The other answers are incorrect.
Answer: (D) “Remain supine for the time specified by the
physician.” The nurse should instruct the client to remain supine for
the time specified by the physician. Local anesthetics used in a
subarachnoid block don’t alter the gag reflex. No interactions
between local anesthetics and food occur. Local anesthetics don’t
cause hematuria.
Answer: (C) Sigmoidoscopy. Used to visualize the lower GI tract,
sigmoidoscopy and proctoscopy aid in the detection of two-thirds of
all colorectal cancers. Stool Hematest detects blood, which is a sign
of colorectal cancer; however, the test doesn’t confirm the
diagnosis. CEA may be elevated in colorectal cancer but isn’t
considered a confirming test. An abdominal CT scan is used to stage
the presence of colorectal cancer.
Answer: (B) A fixed nodular mass with dimpling of the overlying
skin. A fixed nodular mass with dimpling of the overlying skin
is common during late stages of breast cancer. Many women have
slightly asymmetrical breasts. Bloody nipple discharge is a sign of
intraductal papilloma, a benign condition. Multiple firm, round,
freely movable masses that change with the menstrual cycle indicate
fibrocystic breasts, a benign condition.
Answer: (A) Liver. The liver is one of the five most common cancer
metastasis sites. The others are the lymph nodes, lung, bone, and
brain. The colon, reproductive tract, and WBCs are occasional
metastasis sites.
Answer: (D) The client wears a watch and wedding band. During an
MRI, the client should wear no metal objects, such as jewelry,
because the strong magnetic field can pull on them, causing injury to
the client and (if they fly off) to others. The client must lie still during
the MRI but can talk to those performing the test by way of
the microphone inside the scanner tunnel. The client should hear
thumping sounds, which are caused by the sound waves thumping
on the magnetic field.
Answer: (C) The recommended daily allowance of calcium may be
found in a wide variety of foods. Premenopausal women require
1,000 mg of calcium per day. Postmenopausal women require 1,500
mg per day. It’s often, though not always, possible to get the
recommended daily requirement in the foods we eat. Supplements
are available but not always necessary. Osteoporosis doesn’t show
up on ordinary X-rays until 30% of the bone loss has occurred. Bone
densitometry can detect bone loss of 3% or less. This test is
sometimes recommended routinely for women over 35 who are at
risk. Strenuous exercise won’t cause fractures.
Answer: (C) Joint flexion of less than 50%. Arthroscopy is
contraindicated in clients with joint flexion of less than 50% because
of technical problems in inserting the instrument into the joint to
see it clearly. Other contraindications for this procedure include skin
and wound infections. Joint pain may be an indication, not
a contraindication, for arthroscopy. Joint deformity and joint
stiffness aren’t contraindications for this procedure.
Answer: (D) Gouty arthritis. Gouty arthritis, a metabolic disease, is
characterized by urate deposits and pain in the joints, especially
those in the feet and legs. Urate deposits don’t occur in septic or
traumatic arthritis. Septic arthritis results from bacterial invasion of
a joint and leads to inflammation of the synovial lining. Traumatic
arthritis results from blunt trauma to a joint or
ligament. Intermittent arthritis is a rare, benign condition marked by
regular, recurrent joint effusions, especially in the knees.
Answer: (B) 30 ml/hour. An infusion prepared with 25,000 units of
heparin in 500 ml of saline solution yields 50 units of heparin per
milliliter of solution. The equation is set up as 50 units times X (the
unknown quantity) equals 1,500 units/hour, X equals 30 ml/hour.
Answer: (B) Loss of muscle contraction decreasing venous
return. In clients with hemiplegia or hemiparesis loss of
muscle contraction decreases venous return and may cause swelling
of the affected extremity. Contractures, or bony calcifications may
occur with a stroke, but don’t appear with swelling. DVT may
develop in clients with a stroke but is more likely to occur in the
lower extremities. A stroke isn’t linked to protein loss.
Answer: (B) It appears on the distal interphalangeal
joint. Heberden’s nodes appear on the distal interphalageal joint
on both men and women. Bouchard’s node appears on the
dorsolateral aspect of the proximal interphalangeal joint.
Answer: (B) Osteoarthritis is a localized disease rheumatoid
arthritis is systemic.  Osteoarthritis is a localized disease,
rheumatoid arthritis is systemic. Osteoarthritis isn’t gender-specific,
but rheumatoid arthritis is. Clients have dislocations and
subluxations in both disorders.
Answer: (C) The cane should be used on the unaffected side. A cane
should be used on the unaffected side. A client with osteoarthritis
should be encouraged to ambulate with a cane, walker, or other
assistive device as needed; their use takes weight and stress
off joints.
Answer: (A) 9 U regular insulin and 21 U neutral protamine
Hagedorn (NPH).  A 70/30 insulin preparation is 70% NPH and 30%
regular insulin. Therefore, a correct substitution requires mixing 21
U of NPH and 9 U of regular insulin. The other choices are incorrect
dosages for the prescribed insulin.
Answer: (C) colchicines. A disease characterized by joint
inflammation (especially in the great toe), gout is caused by urate
crystal deposits in the joints. The physician prescribes colchicine to
reduce these deposits and thus ease joint inflammation. Although
aspirin is used to reduce joint inflammation and pain in clients with
osteoarthritis and rheumatoid arthritis, it isn’t indicated for gout
because it has no effect on urate crystal formation. Furosemide, a
diuretic, doesn’t relieve gout. Calcium gluconate is used to reverse a
negative calcium balance and relieve muscle cramps, not to treat
gout.
Answer: (A) Adrenal cortex. Excessive secretion of aldosterone in
the adrenal cortex is responsible for the client’s hypertension. This
hormone acts on the renal tubule, where it promotes reabsorption
of sodium and excretion of potassium and hydrogen ions. The
pancreas mainly secretes hormones involved in fuel metabolism.
The adrenal medulla secretes the catecholamines — epinephrine
and norepinephrine. The parathyroids secrete parathyroid hormone.
Answer: (C) They debride the wound and promote healing by
secondary intention. For this client, wet-to-dry dressings are most
appropriate because they clean the foot ulcer by debriding exudate
and necrotic tissue, thus promoting healing by secondary intention.
Moist, transparent dressings contain exudate and provide a moist
wound environment. Hydrocolloid dressings prevent the entrance of
microorganisms and minimize wound discomfort. Dry sterile
dressings protect the wound from mechanical trauma and promote
healing.
Answer: (A) Hyperkalemia. In adrenal insufficiency, the client has
hyperkalemia due to reduced aldosterone secretion. BUN increases
as the glomerular filtration rate is reduced. Hyponatremia is caused
by reduced aldosterone secretion. Reduced cortisol secretion leads
to impaired glyconeogenesis and a reduction of glycogen in the liver
and muscle, causing hypoglycemia.
Answer: (C) Restricting fluids. To reduce water retention in a client
with the SIADH, the nurse should restrict fluids. Administering fluids
by any route would further increase the client’s already heightened
fluid load.
Answer: (D) glycosylated hemoglobin level. Because some of the
glucose in the bloodstream attaches to some of the hemoglobin and
stays attached during the 120-day life span of red blood cells,
glycosylated hemoglobin levels provide information about blood
glucose levels during the previous 3 months. Fasting blood glucose
and urine glucose levels only give information about glucose levels
at the point in time when they were obtained. Serum
fructosamine levels provide information about blood glucose control
over the past 2 to 3 weeks.
Answer: (C) 4:00 pm. NPH is an intermediate-acting insulin that
peaks 8 to 12 hours after administration. Because the nurse
administered NPH insulin at 7 a.m., the client is at greatest risk for
hypoglycemia from 3 p.m. to 7 p.m.
Answer: (A) Glucocorticoids and androgens. The adrenal glands
have two divisions, the cortex and medulla. The cortex produces
three types of hormones: glucocorticoids, mineralocorticoids, and
androgens. The medulla produces catecholamines — epinephrine
and norepinephrine.
Answer: (A) Hypocalcemia. Hypocalcemia may follow thyroid
surgery if the parathyroid glands were removed accidentally. Signs
and symptoms of hypocalcemia may be delayed for up to 7 days
after surgery. Thyroid surgery doesn’t directly cause serum sodium,
potassium, or magnesium abnormalities. Hyponatremia may occur if
the client inadvertently received too much fluid; however, this can
happen to any surgical client receiving I.V. fluid therapy, not just one
recovering from thyroid surgery. Hyperkalemia
and hypermagnesemia usually are associated with reduced renal
excretion of potassium and magnesium, not thyroid surgery.
Answer: (D) Carcinoembryonic antigen level. In clients who smoke,
the level of carcinoembryonic antigen is elevated. Therefore, it can’t
be used as a general indicator of cancer. However, it is helpful in
monitoring cancer treatment because the level usually falls to
normal within 1 month if treatment is successful. An elevated acid
phosphatase level may indicate prostate cancer. An elevated
alkaline phosphatase level may reflect bone metastasis. An elevated
serum calcitonin level usually signals thyroid cancer.
Answer: (B) Dyspnea, tachycardia, and pallor. Signs of iron-
deficiency anemia include dyspnea, tachycardia, and pallor as well as
fatigue, listlessness, irritability, and headache. Night sweats, weight
loss, and diarrhea may signal acquired immunodeficiency syndrome
(AIDS). Nausea, vomiting, and anorexia may be signs of hepatitis B.
Itching, rash, and jaundice may result from an allergic or hemolytic
reaction.
Answer: (D) “I’ll need to have a C-section if I become pregnant and
have a baby.” The human immunodeficiency virus (HIV) is
transmitted from mother to child via the transplacental route, but a
Cesarean section delivery isn’t necessary when the mother is HIV-
positive. The use of birth control will prevent the conception of a
child who might have HIV. It’s true that a mother who’s HIV positive
can give birth to a baby who’s HIV negative.
Answer: (C) “Avoid sharing such articles as toothbrushes and
razors.” The human immunodeficiency virus (HIV), which
causes AIDS, is most concentrated in the blood. For this reason, the
client shouldn’t share personal articles that may be blood-
contaminated, such as toothbrushes and razors, with other family
members. HIV isn’t transmitted by bathing or by eating from plates,
utensils, or serving dishes used by a person with AIDS.
Answer: (B) Pallor, tachycardia, and a sore tongue. Pallor,
tachycardia, and a sore tongue are all characteristic findings in
pernicious anemia. Other clinical manifestations include anorexia;
weight loss; a smooth, beefy red tongue; a wide pulse
pressure; palpitations; angina; weakness; fatigue; and paresthesia of
the hands and feet. Bradycardia, reduced pulse pressure, weight
gain, and double vision aren’t characteristic findings in pernicious
anemia.
Answer: (B) Administer epinephrine, as prescribed, and prepare
to intubate the client if necessary. To reverse anaphylactic shock,
the nurse first should administer epinephrine, a potent
bronchodilator as prescribed. The physician is likely to order
additional medications, such as antihistamines and corticosteroids; if
these medications don’t relieve the respiratory compromise
associated with anaphylaxis, the nurse should prepare to intubate
the client. No antidote for penicillin exists; however, the
nurse should continue to monitor the client’s vital signs. A client
who remains hypotensive may need fluid resuscitation and fluid
intake and output monitoring; however, administering epinephrine
is the first priority.
Answer: (D) bilateral hearing loss. Prolonged use of aspirin and
other salicylates sometimes causes bilateral hearing loss of 30 to 40
decibels. Usually, this adverse effect resolves within 2 weeks after
the therapy is discontinued. Aspirin doesn’t lead to weight gain or
fine motor tremors. Large or toxic salicylate doses may cause
respiratory alkalosis, not respiratory acidosis.
Answer: (D) Lymphocyte. The lymphocyte provides adaptive
immunity — recognition of a foreign antigen and formation of
memory cells against the antigen. Adaptive immunity is mediated by
B and T lymphocytes and can be acquired actively or passively. The
neutrophil is crucial to phagocytosis. The basophil plays an
important role in the release of inflammatory mediators. The
monocyte functions in phagocytosis and monokine production.
Answer: (A) moisture replacement. Sjogren’s syndrome is an
autoimmune disorder leading to progressive loss of lubrication of
the skin, GI tract, ears, nose, and vagina. Moisture replacement is
the mainstay of therapy. Though malnutrition and electrolyte
imbalance may occur as a result of Sjogren’s syndrome’s effect on
the GI tract, it isn’t the predominant problem. Arrhythmias aren’t
a problem associated with Sjogren’s syndrome.
Answer: (C) stool for Clostridium difficile test. Immunosuppressed
clients — for example, clients receiving chemotherapy, — are at risk
for infection with C. difficile, which causes “horse barn” smelling
diarrhea. Successful treatment begins with an accurate diagnosis,
which includes a stool test. The ELISA test is diagnostic for human
immunodeficiency virus (HIV) and isn’t indicated in this case. An
electrolyte panel and hemogram may be useful in the
overall evaluation of a client but aren’t diagnostic for specific causes
of diarrhea. A flat plate of the abdomen may provide useful
information about bowel function but isn’t indicated in the case of
“horse barn” smelling diarrhea.
Answer: (D) Western blot test with ELISA. HIV infection is detected
by analyzing blood for antibodies to HIV, which form approximately
2 to 12 weeks after exposure to HIV and denote infection. The
Western blot test — electrophoresis of antibody proteins — is more
than 98% accurate in detecting HIV antibodies when used in
conjunction with the ELISA. It isn’t specific when used alone.
Erosette immunofluorescence is used to detect viruses in general; it
doesn’t confirm HIV infection. Quantification of T-lymphocytes is a
useful monitoring test but isn’t diagnostic for HIV. The ELISA test
detects HIV antibody particles but may yield inaccurate results; a
positive ELISA result must be confirmed by the Western blot test.
Answer: (C) Abnormally low hematocrit (HCT) and hemoglobin
(Hb) levels. Low preoperative HCT and Hb levels indicate the client
may require a blood transfusion before surgery. If the HCT and Hb
levels decrease during surgery because of blood loss, the potential
need for a transfusion increases. Possible renal failure is indicated by
elevated BUN or creatinine levels. Urine constituents aren’t found in
the blood. Coagulation is determined by the presence of appropriate
clotting factors, not electrolytes.
Answer: (A) Platelet count, prothrombin time, and partial
thromboplastin time. The diagnosis of DIC is based on the results of
laboratory studies of prothrombin time, platelet count, thrombin
time, partial thromboplastin time, and fibrinogen level as well as
client history and other assessment factors. Blood glucose levels,
WBC count, calcium levels, and potassium levels aren’t used to
confirm a diagnosis of DIC.
Answer: (D) Strawberries. Common food allergens include berries,
peanuts, Brazil nuts, cashews, shellfish, and eggs. Bread, carrots, and
oranges rarely cause allergic reactions.
Answer: (B) A client with cast on the right leg who states, “I have a
funny feeling in my right leg.” It may indicate neurovascular
compromise, requires immediate assessment.
Answer: (D) A 62-year-old who had an abdominal-perineal
resection three days ago; client complaints of chills. The client is at
risk for peritonitis; should be assessed for further symptoms and
infection.
Answer: (C) The client spontaneously flexes his wrist when the
blood pressure is obtained. Carpal spasms indicate hypocalcemia.
Answer: (D) Use comfort measures and pillows to position the
client.Using comfort measures and pillows to position the client is
a non-pharmacological methods of pain relief.
Answer: (B) Warm the dialysate solution. Cold dialysate increases
discomfort. The solution should be warmed to body temperature in
warmer or heating pad; don’t use microwave oven.
Answer: (C) The client holds the cane with his left hand, moves the
cane forward followed by the right leg, and then moves the left
leg. The cane acts as a support and aids in weight bearing for
the weaker right leg.
Answer: (A) Ask the woman’s family to provide personal items
such as photos or mementos.Photos and mementos provide visual
stimulation to reduce sensory deprivation.
Answer: (B) The client lifts the walker, moves it forward 10 inches,
and then takes several small steps forward. A walker needs to be
picked up, placed down on all legs.
Answer: (C) Isolation from their families and familiar
surroundings. Gradual loss of sight, hearing, and taste interferes
with normal functioning.
Answer: (A) Encourage the client to perform pursed lip
breathing. Purse lip breathing prevents the collapse of lung unit and
helps client control rate and depth of breathing.
SET 2
1. The nurse is going to replace the Pleur-O-Vac attached to the
client with a small, persistent left upper lobe pneumothorax with a
Heimlich Flutter Valve. Which of the following is the best rationale
for this?
Promote air and pleural drainage
Prevent kinking of the tube
Eliminate the need for a dressing
Eliminate the need for a water-seal drainage
2. The client with acute pancreatitis and fluid volume deficit is
transferred from the ward to the ICU. Which of the following will
alert the nurse?
Decreased pain in the fetal position
Urine output of 35mL/hr
CVP of 12 mmHg
Cardiac output of 5L/min
3. The nurse in the morning shift is making rounds in the ward. The
nurse enters the client’s room and found the client in discomfort
condition. The client complains of stiffness in the joints. To reduce
the early morning stiffness of the joints of the client,the nurse can
encourage the client to:
Sleep with a hot pad
Take to aspirins before arising, and wait 15 minutes before
attempting locomotion
Take a hot tub bath or shower in the morning
Put joints through passive ROM before trying to move them actively
4. The nurse is planning of care to a client with peptic ulcer disease.
To avoid the worsening condition of the client, the nurse should
carefully plan the diet of the client. Which of the following will be
included in the diet regime of the client?
Eating mainly bland food and milk or dairy products
Reducing intake of high-fiber foods
Eating small, frequent meals and a bedtime snack
Eliminating intake of alcohol and coffee
5. The physician has given instruction to the nurse that the client can
be ambulated on crutches, with no weight bearing on the affected
limb. The nurse is aware that the appropriate crutch gait for the
nurse to teach the client would be:
Tripod gait
Two-point gait
Four-point gait
Three-point gait
6. The client is transferred to the nursing care unit from the
operating room after a transurethral resection of the prostate. The
client is complaining of pain in the abdomen area. The nurse
suspects of bladder spasms, which of the following is the best
nursing action to minimize the pain felt by the client?
Advising the client not to urinate around catheter
Intermittent catheter irrigation with saline
Giving prescribed narcotics every 4 hour
Repositioning catheter to relieve pressure
7. A client is diagnosed with peptic ulcer. The nurse caring for the
client expects the physician to order which diet?
NPO
Small feedings of bland food
A regular diet given frequently in small amounts
Frequent feedings of clear liquids
8. The nurse is going to insert a Miller-Abbott tube to the client.
Before insertion of the tube, the balloon is tested for patency and
capacity and then deflated. Which of the following nursing measure
will ease the insertion to the tube?
Positioning the client in Semi-Fowler’s position
Administering a sedative to reduce anxiety
Chilling the tube before insertion
Warming the tube before insertion
9. The physician ordered a low-sodium diet to the client. Which of
the following food will the nurse avoid to give to the client?
Orange juice.
Whole milk.
Ginger ale.
Black coffee.
10. Mr. Bean, a 70-year-old client is admitted in the hospital for
almost one month. The nurse understands that prolonged
immobilization could lead to decubitus ulcers. Which of the
following would be the least appropriate nursing intervention in the
prevention of decubitus?
Giving backrubs with alcohol
Use of a bed cradle
Frequent assessment of the skin
Encouraging a high-protein diet
11. The physician prescribed digoxin 0.125 mg PO qd to a client and
instructed the nurse that the client is on high-potassium diet. High
potassium foods are recommended in the diet of a client taking
digitalis preparations because a low serum potassium has which of
the following effects?
Potentiates the action of digoxin
Promotes calcium retention
Promotes sodium excretion
Puts the client at risk for digitalis toxicity
12. The nurse is caring for a client who is transferred from the
operating room for pneumonectomy. The nurse knows that
immediately following pneumonectomy; the client should be in
what position?
Supine on the unaffected side
Low-Fowler’s on the back
Semi-Fowler’s on the affected side
Semi-Fowler’s on the unaffected side
13. A client is placed on digoxin, high potassium foods are
recommended in the diet of the client. Which of the following foods
willthe nurse give to the client?
Whole grain cereal, orange juice, and apricots
Turkey, green bean, and Italian bread
Cottage cheese, cooked broccoli, and roast beef
Fish, green beans and cherry pie
14. The nurse is assigned to care to a client who undergone
thyroidectomy. What nursing intervention is important during the
immediate postoperative period following a thyroidectomy?
Assess extremities for weakness and flaccidity
Support the head and neck during position changes
Position the client in high Fowler’s
Medicate for restlessness and anxiety
15. What would be the recommended diet the nurse will implement
to a client with burns of the head, face, neck and anterior chest?
Serve a high-protein, high-carbohydrate diet
Encourage full liquid diet
Serve a high-fat diet, high-fiber diet
Monitor intake to prevent weight gain
16. A client with multiple fractures of both lower extremities is
admitted for 3 days ago and is on skeletal traction. The client is
complaining of having difficulty in bowel movement. Which of the
following would be the most appropriate nursing intervention?
Administer an enema
Perform range-of-motion exercise to all extremities
Ensure maximum fluid intake (3000ml/day)
Put the client on the bedpan every 2 hours
17. John is diagnosed with Addison’s disease and admitted in the
hospital. What would be the appropriate nursing care for John?
Reducing physical and emotional stress
Providing a low-sodium diet
Restricting fluids to 1500ml/day
Administering insulin-replacement therapy
18. Mr. Smith is scheduled for an above-the-knee amputation. After
the surgery he was transferred to the nursing care unit. The nurse
assigned to him knows that 72 hours after the procedure the client
should be positioned properly to prevent contractures. Which of the
following is the best position to the client?
Side-lying, alternating left and right sides
Sitting in a reclining chair twice a day
Lying on abdomen several times daily
Supine with stump elevated at least 30 degrees
19. A client is scheduled to have an inguinal herniorraphy in the
outpatient surgical department. The nurse is providing health
teaching about post surgical care to the client. Which of the
following statement if made by the client would reflect the need for
more teaching?
“I should call the physician if I have a cough or cold before surgery”
“I will be able to drive soon after surgery”
“I will not be able to do any heavy lifting for 3-6 weeks after surgery”
“I should support my incision if I have to cough or turn”
20. Ms Jones is brought to the emergency room and is complaining
of muscle spasms, numbness, tremors and weakness in the arms and
legs. The client was diagnosed with multiple sclerosis. The nurse
assigned to Ms. Jones is aware that she has to prevent fatigue to the
client to alleviate the discomfort. Which of the following teaching is
necessary to prevent fatigue?
Avoid extremes in temperature
Install safety devices in the home
Attend support group meetings
Avoid physical exercise
21. Mr. Stewart is in sickle cell crisis and complaining pain in the
joints and difficulty of breathing. On the assessment of the nurse, his
temperature is 38.1 ºC. The physician ordered Morphine sulfate via
patient-controlled analgesia (PCA), and oxygen at 4L/min. A priority
nursing diagnosis to Mr. Stewart is risk for infection. A nursing
intervention to assist in preventing infection is:
Using standard precautions and medical asepsis
Enforcing a “no visitors” rule
Using moist heat on painful joints
Monitoring a vital signs every 2 hour
22. Mrs. Maupin is a professor in a prestigious university for 30
years. After lecture, she experience blurring of vision and tiredness.
Mrs. Maupin is brought to the emergency department. On
assessment, the nurse notes that the blood pressure of the client is
139/90. Mrs. Maupin has been diagnosed with essential
hypertension and placed on medication to control her BP. Which
potential nursing diagnosis will be a priority for discharge teaching?
Sleep Pattern disturbance
Impaired physical mobility
Noncompliance
Fluid volume excess
23. Following a needle biopsy of the kidney, which assessment is an
indication that the client is bleeding?
Slow, irregular pulse
Dull, abdominal discomfort
Urinary frequency
Throbbing headache
24. A client with acute bronchitis is admitted in the hospital. The
nurse assigned to the client is making a plan of care regarding
expectoration of thick sputum. Which nursing action is most
effective?
Place the client in a lateral position every 2 hour
Splint the patient’s chest with pillows when coughing
Use humified oxygen
Offer fluids at regular intervals
25. The nurse is going to assess the bowel sound of the client. For
accurate assessment of the bowel sound, the nurse should listen for
at least:
5 minutes
60 seconds
30 seconds
2 minutes
26. The nurse encourages the client to wear compression stockings.
What is the rationale behind in using compression stockings?
Compression stockings promote venous return
Compression stockings divert blood to major vessels
Compression stockings decreases workload on the heart
Compression stockings improve arterial circulation
27. Mr. Whitman is a stroke client and is having difficulty in
swallowing. Which is the best nursing intervention is most likely to
assist the client?
Placing food in the unaffected side of the mouth
Increasing fiber in the diet
Asking the patient to speak slowly
Increasing fluid intake
28. Following nephrectomy, the nurse closely monitors the urinary
output of the client. Which assessment finding is an early indicator
of fluid retention in the postoperative period?
Periorbital edema
Increased specific gravity of urine
A urinary output of 50mL/hr
Daily weight gain of 2 lb or more
29. A nurse is completing an assessment to a client with cirrhosis.
Which of the following nursing assessment is important to notify the
physician?
Expanding ecchymosis
Ascites and serum albumin of 3.2 g/dl
Slurred speech
Hematocrit of 37% and hemoglobin of 12g/dl
30. Mr. Park is 32-year-old, a badminton player and has a type 1
diabetes mellitus. After the game, the client complains of becoming
diaphoretic and light-headedness. The client asks the nurse how to
avoid this reaction. The nurse will recommend to:
Allow plenty of time after the insulin injection and before beginning
the match
Eat a carbohydrate snack before and during the badminton match
Drink plenty of fluids before, during, and after bed time
Take insulin just before starting the badminton match
31. A client is rushed to the emergency room due to serious vehicle
accident. The nurse is suspecting of head injury. Which of the
following assessment findings would the nurse report to the
physician?
CVP of 5mmHa
Glasgow Coma Scale score of 13
Polyuria and dilute urinary output
Insomnia
32. Mrs. Moore, 62-year-old, with diabetes is in the emergency
department. She stepped on a sharp sea shells while walking
barefoot along the beach. Mrs. Moore did not notice that the object
pierced the skin until later that evening. What problem does the
client most probably have?
Nephropathy
Macroangiopathy
Carpal tunnel syndrome
Peripheral neuropathy
33. A client with gangrenous foot has undergone a below-knee
amputation. The nurse in the nursing care unit knows that the
priority nursing intervention in the immediate post operative care of
this client is:
Elevate the stump on a pillow for the first 24 hours
Encourage use of trapeze
Position the client prone periodically
Apply a cone-shaped dressing
34. A client with a diagnosis of gastric ulcer is complaining of
syncope and vertigo. What would be the initial nursing intervention
by the nurse?
Monitor the client’s vital signs
Keep the client on bed rest
Keep the patient on bed rest
Give a stat dose of Sucralfate (Carafate)
35. After a right lower lobectomy on a 55-year-old client, which
action should the nurse initiate when the client is transferred from
the post anesthesia care unit?
Notify the family to report the client’s condition
Immediately administer the narcotic as ordered
Keep client on right side supported by pillows
Encourage coughing and deep breathing every 2 hours
36. The nurse is providing a discharge instruction about the
prevention of urinary stasis to a client with frequent bladder
infection. Which of the following will the nurse include in the
instruction?
Drink 3-4 quarts of fluid every day
Empty the bladder every 2-4 hours while awake
Encourage the use of coffee, tea, and colas for their diuretic effect
Teach Kegel exercises to control bladder flow
37. A male client visits the clinic for check-up. The client tells the
nurse that there is a yellow discharge from his penis. He also
experiences a burning sensation when urinating. The nurse is
suspecting of gonorrhea. What teaching is necessary for this client?
Sex partner of 3 months ago must be treated
Women with gonorrhea are symptomatic
Use a condom for sexual activity
Sex partner needs to be evaluated
38. A client with AIDS is admitted in the hospital. He is receiving
intravenous therapy. While the nurse is assessing the IV site, the
client becomes confused and restless and the intravenous catheter
becomes disconnected and minimal amount of the client’s blood
spills onto the floor. Which action will the nurse take to remove the
blood spill?
Promptly clean with a 1:10 solution of household bleach and water
Promptly clean up the blood spill with full-strength antimicrobial
cleaning solution
Immediately mop the floor with boiling water
Allow the blood to dry before cleaning to decrease the possibility of
cross-contamination
39. Before surgery, the physician ordered pentobarbital sodium
(Nembutal) for the client to sleep. The night before the scheduled
surgery, the nurse gave the pre-medication. One hour later the
client is still unable to sleep. The nurse review the client’s chart and
note the physician’s prescription with an order to repeat. What
should the nurse do next?
Rub the client’s back until relaxed
Prepare a glass of warm milk
Give the second dose of pentobarbital sodium
Explore the client’s feelings about surgery
40. The nurse on the night shift is making rounds in the nursing care
unit. The nurse is about to enter to the client’s room when a
ventilator alarm sounds, what is the first action the nurse should do?
Assess the lung sounds
Suction the client right away
Look at the client
Turn and position the client
41. What effective precautions should the nurse use to control the
transmission of methicillin-resistant Staphylococcus aureus (MRSA)?
Use gloves and handwashing before and after client contact
Do nasal cultures on healthcare providers
Place the client on total isolation
Use mask and gown during care of the MRSA client
42. The postoperative gastrectomy client is scheduled for discharge.
The client asks the nurse, “When I will be allowed to eat three meals
a day like the rest of my family?”. The appropriate nursing response
is:
“You will probably have to eat six meals a day for the rest of your
life.”
“Eating six meals a day can be a bother, can’t it?”
“Some clients can tolerate three meals a day by the time they leave
the hospital. Maybe it will be a little longer for you.”
“ It varies from client to client, but generally in 6-12 months most
clients can return to their previous meal patterns”
43. A male client with cirrhosis is complaining of belly pain, itchiness
and his breasts are getting larger and also the abdomen. The client is
so upset because of the discomfort and asks the nurse why his
breast and abdomen are getting larger. Which of the following is the
appropriate nursing response?
“How much of a difference have you noticed”
“It’s part of the swelling your body is experiencing”
“It’s probably because you have been less physically active”
“Your liver is not destroying estrogen hormones that all men
produce”
44. A client is diagnosed with detached retina and scheduled for
surgery. Preoperative teaching of the nurse to the client includes:
No eye pain is expected postoperatively
Semi-fowler’s position will be used to reduce pressure in the eye.
Eye patches may be used postoperatively
Return of normal vision is expected following surgery
45. A 70-year-old client is brought to the emergency department
with a caregiver. The client has manifestations of anorexia, wasting
of muscles and multiple bruises. What nursing interventions would
the nurse implement?
Talk to the client about the caregiver and support system
Complete a gastrointestinal and neurological assessment
Check the lab data for serum albumin, hematocrit and hemoglobin
Complete a police report on elder abuse
46. A nurse is providing a discharge instruction to the client about
the self-catheterization at home. Which of the following instructions
would the nurse include?
Wash the catheter with soap and water after each use
Lubricate the catheter with Vaseline
Perform the Valsalva maneuver to promote insertion
Replace the catheter with a new one every 24 hour
47. The nurse in the nursing care unit is assigned to care to a client
who is Immunocompromised. The client tells the nurse that his chest
is painful and the blisters are itchy. What would be the nursing
intervention to this client?
Call the physician
Give a prn pain medication
Clarify if the client is on a new medication
Use gown and gloves while assessing the lesions
48. A client is admitted and has been diagnosed with bacterial
(meningococcal) meningitis. The infection control registered nurse
visits the staff nurse caring to the client. What statement made by
the nurse reflects an understanding of the management of this
client?
speech pattern may be altered
Respiratory isolation is necessary for 24 hours after antibiotics are
started
Perform skin culture on the macular popular rash
Expect abnormal general muscle contractions
49. A 18-year-old male client had sustained a head injury from a
motorbike accident. It is uncertain whether the client may have
minimal but permanent disability. The family is concerned regarding
the client’s difficulty accepting the possibility of long term effects.
Which nursing diagnosis is best for this situation?
Nutrition, less than body requirements
Injury, potential for sensory-perceptual alterations
Impaired mobility, related to muscle weakness
Anticipatory grieving, due to the loss of independence
50. A client with AIDS is scheduled for discharge. The client tells the
nurse that one of his hobbies at home is gardening. What will be the
discharge instruction of the nurse to the client knowing that the
client is prone to toxoplasmosis?
Wash all vegetables before cooking
Wear gloves when gardening
Wear a mask when travelling to foreign countries
Avoid contact with cats and birds
Answers and Rationales
D. The Heimlich flutter valve has a one-way valve that allows air and
fluid to drain. Underwater seal drainage is not necessary. This can be
connected to a drainage bag for the patient’s mobility. The absence
of a long drainage tubing and the presence of a one-way valve
promote effective therapy
C. C = the normal CVP is 0-8 mmHg. This value reflects hypervolemia.
The right ventricular function of this client reflects fluid volume
overload, and the physician should be notified.
C. A hot tub bath or shower in the morning helps many patients
limber up and reduces the symptoms of early morning stiffness. Cold
and ice packs are used to a lesser degree, though some clients state
that cold decreases localized pain, particularly during acute attacks.
D. These substances stimulate the production of hydrochloric acid,
which is detrimental in peptic ulcer disease.
D. The three-point gait is appropriate when weight bearing is not
allowed on the affected limb. The swing-to and swing-through
crutch gaits may also be used when only one leg can be used for
weight bearing
A. The client needs to be told before surgery that the catheter
causes the urge to void. Attempts to void around the catheter cause
the bladder muscles to contract and result in painful spasms.
B. Bland feedings should be given in small amounts on a frequent
basis to neutralize the hydrochloric acid and to prevent overload
C. Chilling the tube before insertion assists in relieving some of the
nasal discomfort. Water-soluble lubricants along with viscous
lidocaine (Xylocaine) may also be used. It is usually only lightly
lubricated before insertion
B. Whole milk should be avoided to include in the client’s diet
because it has 120 mg of sodium in 8 0z of milk.
A. Alcohol is extremely drying and contributes to skin break down.
An emollient lotion should be used.
D.  Potassium influences the excitability of nerves and muscles.
When potassium is low and the client is on digoxin, the risk of
digoxin toxicity is increased.
C. This position allows maximum expansion, ventilation, and
perfusion of the remaining lung.
A. These foods are high in potassium
B. Stress on the suture line should be avoided. Prevent flexion or
hyperextension of the neck, and provide a small pillow under
thehead and neck. Neck muscles have been affected during a
thyroidectomy, support essential for comfort and incisional support.
A. A positive nitrogen balance is important for meeting metabolic
needs, tissue repair, and resistance to infection. Caloric goals may be
as high as 5000 calories per day.
C. The best early intervention would be to increase fluid intake,
because constipation is common when activity is decreased or usual
routines have been interrupted.
A. Because the client’s ability is to react to stress is decreased,
maintaining a quiet environment becomes A nursing priority.
Dehydration is a common problem in Addison’s disease, so close
observation of the client’s hydration level is crucial. To promote
optimal hydration and sodium intake, fluid intake is increased,
particularly fluid containing electrolytes, such as broths, carbonated
beverages, and juices.
C. At about 48-72 hours, the client must be turned onto the
abdomen to prevent flexion contractures.
B. The client should not drive for 2 weeks after surgery to avoid
stress on the incision. This reflects a need for additional teaching.
A. Extremes in heat and cold will exacerbate symptoms. Heat delays
transmission of impulses and increases fatigue.
A. Vigilant implementation of standard precautions and medical
asepsis is an effective means of preventing infection
C. Noncompliance is a major problem in the management of chronic
disease. In hypertension, the client often does not feel ill and thus
does not see a need to follow a treatment regimen.
B. An accumulation of blood from the kidney into the abdomen
would manifest itself with these symptoms
D. Fluids liquefy secretions and therefore make it easier to
expectorate
D. Physical assessment guidelines recommend listening for atleast 2
minutes in each quadrant (and up to 5 minutes, not at least 5
minutes).
A. Compression stockings promote venous return and prevent
peripheral pooling.
A. Placing food in the unaffected side of the mouth assists in the
swallowing process because the client has sensation on that side and
will have more control over the swallowing process.
D. Daily weights are taken following nephrectomy. Daily increases of
2 lb or more are indicative of fluid retention and should be reported
to the physician. Intake and output records may also reflect this
imbalance.
A. Clients with cirrhosis have already coagulation due to
thrombocytopenia and vitamin K deficiency. This could be a sign of
bleeding
B. Exercise enhances glucose uptake, and the client is at risk for an
insulin reaction. Snacks with carbohydrates will help.
C. These are symptoms of diabetes insipidus. The patient can
become hypovolemic and vasopressin may reverse the Polyuria.
D. Peripheral neuropathy refers to nerve damage of the hands and
feet. The client did not notice that the object pierced the skin.
A. The elevation of the stump on a pillow for the first 24 hours
decreases edema and increases venous return.
B. The priority is to maintain client’s safety. With syncope and
vertigo, the client is at high risk for falling.
D. Coughing and deep breathing are essential for re-expansion of
the lung
B. Avoiding stasis of urine by emptying the bladder every 2-4 hours
will prevent overdistention of the bladder and future urinary tract
infections.
D. If infected, the sex partner must be evaluated and treated
A. A 1:10 solution of household bleach and water is recommended
by the Centers for Disease Control and Prevention to kill the human
immunodeficiency virus (HIV).
D. Given the data, presurgical anxiety is suspected. The client needs
an opportunity to talk about concerns related to surgery before
further actions (which may mask the anxiety).
C. A quick look at the client can help identify the type and cause of
the ventilator alarm. Disconnection of the tube from the ventilator,
bronchospasm, and anxiety are some of the obvious reasons that
could trigger an alarm.
A. Contact isolation has been advised by the Centers for Disease
Control and Prevention (CDC) to control transmission of MRSA,
which includes gloves and handwashing.
D. In response to the question of the client, the nurse needs to
provide brief, accurate information. Some clients who have had
gastrectomies are able to tolerate three meals a day before
discharge from the hospital. However, for the majority of clients, it
takes 6-12 months before their surgically reduced stomach has
stretched enough to accommodate a larger meal.
A. This allows the client to elaborate his concern and provides the
nurse a baseline of assessment
C. Use of eye patches may be continued postoperatively, depending
on surgeon preference. This is done to achieve >90% success rate of
the surgery.
B. Assessment and more data collection are needed. The client may
have gastrointestinal or neurological problems that account for the
symptoms. The anorexia could result from medications, poor
dentition, or indigestion, the bruises may be attributed to ataxia,
frequent falls, vertigo, or medication.
A. The catheter should be washed with soap and water after
withdrawal and placed in a clean container. It can be reused until it
is too hard or too soft for insertion. Self-care, prevention of
complications, and cost-effectiveness are important in home
management.
D. The client may have herpes zoster (shingles), a viral infection. The
nurse should use standard precautions in assessing the lesions.
Immunocompromised clients are at risk for infection.
B. After a minimum of 24 hours of IV antibiotics, the client is no
longer considered communicable. Evaluation of the nurse’s
knowledge is needed for safe care and continuity of care.
D. Stem of the question supports this choice by stating that the
client has difficulty accepting the potential disability.
B. Toxoplasmosis is an opportunistic infection and a parasite of birds
and mammals. The oocysts remain infectious in moist soil for about
1 year.
SET 3
1. After a cerebrovascular accident, a 75 yr old client is admitted to
the health care facility. The client has left-sided weakness and an
absent gag reflex. He’s incontinent and has a tarry stool. His blood
pressure is 90/50 mm Hg, and his hemoglobin is 10 g/dl. Which of
the following is a priority for this client?
checking stools for occult blood
performing range-of-motion exercises to the left side
keeping skin clean and dry
elevating the head of the bed to 30 degrees
2. The nurse is caring for a client with a colostomy. The client tells
the nurse that he makes small pin holes in the drainage bag to help
relieve gas. The nurse should teach him that this action:
destroys the odor-proof seal
wont affect the colostomy system
is appropriate for relieving the gas in a colostomy system 52 mm Hg
destroys the moisture barrier seal 88 mm Hg
3. When assessing the client with celiac disease, the nurse can 48 mm Hg
expect to find which of the following? 68 mm Hg
steatorrhea 11. A 52 yr-old female tells the nurse that she has found a painless
jaundiced sclerae lump in her right breast during her monthly self-examination. Which
clay-colored stools assessment finding would strongly suggest that this client’s lump is
widened pulse pressure cancerous?
4. A client is hospitalized with a diagnosis of chronic eversion of the right nipple and a mobile mass
glomerulonephritis. The client mentions that she likes salty foods. nonmobile mass with irregular edges
The nurse should warn her to avoid foods containing sodium mobile mass that is oft and easily delineated
because: nonpalpable right axillary lymph nodes
reducing sodium promotes urea nitrogen excretion 12. A Client is scheduled to have a descending colostomy. He’s very
reducing sodium improves her glomerular filtration rate anxious and has many questions regarding the surgical procedure,
reducing sodium increases potassium absorption care of stoma, and lifestyle changes. It would be most appropriate
reducing sodium decreases edema for the nurse to make a referral to which member of the health care
5. The nurse is caring for a client with a cerebral injury that impaired team?
his speech and hearing. Most likely, the client has experienced Social worker
damage to the: registered dietician
frontal lobe occupational therapist
parietal lobe enterostomal nurse therapist
occipital lobe 13. Ottorrhea and rhinorrhea are most commonly seen with which
temporal lobe type of skull fracture?
6. The nurse is assessing a postcraniotomy client and finds the urine basilar
output from a catheter is 1500 ml for the 1st hour and the same for temporal
the 2nd hour. The nurse should suspect: occipital
Cushing’s syndrome parietal
Diabetes mellitus 14. A male client should be taught about testicular examinations:
Adrenal crisis when sexual activity starts
Diabetes insipidus after age 60
7. The nurse is providing postprocedure care for a client who after age 40
underwent percutaneous lithotripsy. In this procedure, an ultrasonic before age 20
probe inserted through a nephrostomy tube into the renal pelvis 15. Before weaning a client from a ventilator, which assessment
generates ultra-high-frequency sound waves to shatter renal calculi. parameter is most important for the nurse to review?
The nurse should instruct the client to: fluid intake for the last 24 hours
limit oral fluid intake for 1 to 2 weeks baseline arterial blood gas (ABG) levels
report the presence of fine, sandlike particles through the prior outcomes of weaning
nephrostomy tube. electrocardiogram (ECG) results
Notify the physician about cloudy or foul smelling urine 16. The nurse is speaking to a group of women about early detection
Report bright pink urine within 24 hours after the procedure of breast cancer. The average age of the women in the group is 47.
8. A client with a serum glucose level of 618 mg/dl is admitted to the Following the American Cancer Society (ACS) guidelines, the nurse
facility. He’s awake and oriented, has hot dry skin, and has the should recommend that the women:
following vital signs: temperature of 100.6º F (38.1º C), heart rate of perform breast self-examination annually
116 beats/minute, and blood pressure of 108/70 mm Hg. Based on have a mammogram annually
these assessment findings, which nursing diagnosis takes the highest have a hormonal receptor assay annually
priority? have a physician conduct a clinical evaluation every 2 years
deficient fluid volume related to osmotic diuresis 17. When caring for a client with esophageal varices, the nurse
decreased cardiac output related to elevated heart rate knows that bleeding in this disorder usually stems from:
imbalanced nutrition: Less than body requirements related to insulin esophageal perforation
deficiency pulmonary hypertension
ineffective thermoregulation related to dehydration portal hypertension
9. Capillary glucose monitoring is being performed every 4 hours for peptic ulcers
a client diagnosed with diabetic ketoacidosis. Insulin is administered 18. A 49-yer-old client was admitted for surgical repair of a Colles’
using a scale of regular insulin according to glucose results. At 2 fracture. An external fixator was placed during surgery. The surgeon
p.m., the client has a capillary glucose level of 250 mg/dl for which explains that this method of repair:
he receives 8 U of regular insulin. The has very low complication rate
nurse should expect the dose’s: maintains reduction and overall hand function
onset to be at 2 p.m. and its peak at 3 p.m. is less bothersome than a cast
onset to be at 2:15 p.m. and its peak at 3 p.m. is best for older people
onset to be at 2:30 p.m. and its peak at 4 p.m. 19. A client is hospitalized with a diagnosis of chronic renal failure.
onset to be at 4 p.m. and its peak at 6 p.m. An arteriovenous fistula was created in his left arm for hemodialysis.
10. A client with a head injury is being monitored for increased When preparing the client for discharge, the nurse should reinforce
intracranial pressure (ICP). His blood pressure is 90/60 mmHG and which dietary instruction?
the ICP is 18 mmHg; therefore his cerebral perfusion pressure (CPP) “Be sure to eat meat at every meal.”
is: “Monitor your fruit intake and eat plenty of bananas.”
“Restrict your salt intake.” strongly support a diagnosis of acute leukemia is the existence of a
“Drink plenty of fluids.” large number of immature:
20. The nurse is caring for a client who has just had a modified lymphocytes
radical mastectomy with immediate reconstruction. She’s in her 30s thrombocytes
and has tow children. Although she’s worried about her future, she reticulocytes
seems to be adjusting well to her diagnosis. What should the nurse leukocytes
do to support 29. The nurse is performing wound care on a foot ulcer in a client
her coping? with type 1 diabetes mellitus. Which technique demonstrates
Tell the client’s spouse or partner to be supportive while she surgical asepsis?
recovers. Putting on sterile gloves then opening a container of sterile saline.
Encourage the client to proceed with the next phase of treatment. Cleaning the wound with a circular motion, moving from outer
Recommend that the client remain cheerful for the sake of her circles toward the center.
children. Changing the sterile field after sterile water is spilled on it.
Refer the client to the American Cancer Society’s Reach for Recovery Placing a sterile dressing ½” (1.3 cm) from the edge of the sterile
program or another support program. field.
21. A 21 year-old male has been seen in the clinic for a thickening in 30. A client with a forceful, pounding heartbeat is diagnosed with
his right testicle. The physician ordered a human chorionic mitral valve prolapse. This client should avoid which of the
gonadotropin (HCG) level. The nurse’s explanation to the client following?
should include the fact that: high volumes of fluid intake
The test will evaluate prostatic function. aerobic exercise programs
The test was ordered to identify the site of a possible infection. caffeine-containing products
The test was ordered because clients who have testicular cancer has foods rich in protein
elevated levels of HCG. 31. A client with a history of hypertension is diagnosed with primary
The test was ordered to evaluate the testosterone level. hyperaldosteronism. This diagnosis indicates that the client’s
22. A client is receiving captopril (Capoten) for heart failure. The hypertension is caused by excessive hormone secretion from which
nurse should notify the physician that the medication therapy is organ?
ineffective if an assessment reveals: adrenal cortex
A skin rash. pancreas
Peripheral edema. adrenal medulla
A dry cough. parathyroid
Postural hypotension. 32. A client has a medical history of rheumatic fever, type 1 (insulin
23. Which assessment finding indicates dehydration? dependent) diabetes mellitus, hypertension, pernicious anemia, and
Tenting of chest skin when pinched. appendectomy. She’s admitted to the hospital and undergoes mitral
Rapid filling of hand veins. valve replacement surgery. After discharge, the client is scheduled
A pulse that isn’t easily obliterated. for a tooth extraction. Which history finding is a major risk factor for
Neck vein distention infective endocarditis?
24. The nurse is teaching a client with a history of atherosclerosis. To appendectomy
decrease the risk of atherosclerosis, the nurse should encourage the pernicious anemia
client to: diabetes mellitus
Avoid focusing on his weight. valve replacement
Increase his activity level. 33. A 62 yr-old client diagnosed with pyelonephritis and possible
Follow a regular diet. septicemia has had five urinary tract infections over the past two
Continue leading a high-stress lifestyle. years. She’s fatigued from lack of sleep; urinates frequently, even
25. For a client newly diagnosed with radiationinduced during the night; and has lost weight recently. Test reveal the
thrombocytopenia, the nurse should include which intervention in following: sodium level 152 mEq/L, osmolarity 340 mOsm/L, glucose
the plan of care? level 125 mg/dl, and potassium level 3.8 mEq/L. which of the
Administer aspirin if the temperature exceeds 38.8º C. following nursing diagnoses is most appropriate for this client?
Inspect the skin for petechiae once every shift. Deficient fluid volume related to inability to conserve water
Provide for frequent periods of rest. Imbalanced nutrition: less than body requirements related to
Place the client in strict isolation. hypermetabolic state
26. A client is chronically short of breath and yet has normal lung Deficient fluid volume related to osmotic diuresis induced by
ventilation, clear lungs, and an arterial oxygen saturation (SaO2) 96% hypernatremia
or better. The client most likely has: Imbalanced nutrition: less than body requirements related to
poor peripheral perfusion catabolic effects of insulin deficiency
a possible Hematologic problem 34. A 20 yr-old woman has just been diagnosed with Crohn’s
a psychosomatic disorder disease. She has lost 10 lb (4.5 kg) and has cramps and occasional
left-sided heart failure diarrhea. The nurse should include which of the following when
27. For a client in addisonian crisis, it would be very risky for a nurse doing a nutritional assessment?
to administer: Let the client eat as desired during the hospitalization.
potassium chloride Weight the client daily.
normal saline solution Ask the client to list what she eats during a typical day.
hydrocortisone Place the client on I & O status and draw blood for electrolyte levels.
fludrocortisone 35. When instructions should be included in the discharge teaching
28. The nurse is reviewing the laboratory report of a client who plan for a client after thyroidectomy for Grave’s disease?
underwent a bone marrow biopsy. The finding that would most Keep an accurate record of intake and output.
Use nasal desmopressin acetate DDAVP).
Be sure to get regulate follow-up care.
Be sure to exercise to improve cardiovascular fitness.
36. A client comes to the emergency department with chest pain,
dyspnea, and an irregular heartbeat. An electrocardiogram shows a
heart rate of 110 beats/minute (sinus tachycardia) with frequent
premature ventricular contractions. Shortly after admission, the
client has ventricular tachycardia and becomes unresponsive. After
successful resuscitation, the client is taken to the intensive care unit.
Which nursing diagnosis is appropriate at this time?
Deficient knowledge related to interventions used to treat acute
illness
Impaired physical mobility related to complete bed rest
Social isolation related to restricted visiting hours in the intensive
care unit
Anxiety related to the threat of death
37. A client is admitted to the health care facility with active
tuberculosis. The nurse should include which intervention in the
plan of care?
Putting on a mask when entering the client’s room.
Instructing the client to wear a mask at all times
Wearing a gown and gloves when providing direct care
Keeping the door to the client’s room open to observe the client
38. The nurse is caring for a client who underwent a subtotal
gastrectomy 24 hours earlier. The client has a nasogastric (NG) tube.
The nurse should:
Apply suction to the NG tube every hour.
Clamp the NG tube if the client complains of nausea.
Irrigate the NG tube gently with normal saline solution.
Reposition the NG tube if pulled out.
39. Which statement about fluid replacement is accurate for a client
with hyperosmolar hyperglycemic nonketotic syndrome (HHNS)?
administer 2 to 3 L of IV fluid rapidly
administer 6 L of IV fluid over the first 24 hours
administer a dextrose solution containing normal saline solution
administer IV fluid slowly to prevent circulatory overload and
collapse
40. Which of the following is an adverse reaction to glipizide
(Glucotrol)?
headache
constipation
hypotension
photosensitivity
41. The nurse is caring for four clients on a stepdown intensive care
unit. The client at the highest risk for developing nosocomial
pneumonia is the one who:
has a respiratory infection
is intubated and on a ventilator
has pleural chest tubes
is receiving feedings through a jejunostomy tube
42. The nurse is teaching a client with chronic bronchitis about
breathing exercises. Which of the following should the nurse include
in the teaching?
Make inhalation longer than exhalation.
Exhale through an open mouth.
Use diaphragmatic breathing.
Use chest breathing.
43. A client is admitted to the hospital with an exacerbation of her
chronic systemic lupus erythematosus (SLE). She gets angry when
her call bell isn’t answered immediately. The most appropriate
response to her would be:
“You seem angry. Would you like to talk about it?”
“Calm down. You know that stress will make your symptoms worse.”
“Would you like to talk about the problem with the nursing
supervisor?”
“I can see you’re angry. I’ll come back when you’ve calmed down.”
44. On a routine visit to the physician, a client with chronic arterial
occlusive disease reports stopping smoking after 34 years. To relive
symptoms of intermittent claudication, a condition associated with
chronic arterial occlusive disease, the nurse should recommend
which additional measure?
Taking daily walks.
Engaging in anaerobic exercise.
Reducing daily fat intake to less than 45% of total calories
Avoiding foods that increase levels of highdensity lipoproteins
(HDLs)
45. A physician orders gastric decompression for a client with small
bowel obstruction. The nurse should plan for the suction to be:
low pressure and intermittent
low pressure and continuous
high pressure and continuous
high pressure and intermittent
46. Which nursing diagnosis is most appropriate for an elderly client
with osteoarthritis?
Risk for injury
Impaired urinary elimination
Ineffective breathing pattern
Imbalanced nutrition: less than body requirements
47. Parathyroid hormone (PTH) has which effects on the kidney?
Stimulation of calcium reabsorption and phosphate excretion
Stimulation of phosphate reabsorption and calcium excretion
Increased absorption of vit D and excretion of vit E
Increased absorption of vit E and excretion of Vit D
48. A visiting nurse is performing home assessment for a 59-yr old
man recently discharged after hip replacement surgery. Which home
assessment finding warrants health promotion teaching from the
nurse?
A bathroom with grab bars for the tub and toilet
Items stored in the kitchen so that reaching up and bending down
aren’t necessary
Many small, unsecured area rugs
Sufficient stairwell lighting, with switches to the top and bottom of
the stairs
49. A client with autoimmune thrombocytopenia and a platelet
count of 800/uL develops epistaxis and melena. Treatment with
corticosteroids and immunoglobulins has been unsuccessful, and the
physician recommends a splenectomy. The client states, “I don’t
need surgery—this will go away on its own.” In considering her
response to the client, the nurse must depend on the ethical
principle of:
beneficence
autonomy
advocacy
justice
50. Which of the following is t he most critical intervention needed
for a client with myxedema coma?
Administering and oral dose of levothyroxine (Synthroid)
Warming the client with a warming blanket
Measuring and recording accurate intake and output
Maintaining a patent airway
51. Because diet and exercise have failed to control a 63 yr-old
client’s blood glucose level, the client is prescribed glipizide
(Glucotrol). After oral administration, the onset of action is:
15 to 30 minutes
30 to 60 minutes
1 to 1 ½ hours
2 to 3 hours
52. A client with pneumonia is receiving supplemental oxygen, 2
L/min via nasal cannula. The client’s history includes chronic
obstructive pulmonary disease (COPD) and coronary artery disease.
Because of these findings, the nurse closely monitors the oxygen
flow and the client’s respiratory status. Which complication may
arise if the client receives a high oxygen concentration?
Apnea
Anginal pain
Respiratory alkalosis
Metabolic acidosis
53. A client with type 1 diabetes mellitus has been on a regimen of
multiple daily injection therapy. He’s being converted to continuous
subcutaneous insulin therapy. While teaching the client bout
continuous subcutaneous insulin therapy, the nurse would be
accurate in telling him the regimen includes the use of:
intermediate and long-acting insulins
short and long-acting insulins
short-acting only
short and intermediate-acting insulins
54. a client who recently had a cerebrovascular accident requires a
cane to ambulate. When teaching about cane use, the rationale for
holding a cane on the uninvolved side is to:
prevent leaning
distribute weight away from the involved side
maintain stride length
prevent edema
55. A client with a history of an anterior wall myocardial infarction is
being transferred from the coronary care unit (CCU) to the cardiac
stepdown unit (CSU). While giving report to the CSU nurse, the CCU
nurse says, “His pulmonary artery wedge pressures have been in the
high normal range.” The CSU nurse should be especially observant
for:
hypertension
high urine output
dry mucous membranes
pulmonary crackles
56. The nurse is caring for a client with a fractures hip. The client is
combative, confused, and trying to get out of bed. The nurse should:
leave the client and get help
obtain a physician’s order to restrain the client
read the facility’s policy on restraints
order soft restraints from the storeroom
57. For the first 72 hours after thyroidectomy surgery, the nurse
would assess the client for Chvostek’s sign and Trousseau’s sign
because they indicate which of the following?
hypocalcemia
hypercalcemia
hypokalemia
Hyperkalemia
58. In a client with enteritis and frequent diarrhea, the nurse should
anticipate an acidbase imbalance of:
respiratory acidosis
respiratory alkalosis
metabolic acidosis
metabolic alkalosis
59. When caring for a client with the nursing diagnosis Impaired
swallowing related to neuromuscular impairment, the nurse should:
position the client in a supine position
elevate the head of the bed 90 degrees during meals
encourage the client to remove dentures
encourage thin liquids for dietary intake
60. A nurse is caring for a client who has a tracheostomy and
temperature of 39º C. which intervention will most likely lower the
client’s arterial blood oxygen saturation?
Endotracheal suctioning
Encouragement of coughing
Use of cooling blanket
Incentive spirometry
61. A client with a solar burn of the chest, back, face, and arms is
seen in urgent care. The nurse’s primary concern should be:
fluid resuscitation
infection
body image
pain management
62. Which statement is true about crackles?
They’re grating sounds.
They’re high-pitched, musical squeaks.
They’re low-pitched noises that sound like snoring.
They may be fine, medium, or course.
63. A woman whose husband was recently diagnosed with active
pulmonary tuberculosis (TB) is a tuberculin skin test converter.
Management of her care would include:
scheduling her for annual tuberculin skin testing
placing her in quarantine until sputum cultures are negative
gathering a list of persons with whom she has had recent contact
advising her to begin prophylactic therapy with isoniazid (INH)
64. The nurse is caring for a client who ahs had an above the knee
amputation. The client refuses to look at the stump. When the nurse
attempts to speak with the client about his surgery, he tells the
nurse that he doesn’t wish to discuss it. The client also refuses to
have his family visit. The nursing diagnosis that best describes the
client’s problem is:
Hopelessness
Powerlessness
Disturbed body image
Fear
65. A client with three children who is still I the child bearing years is
admitted for surgical repair of a prolapsed bladder. The nurse would
find that the client understood the surgeon’s preoperative teaching
when the client states:
“If I should become pregnant again, the child would be delivered by
cesarean delivery.”
“If I have another child, the procedure may need to be repeated.”
“This surgery may render me incapable of conceiving another child.”
“This procedure is accomplished in two separate surgeries.”
66. A client experiences problems in body temperature regulation
associated with a skin impairment. Which gland is most likely
involved?
Eccrine
Sebaceous
Apocrine
Endocrine
67. A school cafeteria worker comes to the physician’s office
complaining of severe scalp itching. On inspection, the nurse finds
nail marks on the scalp and small light-colored round specks
attached to the hair shafts close to the scalp. These findings suggest
that the client suffers from:
scabies
head lice
tinea capitis
impetigo
68. Following a small-bowel resection, a client develops fever and
anemia. The surface surrounding the surgical wound is warm to
touch and necrotizing fasciitis is suspected. Another manifestation
that would most suggest necrotizing fasciitis is:
erythema
leukocytosis
pressure-like pain
swelling
69. A 28 yr-old nurse has complaints of itching and a rash of both
hands. Contact dermatitis is initially suspected. The diagnosis is
confirmed if the rash appears:
erythematous with raised papules
dry and scaly with flaking skin Turn and reposition the client a minimum of every 8 hours.
inflamed with weeping and crusting lesions Vigorously massage lotion into bony prominences.
excoriated with multiple fissures Post a turning schedule at the client’s bedside.
70. When assessing a client with partial thickness burns over 60% of Slide the client, rather than lifting when turning.
the body, which of the following should the nurse report 79. Following a full-thickeness (3rd degree) burn of his left arm, a
immediately? client is treated with artificial skin. The client understands
Complaints of intense thirst postoperative care of the artificial skin when he states that during
Moderate to severe pain the first 7 days after the procedure, he’ll restrict:
Urine output of 70 ml the 1st hour range of motion
Hoarseness of the voice protein intake
71. A client is admitted to the hospital following a burn injury to the going outdoors
left hand and arm. The client’s burn is described as white and fluid ingestion
leathery with no blisters. Which degree of severity is this burn? 80. A client received burns to his entire back and left arm. Using the
first-degree burn Rule of Nines, the nurse can calculate that he has sustained burns on
second-degree burn what percentage of his body?
third-degree burn 9%
fourth-degree burn 18%
72. The nurse is caring for client with a new donor site that was 27%
harvested to treat a new burn. The nurse position the client to: 36%
allow ventilation of the site 81. The nurse is providing care for a client who has a sacral pressure
make the site dependent ulcer with wet-to-dry dressing. Which guideline is appropriate for a
avoid pressure on the site wet-to-dry dressing?
keep the site fully covered The wound should remain moist form the dressing.
73. a 45-yr-old auto mechanic comes to the physician’s office The wet-to-dry dressing should be tightly packed into the wound.
because an exacerbation of his psoriasis is making it difficult to work. The dressing should be allowed to dry out before removal.
He tells the nurse that his finger joints are stiff and sore in the A plastic sheet-type dressing should cover the wet dressing.
morning. The nurse should respond by: 82. While in skilled nursing facility, a client contracted scabies, which
Inquiring further about this problem because psoriatic arthritis can is diagnosed the day after discharge. The client is living at her 
accompany psoriasis vulgaris daughter’s home with six other persons. During her visit to the clinic,
Suggesting he take aspirin for relief because it’s probably early she asks a staff nurse, “What should my family do?” the most
rheumatoid arthritis accurate response from the nurse is:
Validating his complaint but assuming it’s an adverse effect of his “All family members will need to be treated.”
vocation “If someone develops symptoms, tell him to see a physician right
Asking him if he has been diagnosed or treated for carpal tunnel away.”
syndrome “Just be careful not to share linens and towels with family
74. The nurse is providing home care instructions to a client who has members.”
recently had a skin graft. Which instruction is most important for the “After you’re treated, family members won’t be at risk for
client to remember? contracting scabies.”
Use cosmetic camouflage techniques. 83. In an industrial accident, client who weighs 155 lb (70.3 kg)
Protect the graft from direct sunlight. sustained full-thickness burns over 40% of his body. He’s in the burn
Continue physical therapy. unit receiving fluid resuscitation. Which observation shows that the
Apply lubricating lotion to the graft site. fluid resuscitation is benefiting the client?
75. a 28 yr-old female nurse is seen in the employee health A urine output consistently above 100 ml/hour.
department for mild itching and rash of both hands. Which of the A weight gain of 4 lb (1.8 kg) in 24 hours.
following could be causing this reaction? Body temperature readings all within normal limits
possible medication allergies An electrocardiogram (ECG) showing no arrhythmias.
current life stressors she may be experiencing 84. The nurse is reviewing the laboratory results of a client with
chemicals she may be using and use of latex gloves rheumatoid arthritis. Which of the following laboratory results
recent changes made in laundry detergent or bath soap. should the nurse expect to find?
76. The nurse assesses a client with urticaria. The nurse understands Increased platelet count
that urticaria is another name for: Elevated erythrocyte sedimentation rate (ESR)
hives Electrolyte imbalance
a toxin Altered blood urea nitrogen (BUN) and creatinine levels
a tubercle 85. Which nursing diagnosis takes the highest priority for a client
a virus with Parkinson’s crisis?
77. A client with psoriasis visits the dermatology clinic. When Imbalanced nutrition: less than body requirements
inspecting the affected areas, the nurse expects to see which type of Ineffective airway clearance
secondary lesion? Impaired urinary elimination
scale Risk for injury
crust 86. A client with a spinal cord injury and subsequent urine retention
ulcer receives intermittent catheterization every 4 hours. The average
scar catheterized urine volume has been 550 ml. The nurse should plan
78. The nurse is caring for a bedridden, elderly adult. To prevent to:
pressure ulcers, which intervention should the nurse include in the Increase the frequency of the catheterizations.
plan of care? Insert an indwelling urinary catheter
Place the client on fluid restrictions
Use a condom catheter instead of an invasive one.
87.The nurse is caring for a client who is to undergo a lumbar
puncture to assess for the presence of blood in the cerebrospinal
fluid (CSF) and to measure CSF pressure. Which result would indicate
n abnormality?
The presence of glucose in the CSF.
A pressure of 70 to 200 mm H2O
The presence of red blood cells (RBCs) in the first specimen tube
A pressure of 00 to 250 mmH2O
88. The nurse is administering eyedrops to a client with glaucoma.
To achieve maximum absorption, the nurse should instill the
eyedrop into the:
conjunctival sac
pupil
sclera
vitreous humor
89. A 52 yr-old married man with two adolescent children is
beginning rehabilitation following a cerebrovascular accident. As the
nurse is planning the client’s care, the nurse should recognize that
his condition will affect:
only himself
only his wife and children
him and his entire family
no one, if he has complete recovery
90. Which action should take the highest priority when caring for a
client with hemiparesis caused by a cerebrovascular accident (CVA)?
Perform passive range-of-motion (ROM) exercises.
Place the client on the affected side.
Use hand rolls or pillows for support.
Apply antiembolism stockings
91. The nurse is formulating a teaching plan for a client who has just
experienced a transient ischemic attack (TIA). Which fact should the
nurse include in the teaching plan?
TIA symptoms may last 24 to 48 hours.
Most clients have residual effects after having a TIA.
TIA may be a warning that the client may have cerebrovascular
accident (CVA)
The most common symptom of TIA is the inability to speak.
92. The nurse has just completed teaching about postoperative
activity to a client who is going to have a cataract surgery. The nurse
knows the teaching has been effective if the client:
coughs and deep breathes postoperatively
ties his own shoes
asks his wife to pick up his shirt from the floor after he drops it.
States that he doesn’t need to wear an eyepatch or guard to bed
93. The least serious form of brain trauma, characterized by a brief
loss of consciousness and period of confusion, is called:
contusion
concussion
coup
contrecoup
94. When the nurse performs a neurologic assessment on Anne
Jones, her pupils are dilated and don’t respond to light.
glaucoma
damage to the third cranial nerve
damage to the lumbar spine
Bell’s palsy
95. A 70 yr-old client with a diagnosis of leftsided cerebrovascular
accident is admitted to the facility. To prevent the development of
diffuse osteoporosis, which of the following objectives is most
appropriate?
Maintaining protein levels.
Maintaining vitamin levels.
Promoting weight-bearing exercises
Promoting range-of-motion (ROM) exercises
96. A client is admitted with a diagnosis of meningitis caused by
Neisseria meningitides. The nurse should institute which type of
isolation precautions?
Contact precautions
Droplet precautions
Airborne precautions
Standard precautions
97. A young man was running along an ocean pier, tripped on an
elevated area of the decking, and struck his head on the pier railing.
According to his friends, “He was unconscious briefly and then
became alert and behaved as though nothing had happened.”
Shortly afterward, he began complaining of a headache and asked to
be taken to the emergency department. If the client’s intracranial
pressure (ICP) is increasing, the nurse would expect to observe
which of the
following signs first?
pupillary asymmetry
irregular breathing pattern
involuntary posturing
declining level of consciousness
98. Emergency medical technicians transport a 28 yr-old iron worker
to the emergency department. They tell the nurse, “He fell from a
two-story building. He has a large contusion on his left chest and a
hematoma in the left parietal area. He has compound fracture of his
left femur and he’s comatose. We intubated him and he’s
maintaining an arterial oxygen saturation of 92% by pulse oximeter
with a manual-resuscitation bag.” Which intervention by the nurse
has the highest priority?
Assessing the left leg
Assessing the pupils
Placing the client in Trendelenburg’s position
Assessing the level of consciousness
99. Alzheimer’s disease is the secondary diagnosis of a client
admitted with myocardial infarction. Which nursing intervention
should appear on this client’s plan of care?
Perform activities of daily living for the client to decease frustration.
Provide a stimulating environment.
Establish and maintain a routine.
Try to reason with the client as much as possible.
100. For a client with a head injury whose neck has been stabilized,
the preferred bed position is:
Trendelenburg’s
30-degree head elevation
flat
side-lying
Answers and Rationales
ANS: D
Because the client’s gag reflex is absent, elevating the head of the
bed to 30 degrees helps minimize the client’s risk of aspiration.
Checking the stools, performing ROM exercises, and keeping the skin
clean and dry are important, but preventing aspiration through
positioning is the priority.
ANS: A
Any hole, no matter how small, will destroy the odor-proof seal of a
drainage bag. Removing the bag or unclamping it is the only
appropriate method for relieving gas.
ANS: A
because celiac disease destroys the absorbing surface of the
intestine, fat isn’t absorbed but is passed in the stool. Steatorrhea is
bulky, fatty stools that have a foul odor. Jaundiced sclerae result
from elevated bilirubin levels. Clay-colored stools are seen with
biliary disease when bile flow is blocked. Celiac disease doesn’t
cause a widened pulse pressure.
ANS: D
Reducing sodium intake reduces fluid retention. Fluid retention
increases blood volume, which changes blood vessel permeability
and allows plasma to move into interstitial tissue, causing edema.
Urea nitrogen excretion can be increased only by improved renal
function. Sodium intake doesn’t affect the glomerular filtration rate.
Potassium absorption is improved only by increasing the glomerular
filtration rate; it isn’t affected by sodium intake.
ANS: D
The portion of the cerebrum that controls speech and hearing is the
temporal lobe. Injury to the frontal lobe causes personality changes,
difficulty speaking, and disturbance in memory, reasoning, and
concentration. Injury to the parietal lobe causes sensory alterations
and problems with spatial relationships. Damage to the occipital
lobe causes vision disturbances.
ANS: D
Diabetes insipidus is an abrupt onset of extreme polyuria that
commonly occurs in clients after brain surgery. Cushing’s syndrome
is excessive glucocorticoid secretion resulting in sodium and water
retention. Diabetes mellitus is a hyperglycemic state marked by
polyuria, polydipsia, and polyphagia. Adrenal crisis is undersecretion
of glucocorticoids resulting in profound hypoglycemia, hypovolemia,
and hypotension.
ANS: C
The client should report the presence of foulsmelling or cloudy
urine. Unless contraindicated, the client should be instructed to
drink large quantities of fluid each day to flush the kidneys. Sand-like
debris is normal because of residual stone products. Hematuria is
common after lithotripsy.
ANS: A
A serum glucose level of 618 mg/dl indicates hyperglycemia, which
causes polyuria and deficient fluid volume. In this client, tachycardia
is more likely to result from deficient fluid volume than from
decreased cardiac output because his blood pressure is normal.
Although the client’s serum glucose is elevated, food isn’t a priority
because fluids and insulin should be administered to lower the
serum glucose level. Therefore, a diagnosis of Imbalanced Nutrition:
Less then body requirements isn’t appropriate. A temperature of
100.6º F isn’t life threatening, eliminating ineffective
thermoregulation as the top priority.
ANS: C
Regular insulin, which is a short-acting insulin, has an onset of 15 to
30 minutes and a peak of 2 to 4 hours. Because the nurse gave the
insulin at 2 p.m., the expected onset would be from 2:15 to 2:30
p.m. and the peak from 4 p.m. to 6 p.m.
ANS: A
CPP is derived by subtracting the ICP from the mean arterial
pressure (MAP). For adequate cerebral perfusion to take place, the
minimum goal is 70 mmHg. The MAP is derived using the following
formula:
MAP = ((diastolic blood pressure x 2) + systolic blood pressure) / 3
MAP = ((60 x2) + 90) / 3
MAP = 70 mmHg
To find the CPP, subtract the client’s ICP from the MAP; in this case ,
70 mmHg – 18 mmHg = 52 mmHg.
ANS: B
Breast cancer tumors are fixed, hard, and poorly delineated with
irregular edges. Nipple retraction —not eversion—may be a sign of
cancer. A mobile mass that is soft and easily delineated is most often
a fluid-filled benigned cyst. Axillary lymph nodes may or may not be
palpable on initial detection of a cancerous mass.
ANS: D
An enterostomal nurse therapist is a registered nurse who has
received advance education in an accredited program to care for
clients with stomas. The enterostomal nurse therapist can assist
with selection of an appropriate stoma site, teach about stoma care,
and provide emotional support.
ANS: A
Ottorrhea and rhinorrhea are classic signs of basilar skull fracture.
Injury to the dura commonly occurs with this fracture, resulting in
cerebrospinal fluid (CSF) leaking through the ears and nose. Any fluid
suspected of being CSF should be checked for glucose or have a halo
test done.
ANS: D
Testicular cancer commonly occurs in men between ages 20 and 30.
A male client should be taught how to perform testicular self-
examination before age 20, preferably when he enters his teens.
ANS: B
Before weaning a client from mechanical ventilation, it’s most
important to have a baseline ABG levels. During the weaning
process, ABG levels will be checked to assess how the client is
tolerating the procedure. Other assessment parameters are less
critical. Measuring fluid volume intake and output is always
important when a client is being mechanically ventilated. Prior
attempts at weaning and ECG results are documented on the client’s
record, and the nurse can refer to them before the weaning process
begins.
ANS: B
According to the ACS guidelines, “Women older than age 40 should
perform breast selfexamination monthly (not annually).” The
hormonal receptor assay is done on a known breast tumor to
determine whether the tumor is estrogen- or progesterone-
dependent.
ANS: C
Increased pressure within the portal veins causes them to bulge,
leading to rupture and bleeding into the lower esophagus. Bleeding
associated with esophageal varices doesn’t stem from esophageal
perforation, pulmonary hypertension, or peptic ulcers.
ANS: B
Complex intra-articular fractures are repaired with external fixators
because they have a better long-term outcome than those treated
with casting. This is especially true in a young client. The incidence of
complications, such as pin tract infections and neuritis, is 20% to
60%. Clients must be taught how to do pin care and assess for
development of neurovascular complications.
ANS: C
In a client with chronic renal failure, unrestricted intake of sodium,
protein, potassium, and fluids may lead to a dangerous
accumulation of electrolytes and protein metabolic products, such
as amino acids and ammonia. Therefore, the client must limit his
intake of sodium, meat (high in Protein), bananas (high in
potassium), and fluid because the kidneys can’t secrete adequate
urine.
ANS: D
The client isn’t withdrawn or showing other signs of anxiety or
depression. Therefore, the nurse can probably safely approach her
about talking with others who have had similar experiences, either
through Reach for Recovery or another formal support group. The
nurse may educate the client’s spouse or partner to listen to
concerns, but the nurse shouldn’t tell the client’s spouse what to do.
The client must consult with her physician and make her own
decisions
about further treatment. The client needs to express her sadness,
frustration, and fear. She can’t be expected to be cheerful at all
times.
ANS: C
HCG is one of the tumor markers for testicular cancer. The HCG level
won’t identify the site of an infection or evaluate prostatic function
or testosterone level.
ANS: B
Peripheral edema is a sign of fluid volume overload and worsening
heart failure. A skin rash, dry cough, and postural hypotension are
adverse reactions to captopril, but the don’t indicate that therapy
isn’t effective.
ANS: A
Tenting of chest skin when pinched indicates decreased skin
elasticity due to dehydration. Hand veins fill slowly with
dehydration, not rapidly. A pulse that isn’t easily obliterated and
neck vein distention indicate fluid overload, not dehydration.
ANS: B
The client should be encouraged to increase his activity level.
Maintaining an ideal weight; following a low-cholesterol, low-
sodium diet; and avoiding stress are all important factors in
decreasing the risk of atherosclerosis.
ANS: B
Because thrombocytopenia impairs blood clotting, the nurse should
assess the client regularly for signs of bleeding, such as petechiae,
purpura, epistaxis, and bleeding gums. The nurse should avoid
administering aspirin because it can increase the risk of bleeding.
Frequent rest periods are indicated for clients with anemia, not
thrombocytopenia. Strict isolation is indicated only for clients who
have highly contagious or virulent infections that are spread by air or
physical contact.
ANS: B
SaO2 is the degree to which hemoglobin is saturated with oxygen. It
doesn’t indicate the client’s overall Hgb adequacy. Thus, an
individual with a subnormal Hgb level could have normal SaO2 and
still be short of breath. In this case, the nurse could assume that the
client has a Hematologic problem. Poor peripheral perfusion would
cause subnormal SaO2. There isn’t enough data to assume that the
client’s problem is psychosomatic. If the problem were
left-sided heart failure, the client would exhibit pulmonary crackles.
ANS: A
Addisonian crisis results in Hyperkalemia; therefore, administering
potassium chloride is contraindicated. Because the client will be
hyponatremic, normal saline solution is indicated. Hydrocortisone
and fludrocortisone are both useful in replacing deficient adrenal
cortex hormones.
ANS: D
Leukemia is manifested by an abnormal overpopulation of immature
leukocytes in the bone marrow.
ANS: C
A sterile field is considered contaminated when it becomes wet.
Moisture can act as a wick, allowing microorganisms to contaminate
the field. The outside of containers, such as sterile saline bottles,
aren’t sterile. The containers should be opened before sterile gloves
are put on and the solution poured over the sterile dressings placed
in a sterile basin. Wounds should be cleaned from the most
contaminated area to the least contaminated area—for example,
from the center outward. The outer inch of a sterile field shouldn’t
be considered sterile.
ANS: C
Caffeine is a stimulant, which can exacerbate palpitations and should
be avoided by a client with symptomatic mitral valve prolapse. High
fluid intake helps maintain adequate preload and cardiac output.
Aerobic exercise helps in increase cardiac output and decrease heart
rate. Protein-rich foods aren’t restricted but high calorie foods are.
ANS: A
Excessive of aldosterone in the adrenal cortex is responsible for the
client’s hypertension. This hormone acts on the renal tubule, where
it promotes reabsorption of sodium and excretion of potassium and
hydrogen ions. The pancreas mainly secretes hormones involved in
fuel metabolism. The adrenal medulla secretes the cathecolamines
—epinephrine and norepinephrine. The parathyroids secrete
parathyroid hormone.
ANS: D
A heart valve prosthesis, such as a mitral valve replacement, is a
major risk factor for infective endocarditis. Other risk factors include
a history of heart disease (especially mitral valve prolapse), chronic
debilitating disease, IV drug abuse, and immunosuppression.
Although diabetes mellitus may predispose a person to
cardiovascular disease, it isn’t a major risk factor for infective
endocarditis, nor is an appendectomy or pernicious anemia.
ANS: A
The client has signs and symptoms of diabetes insipidus, probably
caused by the failure of her renal tubules to respond to antidiuretic
hormone as a consequence of pyelonephritis. The hypernatremia is
secondary to her water loss. Imbalanced nutrition related to
hypermetabolic state or catabolic effect of insulin deficiency is an
inappropriate nursing diagnosis for the client.
ANS: C
When performing a nutritional assessment, one of the first things
the nurse should do is to assess what the client typically eats. The
client shouldn’t be permitted to eat as desired. Weighing the client
daily, placing her on I & O status, and drawing blood to determine
electrolyte level aren’t part of a nutritional assessment.
Ans. C
Regular follow-up care for the client with Grave’s disease is critical
because most cases eventually result in hypothyroidism. Annual
thyroid-stimulating hormone tests and the client’s ability to
recognize signs and symptoms of thyroid dysfunction will help
detect thyroid abnormalities early. Intake and output is important
for clients with fluid and electrolyte imbalances but not thyroid
disorders. DDAVP is used to treat diabetes insipidus. While exercise
to improve cardiovascular fitness is important, for this client the
importance of regular follow-up is most critical.
ANS: D
Anxiety related to the threat of death is an appropriate nursing
diagnosis because the client’s anxiety can adversely affect hear rate
and rhythm by stimulating the autonomic nervous system. Also,
because the client required resuscitation, the threat of death is a
real and immediate concern. Unless anxiety is dealt with first, the
client’s emotional state will impede learning. Client teaching should
be limited to clear concise explanations that reduce anxiety and
promote cooperation. An anxious client has difficulty learning, so the
deficient knowledge would continue despite attempts teaching.
Impaired physical mobility and social isolation are necessitated by
the client’s critical condition; therefore, they aren’t considered
problems warranting nursing diagnoses.
ANS: A
Because tuberculosis is transmitted by droplet nuclei from the
respiratory tract, the nurse should put on a mask when entering the
client’s room. Having the client wear a mask at all the times would
hinder sputum expectoration and make the mask moist from
respirations. If no contact with the client’s blood or body fluids is
anticipated, the nurse need not wear a gown or gloves when
providing direct care. A client with tuberculosis should be in a room
with laminar air flow, and the door should be closed at all times.
ANS: C
The nurse can gently irrigate the tube but must take care not to
reposition it. Repositioning can cause bleeding. Suction should be
applied continuously, not every hour. The NG tube shouldn’t be
clamped postoperatively because secretions and gas will
accumulate, stressing the suture line.
ANS: A
Regardless of the client’s medical history, rapid fluid resuscitation is
critical for maintaining cardiovascular integrity. Profound
intravascular depletion requires aggressive fluid replacement. A
typical fluid resuscitation protocol is 6 L of fluid over the first 12
hours, with more fluid to follow over the next 24 hours. Various
fluids can be used, depending on the degree of hypovolemia.
Commonly prescribed fluids include dextran (in case of hypovolemic
shock), isotonic normal saline solution and, when the client is
stabilized, hypotonic half-normal saline solution.
ANS: D
Glipizide may cause adverse skin reactions, such as pruritus, and
photosensitivity. It doesn’t cause headache, constipation, or
hypotension.
ANS: B
When clients are on mechanical ventilation, the artificial airway
impairs the gag and cough reflexes that help keep organisms out of
the lower respiratory tract. The artificial airway also prevents the
upper respiratory system from humidifying and heating air to
enhance mucociliary clearance. Manipulations of the artificial airway
sometimes allow secretions into the lower airways. Whit standard
procedures the other choices wouldn’t be at high risk.
ANS: C
In chronic bronchitis, the diaphragmatic is flat and weak.
Diaphragmatic breathing helps to strengthen the diaphragm and
maximizes ventilation. Exhalation should longer than inhalation to
prevent collapse of the bronchioles. The client with chronic
bronchitis should exhale through pursed lips to prolong exhalation,
keep the bronchioles from collapsing, and prevent air trapping.
Diaphragmatic breathing—not chest breathing—increases lung
expansion.
ANS: A
Verbalizing the observed behavior is a therapeutic communication
technique in which the nurse acknowledges what the client is
feeling. Offering to listen to the client express her anger can help the
nurse and the client understand its cause and begin to deal with it.
Although stress can exacerbate the symptoms of SLE, telling the
client to calm down doesn’t acknowledge her feelings. Offering to
get the nursing supervisor also doesn’t acknowledge the client’s
feelings. Ignoring the client’s feelings suggest that the nurse has no
interest in what the client has said.
ANS: A
Daily walks relieve symptoms of intermittent claudication, although
the exact mechanism is unclear. Anaerobic exercise may exacerbate
these symptoms. Clients with chronic arterial occlusive disease must
reduce daily fat intake to 30% or less of total calories. The client
should limit dietary cholesterol because hyperlipidemia is associated
with atherosclerosis, a known cause of arterial occlusive disease.
However, HDLs have the lowest cholesterol concentration,
so this client should eat foods that raise HDL levels.
ANS: A
Gastric decompression is typically low pressure and intermittent.
High pressure and continuous gastric suctioning predisposes the
gastric mucosa to injury and ulceration.
ANS: A
In osteoarthritis, stiffness is common in large, weight bearing joints
such as the hips. This joint stiffness alters functional ability and
range of motion, placing the client at risk for falling and injury.
Therefore, client safety is in jeopardy. Osteoporosis doesn’t affect
urinary elimination, breathing, or nutrition.
ANS: A
PTH stimulates the kidneys to reabsorb calcium and excrete
phosphate and converts vit D to its active form: 1 , 25 dihydroxy
vitamin D. PTH doesn’t have a role in the metabolism of Vit E.
ANS: C
The presence of unsecured area rugs poses a hazard in all homes,
particularly in one with a resident at high risk for falls.
ANS: B
Autonomy ascribes the right of the individual to make his own
decisions. In this case, the client is capable of making his own
decision and the nurse should support his autonomy. Beneficence
and justice aren’t the principles that directly relate to the situation.
Advocacy is the nurse’s role in supporting the principle of autonomy.
ANS: D
Because respirations are depressed in myxedema coma, maintaining
a patent airway is the most critical nursing intervention. Ventilatory
support is usually needed. Thyroid replacement will be administered
IV. Although myxedema coma is associated with severe
hypothermia, a warming blanket shouldn’t be used because it may
cause vasodilation and shock. Gradual warming blankets would be
appropriate. Intake and output are very important but aren’t critical
interventions at this time.
ANS: A
Glipizide begins to act in 15 to 30 minutes. The other options are
incorrect.
ANS: A
Hypoxia is the main breathing stimulus for a client with COPD.
Excessive oxygen administration may lead to apnea by removing
that stimulus. Anginal pain results from a reduced myocardial
oxygen supply. A client with COPD may have anginal pain from
generalized vasoconstriction secondary to hypoxia; however,
administering oxygen at any concentration dilates blood vessels,
easing anginal pain. Respiratory alkalosis results from alveolar
hyperventilation, not excessive oxygen administration. In a client
with COPD, high oxygen concentrations decrease the ventilatory
drive, leading to respiratory acidosis, not alkalosis. High oxygen
concentrations don’t cause metabolic acidosis.
ANS: C
Continuous subcutaneous insulin regimen uses a basal rate and
boluses of short-acting insulin. Multiple daily injection therapy uses
a combination of short-acting and intermediate or long-acting
insulins.
ANS: B
Holding a cane on the uninvolved side distributes weight away from
the involved side. Holding the cane close to the body prevents
leaning. Use of a cane won’t maintain stride length or prevent
edema.
ANS: D
High pulmonary artery wedge pressures are diagnostic for left-sided
heart failure. With leftsided heart failure, pulmonary edema can
develop causing pulmonary crackles. In leftsided heart failure,
hypotension may result and urine output will decline. Dry mucous
membranes aren’t directly associated with elevated pulmonary
artery wedge pressures.
ANS: B
It’s mandatory in most settings to have a physician’s order before
restraining a client. A client should never be left alone while the
nurse summons assistance. All staff members require annual
instruction on the use of restraints, and the nurse should be familiar
with the facility’s policy.
ANS: A
The client who has undergone a thyroidectomy is t risk for
developing hypocalcemia from inadvertent removal or damage to
the parathyroid gland. The client with hypocalcemia will exhibit a
positive Chvostek’s sign (facial muscle contraction when the facial
nerve in front of the ear is tapped) and a positive Trousseau’s sign
(carpal spasm when a blood pressure cuff is inflated for few
minutes). These signs aren’t present with hypercalcemia,
hypokalemia, or Hyperkalemia.
ANS: C
Diarrhea causes a bicarbonate deficit. With loss of the relative
alkalinity of the lower GI tract, the relative acidity of the upper GI
tract predominates leading to metabolic acidosis. Diarrhea doesn’t
lead to respiratory acid-base imbalances, such as respiratory acidosis
and respiratory alkalosis. Loss of acid, which occurs with severe
vomiting, may lead to metabolic alkalosis.
ANS: B
The head of the bed must be elevated while the client is eating. The
client should be placed in a recumbent position—not a supine
position— when lying down to reduce the risk of aspiration.
Encourage the client to wear properly fitted dentures to enhance his
chewing ability. Thickened liquids, not thin liquids, decrease
aspiration risk.
ANS: A
Endotracheal suctioning secretions as well as gases from the airway
and lowers the arterial oxygen saturation (SaO2) level. Coughing and
incentive spirometry improve oxygenation and should raise or
maintain oxygen saturation. Because of superficial vasoconstriction,
using a cooling blanket can lower peripheral oxygen saturation
readings, but SaO2 levels wouldn’t be affected.
ANS: D
With a superficial partial thickness burn such as a solar burn
(sunburn), the nurse’s main concern is pain management. Fluid
resuscitation and infection become concerns if the burn extends to
the dermal and subcutaneous skin layers. Body image disturbance is
a concern that has a lower priority than pain management.
ANS: D
Crackles result from air moving through airways that contain fluid.
Heard during inspiration and expiration, crackles are discrete sounds
that vary in pitch and intensity. They’re classified as fine, medium, or
coarse. Pleural friction rubs have a distinctive grating sound. As the
name indicates, these breath sounds result when inflamed pleurae
rub together. Continuous, highpitched, musical squeaks, called
wheezes, result when air moves rapidly through airways narrowed
by asthma or infection or when an airway is partially obstructed by a
tumor or foreign body. Wheezes, like gurgles, occur on expiration
and sometimes on inspiration. Loud, coarse, low-pitched sounds
resembling snoring are called gurgles. These sounds develop when
thick secretions partially obstruct airflow through the large upper
airways.
Ans. D
Individuals who are tuberculin skin test converters should begin a 6-
month regimen of an antitubercular drug such as INH, and they
should never have another skin test. After an individual has a
positive tuberculin skin test, subsequent skin tests will cause severe
skin reactions but won’t provide new information about the client’s
TB status. The client doesn’t have active TB, so can’t transmit, or
spread, the bacteria. Therefore, she shouldn’t be quarantined or
asked for information about recent contacts.
ANS: C
Disturbed body image is a negative perception of the self that makes
healthful functioning more difficult. The defining characteristics for
this nursing diagnosis include undergoing a change in body structure
or function, hiding or overexposing a body part, not looking at a
body part, and responding verbally or nonverbally to the actual or
perceived change in structure or function. This client may have any
of the other diagnoses, but the signs and symptoms described in he
case most closely match the defining characteristics for disturbed
body image.
ANS: B
Because the pregnant uterus exerts a lot of pressure on the urinary
bladder, the bladder repair may need to be repeated. These clients
don’t necessarily have to have a cesarean delivery if they become
pregnant, and this procedure doesn’t render them sterile. This
procedure is completed in one surgery.
ANS: A
Eccrine glands are associated with body temperature regulation.
Sebaceous glands lubricate the skin and hairs, and apocrine glands
are involved in bacteria decomposition. Endocrine glands secrete
hormones responsible for the regulation of body processes, such as
metabolism and glucose regulation.
ANS: B
The light-colored spots attached to the hair shafts are nits, which are
the eggs of head lice. They can’t be brushed off the hair shaft like
dandruff. Scabies is a contagious dermatitis caused by the itch mite,
Sacoptes scabiei, which lives just beneath the skin. Tinea capitis, or
ringworm, causes patchy hair loss and circular lesions with healing
centers. Impetigo is an infection caused by Staphylococcus or
Sterptococcus, manifested by vesicles or pustules that form a thick,
honey-colored crust.
ANS: C
Severe pressure-like pain out of proportion to visible signs
distinguishes necrotizing fasciitis from cellulites. Erythema,
leukocytosis, and swelling are present in both cellulites and
necrotizing fasciitis.
ANS: A
Contact dermatitis is caused by exposure to a physical or chemical
allergen, such as cleaning products, skin care products, and latex
gloves. Initial symptoms of itching, erythema, and raised papules
occur at the site of the exposure and can begin within 1 hour of
exposure. Allergic reactions tend to be red and not scaly or flaky.
Weeping, crusting lesions are also uncommon unless the reaction is
quite severe or has been present for a long time. Excoriation is more
common in skin disorders associated with a moist environment.
ANS: D
Hoarseness indicate injury to the respiratory system and could
indicate the need for immediate intubation. Thirst following burns is
expected because of the massive fluid shifts and resultant loss
leading to dehydration. Pain, either severe or moderate, is expected
with a burn injury. The client’s output is adequate.
ANS: C
Third-degree burn may appear white, red, or black and are dry and
leathery with no blisters. There may be little pain because nerve
endings have been destroyed. First-degree burns are superficial and
involve the epidermis only. There is local pain and redness but no
blistering. Second-degree burn appear red and moist with blister
formation and are painful. Fourth-degree burns involve underlying
muscle and bone tissue.
ANS: C
A universal concern I the care of donor sites for burn care is to keep
the site away from sources of pressure. Ventilation of the site and
keeping the site fully covered are practices in some institutions but
aren’t hallmarks of donor site care. Placing the site in a position of
dependence isn’t a justified aspect of donor site care.
ANS: A
Anyone with psoriasis vulgaris who reports joint pain should be
evaluated for psoriaic arthritis. Approximately 15% to 20% of
individuals with psoriasis will also develop psoriatic arthritis, which
can be painful and cause deformity. It would be incorrect to assume
that his pain is caused by early rheumatoid arthritis or his vocation
without asking more questions or performing diagnostic studies.
Carpal tunnel syndrome causes sensory and motor changes in the
fingers rather than localized pain in the joints.
ANS: B
To avoid burning and sloughing, the client must protect the graft
from sunlight. The other three interventions are all helpful to the
client and his recovery but are less important.
ANS: C
Because the itching and rash are localized, an environmental cause
in the workplace should be suspected. With the advent of universal
precautions, many nurses are experiencing allergies to latex gloves.
Allergies to medications, laundry detergents, or bath soaps or a
dermatologic reaction to stress usually elicit a more generalized or
widespread rash.
ANS: A
Hives and urticaria are two names for the same skin lesion. Toxin is a
poison. A tubercle is a tiny round nodule produced by the
tuberculosis bacillus. A virus is an infectious parasite.
ANS: A
A scale is the characteristic secondary lesion occurring in psoriasis.
Although crusts, ulcers, and scars also are secondary lesions in skin
disorders, they don’t accompany psoriasis.
ANS: C
A turning schedule with a signing sheet will help ensure that the
client gets turned and thus, help prevent pressure ulcers. Turning
should occur every 1-2 hours—not every 8 hours—for clients who
are in bed for prolonged periods. The nurse should apply lotion to
keep the skin moist but should avoid vigorous massage, which could
damage capillaries. When moving the client, the nurse should lift
rather than slide the client to void shearing.
ANS: A
To prevent disruption of the artificial skin’s adherence to the wound
bed, the client should restrict range of motion of the involved limb.
Protein intake and fluid intake are important for healing and
regeneration and shouldn’t be restricted. Going outdoors is
acceptable as long as the left arm is protected from direct sunlight.
ANS: C
According to the Rule of Nines, the posterior and anterior trunk, and
legs each make up 18% of the total body surface. The head, neck,
and arms each make up 9% of total body durface, and the perineum
makes up 1%. In this case, the client received burns to his back (18%)
and one arm (9%), totaling 27%.
ANS: A
A wet-to-dry saline dressing should always keep the wound moist.
Tight packing or dry packing can cause tissue damage and pain. A dry
gauze —not a plastic-sheet-type dressing—should cover the wet
dressing.
ANS: A
When someone in a group of persons sharing a home contracts
scabies, each individual in the same home needs prompt treatment
whether he’s symptomatic or not. Towels and linens should be
washed in hot water. Scabies can be transmitted from one person to
another before symptoms develop
ANS: A
In a client with burns, the goal of fluid resuscitation is to maintain a
mean arterial blood pressure that provides adequate perfusion of
vital structures. If the kidneys are adequately perfused, they will
produce an acceptable urine output of at least 0.5 ml/kg/hour. Thus,
the expected urine output of a 155-lb client is 35 ml/hour, and a
urine output consistently above 100 ml/hour is more than adequate.
Weight gain from fluid resuscitation isn’t a goal. In fact, a 4 lb weight
gain in 24 hours suggests third spacing. Body temperature readings
and ECG interpretations may demonstrate secondary benefits of
fluid resuscitation but aren’t primary indicators.
 ANS: B
The ESR test is performed to detect inflammatory processes in the
body. It’s a nonspecific test, so the health care professional must
view results in conjunction with physical signs and symptoms.
Platelet count, electrolytes, BUN, and creatinine levels aren’t usually
affected by the inflammatory process.
ANS: B
In Parkinson’s crisis, dopamine-related symptoms are severely
exacerbated, virtually immobilizing the client. A client who is
confined to bed during a crisis is at risk for aspiration and
pneumonia. Also, excessive drooling increases the risk of airway
obstruction. Because of these concerns, ineffective airway clearance
is the priority diagnosis for this client. Although imbalanced
nutrition:less than body requirements, impaired urinary elimination
and risk for injury also are appropriate diagnoses for this client, they
aren’t immediately lifethreatening and thus are less urgent.
ANS: A
As a rule of practice, if intermittent catheterization for urine
retention typically yields 500 ml or more, the frequency of
catheterization should be increased. Indwelling catheterization is
less preferred because of the risk of urinary tract infection and the
loss of bladder tone. Fluid restrictions aren’t indicated for this case;
the problem isn’t overhydration, rather it’s urine retention. A
condom catheter doesn’t help empty the bladder of a client with
urine retention.
ANS: D
The normal pressure is 70 to 200 mm H2O are considered abnormal.
The presence of glucose is an expected finding in CSF, and RBCs
typically occur in the first specimen tube from the trauma caused by
the procedure.
ANS: A
The nurse should instill the eyedrop into the conjunctival sac where
absorption can best take place. The pupil permits light to enter the
eye. The sclera maintains the eye’s shape and size. The vitreous
humor maintains the retina’s placement and the shape of the eye.
ANS: C
According to family theory, any change in a family member, such as
illness, produces role changes in all family members and affects the
entire family, even if the client eventually recovers completely.
ANS: B
To help prevent airway obstruction and reduce the risk of aspiration,
the nurse should position a client with hemiparesis on the affected
side. Although performing ROM exercises, providing pillows for
support, and applying antiembolism stockings can be appropriate for
a client with CVA, the first concern is to maintain a patent airway.
ANS: C
TIA may be a warning that the client will experience a CVA, or
stroke, in the near future. TIA aymptoms last no longer than 24
hours and clients usually have complete recovery after TIA. The most
common symptom of TIA is sudden, painless loss of vision lasting up
to 24 hours.
ANS: C
Bending to pick up something from the floor would increase
intraocular pressure, as would bending to tie his shoes. The client
needs to wear eye protection to bed to prevent accidental injury
during sleep.
 ANS: B
Concussions are considered minor with no structural signs of injury.
A contusion is bruising of the brain tissue with small hemorrhages in
the tissue. Coup and contrecoup are type of injuries in which the
damaged area on the brain forms directly below that site of impact
(coup) or at the
site opposite the injury (contrecoup) due to movement of the brain
within the skull.
ANS: B
The third cranial nerve (oculomotor) is responsible for pupil
constriction. When there is damage to the nerve, the pupils remain
dilated and don’t respond to light. Glaucoma, lumbar spine injury,
and Bell’s palsy won’t affect pupil constriction.
ANS: C
When the mechanical stressors of weight bearing are absent, diffuse
osteoporosis can occur. Therefore, if the client does weight-bearing
exercises, disuse complications can be prevented. Maintaining
protein and vitamins levels is important, but neither will prevent
osteoporosis. ROM exercises will help prevent muscle atrophy and
contractures.
ANS: B
This client requires droplet precautions because the organism can be
transmitted through airborne droplets when the client coughs,
sneezes, or doesn’t cover his mouth. Airborne precautions would be hypocalcemia
instituted for a client infected with tuberculosis. Standard hypernatremia
precautions would be instituted for a client when contact with body hypercalcemia
substances is likely. Contact precautions would be instituted for a 6. A 36 year old female complains of headache and neck pain. The
client infected with an organism that is transmitted through skin-to- nurse’s assessments reveal painful flexion of the neck to the chest.
skin The nurse understands that nuchal rigidity is associated with:
contact. brain tumor
ANS: D CVA
With a brain injury such as an epidural hematoma (a diagnosis that is meningitis
most likely based on this client’s symptoms), the initial sign of subdural hematoma
increasing ICP is a change in the level of consciousness. As 7. The nurse teaching the client about behavioral changes, which can
neurologic deterioration progresses, manifestations involving affect development of atherosclerosis, should discuss which of the
pupillary symmetry, breathing patterns, and posturing will following as a non-modifiable risk factor for atherosclerosis?
occur. cigarette smoking
ANS: A hyperlipidemia
In the scenario, airway and breathing are established so the nurse’s female over 55 years of age
next priority should be circulation. With a compound fracture of the sedentary lifestyle
femur, there is a high risk of profuse bleeding; therefore, the nurse 8. A 76 year old man enters the ER with complaints of back pain and
should assess the site. Neurologic assessment is a secondary feeling fatigued. Upon examination, his blood pressure is 190/100,
concern to airway, breathing and circulation. The nurse doesn’t have pulse is 118, and hematocrit and hemoglobin are both low. The
enough data to warrant putting the client in Trendelenburg’s nurse palpates the abdomen which is soft, non-tender and
position. auscultates an abdominal pulse. The most likely diagnosis is:
ANS: C Buerger’s disease
Establishing and maintaining a routine is essential to decreasing CHF
extraneous stimuli. The client should participate in daily care as Secondary hypertension
much as possible. Attempting to reason with such clients isn’t Aneurysm
successful, because they can’t participate in abstract thinking. 9. Nurse Fiona is caring a patient with Raynaud’s disease. Which of
ANS: B the following outcomes concerning medication regimen is of highest
For clients with increased intracranial pressure (ICP), the head of the priority?
bed is elevated to promote venous outflow. Trendelenburg’s Controlling the pain once vasospasm occur
position is contraindicated because it can raise ICP. Flat or neutral Relaxing smooth muscle to avoid vasospasms
positioning is indicated when elevating the head of the bed would Preventing major disabilities that may occur
increase the risk of neck injury or airway obstruction. Sidelying isn’t Avoiding lesions on the feet
specifically a therapeutic treatment for increased ICP. 10. Mr. Roberto Robles complains of a severe headache and is
extremely anxious. The nurse checks his vital signs and finds him to
SET 4 have a heart rate of 57 bpm and a blood pressure of 230/110 mmHg.
1. Lisa is newly diagnosed with asthma and is being discharged from The nurse should also assess for?
the hospital after an episode of status asthmaticus. Discharge presence of bowel sounds
teaching should include which of the following: presence of babinski reflex
Limitations in sports that will be imposed by the illness fecal incontinence
Specific instructions on staying cal during an attack urinary catheter patency
The relationship of symptoms and a specific trigger such as physical 11. A 40n year old male patient is complaining of chronic progressive
exercise and mental deterioration is admitted to the unit. The nurse
Incidence of status asthmaticus in children and teens recognizes that these characteristics indicate a disease that results in
2. Which of the following symptoms is most characteristic of a client degeneration of the basal ganglia and cerebral cortex. The disease is
with a cancer of the lung? called:
air hunger multiple sclerosis
exertional dyspnea myasthenia gravis
cough with night sweats Huntington’s disease
persistent changing cough Guillain-Barre syndrome
3. The client has ST segment depression on his 12-lead ECG. The 12. Dianne Hizon is a 27 year old woman who has been admitted to
nurse determines that this would indicate the following: the ER due to severe vomiting. Her ABG values are pH= 7.50, PaCO2=
necrosis 85, HCO3= 31, and SaO2= 93%. The nurse interpretation of this ABG
injury analysis is:
ischemia respiratory acidosis
nothing significant respiratory alkalosis
4. Red has just returned from the postanesthesia care unit (PACU) metabolic acidosis
from a hemorrhidectomy. His postoperative orders include sitz baths metabolic alkalosis
every morning. The nurse understands that sitz bath is use for: 13. Mr. Perkson has a parkinson’s disease and he finds the resting
promote healing tremor he is experiencing in his right hand very frustrating. The
relive tension nurse advises him to:
lower body temperature take a warm bath
cause swelling hold an object
5. Trousseau’s sign is associated with which electrolyte imbalance? practice deep breathing
hyponatremia take diazepam as needed
14. A shuffling gait is typically associated with the patient who has:
Parkinson’s disease
Multiple sclerosis
Raynaud’s disease
Myasthenia gravis
15. The priority in preparing the room for a client with a C7 spinal
cord injury is having:
the halo brace device
a catheterization tray
a ventilator on stand by
the spinal kinetic bed
16. A 47 year old man with liver failure who has developed ascites.
The nurse understands that ascites is due to:
dehydration
protein deficiency
bleeding disorders
vitamin deficiency
17. A client with rheumatoid arthritis may reveal which of the
following assessment data:
Heberden’s nodes
Morning stiffness no longer than 30 minutes
Asymmetric joint swelling
Swan neck deformities
18. Elsa Santos is a 18 year old student admitted to the ward with a
diagnosis of epilepsy. She tells the nurse that she is experiencing a
generalized tingling sensation and is “smelling roses”. The nurse
understands that Esla is probably experiencing:
an acute alcohol withdrawal
an acute CVA
an aura
an olfactory hallucination
19. Mr. Lucas, a 63 year old, went to the clinic complaining of
hoarseness of voice and a cough. His wife states that his voice has
changed in the last few months. The nurse interprets that Mr.
Lucas’s symptoms are consistent with which of the following
disorders:
chronic sinusitis
laryngeal cancer
gastroesophageal reflux disease
coronary artery disease
20. Sarah complains of a nursing sensation, cramping pain in the top
part of her abdomen that becomes worse in the afternoon and
sometimes awakes her at night. She reports that when she eats, it
helps the pain go away but that pain is now becoming more intense.
Which of the following is the best condition for the nurse to draw:
these symptoms are consistent with an ulcer
The client probably has indigestion
A snack before going to bed should be advised
The client probably developing cholelithiasis
21. Nurse Cynthia is providing a discharge teaching to a client with
chronic cirrhosis. His wife asks her to explain why there is so much
emphasis on bleeding precautions. Which of the following provides
the most appropriate response?
“The low protein diet will result in reduced clotting.”
“The increased production of bile decreases clotting factors.”
“The liver affected by cirrhosis is unable to produce clotting factors.”
“The required medications reduce clotting factors.”
22. Betty Lee is a 58 year old woman who is being admitted to the
medical ward with trigeminal neuralgia. The nurse anticipates that
Mr. Lee will demonstrate which of the following major complaints?
excruciating, intermittent, paroxysmal facial pain
unilateral facial droop
painless eye spasm
mildly painful unilateral eye twitching
23. A 38 year old woman returns from a subtotal thryroidectomy for
the treatment of hyperthyroidism. Upon assessment, the immediate
priority that the nurse would include is:
Assess for pain
Assess for neurological status
Assess fluid volume status
Assess for respiratory distress
24. Nurse Shiela is teaching self-care to a client with psoriasis. The
nurse should encourage which of the following for his scaled lesion?
Importance of follow-up appointments
Emollients and moisturizers to soften scales
Keep occlusive dressings on the lesions 24 hours a day
Use of a clean razor blade each time he shaves
25. A 48 year old woman presents to the hospital complaining of
chest pain, tachycardia and dyspnea. On exam, heart sounds are
muffled. Which of the following assessment findings would support
a diagnosis of cardiac tamponade?
A deviated trachea
Absent breath sounds to the lower lobes
Pulse 40 with inspiration
Blood pressure 140/80
Answers and Rationales
C. The relationship of symptoms and a specific trigger such as
physical exercise. COPD clients have low oxygen and high carbon
dioxide levels. Therefore, hypoxia is the main stimulus for ventilation
is persons with chronic hypercapnea. Increasing the level of oxygen
would decrease the stimulus to breathe.
D. persistent changing cough. The most common sign of lung cancer
is a persistent cough that changes. Other signs are dyspnea, bloody
sputum and long term pulmonary infection. Option A is common
with asthma, option B is common with COPD and option C is
common with TB.
C. ischemia. Depressed ST segment and inverted T-waves represent
myocardial ischemia. Injury has a ST segment elevation.
A. promote healing. Sitz bath provides moist heat to the perineal
and anal area to clean, promote healing and drainage and reduce
soreness to the area. Sitz bath helps healing with cleaning action and
promotion of circulation, thereby reducing swelling. Sitz bath usually
has no therapeutic value in lowering body temperature. Although
relief of tension can occur, this effect is secondary to the promotion
of healing.
B. hypocalcemia. Trousseau’s sign is a carpal pedal spasm elicited
when a blood pressure cuff is inflated on the arm of a patient with
hypocalcemia.
C. meningitis. A patient with meningitis will exhibit signs that
include photophobia and nuchal rigidity, which is pain on the flexion
of the chin to chest.
C. female over 55 years of age. Lifestyle, cigarette smoking and
hyperlipidemia can be changed by changing behaviors.
D. Aneurysm. The symptoms exhibited by the client are typical of an
abdominal aortic aneurysm. The most significant sign is the audible
pulse in the abdominal area. If hemorrhage were present, the
abdomen would be tender and firm.
B. Relaxing smooth muscle to avoid vasospasms. The major task of
the health care team is to medicate the client drugs that produce
smooth muscle relaxation, which will decrease the vasospasm and
increase the arterial flow to the affected part. The drugs used are
calcium antagonists.
D. urinary catheter patency. The patient is complaining of
symptoms of autonomic dysreflexia, which consists of the triad of
hypertension, bradycardia and a headache. Major causes of
autonomic dysreflexia include urinary bladder distention and fecal
impaction. Checking the patency of the urinary catheter will check
for bladder distention.
C. Huntington’s disease. Huntington’s disease is a hereditary disease
in which degeneration of the basal ganglia and cerebral cortex
causes chronic progressive chorea (muscle twitching) and mental
deterioration, ending in dementia. Huntington’s disease usually
strikes people ages 25 to 55.
D. metabolic alkalosis. Ms. Hizon’s pH is above 7.45, which makes it
alkalatic, and her bicarbonate is high which is also makes it basic.
Thus, the diagnosis is metabolic alkalosis.
B. hold an object. The resting or non-intentional tremor may be
controlled with purposeful movement such as holding an object. A
warm bath, deep breathing and diazepam will promote relaxation
but are not specific interventions for tremor.
A. Parkinson’s disease. A shuffling gait from the musculoskeletal
rigidity of the patient with Parkinson’s disease is common. Patients
experiencing a stroke usually exhibit loss of voluntary control over
motor movements associated with generalized weakness; a shuffling
gait is usually not observed in stroke patient.
C. a ventilator on stand by. Although a ventilator is not required for
injury below C3, the innervation of intercostal muscles is affected.
Hemorrhage and cord swelling extends the level of injury making it
likely that this client will need a ventilator.
B. protein deficiency. Protein deficiency allows fluid to leak out of
the vascular system and third space into the tissues and spaces in
the body such as the peritoneal space. Bleeding tendencies,
dehydration and vitamin deficiency can occur but don’t cause
ascites.
D. Swan neck deformities. Swan neck deformities of the hand are
classic deformities associated with rheumatoid arthritis secondary to
the presence of fibrous connective tissue within the joint space.
Clients with RA do experience morning stiffness, but it can last from
30 minutes up to several hours. RA is characterized by symmetrical
joint movement, and heberden’s nodes are characteristic of
osteoarthritis.
C. an aura. An aura frequently precedes an epileptic seizure and may
manifest as vague physic discomfort or specific aromas. Patients
experiencing auras aren’t having a CVA, substance withdrawal or
hallucination.
B. laryngeal cancer. These symptoms, along with dysphagia, foul-
smelling breath, and pain when drinking hot or acidic, are common
signs of laryngeal cancer.
A. these symptoms are consistent with an ulcer. The description of
pain is consistent with ulcer pain. The pain is epigastric and is worse
when the stomach is empty and is relived by food.
C. “The liver affected by cirrhosis is unable to produce clotting
factors.” When bile production is reduced, the body has reduced
ability to absorb fat-soluble vitamins. Without adequate Vitamin K
absorption, clotting factors II, VII, IX, and X are not produced in
sufficient amounts.
A. excruciating, intermittent, paroxysmal facial pain. Trigeminal
neuralgia is a syndrome of excruciating, intermittent, paroxysmal
facial pain. It manifests as intense, periodic pain in the lips, gums,
teeth or chin. The other symptoms aren’t characteristic of trigeminal
neuralgia.
D. Assess for respiratory distress. Though fluid volume status,
neurological status and pain are all important assessment, the
immediate priority for postoperative is the airway management.
Respiratory distress may result from hemorrhage, edema, laryngeal
damage or tetany.
B. Emollients and moisturizers to soften scales. Emollients will ease
dry skin that increases pruritus and causes psoriasis to be worse.
Washing and drying the skin with rough linens or pressure may
cause excoriation. Constant occlusion may increase the effects of the
medication and increase the risk of infection.
C. Pulse 40 with inspiration. Paradoxical pulse is a hallmark
symptom of cardiac tamponade. As pressure is exerted on the left
ventricle from fluid, the natural increase in pressure from the right
ventricle during inspiration creates even more pressure, diminishing
cardiac output.
SET 5
1. A patient is admitted to the medical surgical unit following
surgery. Four days after surgery, the patient spikes a 38.9 degrees C
oral temperature and exhibits a wet, productive cough. The nurse
assesses the patient with understanding that an infection that is
acquired during hospitalization is known as:
a community acquired infection
an iatrogenic infection
a nosocomial infection
an opportunistic infection
2. A client with anemia has a hemoglobin of 6.5 g/dL. The client is
experiencing symptoms of cerebral tissue hypoxia. Which of the
following nursing interventions would be most important in
providing care?
Providing rest periods throughout the day
Instituting energy conservation techniques
Assisting in ambulation to the bathroom
Checking temperature of water prior to bathing
3. A client was involved in a motor vehicular accident in which the
seat belt was not worn. The client is exhibiting crepitus, decrease
breath sounds on the left, complains of shortness of breath, and has
a respiratory rate of 34 breaths per minute. Which of the following
assessment findings would concern the nurse most?
Temperature of 102 degrees F and productive cough
ABG with PaO2 of 92 and PaCO2 of 40 mmHg
Trachea deviating to the right
Barrel-chested appearance
4. The proper way to open an envelop-wrapped sterile package after
removing the outer package or tape is to open the first position of
the wrapper:
away from the body
to the left of the body
to the right of the body
toward the body
5. Assessment of a client with possible thrombophlebitis to the left
leg and a deep vein thrombosis is done by pulling up on the toes
while gently holding down on the knee. The client complains of
extreme pain in the calf. This should be documented as:
positive tourniquet test
positive homan’s sign
negative homan’s sign
negative tourniquet test
6. Thomas Elison is a 79 year old man who is admitted with diagnosis
of dementia. The doctor orders a series of laboratory tests to
determine whether Mr. Elison’s dementia is treatable. The nurse
understands that the most common cause of dementia in this
population is:
AIDS
Alzheimer’s disease
Brain tumors
Vascular disease
7. Which of the following nursing interventions is contraindicated in
the care of a client with acute osteomyelitis?
Apply heat compress to the affected area
Immobilize the affected area
Administer narcotic analgesics for pain
Administer OTC analgesics for pain
8. A client with congestive heart failure has digoxin (Lanoxin)
ordered everyday. Prior to giving the medication, the nurse checks
the digoxin level which is therapeutic and ausculates an apical pulse.
The apical pulse is 63 bpm for 1 full minute. The nurse should:
Hold the Lanoxin 18. A 24 year old male patient comes to the clinic after contracting
Give the half dose now, wait an hour and give the other half genital herpes. Which of the following intervention would be most
Call the physician appropriate?
Give the Lanoxin as ordered Encourage him to maintain bed rest for several days
9. Nurse Marian is caring for a client with haital hernia, which of the Monitor temperature every 4 hours
following should be included in her teaching plan regarding causes: Instruct him to avoid sexual contact during acute phases of illness
To avoid heavy lifting Encourage him to use antifungal agents regularly
A dietary plan based on soft foods 19. An 8 year old boy is brought to the trauma unit with a chemical
Its prevalence in young adults burn to the face. Priority assessment would include which of the
Its prevalence in fair-skinned individuals following?
10. Joseph has been diagnosed with hepatic encephalopathy. The Skin integrity
nurse observes flapping tremors. The nurse understands that BP and pulse
flapping tremors associated with hepatic encephalopathy are also Patency of airway
known as: Amount of pain
aphasia 20. A client with anemia due to chemotherapy has a hemoglobin of
ascites 7.0 g/dL. Which of the following complaints would be indicative of
astacia tissue hypoxia related to anemia?
asterixis dizziness
11. Hyperkalemia can be treated with administration of 50% fatigue relieved by rest
dextrose and insulin. The 50% dextrose: skin that is warm and dry to the touch
causes potassium to be excreted apathy
causes potassium to move into the cell 21. Hazel Murray, 32 years old complains of abrupt onset of chest
causes potassium to move into the serum and back pain and loss of radial pulses. The nurse suspects that Mrs.
counteracts the effects of insulin Murray may have:
12. Which of the following findings would strongly indicate the Acute MI
possibility of cirrhosis? CVA
dry skin Dissecting abdominal aorta
hepatomegaly Dissecting thoracic aneurysm
peripheral edema 22. Nurse Alexandra is establishing a plan of care for a client newly
pruritus admitted with SIADH. The priority diagnosis for this client would be
13. Aling Puring has just been diagnosed with close-angle (narrow- which of the following?
angle) glaucoma. The nurse assesses the client for which of the Fluid volume deficit
following common presenting symptoms of the disorder? Anxiety related to disease process
halo vision Fluid volume excess
dull eye pain Risk for injury
severe eye and face pain 23. Nursing management of the client with a UTI should include:
impaired night vision Taking medication until feeling better
14. Chvostek’s sign is associated with which electrolyte impabalnce? Restricting fluids
hypoclacemia Decreasing caffeine drinks and alcohol
hypokalemia Douching daily
hyponatremia 24. Felicia Gomez is 1 day postoperative from coronary artery
hypophosphatenia bypass surgery. The nurse understands that a postoperative patient
15. What laboratory test is a common measure of the renal who’s maintained on bed rest is at high risk for developing:
function? angina
CBC arterial bleeding
BUN/Crea deep vein thrombosis (DVT)
Glucose dehiscence of the wound
Alanine amino transferase (ALT) 25. Which of the following statement is true regarding the visual
16. Nurse Edward is performing discharge teaching for a newly changes associated with cataracts?
diagnosed diabetic patient scheduled for a fasting blood glucose Both eyes typically cataracts at the same time
test. The nurse explains to the patient that hyperglycemia is defined The loss of vision is experienced as a painless, gradual blurring
as a blood glucose level above: The patient is suddenly blind
100 mg/dl The patient is typically experiences a painful, sudden blurring of
120 mg/dl vision.
130 mg/dl Answers and Rationales
150 mg/dl C. a nosocomial infection. Nosocomial, or hospital-acquired are
17. Mang Edison is on bed rest has developed an ulcer that is full infections acquired during hospitalization for which the patient isn’t
thickness and is penetrating the subcutaneous tissue. The nurse being primarily treated. Community acquired or opportunistic
documents that this ulcer is in which of the following stages? infections may not be acquired during hospitalization. An iatrogenic
Stage 1 infection is caused by the doctor or by medical therapy. And an
Stage 2 opportunistic infection affects a compromised host.
Stage 3 C. Assisting in ambulation to the bathroom. Cerebral tissue hypoxia
Stage 4 is commonly associated with dizziness. The greatest potential risk to
the client with dizziness is injury, especially with changes in position.
Planning for periods of rest and conserving energy are important
with someone with anemia because of his or her fatigue level but
most important is safety.
C. Trachea deviating to the right. A mediastinal shift is indicative of
a tension pneumothorax along with the other symptoms in the
question. Since the individual was involved in a MVA, assessment
would be targeted at acute traumatic injuries to the lungs, heart or
chest wall rather than other conditions indicated in the other
answers. Option A is common with pneumonia; values in option B
are not alarming; and option D is typical of someone with COPD.
A. away from the body. When opening an envelop-wrapped sterile
package, reaching across the package and using the first motion to
open the top cover away from the body eliminates the need to later
reach across the steri9le field while opening the package. To remove
equipment from the package, opening the first portion of the
package toward, to the left, or to the right of the body would require
reaching across a sterile field.
B. positive homan’s sign. Pain in the calf while pulling up on the toes
is abnormal and indicates a positive test. If the client feels nothing or
just feels like the calf muscle is stretching, it is considered negative.
A tourniquet test is used to measure for varicose veins.
B. Alzheimer’s disease. Alzheimer’s disease is the most common
cause of dementia in the elderly population. AIDS, brain tumors and
vascular disease are all less common causes of progressive loss of
mental function in elderly patients.
A. Apply heat compress to the affected area. Options B, C and D are
appropriate nursing interventions when caring for a client diagnosed
with osteomyelitis. The application of heat can increase edema and
pain in the affected area and spread bacteria through vasodilation.
D. Give the Lanoxin as ordered. The Lanoxin should be held for a
pulse of 60 bpm. Nurses cannot arbitrarily give half of a dose
without a physician’s order. Unless specific parameters are given
concerning pulse rate, most resources identify 60 as the reference
pulse.
A. To avoid heavy lifting. Heavy lifting is one factor that leads to
development of a hiatal hernia. Dietary factors involve limiting fat
intake, not restricting client to soft foods. It is more prevalent in
individuals who are middle-aged or older. Fair-skinned individuals
are not prone to this condition.
D. asterixis. Flapping tremors associated with hepatic
encephalophaty are asterixis. Aphasia is the inability to speak.
Ascites is an accumulation of fluid in the peritoneal cavity. Astacia is
the inability to stand or sit still.
D. counteracts the effects of insulin. The 50% dextrose is given to
counteract the effects of insulin. Insulin drives the potassium into
the cell, thereby lowering the serum potassium levels. The dextrose
doesn’t directly cause potassium excretion or any movement of
potassium.
B. hepatomegaly. Although option D is correct, it is not a strong
indicator of cirrhosis. Pruritus can occur for many reasons. Options A
and C are incorrect, fluid accumulations is usually in the form of
ascites in the abdomen. Hepatomegaly is an enlarged liver, which is
correct. The spleen may also be enlarged.
C. severe eye and face pain. Narrow-angle glaucoma develops
abruptly and manifests with acute face and eye pain and is a medial
emergency. Halo vision, dull eye pain and impaired night vision are
symptoms associated with open-angle glaucoma.
A. hypoclacemia. Chvostek’s sign is a spasm of the facial muscles
elicited by tapping the facial nerve and is associated with
hypocalcemia. Clinical signs of hypokalemia are muscle weakness,
leg cramps, fatigue, nausea and vomiting. Muscle cramps, anorexia,
nausea and vomiting are clinical signs of hyponatremia. Clinical
manifestations associated with hypophosphatemia include muscle
pain, confusion, seizures and coma.
B. BUN/Crea. The BUN is primarily used as indicator of kidney
function because most renal diseases interfere with its excretion and
cause blood vessels to rise. Creatinine is produced in relatively
constant amounts, according to the amount of muscle mass and is
excreted entirely by the kidneys making it a good indicator of renal
function.
B. 120 mg/dl. Hyperglycemia is defined as a blood glucose level
greater than 120 mg/dl. Blood glucose levels of 120 mg/dl, 130
mg/dl and 150 mg/dl are considered hyperglycemic. A blood glucose
of 100 mg/dl is normal.
C. Stage 3. A stage 3 ulcer is full thickness involving the
subcutaneous tissue. A stage 1 ulcer has a defined area of persistent
redness in lightly pigmented skin. A stage 2 ulcer involves partial
thickness skin loss. Stage 4 ulcers extend through the skin and
exhibit tissue necrosis and muscle or bone involvement.
C. Instruct him to avoid sexual contact during acute phases of
illness. Herpes is a virus and is spread through direct contact. An
antifungal would not be useful; bed rest and temperature
measurement are usually not necessary.
C. Patency of airway. A burn face, neck or chest may cause airway
closure because of the edema that occurs within hours. Remember
the ABC’s: airway, breathing and circulation. Airway always comes
first, even before pain. The nurse will also assess options B and D,
but these are not the highest priority assessments.
A. dizziness. Central tissue hypoxia is commonly associated with
dizziness. Recognition of cerebral hypoxia is critical since the body
will attempt to shunt oxygenated blood to vital organs.
D. Dissecting thoracic aneurysm. A dissecting thoracic aneurysm
may cause loss of radical pulses and severe chest and back pain. An
MI typically doesn’t cause loss of radial pulses or severe back pain.
CVA and dissecting abdominal aneurysm are incorrect responses.
C. Fluid volume excess. SIADH results in fluid retention and
hyponatremia. Correction is aimed at restoring fluid and electrolyte
balance. Anxiety and risk for injury should be addressed following
fluid volume excess.
C. Decreasing caffeine drinks and alcohol. Caffeine and alcohol can
increase bladder spasms and mucosal irritation, thus increase the
signs and symptoms of UTI. All antibiotics should be taken
completely to prevent resistant strains of organisms.
C. deep vein thrombosis (DVT). DVT, is the most probable
complication for postoperative patients on bed rest. Options A, B
and D aren’t likely complications of the post operative period.
B. The loss of vision is experienced as a painless, gradual
blurring. Typically, a patient with cataracts experiences painless,
gradual loss of vision. Although both eyes may develop at different
rates.
SET 6
1. Randy has undergone kidney transplant, what assessment would
prompt Nurse Katrina to suspect organ rejection?
Sudden weight loss
Polyuria
Hypertension
Shock
2. The immediate objective of nursing care for an overweight, mildly
hypertensive male client with ureteral colic and hematuria is to
decrease:
Pain
Weight
Hematuria
Hypertension
3. Matilda, with hyperthyroidism is to receive Lugol’s iodine solution
before a subtotal thyroidectomy is performed. The nurse is aware
that this medication is given to:
Decrease the total basal metabolic rate.
Maintain the function of the parathyroid glands.
Block the formation of thyroxine by the thyroid gland.
Decrease the size and vascularity of the thyroid gland.
4. Ricardo, was diagnosed with type I diabetes. The nurse is aware
that acute hypoglycemia also can develop in the client who is
diagnosed with:
Liver disease
Hypertension
Type 2 diabetes
Hyperthyroidism
5. Tracy is receiving combination chemotherapy for treatment of
metastatic carcinoma. Nurse Ruby should monitor the client for the
systemic side effect of:
Ascites
Nystagmus
Leukopenia
Polycythemia
6. Norma, with recent colostomy expresses concern about the
inability to control the passage of gas. Nurse Oliver should suggest
that the client plan to:
Eliminate foods high in cellulose.
Decrease fluid intake at meal times.
Avoid foods that in the past caused flatus.
Adhere to a bland diet prior to social events.
7. Nurse Ron begins to teach a male client how to perform
colostomy irrigations. The nurse would evaluate that the
instructions were understood when the client states, “I should:
Lie on my left side while instilling the irrigating solution.”
Keep the irrigating container less than 18 inches above the stoma.”
Instill a minimum of 1200 ml of irrigating solution to
stimulate evacuation of the bowel.”
Insert the irrigating catheter deeper into the stoma if
cramping occurs during the procedure.”
8. Patrick is in the oliguric phase of acute tubular necrosis and is
experiencing fluid and electrolyte imbalances. The client is
somewhat confused and complains of nausea and muscle weakness.
As part of the prescribed therapy to correct this electrolyte
imbalance, the nurse would expect to:
Administer Kayexalate
Restrict foods high in protein
Increase oral intake of cheese and milk.
Administer large amounts of normal saline via I.V.
9. Mario has burn injury. After Forty48 hours, the physician orders
for Mario 2 liters of IV fluid to be administered q12 h. The drop
factor of the tubing is 10 gtt/ml. The nurse should set the flow to
provide:
18 gtt/min
28 gtt/min
32 gtt/min
36 gtt/min
10.Terence suffered form burn injury. Using the rule of nines, which
has the largest percent of burns?
Face and neck
Right upper arm and penis
Right thigh and penis
Upper trunk
11. Herbert, a 45 year old construction engineer is brought to the
hospital unconscious after falling from a 2-story building. When
assessing the client, the nurse would be most concerned if the
assessment revealed:
Reactive pupils
A depressed fontanel
Bleeding from ears
An elevated temperature
12. Nurse Sherry is teaching male client regarding his permanent
artificial pacemaker. Which information given by the nurse shows
her knowledge deficit about the artificial cardiac pacemaker?
take the pulse rate once a day, in the morning upon awakening
May be allowed to use electrical appliances
Have regular follow up care
May engage in contact sports
13.The nurse is ware that the most relevant knowledge about
oxygen administration to a male client with COPD is
Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for
breathing.
Hypoxia stimulates the central chemoreceptors in the medulla that
makes the client breath.
Oxygen is administered best using a non-rebreathing mask
Blood gases are monitored using a pulse oximeter.
14.Tonny has undergoes a left thoracotomy and a partial
pneumonectomy. Chest tubes are inserted, and one-bottle water-
seal drainage is instituted in the operating room. In the
postanesthesia care unit Tonny is placed in Fowler’s position on
either his right side or on his back. The nurse is aware that this
position:
Reduce incisional pain.
Facilitate ventilation of the left lung.
Equalize pressure in the pleural space.
Increase venous return
15.Kristine is scheduled for a bronchoscopy. When teaching Kristine
what to expect afterward, the nurse’s highest priority of information
would be:
Food and fluids will be withheld for at least 2 hours.
Warm saline gargles will be done q 2h.
Coughing and deep-breathing exercises will be done q2h.
Only ice chips and cold liquids will be allowed initially.
16.Nurse Tristan is caring for a male client in acute renal failure. The
nurse should expect hypertonic glucose, insulin infusions, and
sodium bicarbonate to be used to treat:
hypernatremia.
hypokalemia.
hyperkalemia.
hypercalcemia.
17.Ms. X has just been diagnosed with condylomata acuminata
(genital warts). What information is appropriate to tell this client?
This condition puts her at a higher risk for cervical cancer; therefore,
she should have a Papanicolaou (Pap) smear annually.
The most common treatment is metronidazole (Flagyl), which should
eradicate the problem within 7 to 10 days.
The potential for transmission to her sexual partner will be
eliminated if condoms are used every time they have sexual
intercourse.
The human papillomavirus (HPV), which causes condylomata
acuminata, can’t be transmitted during oral sex.
18.Maritess was recently diagnosed with a genitourinary problem
and is being examined in the emergency department. When
palpating the her kidneys, the nurse should keep which anatomical
fact in mind?
The left kidney usually is slightly higher than the right one.
The kidneys are situated just above the adrenal glands.
The average kidney is approximately 5 cm (2″) long and 2 to 3 cm
(¾” to 1-1/8″) wide.
The kidneys lie between the 10th and 12th thoracic vertebrae.
19.Jestoni with chronic renal failure (CRF) is admitted to the urology
unit. The nurse is aware that the diagnostic test are consistent with
CRF if the result is:
Increased pH with decreased hydrogen ions.
Increased serum levels of potassium, magnesium, and calcium.
Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/
dl.
Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein (PSP)
excretion 75%.
20. Katrina has an abnormal result on a Papanicolaou test. After
admitting that she read her chart while the nurse was out of the
room, Katrina asks what dysplasia means. Which definition should
the nurse provide?
Presence of completely undifferentiated tumor cells that don’t
resemble cells of the tissues of their origin.
Increase in the number of normal cells in a normal arrangement in a
tissue or an organ.
Replacement of one type of fully differentiated cell by another in
tissues where the second type normally isn’t found.
Alteration in the size, shape, and organization of differentiated cells.
21. During a routine checkup, Nurse Mariane assesses a male client
with acquired immunodeficiency syndrome (AIDS) for signs and
symptoms of cancer. What is the most common AIDS-related
cancer?
Squamous cell carcinoma
Multiple myeloma
Leukemia
Kaposi’s sarcoma
22.Ricardo is scheduled for a prostatectomy, and the
anesthesiologist plans to use a spinal (subarachnoid) block during
surgery. In the operating room, the nurse positions the client
according to the anesthesiologist’s instructions. Why does the client
require special positioning for this type of anesthesia?
To prevent confusion
To prevent seizures
To prevent cerebrospinal fluid (CSF) leakage
To prevent cardiac arrhythmias
23.A male client had a nephrectomy 2 days ago and is now
complaining of abdominal pressure and nausea. The first nursing
action should be to:
Auscultate bowel sounds.
Palpate the abdomen.
Change the client’s position.
Insert a rectal tube.
24.Wilfredo with a recent history of rectal bleeding is being
prepared for a colonoscopy. How should the nurse Patricia position
the client for this test initially?
Lying on the right side with legs straight
Lying on the left side with knees bent
Prone with the torso elevated
Bent over with hands touching the floor
25.A male client with inflammatory bowel disease undergoes an
ileostomy. On the first day after surgery, Nurse Oliver notes that the
client’s stoma appears dusky. How should the nurse interpret this
finding?
Blood supply to the stoma has been interrupted.
This is a normal finding 1 day after surgery.
The ostomy bag should be adjusted.
An intestinal obstruction has occurred.
26.Anthony suffers burns on the legs, which nursing intervention
helps prevent contractures?
Applying knee splints
Elevating the foot of the bed
Hyperextending the client’s palms
Performing shoulder range-of-motion exercises
27.Nurse Ron is assessing a client admitted with second- and third-
degree burns on the face, arms, and chest. Which finding indicates a
potential problem?
Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg.
Urine output of 20 ml/hour.
White pulmonary secretions.
Rectal temperature of 100.6° F (38° C).
28. Mr. Mendoza who has suffered a cerebrovascular accident (CVA)
is too weak to move on his own. To help the client avoid pressure
ulcers, Nurse Celia should:
Turn him frequently.
Perform passive range-of-motion (ROM) exercises.
Reduce the client’s fluid intake.
Encourage the client to use a footboard.
29.Nurse Maria plans to administer dexamethasone cream to a
female client who has dermatitis over the anterior chest. How
should the nurse apply this topical agent?
With a circular motion, to enhance absorption.
With an upward motion, to increase blood supply to the affected
area
In long, even, outward, and downward strokes in the direction of
hair growth
In long, even, outward, and upward strokes in the direction opposite
hair growth
30.Nurse Kate is aware that one of the following classes of
medication protect the ischemic myocardium by blocking
catecholamines and sympathetic nerve stimulation is:
Beta -adrenergic blockers
Calcium channel blocker
Narcotics
Nitrates
31.A male client has jugular distention. On what position should the
nurse place the head of the bed to obtain the most accurate reading
of jugular vein distention?
High Fowler’s
Raised 10 degrees
Raised 30 degrees
Supine position
32.The nurse is aware that one of the following classes of
medications maximizes cardiac performance in clients with heart
failure by increasing ventricular contractility?
Beta-adrenergic blockers
Calcium channel blocker
Diuretics
Inotropic agents
33.A male client has a reduced serum high-density lipoprotein (HDL)
level and an elevated low-density lipoprotein (LDL) level. Which of
the following dietary modifications is not appropriate for this client?
Fiber intake of 25 to 30 g daily
Less than 30% of calories form fat
Cholesterol intake of less than 300 mg daily
Less than 10% of calories from saturated fat
34. A 37-year-old male client was admitted to the coronary care unit
(CCU) 2 days ago with an acute myocardial infarction. Which of the
following actions would breach the client confidentiality?
The CCU nurse gives a verbal report to the nurse on the telemetry
unit before transferring the client to that unit
The CCU nurse notifies the on-call physician about a change in the
client’s condition
The emergency department nurse calls up the latest
electrocardiogram results to check the client’s progress.
At the client’s request, the CCU nurse updates the client’s wife on
his condition
35. A male client arriving in the emergency department is receiving
cardiopulmonary resuscitation from paramedics who are giving
ventilations through an endotracheal (ET) tube that they placed in
the client’s home. During a pause in compressions, the cardiac
monitor shows narrow QRS complexes and a heart rate of
beats/minute with a palpable pulse. Which of the following actions
should the nurse take first?
Start an L.V. line and administer amiodarone (Cardarone), 300 mg
L.V. over 10 minutes.
Check endotracheal tube placement. 44. Francis with leukemia has neutropenia. Which of the following
Obtain an arterial blood gas (ABG) sample. functions must frequently assessed?
Administer atropine, 1 mg L.V. Blood pressure
36. After cardiac surgery, a client’s blood pressure measures 126/80 Bowel sounds
mm Hg. Nurse Katrina determines that mean arterial pressure (MAP) Heart sounds
is which of the following? Breath sounds
46 mm Hg 45. The nurse knows that neurologic complications of multiple
80 mm Hg myeloma (MM) usually involve which of the following body system?
95 mm Hg Brain
90 mm Hg Muscle spasm
37. A female client arrives at the emergency department with chest Renal dysfunction
and stomach pain and a report of black tarry stool for several Myocardial irritability
months. Which of the following order should the nurse Oliver 46. Nurse Patricia is aware that the average length of time from
anticipate? human immunodeficiency virus (HIV) infection to the development
Cardiac monitor, oxygen, creatine kinase and lactate dehydrogenase of acquired immunodeficiency syndrome (AIDS)?
levels Less than 5 years
Prothrombin time, partial thromboplastin time, fibrinogen and fibrin 5 to 7 years
split product values. 10 years
Electrocardiogram, complete blood count, testing for occult blood, More than 10 years
comprehensive serum metabolic panel. 47. An 18-year-old male client admitted with heat stroke begins to
Electroencephalogram, alkaline phosphatase and aspartate show signs of disseminated intravascular coagulation (DIC). Which of
aminotransferase levels, basic serum metabolic panel the following laboratory findings is most consistent with DIC?
38. Macario had coronary artery bypass graft (CABG) surgery 3 days Low platelet count
ago. Which of the following conditions is suspected by the nurse Elevated fibrinogen levels
when a decrease in platelet count from 230,000 ul to 5,000 ul is Low levels of fibrin degradation products
noted? Reduced prothrombin time
Pancytopenia 48. Mario comes to the clinic complaining of fever, drenching night
Idiopathic thrombocytopemic purpura (ITP) sweats, and unexplained weight loss over the past 3 months.
Disseminated intravascular coagulation (DIC) Physical examination reveals a single enlarged supraclavicular lymph
Heparin-associated thrombosis and thrombocytopenia (HATT) node. Which of the following is the most probable diagnosis?
39. Which of the following drugs would be ordered by the physician Influenza
to improve the platelet count in a male client with idiopathic Sickle cell anemia
thrombocytopenic purpura (ITP)? Leukemia
Acetylsalicylic acid (ASA) Hodgkin’s disease
Corticosteroids 49. A male client with a gunshot wound requires an emergency
Methotrezate blood transfusion. His blood type is AB negative. Which blood type
Vitamin K would be the safest for him to receive?
40. A female client is scheduled to receive a heart valve replacement AB Rh-positive
with a porcine valve. Which of the following types of transplant is A Rh-positive
this? A Rh-negative
Allogeneic O Rh-positive
Autologous Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL)
Syngeneic and beginning chemotherapy.
Xenogeneic 50. Stacy is discharged from the hospital following her
41. Marco falls off his bicycle and injuries his ankle. Which of the chemotherapy treatments. Which statement of Stacy’s mother
following actions shows the initial response to the injury in the indicated that she understands when she will contact the physician?
extrinsic pathway? “I should contact the physician if Stacy has difficulty in sleeping”.
Release of Calcium “I will call my doctor if Stacy has persistent vomiting and diarrhea”.
Release of tissue thromboplastin “My physician should be called if Stacy is irritable and unhappy”.
Conversion of factors XII to factor XIIa “Should Stacy have continued hair loss, I need to call the doctor”.
Conversion of factor VIII to factor VIIIa 51. Stacy’s mother states to the nurse that it is hard to see Stacy
42. Instructions for a client with systemic lupus erythematosus (SLE) with no hair. The best response for the nurse is:
would include information about which of the following blood “Stacy looks very nice wearing a hat”.
dyscrasias? “You should not worry about her hair, just be glad that she is alive”.
Dressler’s syndrome “Yes it is upsetting. But try to cover up your feelings when you are
Polycythemia with her or else she may be upset”.
Essential thrombocytopenia “This is only temporary; Stacy will re-grow new hair in 3-6 months,
Von Willebrand’s disease but may be different in texture”.
43. The nurse is aware that the following symptoms is most 52. Stacy has beginning stomatitis. To promote oral hygiene and
commonly an early indication of stage 1 Hodgkin’s disease? comfort, the nurse in-charge should:
Pericarditis Provide frequent mouthwash with normal saline.
Night sweat Apply viscous Lidocaine to oral ulcers as needed.
Splenomegaly Use lemon glycerine swabs every 2 hours.
Persistent hypothermia Rinse mouth with Hydrogen Peroxide.
53. During the administration of chemotherapy agents, Nurse Oliver 62. When Mr. Gonzales regained consciousness, the physician
observed that the IV site is red and swollen, when the IV is touched orders 50 ml of Lactose p.o. every 2 hours. Mr. Gozales develops
Stacy shouts in pain. The first nursing action to take is: diarrhea. The nurse best action would be:
Notify the physician “I’ll see if your physician is in the hospital”.
Flush the IV line with saline solution “Maybe your reacting to the drug; I will withhold the next dose”.
Immediately discontinue the infusion “I’ll lower the dosage as ordered so the drug causes only 2 to 4
Apply an ice pack to the site, followed by warm compress. stools a day”.
54. The term “blue bloater” refers to a male client which of the “Frequently, bowel movements are needed to reduce sodium level”.
following conditions? 63. Which of the following groups of symptoms indicates a ruptured
Adult respiratory distress syndrome (ARDS) abdominal aortic aneurysm?
Asthma Lower back pain, increased blood pressure, decreased re blood cell
Chronic obstructive bronchitis (RBC) count, increased white blood (WBC) count.
Emphysema Severe lower back pain, decreased blood pressure, decreased RBC
55. The term “pink puffer” refers to the female client with which of count, increased WBC count.
the following conditions? Severe lower back pain, decreased blood pressure, decreased RBC
Adult respiratory distress syndrome (ARDS) count, decreased RBC count, decreased WBC count.
Asthma Intermitted lower back pain, decreased blood pressure, decreased
Chronic obstructive bronchitis RBC count, increased WBC count.
Emphysema 64. After undergoing a cardiac catheterization, Tracy has a large
56. Jose is in danger of respiratory arrest following the puddle of blood under his buttocks. Which of the following steps
administration of a narcotic analgesic. An arterial blood gas value is should the nurse take first?
obtained. Nurse Oliver would expect the paco2 to be which of the Call for help.
following values? Obtain vital signs
15 mm Hg Ask the client to “lift up”
30 mm Hg Apply gloves and assess the groin site
40 mm Hg 65. Which of the following treatment is a suitable surgical
80 mm Hg intervention for a client with unstable angina?
57. Timothy’s arterial blood gas (ABG) results are as follows; pH Cardiac catheterization
7.16; Paco2 80 mm Hg; Pao2 46 mm Hg; HCO3- 24mEq/L; Sao2 81%. Echocardiogram
This ABG result represents which of the following conditions? Nitroglycerin
Metabolic acidosis Percutaneous transluminal coronary angioplasty (PTCA)
Metabolic alkalosis 66. The nurse is aware that the following terms used to describe
Respiratory acidosis reduced cardiac output and perfusion impairment due to ineffective
Respirator y alkalosis pumping of the heart is:
58. Norma has started a new drug for hypertension. Thirty minutes Anaphylactic shock
after she takes the drug, she develops chest tightness and becomes Cardiogenic shock
short of breath and tachypneic. She has a decreased level of Distributive shock
consciousness. These signs indicate which of the following Myocardial infarction (MI)
conditions? 67. A client with hypertension ask the nurse which factors can cause
Asthma attack blood pressure to drop to normal levels?
Pulmonary embolism Kidneys’ excretion to sodium only.
Respiratory failure Kidneys’ retention of sodium and water
Rheumatoid arthritis Kidneys’ excretion of sodium and water
Situation: Mr. Gonzales was admitted to the hospital with ascites Kidneys’ retention of sodium and excretion of water
and jaundice. To rule out cirrhosis of the liver: 68. Nurse Rose is aware that the statement that best explains why
59. Which laboratory test indicates liver cirrhosis? furosemide (Lasix) is administered to treat hypertension is:
Decreased red blood cell count It dilates peripheral blood vessels.
Decreased serum acid phosphate level It decreases sympathetic cardioacceleration.
Elevated white blood cell count It inhibits the angiotensin-coverting enzymes
Elevated serum aminotransferase It inhibits reabsorption of sodium and water in the loop of Henle.
60.The biopsy of Mr. Gonzales confirms the diagnosis of cirrhosis. 69. Nurse Nikki knows that laboratory results supports the diagnosis
Mr. Gonzales is at increased risk for excessive bleeding primarily of systemic lupus erythematosus (SLE) is:
because of: Elavated serum complement level
Impaired clotting mechanism Thrombocytosis, elevated sedimentation rate
Varix formation Pancytopenia, elevated antinuclear antibody (ANA) titer
Inadequate nutrition Leukocysis, elevated blood urea nitrogen (BUN) and creatinine levels
Trauma of invasive procedure 70. Arnold, a 19-year-old client with a mild concussion is discharged
61. Mr. Gonzales develops hepatic encephalopathy. Which clinical from the emergency department. Before discharge, he complains of
manifestation is most common with this condition? a headache. When offered acetaminophen, his mother tells the
Increased urine output nurse the headache is severe and she would like her son to have
Altered level of consciousness something stronger. Which of the following responses by the nurse
Decreased tendon reflex is appropriate?
Hypotension “Your son had a mild concussion, acetaminophen is strong enough.”
“Aspirin is avoided because of the danger of Reye’s syndrome in
children or young adults.”
“Narcotics are avoided after a head injury because they may hide a
worsening condition.”
Stronger medications may lead to vomiting, which increases the
intracarnial pressure (ICP).”
71. When evaluating an arterial blood gas from a male client with a
subdural hematoma, the nurse notes the Paco2 is 30 mm Hg. Which
of the following responses best describes the result?
Appropriate; lowering carbon dioxide (CO2) reduces intracranial
pressure (ICP)
Emergent; the client is poorly oxygenated
Normal
Significant; the client has alveolar hypoventilation
72. When prioritizing care, which of the following clients should the
nurse Olivia assess first?
A 17-year-old clients 24-hours postappendectomy
A 33-year-old client with a recent diagnosis of Guillain-Barre
syndrome
A 50-year-old client 3 days postmyocardial infarction
A 50-year-old client with diverticulitis
73. JP has been diagnosed with gout and wants to know why
colchicine is used in the treatment of gout. Which of the following
actions of colchicines explains why it’s effective for gout?
Replaces estrogen
Decreases infection
Decreases inflammation
Decreases bone demineralization
74. Norma asks for information about osteoarthritis. Which of the
following statements about osteoarthritis is correct?
Osteoarthritis is rarely debilitating
Osteoarthritis is a rare form of arthritis
Osteoarthritis is the most common form of arthritis
Osteoarthritis afflicts people over 60
75. Ruby is receiving thyroid replacement therapy develops the flu
and forgets to take her thyroid replacement medicine. The nurse
understands that skipping this medication will put the client at risk
for developing which of the following lifethreatening complications?
Exophthalmos
Thyroid storm
Myxedema coma
Tibial myxedema
76. Nurse Sugar is assessing a client with Cushing’s syndrome. Which
observation should the nurse report to the physician immediately?
Pitting edema of the legs
An irregular apical pulse
Dry mucous membranes
Frequent urination
77. Cyrill with severe head trauma sustained in a car accident is
admitted to the intensive care unit. Thirty-six hours later, the client’s
urine output suddenly rises above 200 ml/hour, leading the nurse to
suspect diabetes insipidus. Which laboratory findings support the
nurse’s suspicion of diabetes insipidus?
Above-normal urine and serum osmolality levels
Below-normal urine and serum osmolality levels
Above-normal urine osmolality level, below-normal serum
osmolality level
Below-normal urine osmolality level, above-normal serum
osmolality level
78. Jomari is diagnosed with hyperosmolar hyperglycemic
nonketotic syndrome (HHNS) is stabilized and prepared for
discharge. When preparing the client for discharge and home
management, which of the following statements indicates that the
client understands her condition and how to control it?
“I can avoid getting sick by not becoming dehydrated and by paying
attention to my need to urinate, drink, or eat more than usual.”
“If I experience trembling, weakness, and headache, I should drink a
glass of soda that contains sugar.”
“I will have to monitor my blood glucose level closely and notify the
physician if it’s constantly elevated.”
“If I begin to feel especially hungry and thirsty, I’ll eat a snack high in
carbohydrates.”
79. A 66-year-old client has been complaining of sleeping more,
increased urination, anorexia, weakness, irritability, depression, and
bone pain that interferes with her going outdoors. Based on these
assessment findings, the nurse would suspect which of the following
disorders?
Diabetes mellitus
Diabetes insipidus
Hypoparathyroidism
Hyperparathyroidism
80. Nurse Lourdes is teaching a client recovering from addisonian
crisis about the need to take fludrocortisone acetate and
hydrocortisone at home. Which statement by the client indicates an
understanding of the instructions?
“I’ll take my hydrocortisone in the late afternoon, before dinner.”
“I’ll take all of my hydrocortisone in the morning, right after I wake
up.”
“I’ll take two-thirds of the dose when I wake up and one-third in the
late afternoon.”
“I’ll take the entire dose at bedtime.”
81. Which of the following laboratory test results would suggest to
the nurse Len that a client has a corticotropin-secreting pituitary
adenoma?
High corticotropin and low cortisol levels
Low corticotropin and high cortisol levels
High corticotropin and high cortisol levels
Low corticotropin and low cortisol levels
82. A male client is scheduled for a transsphenoidal
hypophysectomy to remove a pituitary tumor. Preoperatively, the
nurse should assess  for potential complications by doing which of
the following?
Testing for ketones in the urine
Testing urine specific gravity
Checking temperature every 4 hours
Performing capillary glucose testing every 4 hours
83. Capillary glucose monitoring is being performed every 4 hours
for a client diagnosed with diabetic ketoacidosis. Insulin is
administered using a scale of regular insulin according to glucose
results. At 2 p.m., the client has a capillary glucose level of 250
mg/dl for which he receives 8 U of regular insulin. Nurse Mariner
should expect the dose’s:
onset to be at 2 p.m. and its peak to be at 3 p.m.
onset to be at 2:15 p.m. and its peak to be at 3 p.m.
onset to be at 2:30 p.m. and its peak to be at 4 p.m.
onset to be at 4 p.m. and its peak to be at 6 p.m.
84. The physician orders laboratory tests to confirm hyperthyroidism
in a female client with classic signs and symptoms of this disorder.
Which test result would confirm the diagnosis?
No increase in the thyroid-stimulating hormone (TSH) level after 30
minutes during the TSH stimulation test
A decreased TSH level
An increase in the TSH level after 30 minutes during the TSH
stimulation test
Below-normal levels of serum triiodothyronine (T3) and serum
thyroxine (T4) as detected by radioimmunoassay
85. Rico with diabetes mellitus must learn how to self-administer
insulin. The physician has prescribed 10 U of U-100 regular insulin
and 35 U of U-100 isophane insulin suspension (NPH) to be taken
before breakfast. When teaching the client how to select and rotate
insulin injection sites, the nurse should provide which instruction?
“Inject insulin into healthy tissue with large blood vessels and 94. If a client requires a pneumonectomy, what fills the area of the
nerves.” thoracic cavity?
“Rotate injection sites within the same anatomic region, not among The space remains filled with air only
different regions.” The surgeon fills the space with a gel
“Administer insulin into areas of scar tissue or hypotrophy whenever Serous fluids fills the space and consolidates the region
possible.” The tissue from the other lung grows over to the other side
“Administer insulin into sites above muscles that you plan to 95. Hemoptysis may be present in the client with a pulmonary
exercise heavily later that day.” embolism because of which of the following reasons?
86. Nurse Sarah expects to note an elevated serum glucose level in a Alveolar damage in the infracted area
client with hyperosmolar hyperglycemic nonketotic syndrome Involvement of major blood vessels in the occluded area
(HHNS). Which other laboratory finding should the nurse anticipate? Loss of lung parenchyma
Elevated serum acetone level Loss of lung tissue
Serum ketone bodies 96. Aldo with a massive pulmonary embolism will have an arterial
Serum alkalosis blood gas analysis performed to determine the extent of hypoxia.
Below-normal serum potassium level The acid-base disorder that may be present is?
87. For a client with Graves’ disease, which nursing intervention Metabolic acidosis
promotes comfort? Metabolic alkalosis
Restricting intake of oral fluids Respiratory acidosis
Placing extra blankets on the client’s bed Respiratory alkalosis
Limiting intake of high-carbohydrate foods 97. After a motor vehicle accident, Armand an 22-year-old client is
Maintaining room temperature in the low-normal range admitted with a pneumothorax. The surgeon inserts a chest tube
88. Patrick is treated in the emergency department for a Colles’ and attaches it to a chest drainage system. Bubbling soon appears in
fracture sustained during a fall. What is a Colles’ fracture? the water seal chamber. Which of the following is the most likely
Fracture of the distal radius cause of the bubbling?
Fracture of the olecranon Air leak
Fracture of the humerus Adequate suction
Fracture of the carpal scaphoid Inadequate suction
89. Cleo is diagnosed with osteoporosis. Which electrolytes are Kinked chest tube
involved in the development of this disorder? 98. Nurse Michelle calculates the IV flow rate for a postoperative
Calcium and sodium client. The client receives 3,000 ml of Ringer’s lactate solution IV to
Calcium and phosphorous run over 24 hours. The IV infusion set has a drop factor of 10 drops
Phosphorous and potassium per milliliter. The nurse should regulate the client’s IV to deliver how
Potassium and sodium many drops per minute?
90. Johnny a firefighter was involved in extinguishing a house fire 18
and is being treated to smoke inhalation. He develops severe 21
hypoxia 48 hours after the incident, requiring intubation and 35
mechanical ventilation. He most likely has developed which of the 40
following conditions? 99. Mickey, a 6-year-old child with a congenital heart disorder is
Adult respiratory distress syndrome (ARDS) admitted with congestive heart failure. Digoxin (lanoxin) 0.12 mg is
Atelectasis ordered for the child. The bottle of Lanoxin contains .05 mg of
Bronchitis Lanoxin in 1 ml of solution. What amount should the nurse
Pneumonia administer to the child?
91. A 67-year-old client develops acute shortness of breath and 1.2 ml
progressive hypoxia requiring right femur. The hypoxia was probably 2.4 ml
caused by which of the following conditions? 3.5 ml
Asthma attack 4.2 ml
Atelectasis 100. Nurse Alexandra teaches a client about elastic stockings. Which
Bronchitis of the following statements, if made by the client, indicates to the  
Fat embolism nurse that the teaching was successful?
92. A client with shortness of breath has decreased to absent breath “I will wear the stockings until the physician tells me to remove
sounds on the right side, from the apex to the base. Which of the them.”
following conditions would best explain this? “I should wear the stockings even when I am sleep.”
Acute asthma “Every four hours I should remove the stockings for a half hour.”
Chronic bronchitis “I should put on the stockings before getting out of bed in the
Pneumonia morning.”
Spontaneous pneumothorax Answers and Rationales
93. A 62-year-old male client was in a motor vehicle accident as an Answer: (C) Hypertension. Hypertension, along with fever, and
unrestrained driver. He’s now in the emergency department tenderness over the grafted kidney, reflects acute rejection.
complaining of difficulty of breathing and chest pain. On Answer: (A) Pain. Sharp, severe pain (renal colic) radiating toward
auscultation of his lung field, no breath sounds are present in the the genitalia and thigh is caused by uretheral distention and smooth
upper lobe. This client may have which of the following conditions? muscle spasm; relief form pain is the priority.
Bronchitis Answer: (D) Decrease the size and vascularity of the thyroid
Pneumonia gland. Lugol’s solution provides iodine, which aids in decreasing
Pneumothorax the vascularity of the thyroid gland, which limits the risk of
Tuberculosis (TB) hemorrhage when surgery is performed.
Answer: (A) Liver Disease. The client with liver disease has a
decreased ability to metabolize carbohydrates because of a
decreased ability to form glycogen (glycogenesis) and to form
glucose from glycogen.
Answer: (C) Leukopenia. Leukopenia, a reduction in WBCs, is a
systemic effect of chemotherapy as a result of myelosuppression.
Answer: (C) Avoid foods that in the past caused flatus. Foods that
bothered a person preoperatively will continue to do so after a
colostomy.
Answer: (B) Keep the irrigating container less than 18 inches above
the stoma.”  This height permits the solution to flow slowly with
little force so that excessive peristalsis is not immediately
precipitated.
Answer: (A) Administer Kayexalate. Kayexalate,a potassium
exchange resin, permits sodium to be exchanged for potassium in
the intestine, reducing the serum potassium level.
Answer:(B) 28 gtt/min.  This is the correct flow rate; multiply the
amount to be infused (2000 ml) by the drop factor (10) and divide
the result by the amount of time in minutes (12 hours x 60 minutes)
Answer: (D) Upper trunk.  The percentage designated for each
burned part of the body using the rule of nines: Head and neck 9%;
Right upper extremity 9%; Left upper extremity 9%; Anterior trunk
18%; Posterior trunk 18%; Right lower extremity 18%; Left lower
extremity 18%; Perineum 1%.
Answer: (C) Bleeding from ears.  The nurse needs to perform a
thorough assessment that could indicate alterations in cerebral
function, increased intracranial pressures, fractures and bleeding.
Bleeding from the ears occurs only with basal skull fractures that can
easily contribute to increased intracranial pressure and brain
herniation.
Answer: (D) may engage in contact sports. The client should be
advised by the nurse to avoid contact sports. This will prevent
trauma to the area of the pacemaker generator.
Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic
stimulus for breathing. COPD causes a chronic CO2 retention that
renders the medulla insensitive to the CO2 stimulation for breathing.
The hypoxic state of the client then becomes the stimulus for
breathing. Giving the client oxygen in low concentrations will
maintain the client’s hypoxic drive.
Answer: (B) Facilitate ventilation of the left lung. Since only a
partial pneumonectomy is done, there is a need to promote
expansion of this remaining Left lung by positioning the client on the
opposite unoperated side.
Answer: (A) Food and fluids will be withheld for at least 2
hours.  Prior to bronchoscopy, the doctors sprays the back of
the throat with anesthetic to minimize the gag reflex and thus
facilitate the insertion of the bronchoscope. Giving the client food
and drink after the procedure without checking on the return of the
gag reflex can cause the client to aspirate. The gag reflex usually
returns after two hours.
Answer: (C) hyperkalemia. Hyperkalemia is a common complication
of acute renal failure. It’s life-threatening if immediate action isn’t
taken to reverse it. The administration of glucose and regular insulin,
with sodium bicarbonate if necessary, can temporarily prevent
cardiac arrest by moving potassium into the cells and temporarily
reducing serum potassium levels. Hypernatremia, hypokalemia, and
hypercalcemia don’t usually occur with acute renal failure and aren’t
treated with glucose, insulin, or sodium bicarbonate.
Answer: (A) This condition puts her at a higher risk for cervical
cancer; therefore, she should have a Papanicolaou (Pap) smear
annually. Women with condylomata acuminata are at risk for cancer
of the cervix and vulva. Yearly Pap smears are very important for
early detection. Because condylomata acuminata is a virus, there is
no permanent cure. Because condylomata acuminata can occur on
the vulva, a condom won’t protect sexual partners. HPV can be
transmitted to other parts of the body, such as the mouth,
oropharynx, and larynx.
Answer: (A) The left kidney usually is slightly higher than the right
one. The left kidney usually is slightly higher than the right one.
An adrenal gland lies atop each kidney. The average kidney
measures approximately 11 cm (4-3/8″) long, 5 to 5.8 cm (2″ to 2¼”)
wide, and 2.5 cm (1″) thick. The kidneys are located
retroperitoneally, in the posterior aspect of the abdomen, on either
side of the vertebral column. They lie between the 12th thoracic and
3rd lumbar vertebrae.
Answer: (C) Blood urea nitrogen (BUN) 100 mg/dl and serum
creatinine 6.5 mg/dl. The normal BUN level ranges 8 to 23 mg/dl;
the normal serum creatinine level ranges from 0.7 to 1.5 mg/dl. The
test results in option C are abnormally elevated, reflecting CRF and
the kidneys’ decreased ability to remove nonprotein nitrogen waste
from the blood. CRF causes decreased pH and increased hydrogen
ions — not vice versa. CRF also increases serum levels of potassium,
magnesium, and phosphorous, and decreases serum levels of
calcium. A uric acid analysis of 3.5 mg/dl falls within the normal
range of 2.7 to 7.7 mg/dl; PSP excretion of 75% also falls with the
normal range of 60% to 75%.
Answer: (D) Alteration in the size, shape, and organization
of differentiated cells. Dysplasia refers to an alteration in the size,
shape, and organization of differentiated cells. The presence of
completely undifferentiated tumor cells that don’t resemble cells of
the tissues of their origin is called anaplasia. An increase in the
number of normal cells in a normal arrangement in a tissue or an
organ is called hyperplasia. Replacement of one type of fully
differentiated cell by another in tissues where the second type
normally isn’t found is called metaplasia.
Answer: (D) Kaposi’s sarcoma. Kaposi’s sarcoma is the most
common cancer associated with AIDS. Squamous cell carcinoma,
multiple myeloma, and leukemia may occur in anyone and aren’t
associated specifically with AIDS.
Answer: (C) To prevent cerebrospinal fluid (CSF) leakage. The client
receiving a subarachnoid block requires special positioning to
prevent CSF leakage and headache and to ensure proper anesthetic
distribution. Proper positioning doesn’t help prevent
confusion, seizures, or cardiac arrhythmias.
Answer: (A) Auscultate bowel sounds. If abdominal distention is
accompanied by nausea, the nurse must first auscultate bowel
sounds. If bowel sounds are absent, the nurse should suspect gastric
or small intestine dilation and these findings must be reported to the
physician. Palpation should be avoided postoperatively with
abdominal distention. If peristalsis is absent, changing positions
and inserting a rectal tube won’t relieve the client’s discomfort.
Answer: (B) Lying on the left side with knees bent. For a
colonoscopy, the nurse initially should position the client on the left
side with knees bent. Placing the client on the right side with legs
straight, prone with the torso elevated, or bent over with
hands touching the floor wouldn’t allow proper visualization of the
large intestine.
Answer: (A) Blood supply to the stoma has been interrupted. An
ileostomy stoma forms as the ileum is brought through
the abdominal wall to the surface skin, creating an artificial opening
for waste elimination. The stoma should appear cherry red,
indicating adequate arterial perfusion. A dusky stoma suggests
decreased perfusion, which may result from interruption of the
stoma’s blood supply and may lead to tissue damage or necrosis. A
dusky stoma isn’t a normal finding. Adjusting the ostomy bag
wouldn’t affect stoma color, which depends on blood supply to the
area. An intestinal obstruction also wouldn’t change stoma color.
Answer: (A) Applying knee splints. Applying knee splints prevents
leg contractures by holding the joints in a position of function.
Elevating the foot of the bed can’t prevent contractures because this
action doesn’t hold the joints in a position of function.
Hyperextending a body part for an extended time is
inappropriate because it can cause contractures. Performing
shoulder range-of-motion exercises can prevent contractures in the
shoulders, but not in the legs.
Answer: (B) Urine output of 20 ml/hour. A urine output of less than
40 ml/hour in a client with burns indicates a fluid volume deficit.
This client’s PaO2 value falls within the normal range (80 to 100 mm
Hg). White pulmonary secretions also are normal. The client’s rectal
temperature isn’t significantly elevated and probably results from
the fluid volume deficit.
Answer: (A) Turn him frequently. The most important intervention
to prevent pressure ulcers is frequent position changes, which
relieve pressure on the skin and underlying tissues. If pressure isn’t
relieved, capillaries become occluded, reducing circulation and
oxygenation of the tissues and resulting in cell death and ulcer
formation. During passive ROM exercises, the nurse moves each
joint through its range of movement, which improves joint mobility
and circulation to the affected area but doesn’t prevent
pressure ulcers. Adequate hydration is necessary to maintain
healthy skin and ensure tissue repair. A footboard prevents plantar
flexion and footdrop by maintaining the foot in a dorsiflexed
position.
Answer: (C) In long, even, outward, and downward strokes in
the direction of hair growth. When applying a topical agent, the
nurse should begin at the midline and use long, even, outward, and
downward strokes in the direction of hair growth. This application
pattern reduces the risk of follicle irritation and skin inflammation.
Answer: (A) Beta -adrenergic blockers. 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
infraction 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 bt decreasing left ventricular end
diastolic pressure (preload) and systemic vascular resistance
(afterload).
Answer: (C) Raised 30 degrees. Jugular venous pressure is measured
with a centimeter ruler to obtain the vertical distance between the
sternal angle and the point of highest pulsation with the head of the
bed inclined between 15 to 30 degrees. Increased pressure can’t be
seen when the client is supine or when the head of the bed is raised
10 degrees because the point that marks the pressure level is above
the jaw (therefore, not visible). In high Fowler’s position, the veins
would be barely discernible above the clavicle.
Answer: (D) Inotropic agents. Inotropic agents are administered to
increase the force of the heart’s contractions, thereby increasing
ventricular contractility and ultimately increasing cardiac output.
Beta-adrenergic blockers and calcium channel blockers decrease the
heart rate and ultimately decreased the workload of the heart.
Diuretics are administered to decrease the overall vascular volume,
also decreasing the workload of the heart.
Answer: (B) Less than 30% of calories form fat. A client with low
serum HDL and high serum LDL levels should get less than 30% of
daily calories from fat. The other modifications are appropriate for
this client.
Answer: (C) The emergency department nurse calls up the
latest electrocardiogram results to check the client’s progress. The
emergency department nurse is no longer directly involved with the
client’s care and thus has no legal right to information about his
present condition. Anyone directly involved in his care (such as the
telemetry nurse and the on-call physician) has the right to
information about his condition. Because the client requested that
the nurse update his wife on his condition, doing so doesn’t breach
confidentiality.
Answer: (B) Check endotracheal tube placement. ET tube
placement should be confirmed as soon as the client arrives in the
emergency department. Once the airways is secured, oxygenation
and ventilation should be confirmed using an end-tidal
carbon dioxide monitor and pulse oximetry. Next, the nurse should
make sure L.V. access is established. If the client experiences
symptomatic bradycardia, atropine is administered as ordered 0.5 to
1 mg every 3 to 5 minutes to a total of 3 mg. Then the nurse should
try to find the cause of the client’s arrest by obtaining an ABG
sample. Amiodarone is indicated for ventricular tachycardia,
ventricular fibrillation and atrial flutter – not symptomatic
bradycardia.
Answer: (C) 95 mm Hg. Use the following formula to calculate MAP
MAP = systolic + 2 (diastolic) /3
MAP=[126 mm Hg + 2 (80 mm Hg) ]/3
MAP=286 mm HG/ 3
MAP=95 mm Hg
Answer: (C) Electrocardiogram, complete blood count, testing for
occult blood, comprehensive serum metabolic panel. An
electrocardiogram evaluates the complaints of chest
pain, laboratory tests determines anemia, and the stool test for
occult blood determines blood in the stool. Cardiac monitoring,
oxygen, and creatine kinase and lactate dehydrogenase levels are
appropriate for a cardiac primary problem. A basic metabolic panel
and alkaline phosphatase and aspartate aminotransferase levels
assess liver function. Prothrombin time, partial thromboplastin time,
fibrinogen and fibrin split products are measured to verify bleeding
dyscrasias, An electroencephalogram evaluates brain electrical
activity.
Answer: (D) Heparin-associated thrombosis and
thrombocytopenia (HATT). HATT may occur after CABG surgery due
to heparin use during surgery. Although DIC and ITP cause platelet
aggregation and bleeding, neither is common in a client after
revascularization surgery. Pancytopenia is a reduction in all blood
cells.
Answer: (B) Corticosteroids. Corticosteroid therapy can decrease
antibody production and phagocytosis of the antibody-coated
platelets, retaining more functioning platelets. Methotrexate can
cause thrombocytopenia. Vitamin K is used to treat an excessive
anticoagulate state from warfarin overload, and ASA decreases
platelet aggregation.
Answer: (D) Xenogeneic. An xenogeneic transplant is between is
between human and another species. A syngeneic transplant is
between identical twins, allogeneic transplant is between two
humans, and autologous is a transplant from the same individual.
Answer: (B). Tissue thromboplastin is released when damaged
tissue comes in contact with clotting factors. Calcium is released to
assist the conversion of factors X to Xa. Conversion of factors XII to
XIIa and VIII to VIII a are part of the intrinsic pathway.
Answer: (C) Essential thrombocytopenia. Essential
thrombocytopenia is linked to immunologic disorders, such as SLE
and human immunodeficiency vitus. The disorder known as von
Willebrand’s disease is a type of hemophilia and isn’t linked to
SLE. Moderate to severe anemia is associated with SLE, not
polycythermia. Dressler’s syndrome is pericarditis that occurs after a
myocardial infarction and isn’t linked to SLE.
Answer: (B) Night sweat. In stage 1, symptoms include a single
enlarged lymph node (usually), unexplained fever, night sweats,
malaise, and generalized pruritis. Although splenomegaly may be
present in some clients, night sweats are generally more prevalent.
Pericarditis isn’t associated with Hodgkin’s disease, nor is
hypothermia. Moreover, splenomegaly and pericarditis aren’t
symptoms. Persistent hypothermia is associated with Hodgkin’s but
isn’t an early sign of the disease.
Answer: (D) Breath sounds.  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.
Answer: (B) Muscle spasm. Back pain or paresthesia in the lower
extremities may indicate impending spinal cord compression from a
spinal tumor. This should be recognized and treated promptly as
progression of the tumor may result in paraplegia. The other
options, which reflect parts of the nervous system, aren’t usually
affected by MM.
Answer: (C)10 years. Epidermiologic studies show the average time
from initial contact with HIV to the development of AIDS is 10 years.
Answer: (A) Low platelet count. In DIC, platelets and clotting factors
are consumed, resulting in microthrombi and excessive bleeding. As
clots form, fibrinogen levels decrease and the prothrombin time
increases. Fibrin degeneration products increase as fibrinolysis takes
places.
Answer: (D) Hodgkin’s disease. Hodgkin’s disease typically causes
fever night sweats, weight loss, and lymph mode enlargement.
Influenza doesn’t last for months. Clients with sickle cell anemia
manifest signs and symptoms of chronic anemia with pallor of the
mucous membrane, fatigue, and decreased tolerance for exercise;
they don’t show fever, night sweats, weight loss or lymph node
enlargement. Leukemia doesn’t cause lymph node enlargement.
Answer: (C) A Rh-negative. Human blood can sometimes contain an
inherited D antigen. Persons with the D antigen have Rh-positive
blood type; those lacking the antigen have Rh-negative blood. It’s
important that a person with Rhnegative blood receives Rh-negative
blood. If Rh-positive blood is administered to an Rh-negative person,
the recipient develops anti-Rh agglutinins, and sub sequent
transfusions with Rh-positive blood may cause serious reactions with
clumping and hemolysis of red blood cells.
Answer: (B) “I will call my doctor if Stacy has persistent vomiting
and diarrhea”.  Persistent (more than 24 hours) vomiting, anorexia,
and diarrhea are signs of toxicity and the patient should stop the
medication and notify the health care provider. The other
manifestations are expected side effects of chemotherapy.
Answer: (D) “This is only temporary; Stacy will re-grow new hair in
3-6 months, but may be different in texture”. This is the
appropriate response. The nurse should help the mother how to
cope with her own feelings regarding the child’s disease so as not to
affect the child negatively. When the hair grows back, it is still of the
same color and texture.
Answer: (B) Apply viscous Lidocaine to oral ulcers as
needed. Stomatitis can cause pain and this can be relieved by
applying topical anesthetics such as lidocaine before mouth care.
When the patient is already comfortable, the nurse can proceed
with providing the patient with oral rinses of saline solution mixed
with equal part of water or hydrogen peroxide mixed water in 1:3
concentrations to promote oral hygiene. Every 2-4 hours.
Answer: (C) Immediately discontinue the infusion. Edema or
swelling at the IV site is a sign that the needle has been dislodged
and the IV solution is leaking into the tissues causing the edema. The
patient feels pain as the nerves are irritated by pressure and the IV
solution. The first action of the nurse would be to discontinue
the infusion right away to prevent further edema and other
complication.
Answer: (C) Chronic obstructive bronchitis. Clients with chronic
obstructive bronchitis appear bloated; they have large barrel chest
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 amount of oxygen. Clients with asthma don’t exhibit
characteristics of chronic disease, and clients with emphysema
appear pink and cachectic.
Answer: (D) Emphysema. 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.
Answer: D 80 mm Hg. 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.
Answer: (C) Respiratory acidosis. Because Paco2 is high at 80 mm
Hg and the metabolic measure, HCO3- is normal, the client has
respiratory acidosis. The pH is less than 7.35, academic, which
eliminates metabolic and respiratory alkalosis as possibilities. If the
HCO3- was below 22 mEq/L the client would have metabolic
acidosis.
Answer: (C) Respiratory failure. The client was reacting to the drug
with respiratory signs of impending anaphylaxis, which could lead to
eventually 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.
Answer: (D) Elevated serum aminotransferase. Hepatic cell death
causes release of liver enzymes alanine aminotransferase (ALT),
aspartate aminotransferase (AST) and lactate dehydrogenase (LDH)
into the circulation. Liver cirrhosis is a chronic and irreversible
disease of the liver characterized by generalized inflammation and
fibrosis of the liver tissues.
Answer: (A) Impaired clotting mechanism. Cirrhosis of the liver
results in decreased Vitamin K absorption and formation of clotting
factors resulting in impaired clotting mechanism.
Answer: (B) Altered level of consciousness. Changes in behavior and
level of consciousness are the first sins of hepatic encephalopathy.
Hepatic encephalopathy is caused by liver failure and develops when
the liver is unable to convert protein metabolic product ammonia to
urea. This results in accumulation of ammonia and other toxic in the
blood that damages the cells.
Answer: (C) “I’ll lower the dosage as ordered so the drug causes
only 2 to 4 stools a day”. Lactulose is given to a patients with
hepatic encephalopathy to reduce absorption of ammonia in the
intestines by binding with ammonia and promoting more frequent
bowel movements. If the patient experience diarrhea, it indicates
over dosage and the nurse must reduce the amount of medication
given to the patient. The stool will be mashy or soft. Lactulose is also
very sweet and may cause cramping and bloating.
Answer: (B) Severe lower back pain, decreased blood
pressure, decreased RBC count, increased WBC count.Severe lower
back pain indicates an aneurysm rupture, secondary to pressure
being applied within the abdominal cavity. When ruptured occurs,
the pain is constant because it can’t be alleviated until the aneurysm
is repaired. Blood pressure decreases due to the loss of blood. After
the aneurysm ruptures, the vasculature is interrupted and blood
volume is lost, so blood pressure wouldn’t increase. For the
same reason, the RBC count is decreased – not increased. The WBC
count increases as cell migrate to the site of injury.
Answer: (D) Apply gloves and assess the groin site. Observing
standard precautions is the first priority when dealing with any
blood fluid. Assessment of the groin site is the second priority. This
establishes where the blood is coming from and determineshow
much blood has been lost. The goal in this situation is to stop
the bleeding. The nurse would call for help if it were warranted after
the assessment of the situation. After determining the extent of the
bleeding, vital signs assessment is important. The nurse should
never move the client, in case a clot has formed. Moving can disturb
the clot and cause rebleeding.
Answer: (D) Percutaneous transluminal coronary angioplasty
(PTCA). PTCA can alleviate the blockage and restore blood flow
and oxygenation. An echocardiogram is a noninvasive diagnosis
test. Nitroglycerin is an oral sublingual medication. Cardiac
catheterization is a diagnostic tool – not a treatment.
Answer: (B) Cardiogenic shock. Cardiogenic shock is shock related to
ineffective pumping of the heart. Anaphylactic shock results from an
allergic reaction. Distributive shock results from changes in the
intravascular volume distribution and is usually associated with
increased cardiac output. MI isn’t a shock state, though a severe MI
can lead to shock.
Answer: (C) Kidneys’ excretion of sodium and water. The kidneys
respond to rise in blood pressure by excreting sodium and excess
water. This response ultimately affects sysmolic blood pressure by
regulating blood volume. Sodium or water retention would only
further increase blood pressure. Sodium and water travel
together across the membrane in the kidneys; one can’t travel
without the other.
Answer: (D) It inhibits reabsorption of sodium and water in the
loop of Henle. Furosemide is a loop diuretic that inhibits sodium and
water reabsorption in the loop Henle, thereby causing a decrease in
blood pressure. Vasodilators cause dilation of peripheral blood
vessels, directly relaxing vascular smooth muscle and decreasing
blood pressure. Adrenergic blockers decrease sympathetic
cardioacceleration and decrease blood pressure. Angiotensin-
converting enzyme inhibitors decrease blood pressure due to their
action on angiotensin.
Answer: (C) Pancytopenia, elevated antinuclear antibody (ANA)
titer. Laboratory findings for clients with SLE usually
show pancytopenia, elevated ANA titer, and decreased serum
complement levels. Clients may have elevated BUN and creatinine
levels from nephritis, but the increase does not indicate SLE.
Answer: (C) Narcotics are avoided after a head injury because they
may hide a worsening condition. Narcotics may mask changes in the
level of consciousness that indicate increased ICP and shouldn’t
acetaminophen is strong enough ignores the mother’s question and
therefore isn’t appropriate. Aspirin is contraindicated in conditions
that may have bleeding, such as trauma, and for children or young
adults with viral illnesses due to the danger of Reye’s syndrome.
Stronger medications may not necessarily lead to vomiting but will
sedate the client, thereby masking changes in his level
of consciousness.
Answer: (A) Appropriate; lowering carbon dioxide (CO2)
reduces intracranial pressure (ICP). 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.
Answer: (B) A 33-year-old client with a recent diagnosis of Guillain-
Barre syndrome . Guillain-Barre syndrome is characterized by
ascending paralysis and potential respiratory failure. The order of
client assessment should follow client priorities, with disorder of
airways, breathing, and then circulation. There’s no information to
suggest the postmyocardial infarction client has an arrhythmia or
other complication. There’s no evidence to suggest hemorrhage or
perforation for the remaining clients as a priority of care.
Answer: (C) Decreases inflammation. Then action of colchicines is to
decrease inflammation by reducing the migration of leukocytes to
synovial fluid. Colchicine doesn’t replace estrogen, decrease
infection, or decrease bone demineralization.
Answer: (C) Osteoarthritis is the most common form of
arthritis. Osteoarthritis is the most common form of arthritis and
can be extremely debilitating. It can afflict people of any age,
although most are elderly.
Answer: (C) Myxedema coma. Myxedema coma, severe
hypothyroidism, is a life-threatening condition that may develop if
thyroid replacement medication isn’t taken. Exophthalmos,
protrusion of the eyeballs, is seen with hyperthyroidism. Thyroid
storm is life-threatening but is caused by severe
hyperthyroidism. Tibial myxedema, peripheral mucinous edema
involving the lower leg, is associated with hypothyroidism but isn’t
life-threatening.
Answer: (B) An irregular apical pulse. Because Cushing’s syndrome
causes aldosterone overproduction, which increases urinary
potassium loss, the disorder may lead to hypokalemia. Therefore,
the nurse should immediately report signs and symptoms of
hypokalemia, such as an irregular apical pulse, to the physician.
Edema is an expected finding because aldosterone overproduction
causes sodium and fluid retention. Dry mucous membranes and
frequent urination signal dehydration, which isn’t associated with
Cushing’s syndrome.
Answer: (D) Below-normal urine osmolality level, above-normal
serum osmolality level. In diabetes insipidus, excessive polyuria
causes dilute urine, resulting in a below-normal urine osmolality
level. At the same time, polyuria depletes the body of water, causing
dehydration that leads to an above-normal serum osmolality level.
For the same reasons, diabetes insipidus doesn’t cause above-
normal urine osmolality or below-normal serum osmolality levels.
Answer: (A) “I can avoid getting sick by not becoming dehydrated
and by paying attention to my need to urinate, drink, or eat more
than usual.” Inadequate fluid intake during hyperglycemic episodes
often leads to HHNS. By recognizing the signs of hyperglycemia
(polyuria, polydipsia, and polyphagia) and increasing fluid intake, the
client may prevent HHNS. Drinking a glass of nondiet soda would be
appropriate for hypoglycemia. A client whose diabetes is controlled
with oral antidiabetic agents usually doesn’t need to monitor blood
glucose levels. A highcarbohydrate diet would exacerbate the
client’s condition, particularly if fluid intake is low.
Answer: (D) Hyperparathyroidism. Hyperparathyroidism is most
common in older women and is characterized by bone pain and
weakness from excess parathyroid hormone (PTH). Clients also
exhibit hypercaliuria-causing polyuria. While clients with diabetes
mellitus and diabetes insipidus also have polyuria, they don’t have
bone pain and increased sleeping. Hypoparathyroidism
is characterized by urinary frequency rather than polyuria.
Answer: (C) “I’ll take two-thirds of the dose when I wake up and
one-third in the late afternoon.” Hydrocortisone, a glucocorticoid,
should be administered according to a schedule that closely reflects
the body’s own secretion of this hormone; therefore, two-thirds of
the dose of hydrocortisone should be taken in the morning and one-
third in the late afternoon. This dosage schedule reduces adverse
effects.
Answer: (C) High corticotropin and high cortisol levels. A
corticotropin-secreting pituitary tumor would cause
high corticotropin and high cortisol levels. A high corticotropin level
with a low cortisol level and a low corticotropin level with a low
cortisol level would be associated with hypocortisolism. Low
corticotropin and high cortisol levels would be seen if there was a
primary defect in the adrenal glands.
Answer: (D) Performing capillary glucose testing every 4 hours. The
nurse should perform capillary glucose testing every 4 hours
because excess cortisol may cause insulin resistance, placing
the client at risk for hyperglycemia. Urine ketone testing isn’t
indicated because the client does secrete insulin and, therefore, isn’t
at risk for ketosis. Urine specific gravity isn’t indicated because
although fluid balance can be compromised, it usually isn’t
dangerously imbalanced. Temperature regulation may be affected
by excess cortisol and isn’t an accurate indicator of infection.
Answer: (C) onset to be at 2:30 p.m. and its peak to be at 4
p.m.. Regular insulin, which is a short-acting insulin, has an onset
of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse
gave the insulin at 2 p.m., the expected onset would be from 2:15
p.m. to 2:30 p.m. and the peak from 4 p.m. to 6 p.m.
Answer: (A) No increase in the thyroid-stimulating hormone (TSH)
level after 30 minutes during the TSH stimulation test. In the TSH
test, failure of the TSH level to rise after 30 minutes confirms
hyperthyroidism. A decreased TSH level indicates a pituitary
deficiency of this hormone. Below-normal levels of T3 and T4,
as detected by radioimmunoassay, signal hypothyroidism. A below-
normal T4 level also occurs in malnutrition and liver disease and may
result from administration of phenytoin and certain other drugs.
Answer: (B) “Rotate injection sites within the same anatomic
region, not among different regions.”  The nurse should instruct the
client to rotate injection sites within the same anatomic region.
Rotating sites among different regions may cause excessive day-to-
day variations in the blood glucose level; also, insulin absorption
differs from one region to the next. Insulin should be injected only
into healthy tissue lacking large blood vessels, nerves, or scar tissue
or other deviations. Injecting insulin into areas of hypertrophy may
delay absorption. The client shouldn’t inject insulin into areas
of lipodystrophy (such as hypertrophy or atrophy); to prevent
lipodystrophy, the client should rotate injection sites systematically.
Exercise speeds drug absorption, so the client shouldn’t inject insulin
into sites above muscles that will be exercised heavily.
Answer: (D) Below-normal serum potassium level. A client with
HHNS has an overall body deficit of potassium resulting from
diuresis, which occurs secondary to the
hyperosmolar, hyperglycemic state caused by the relative insulin
deficiency. An elevated serum acetone level and serum ketone
bodies are characteristic of diabetic ketoacidosis. Metabolic acidosis,
not serum alkalosis, may occur in HHNS.
Answer: (D) Maintaining room temperature in the low-normal
range. Graves’ disease causes signs and symptoms
of hypermetabolism, such as heat intolerance, diaphoresis, excessive
thirst and appetite, and weight loss. To reduce heat intolerance
and diaphoresis, the nurse should keep the client’s room
temperature in the low-normal range. To replace fluids lost via
diaphoresis, the nurse should encourage, not restrict, intake of oral
fluids. Placing extra blankets on the bed of a client with heat
intolerance would cause discomfort. To provide needed energy and
calories, the nurse should encourage the client to eat high-
carbohydrate foods.
Answer: (A) Fracture of the distal radius. Colles’ fracture is a
fracture of the distal radius, such as from a fall on an outstretched
hand. It’s most common in women. Colles’ fracture doesn’t refer to
a fracture of the olecranon, humerus, or carpal scaphoid.
Answer: (B) Calcium and phosphorous. In osteoporosis, bones lose
calcium and phosphate salts, becoming porous, brittle, and
abnormally vulnerable to fracture. Sodium and potassium aren’t
involved in the development of osteoporosis.
Answer: (A) Adult respiratory distress syndrome (ARDS). Severe
hypoxia after smoke inhalation is typically related to ARDS. The
other conditions listed aren’t typically associated with
smoke inhalation and severe hypoxia.
Answer: (D) Fat embolism. Long bone fractures are correlated with
fat emboli, whichcause shortness of breath and hypoxia. It’s unlikely
the client has developed asthma or bronchitis without a previous
history. He could develop atelectasis but it typically doesn’t produce
progressive hypoxia.
Answer: (D) Spontaneous pneumothorax. A spontaneous
pneumothorax occurs when the client’s lung collapses, causing an
acute decreased 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.
Answer: (C) Pneumothorax. From the trauma the client
experienced, it’s unlikely he has bronchitis, pneumonia, or TB;
rhonchi with bronchitis, bronchial breath sounds with TB would be
heard.
Answer: (C) Serous fluids fills the space and consolidates the
region. Serous fluid fills the space and eventually
consolidates, preventing extensive mediastinal shift of the heart and
remaining lung. Air can’t be left in the space. There’s no gel that can
be placed in the pleural space. The tissue from the other lung can’t
cross the mediastinum, although a temporary mediastinal shift exits
until the space is filled.
Answer: (A) Alveolar damage in the infracted area. The infracted
area produces alveolar damage that can lead to the production of
bloody sputum, sometimes in massive amounts. Clot formation
usually occurs in the legs. There’s a loss of lung parenchyma and
subsequent scar tissue formation.
Answer: (D) Respiratory alkalosis. A client with massive pulmonary
embolism will have a large region and blow off large amount of
carbon dioxide, which crosses the unaffected alveolar-capillary
membrane more readily than does oxygen and results in respiratory
alkalosis.
Answer: (A) Air leak. Bubbling in the water seal chamber of a chest
drainage system stems from an air leak. In pneumothorax an air leak
can occur as air is pulled from the pleural space. Bubbling doesn’t
normally occur with either adequate or inadequate suction or any
preexisting bubbling in the water seal chamber.
Answer: (B) 21. 3000 x 10 divided by 24 x 60.
Answer: (B) 2.4 ml. .05 mg/ 1 ml = .12mg/ x ml, .05x = .12, x = 2.4
ml.
Answer: (D) “I should put on the stockings before getting out of
bed in the morning. Promote venous return by applying external
pressure on veins.
SET 7
1. Following spinal injury, the nurse should encourage the client to
drink fluids to avoid:
Urinary tract infection.
Fluid and electrolyte imbalance.
Dehydration.
Skin breakdown.
2. The client is transferred from the operating room to recovery
room after an open-heart surgery. The nurse assigned is taking the
vital signs of the client. The nurse notified the physician when the
temperature of the client rises to 38.8 ºC or 102 ºF because elevated
temperatures:
May be a forerunner of hemorrhage.
Are related to diaphoresis and possible chilling.
May indicate cerebral edema.
Increase the cardiac output.
3. After radiation therapy for cancer of the prostate, the client
experienced irritation in the bladder. Which of the following sign of
bladder irritability is correct?
Hematuria
Dysuria
Polyuria
Dribbling
4. A client is diagnosed with a brain tumor in the occipital lobe.
Which of the following will the client most likely experience?
Visual hallucinations.
Receptive aphasia.
Hemiparesis.
Personality changes.
5. A client with Addison’s disease has a blood pressure of 65/60. The
nurse understands that decreased blood pressure of the client with
Addison’s disease involves a disturbance in the production of:
Androgens
Glucocorticoids
Mineralocorticoids
Estrogen
6. The nurse is planning to teach the client about a spontaneous
pneumothorax. The nurse would base the teaching on the
understanding that:
Inspired air will move from the lung into the pleural space.
There is greater negative pressure within the chest cavity.
The heart and great vessels shift to the affected side.
The other lung will collapse if not treated immediately.
7. During an assessment, the nurse recognizes that the client has an
increased risk for developing cancer of the tongue. Which of the
following health history will be a concern?
Heavy consumption of alcohol.
Frequent gum chewing.
Nail biting.
Poor dental habits.
8. The client in the orthopedic unit asks the nurse the reason behind
why compact bone is stronger than cancellous bone. Which of the
following is the correct response of the nurse?
Compact bone is stronger than cancellous bone because of its
greater size.
Compact bone is stronger than cancellous bone because of its
greater weight.
Compact bone is stronger than cancellous bone because of its
greater volume.
Compact bone is stronger than cancellous bone because of its
greater density.
9. The nurse is reviewing the laboratory results of the client. In
reviewing the results of the RBC count, the nurse understands that
the higher the red blood cell count, the :
Greater the blood viscosity.
Higher the blood pH.
Less it contributes to immunity.
Lower the hematocrit.
10. The physician advised the client with Hemiparesis to use a cane.
The client asks the nurse why cane will be needed. The nurse
explains to the client that cane is advised specifically to:
Aid in controlling involuntary muscle movements.
Relieve pressure on weight-bearing joints.
Maintain balance and improve stability.
Prevent further injury to weakened muscles.
11. The nurse is conducting a discharge teaching regarding the
prevention of further problems to a client who undergone surgery
for carpal tunnel syndrome of the right hand. Which of the following
instruction will the nurse includes?
Learn to type using your left hand only.
Avoid typing in a long period of time.
Avoid carrying heavy things using the right hand.
Do manual stretching exercise during breaks.
12. A female client is admitted because of recurrent urinary tract
infections. The client asks the nurse why she is prone to this disease.
The nurse states that the client is most susceptible because of:
Continuity of the mucous membrane.
Inadequate fluid intake.
The length of the urethra.
Poor hygienic practices.
13. A 55-year-old client is admitted with chest pain that radiates to
the neck, jaw and shoulders that occurs at rest, with high body
temperature, weak with generalized sweating and with decreased
blood pressure. A myocardial infarction is diagnosed. The nurse
knows that the most accurate explanation for one of these
presenting adaptations is:
Catecholamines released at the site of the infarction causes
intermittent localized pain.
Parasympathetic reflexes from the infarcted myocardium causes
diaphoresis.
Constriction of central and peripheral blood vessels causes a
decrease in blood pressure.
Inflammation in the myocardium causes a rise in the systemic body
temperature.
14. Following an amputation of a lower limb to a male client, the
nurse provides an instruction on how to prevent a hip flexion
contracture. The nurse should instruct the client to:.
Perform quadriceps muscle setting exercises twice a day.
Sit in a chair for 30 minutes three times a day.
Lie on the abdomen 30 minutes every four hours.
Turn from side to side every 2 hours.
15. The physician scheduled the client with rheumatoid arthritis for
the injection of hydrocortisone into the knee joint. The client asks
the nurse why there is a need for this injection. The nurse explains
that the most important reason for doing this is to:
Lubricate the joint.
Prevent ankylosis of the joint.
Reduce inflammation.
Provide physiotherapy.
16. The nurse is assigned to care for a 57-year-old female client who
had a cataract surgery an hour ago. The nurse should:
Advise the client to refrain from vigorous brushing of teeth and hair.
Instruct the client to avoid driving for 2 weeks.
Encourage eye exercises to strengthen the ocular musculature.
Teach the client coughing and deep-breathing techniques.
17. A client with AIDS develops bacterial pneumonia is admitted in
the emergency department. The client’s arterial blood gases is
drawn and the result is PaO2 80mmHg. then arterial blood gases are
drawn again and the level is reduced from 80 mmHg to 65 mmHg.
The nurse should;
Have arterial blood gases performed again to check for accuracy.
Increase the oxygen flow rate.
Notify the physician.
Decrease the tension of oxygen in the plasma.
18. An 18-year-old college student is brought to the emergency
department due to serious motor vehicle accident. Right above-
knee-amputation is done. Upon awakening from surgery the client
tells the nurse, “What happened to me? I cannot remember
anything?” Which of the following would be the appropriate initial
nursing response?
“You sound concerned; You’ll probably remember more as you wake
up.”
“Tell me what you think happened.”
“You were in a car accident this morning.”
“An amputation of your right leg was necessary because of an
accident.”
19. A 38-year-old client with severe hypertension is hospitalized. The
physician prescribed a Captopril (Capoten) and Alprazolam (Xanax)
for treatment. The client tells the nurse that there is something
wrong with the medication and nursing care. The nurse recognizes
this behavior is probably a manifestation of the client’s:
Reaction to hypertensive medications.
Denial of illness.
Response to cerebral anoxia.
Fear of the health problem.
20. Before discharge, the nurse scheduled the client who had a
colostomy for colorectal cancer for discharge instruction about
resuming activities. The nurse should plan to help the client
understands that:
After surgery, changes in activities must be made to accommodate
for the physiologic changes caused by the operation.
Most sports activities, except for swimming, can be resumed based
on the client’s overall physical condition.
With counseling and medical guidance, a near normal lifestyle,
including complete sexual function is possible.
Activities of daily living should be resumed as quickly as possible to
avoid depression and further dependency.
21. A client is scheduled for bariatric surgery. Preoperative teaching
is done. Which of the following statement would alert the nurse that
further teaching to the client is necessary?
“I will be limiting my intake to 600 to 800 calories a day once I start
eating again.”
“I’m going to have a figure like a model in about a year.”
“I need to eat more high-protein foods.”
“I will be going to be out of bed and sitting in a chair the first day
after surgery.”.
22. The client who had transverse colostomy asks the nurse about
the possible effect of the surgery on future sexual relationship. What
would be the best nursing response?
The surgery will temporarily decrease the client’s sexual impulses.
Sexual relationships must be curtailed for several weeks.
The partner should be told about the surgery before any sexual
activity.
The client will be able to resume normal sexual relationships.
23. A 75-year-old male client tells the nurse that his wife has
osteoporosis and asks what chances he had of getting also
osteoporosis like his wife. Which of the following is the correct
response of the nurse?
“This is only a problem for women.”
“You are not at risk because of your small frame.”
“You might think about having a bone density test,”
“Exercise is a good way to prevent this problem.”
24. An older adult client with acute pain is admitted in the hospital.
The nurse understands that in managing acute pain of the client
during the first 24 hours, the nurse should ensure that:
Ordered PRN analgesics are administered on a scheduled basis.
Patient controlled analgesia is avoided in this population.
Pain medication is ordered via the intramuscular route.
An order for meperidine (Demerol) is secured for pain relief.
25. A nurse is caring to an older adult with presbycusis. In
formulating nursing care plan for this client, the nurse should expect
that hearing loss of the client that is caused by aging to have:
Overgrowth of the epithelial auditory lining.
Copious, moist cerumen.
Difficulty hearing women’s voices.
Tears in the tympanic membrane.
26. The nurse is reviewing the client’s chart about the ordered
medication. The nurse must observe for signs of hyperkalemia when
administering:
Furosemide (Lasix)
Hydrochlorothiazide (HydroDIURIL)
Metolazone (Zaroxolyn)
Spironolactone (Aldactone)
27. The physician prescribed Albuterol (Proventil) to the client with
severe asthma. After the administration of the medication the nurse
should monitor the client for:
Palpitation
Visual disturbance
Decreased pulse rate
Lethargy
28. A client is receiving diltiazem (Cardizem). What should the nurse
include in a teaching plan aimed at reducing the side effects of this
medication?
Take the drug with an antacid.
Lie down after meals.
Avoid dairy products in diet.
Change positions slowly.
29. A client is receiving simvastatin (Zocor). The nurse is aware that
this medication is effective when there is decrease in:
The triglycerides
The INR
Chest pain
Blood pressure
30. A client is taking nitroglycerine tablets, the nurse should teach
the client the importance of:
Increasing the number of tablets if dizziness or hypertension occurs.
Limiting the number of tablets to 4 per day.
Making certain the medication is stored in a dark container.
Discontinuing the medication if a headache develops.
31. The physician prescribes Ibuprofen (Motrin) and
hydroxychloroquine sulfate (Plaquenil) for a 58-year-old male client
with arthritis. The nurse provides information about toxicity of the
hydroxychloroquine. The nurse can determine if the information is
clearly understood if the client states:
“I will contact the physician immediately if I develop blurred vision.”
“I will contact the physician immediately if I develop urinary
retention.”
“I will contact the physician immediately if I develop swallowing
difficulty.”
“I will contact the physician immediately if I develop feelings of
irritability.”
32. The client with an acute myocardial infarction is hospitalized for
almost one week. The client experiences nausea and loss of
appetite. The nurse caring for the client recognizes that these
symptoms may indicate the:
Adverse effects of spironolactone (Aldactone)
Adverse effects of digoxin (Lanoxin)
Therapeutic effects of propranolol (Indiral)
Therapeutic effects of furosemide (Lasix)
33. A client with a partial occlusion of the left common carotid artery
is scheduled for discharge. The client is still receiving Coumadin. The
nurse provided a discharge instruction to the client regarding
adverse effects of Coumadin. The nurse should tell the client to
consult with the physician if:
Swelling of the ankles increases.
Blood appears in the urine.
Increased transient Ischemic attacks occur.
The ability to concentrate diminishes.
34. Levodopa is ordered for a client with Parkinson’s disease. Before
starting the medication, the nurse should know that:
Levodopa is inadequately absorbed if given with meals.
Levodopa may cause the side effects of orthostatic hypotension.
Levodopa must be monitored by weekly laboratory tests.
Levodopa causes an initial euphoria followed by depression.
35. In making a diagnosis of myasthenia gravis Edrophonium HCI
(Tensilon) is used. The nurse knows that this drug will cause a
temporary increase in:
Muscle strength
Symptoms
Blood pressure
Consciousness
36. The nurse can determine the effectiveness of carbamazepine
(Tegretol) in the management of trigeminal neuralgia by monitoring
the client’s:
Seizure activity
Liver function
Cardiac output
Pain relief
37. Administration of potassium iodide solution is ordered to the
client who will undergo a subtotal thyroidectomy. The nurse
understands that this medication is given to:
Ablate the cells of the thyroid gland that produce T4.
Decrease the total basal metabolic rate.
Decrease the size and vascularity of the thyroid.
Maintain function of the parathyroid gland.
38. A client with Addison’s disease is scheduled for discharge. Before
the discharge, the physician prescribes hydrocortisone and
fludrocortisone. The nurse expects the hydrocortisone to:
Increase amounts of angiotensin II to raise the client’s blood
pressure.
Control excessive loss of potassium salts.
Prevent hypoglycemia and permit the client to respond to stress.
Decrease cardiac dysrhythmias and dyspnea.
39. A client with diabetes insipidus is taking Desmopressin acetate
(DDAVP). To determine if the drug is effective, the nurse should
monitor the client’s:
Arterial blood pH
Pulse rate
Serum glucose
Intake and output
40. A client with recurrent urinary tract infections is to be
discharged. The client will be taking nitrofurantoin (Macrobid) 50 mg
po every evening at home. The nurse provides discharge instructions
to the client. Which of the following instructions will be correct?
Strain urine for crystals and stones
Increase fluid intake.
Stop the drug if the urinary output increases
Maintain the exact time schedule for drug taking.
41. A client with cancer of the lung is receiving chemotherapy. The
physician orders antibiotic therapy for the client. The nurse
understands that chemotherapy destroys rapidly growing leukocytes
in the:
Bone marrow
Liver
Lymph nodes
Blood
42. The physician reduced the client’s Dexamethasone (Decadron)
dosage gradually and to continue a lower maintenance dosage. The
client asks the nurse about the change of dosage. The nurse explains
to the client that the purpose of gradual dosage reduction is to
allow:
Return of cortisone production by the adrenal glands.
Production of antibodies by the immune system
Building of glycogen and protein stores in liver and muscle
Time to observe for return of increases intracranial pressure
43. The nurse is assigned to care for a client with diarrhea. Excessive
fluid loss is expected. The nurse is aware that fluid deficit can most
accurately be assessed by:
The presence of dry skin
A change in body weight
An altered general appearance
A decrease in blood pressure
44. Which of the following is the most important electrolyte of
intracellular fluid?
Potassium
Sodium
Chloride
Calcium
45. Which of the following client has a high risk for developing
hyperkalemia?
Crohn’s disease
End-Stage renal disease
Cushing’s syndrome
Chronic heart failure
46. The nurse is reviewing the laboratory result of the client. The
client’s serum potassium level is 5.8 mEq/L. Which of the following is
the initial nursing action?
Call the cardiac arrest team to alert them
Call the laboratory and repeat the test
Take the client’s vital signs and notify the physician
Obtain an ECG strip and have lidocaine available
47. Potassium chloride, 20 mEq, is ordered and to be added in the IV
solution of a client in a diabetic ketoacidosis. The primary reason for
administering this drug is:
Replacement of excessive losses
Treatment of hyperpnea
Prevention of flaccid paralysis
Treatment of cardiac dysrhythmias
48. A female client is brought to the emergency unit. The client is
complaining of abdominal cramps. On assessment, client is
experiencing anorexia and weight is reduced. The physician’s
diagnosis is colitis. Which of the following symptoms of fluid and
electrolyte imbalance should the nurse report immediately?
Skin rash, diarrhea, and diplopia
Development of tetaniy with muscles spasms
Extreme muscle weakness and tachycardia
Nausea, vomiting, and leg and stomach cramps.
49. The client is to receive an IV piggyback medication. When
preparing the medication the nurse should be aware that it is very
important to:
Use strict sterile technique
Use exactly 100mL of fluid to mix the medication
Change the needle just before adding the medication
Rotate the bag after adding the medication
50. The nurse is reviewing the laboratory result of the client. An
arterial blood gas report indicates the client’s pH is 7.20, PCO2 35
mmHg and HCO3 is 19 mEq/L. The results are consistent with:
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
Answers and Rationales
A. Clients in the early stage of spinal cord damage experience an
atonic bladder, which is characterized by the absence of muscle
tone, an enlarged capacity, no feeling of discomfort with distention,
and overflow with a large residual. This leads to urinary stasis and
infection. High fluid intake limits urinary stasis and infection by
diluting the urine and increasing urinary output.
D. The temperature of 102 ºF (38.8ºC) or greater lead to an
increased metabolism and cardiac workload.
B. Dysuria, nocturia, and urgency are all signs an irritable bladder
after radiation therapy.
A. The occipital lobe is involve with visual interpretation.
C. Mineralocorticoids such as aldosterone cause the kidneys to
retain sodium ions. With sodium, water is also retained, elevating
blood pressure. Absence of this hormone thus causes hypotension.
B. As a person with a tear in the lung inhales, air moves through that
opening into the intrapleural and causes partial or complete collapse
of the lungs.
A. Heavy alcohol ingestion predisposes an individual to the
development of oral cancer.
D. The greater the density of compact bone makes it stronger than
the cancellous bone. Compact bone forms from cancellous bone by
the addition of concentric rings of bones substances to the marrow
spaces of cancellous bone. The large marrow spaces are reduced to
haversian canals.
A. Viscosity, a measure of a fluid’s internal resistance to flow, is
increased as the number of red cells suspended in plasma.
C. Hemiparesis creates instability. Using a cane provides a wider
base of support and, therefore greater stability.
D. Manual stretching exercises will assist in keeping the muscles and
tendons supple and pliable, reducing the traumatic consequences of
repetitive activity.
C. The length of the urethra is shorter in females than in males;
therefore microorganisms have a shorter distance to travel to reach
the bladder. The proximity of the meatus to the anus in females also
increases this incidence.
D. Temperature may increase within the first 24 hours and persist as
long as a week.
C. The hips are in extension when the client is prone; this keeps the
hips from flexing.
C. Steroids have an anti-inflammatory effect that can reduce arthritic
pannus formation.
A. Activities such as rigorous brushing of hair and teeth cause
increased intraocular pressure and may lead to hemorrhage in the
anterior chamber.
C. This decrease in PaO2 indicates respiratory failure; it warrants
immediate medical evaluation.
C. This is truthful and provides basic information that may prompt
recollection of what happened; it is a starting point.
D. Clients adapting to illness frequently feel afraid and helpless and
strike out at health team members as a way of maintaining control
or denying their fear.
C. There are few physical restraints on activity postoperatively, but
the client may have emotional problems resulting from the body
image changes.
B. Clients need to be prepared emotionally for the body image
changes that occur after bariatric surgery. Clients generally
experience excessive abdominal skin folds after weight stabilizes,
which may require a panniculectomy. Body image disturbance often
occurs in response to incorrectly estimating one’s size; it is not
uncommon for the client to still feel fat no matter how much weight
is lost.
D. Surgery on the bowel has no direct anatomic or physiologic effect
on sexual performance. However, the nurse should encourage
verbalization.
C. Osteoporosis is not restricted to women; it is a potential major
health problem of all older adults; estimates indicate that half of all
women have at least one osteoporitic fracture and the risk in men is
estimated between 13% and 25%; a bone mineral density
measurement assesses the mass of bone per unit volume or how
tightly the bone is packed.
A. Around-the-clock administration of analgesics is recommended
for acute pain in the older adult population; this help to maintain a
therapeutic blood level of pain medication.
C. Generally, female voices have a higher pitch than male voices;
older adults with presbycusis (hearing loss caused by the aging
process) have more difficulty hearing higher-pitched sounds.
D. Aldactone is a potassium-sparing diuretic; hyperkalemia is an
adverse effect.
A. Albuterol’s sympathomimetic effect causes cardiac stimulation
that may cause tachycardia and palpitation.
D. Changing positions slowly will help prevent the side effect of
orthostatic hypotension.
A. Therapeutic effects of simvastatin include decreased serum
triglyceries, LDL and cholesterol.
C. Nitroglycerine is sensitive to light and moisture ad must be stored
in a dark, airtight container.
A. Visual disturbance are a sign of toxicity because retinopathy can
occur with this drug.
B. Toxic levels of Lanoxin stimulate the medullary chemoreceptor
trigger zone, resulting in nausea and subsequent anorexia.
B. Warfarin derivatives cause an increase in the prothrombin time
and INR, leading to an increased risk for bleeding. Any abnormal or
excessive bleeding must be reported, because it may indicate toxic
levels of the drug.
B. Levodopa is the metabolic precursor of dopamine. It reduces
sympathetic outflow by limiting vasoconstriction, which may result
in orthostatic hypotension.
A. Tensilon, an anticholinesterase drug, causes temporary relief of
symptoms of myasthenia gravis in client who have the disease and is
therefore an effective diagnostic aid.
D. Carbamazepine ( Tegretol) is administered to control pain by
reducing the transmission of nerve impulses in clients with
trigeminal neuralgia.
C. Potassium iodide, which aids in decreasing the vascularity of the
thyroid gland, decreases the risk for hemorrhage.
C. Hydrocortisone is a glucocorticoid that has anti-inflammatory
action and aids in metabolism of carbohydrate, fat, and protein,
causing elevation of blood glucose. Thus it enables the body to
adapt to stress.
D. DDAVP replaces the ADH, facilitating reabsorption of water and
consequent return of normal urine output and thirst.
B. To prevent crystal formation, the client should have sufficient
intake to produce 1000 to 1500 mL of urine daily while taking this
drug.
A. Prolonged chemotherapy may slow the production of leukocytes
in bone marrow, thus suppressing the activity of the immune
system. Antibiotics may be required to help counter infections that
the body can no longer handle easily.
A. Any hormone normally produced by the body must be withdrawn
slowly to allow the appropriate organ to adjust and resume
production.
B. Dehydration is most readily and accurately measured by serial
assessment of body weight; 1 L of fluid weighs 2.2 pounds.
A. The concentration of potassium is greater inside the cell and is
important in establishing a membrane potential, a critical factor in
the cell’s ability to function.
B. The kidneys normally eliminate potassium from the body;
hyperkalemia may necessitate dialysis.
C. Vital signs monitor cardiorespiratory status; hyperkalemia causes
serious cardiac dysrhythmias.
A. Once treatment with insulin for diabetic ketoacidosis is begun,
potassium ions reenter the cell, causing hypokalemia; therefore
potassium, along with the replacement fluid, is generally supplied.
C. Potassium, the major intracellular cation, functions with sodium
and calcium to regulate neuromuscular activity and contraction of
muscle fibers, particularly the heart muscle. In hypokalemia these
symptoms develop.
A. Because IV solutions enter the body’s internal environment, all
solutions and medications utilizing this route must be sterile to
prevent the introduction of microbes.
A. A low pH and bicarbonate level are consistent with metabolic
acidosis.