31. Marichu was given morphine sulfate for pain.

She is sleeping and her respiratory rate is 4

breaths/minute. If action isn’t taken quickly, she might have

which of the following reactions?

a. Asthma attack

b. Respiratory arrest

c. Seizure

d. Wake up on his own

32. A 77-year-old male client is admitted for elective knee surgery. Physical examination reveals shallow
respirations but no sign of respiratory distress. Which of the following is a normal physiologic change
related to aging?

a. Increased elastic recoil of the lungs

b. Increased number of functional capillaries in the alveoli

c. Decreased residual volume

d. Decreased vital capacity

33. Tracy is receiving combination chemotherapy for treatment of metastatic carcinoma. Nurse Ruby
should monitor the client for the systemic side effect of:

a. Ascites

b. Nystagmus

c. Leukopenia

d. Polycythemia

34. Norma, with recent colostomy expresses concern about the inability to control the passage of gas.
Nurse Oliver should suggest that the client plan to:

a. Eliminate foods high in cellulose.

b. Decrease fluid intake at meal times.

c. Avoid foods that in the past caused flatus.

d. Adhere to a bland diet prior to social events.

35. 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:

a. Lie on my left side while instilling the irrigating solution.”

b. Keep the irrigating container less than 18 inches above the stoma.”

c. Instill a minimum of 1200 ml of irrigating solution to stimulate

evacuation of the bowel.”

d. Insert the irrigating catheter deeper into the stoma if cramping

occurs during the procedure.”

36. 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:

a. Administer Kayexalate

b. Restrict foods high in protein

c. Increase oral intake of cheese and milk.

d. Administer large amounts of normal saline via I.V.

37. 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:

a. 18 gtt/min

b. 28 gtt/min

c. 32 gtt/min

d. 36 gtt/min

38.Terence suffered form burn injury. Using the rule of nines, which has the largest percent of burns?

a. Face and neck

b. Right upper arm and penis

c. Right thigh and penis

d. Upper trunk

39. 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:

a. Reactive pupils

b. A depressed fontanel

c. Bleeding from ears

d. An elevated temperature

40. 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?

a. take the pulse rate once a day, in the morning upon awakening
b. May be allowed to use electrical appliances

c. Have regular follow up care

d. May engage in contact sports

41.The nurse is ware that the most relevant knowledge about oxygen administration to a male client
with COPD is

a. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.

b. Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breath.

c. Oxygen is administered best using a non-rebreathing mask

d. Blood gases are monitored using a pulse oximeter.

42.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:

a. Reduce incisional pain.

b. Facilitate ventilation of the left lung.

c. Equalize pressure in the pleural space.

d. Increase venous return

43. What is Nurse John likely to note in a male client being admitted for alcohol withdrawal?

a. Perceptual disorders. b. Impending coma. c. Recent alcohol intake. d. Depression with mutism.

44. Aira has taken amitriptyline HCL (Elavil) for 3 days, but now complains that it “doesn’t help” and
refuses to take it. What should the nurse say or do?

a. Withhold the drug. b. Record the client’s response. c. Encourage the client to tell the doctor. d.
Suggest that it takes awhile before seeing the results.

45. Dervid, an adolescent has a history of truancy from school, running away from home and
“barrowing” other people’s things without their permission. The adolescent denies stealing, rationalizing
instead that as long as no one was using the items, it was all right to borrow them. It is important for the
nurse to understand the psychodynamically, this behavior may be largely attributed to a developmental
defect related to the:

a. Id b. Ego c. Superego d. Oedipal complex

46. In preparing a female client for electroconvulsive therapy (ECT), Nurse Michelle knows that
succinylcoline (Anectine) will be administered for which therapeutic effect?

a. Short-acting anesthesia b. Decreased oral and respiratory secretions. c. Skeletal muscle paralysis. d.
Analgesia. 47. Nurse Gina is aware that the dietary implications for a client in manic phase of bipolar
disorder is:
a. Serve the client a bowl of soup, buttered French bread, and apple slices. b. Increase calories, decrease
fat, and decrease protein. c. Give the client pieces of cut-up steak, carrots, and an apple. d. Increase
calories, carbohydrates, and protein.

48.What parental behavior toward a child during an admission procedure should cause Nurse Ron to
suspect child abuse?

a. Flat affect b. Expressing guilt c. Acting overly solicitous toward the child. d. Ignoring the child. 49.Nurse
Lynnette notices that a female client with obsessive-compulsive disorder washes her hands for long
periods each day. How should the nurse respond to this compulsive behavior?

a. By designating times during which the client can focus on the behavior. b. By urging the client to
reduce the frequency of the behavior as rapidly as possible. c. By calling attention to or attempting to
prevent the behavior. d. By discouraging the client from verbalizing anxieties.

50.After seeking help at an outpatient mental health clinic, Ruby who was raped while walking her dog is
diagnosed with posttraumatic stress disorder (PTSD). Three months later, Ruby returns to the clinic,
complaining of fear, loss of control, and helpless feelings. Which nursing intervention is most appropriate
for Ruby?

a. Recommending a high-protein, low-fat diet.

b. Giving sleep medication, as prescribed, to restore a normal sleepwake cycle.

c. Allowing the client time to heal.

d. Exploring the meaning of the traumatic event with the client.

ANSWER KEY

31. Answer: (B) Respiratory arrest

Rationale: 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.
32. Answer: (D) Decreased vital capacity
Rationale: 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.
33. Answer: (C) Leukopenia
Rationale: Leukopenia, a reduction in WBCs, is a systemic effect of chemotherapy as a result of
myelosuppression.
34. Answer: (C) Avoid foods that in the past caused flatus.
Rationale: Foods that bothered a person preoperatively will continue to do so after a colostomy.
35. Answer: (B) Keep the irrigating container less than 18 inches above the stoma.”
Rationale: This height permits the solution to flow slowly with little force so that excessive peristalsis is
not immediately precipitated.
36. Answer: (A) Administer Kayexalate
Rationale: Kayexalate,a potassium exchange resin, permits sodium to be exchanged for potassium in the
intestine, reducing the serum potassium level.
37. Answer:(B) 28 gtt/min
Rationale: 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)
38. Answer: (D) Upper trunk Rationale: 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%.
39. Answer: (C) Bleeding from ears
Rationale: 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.
40. Answer: (D) may engage in contact sports
Rationale: The client should be advised by the nurse to avoid contact sports. This will prevent trauma to
the area of the pacemaker generator.
41. Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.
Rationale: 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.
42. Answer: (B) Facilitate ventilation of the left lung.
Rationale: 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.
43. Answer: (A) Perceptual disorders.
Rationale: Frightening visual hallucinations are especially common in clients experiencing alcohol
withdrawal.
44. Answer: (D) Suggest that it takes awhile before seeing the results.
Rationale: The client needs a specific response; that it takes 2 to 3 weeks (a delayed effect) until the
therapeutic blood level is reached.
45. Answer: (C) Superego
Rationale: This behavior shows a weak sense of moral consciousness. According to Freudian theory,
personality disorders stem from a weak superego.
46. Answer: (C) Skeletal muscle paralysis.
Rationale: Anectine is a depolarizing muscle relaxant causing paralysis. It is used to reduce the intensity
of muscle contractions during the convulsive stage, thereby reducing the risk of bone fractures or
dislocation.
47. Answer: (D) Increase calories, carbohydrates, and protein.
Rationale: This client increased protein for tissue building and increased calories to replace what is
burned up (usually via carbohydrates).
48. Answer: (C) Acting overly solicitous toward the child.
Rationale: This behavior is an example of reaction formation, a coping mechanism.
49. Answer: (A) By designating times during which the client can focus on the behavior. Rationale: The
nurse should designate times during which the client can focus on the compulsive behavior or obsessive
thoughts. The nurse should urge the client to reduce the frequency of the compulsive behavior
gradually, not rapidly. She shouldn't call attention to or try to prevent the behavior. Trying to prevent
the behavior may cause pain and terror in the client. The nurse should encourage the client to verbalize
anxieties to help distract attention from the compulsive behavior.
50. Answer: (D) Exploring the meaning of the traumatic event with the client.
Rationale: The client with PTSD needs encouragement to examine and understand the meaning of the
traumatic event and consequent losses. Otherwise, symptoms may worsen and the client may become
depressed or engage in self-destructive behavior such as substance abuse. The client must explore the
meaning of the event and won't heal without this, no matter how much time passes. Behavioral
techniques, such as relaxation therapy, may help decrease the client's anxiety and induce sleep. The
physician may prescribe antianxiety agents or antidepressants cautiously to avoid dependence; sleep
medication is rarely appropriate. A special diet isn't indicated unless the client also has an eating
disorder or a nutritional problem.