Daytona Beach Community College Department of Nursing NUR 2744 Practice Exam ANSWERS/Rationale 2744 ANSWERS and

RATIONALE 1. A (these signs and symptoms may be applied to several problems. Obtaining a client history would assist with establishing the cause of the problem). n B—the first thing to do is speak with the patient before invasive procedures although you will likely obtain serum electrolytes at a later time n C—as with patients with SIADH, peripheral edema may not be present if fluid is in intracellular spaces also we do not yet know how much weight gain over how long. n D—The patient presents with no GI symptoms save for nausea. More information is needed to determine cause. 2. D—the patient has had surgery known to cause DI. The question states DI is present. Appropriate treatment is to notify the physician of the increased urine output and anticipate replacement of vital fluids. n A-- Urine has already been assessed for 2 hours, to assess for a longer period delaying fluid replacement may be harmful to the patient. n B—The patient will most likely show changes in urine osmolality and sodium. Urine Acetone is not important in the DI patient. These changes will not affect treatment and waiting for results to treat may be harmful n C—the patient will most likely show changes in serum electrolytes and osm. These changes will not affect treatment and waiting for results may be harmful to the patient. 3. D—In a patient with cardiogenic shock, you should anticipate initial administration of IV Fluids or fluid volume expanders such as plasmanex (normal serum albumin) to increase cardiac output by increasing myocardial muscle fiber stretch which increases contractility.

A—you should discontinue nitrates or other drugs that reduce blood volume, preload, or myocardial fiber stretching. n B—You should not administer Metoprolol (lopressor) because it may decrease contractility and may worsen shock. This drug also lowers blood pressure. n C—Morphine decreases preload hence decreasing contractility. 4. B—This statement avoids inflammatory accusations and reinforces positive behavior. It also communicates the team leader’s expectation that everyone will follow the floating requirement. n A—This statement is inflammatory and ‘never’ is usually an exaggeration. n C—This statement is apologetic and confrontational. n D—This statement offers a false promise when floating requests are likely to occur again,
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this statement may destroy a trusting relationship with the team leader. 5. C—the halo’s wrench and tool kit should be available at all times and should be visible in the room in case the chest plate must be removed for CPR n A—Logrolling the patient is no longer necessary as the halo traction device stabilizes the fracture with movement. n B—Keeping the HOB at 30 to 45 degrees is not necessary for patients in halo traction devices. n D—The stem of the question identifies no risks for aspiration hence this invasive procedure is not necessary and could cause harm. 6. B—Recurring chest pain 12 hours post MI indicates extension of the MI. To verify, the nurse should obtain a 12 lead EKG and notify the physician of a change in condition n A—recurring chest pain is not a sign of reperfusion n C—administration of a thrombolytic would require a physician’s order as does the heparin. n D—While morphine sulfate may increase oxygen delivery and decrease sensation of pain,

it requires an order and nothing in the stem indicates that an order for lidocaine is warranted. 7. D—Bladder distention or other similar stimuli are the trigger for this spinal cord response after spinal shock. Monitoring the Foley cath for patency can prevent an episode from occurring. n A—chloral hydrate is a sedative which is not indicated for this patient n B—laboratory findings will not predict an event as it is caused by a physical stimulus n C—the patient should be repositioned every 2 hours to prevent skin lesions, keeping the patient in trendelenberg position will not help prevent an episode and may potentially be harmful. 8. C—The fundamental problem with pulmonary edema is that the patient’s lungs are fluid overloaded making exchange of gasses at the alveolar level very difficult if not impossible. If the patient is not breathing he will die making this the highest priority diagnosis n A—The problem is at the alveolar level and makes the exchange of gasses impossible. Changing the breathing pattern will not help, we must get to the fundamental problem. n B—While the patient would definitely have a nursing diagnosis of anxiety, this is not the priority at this time n D—The patient has a fluid volume overload, not deficit. 9. A—post intubation, it is most important to assess for bilateral breath sounds first. The endotracheal tube may have been inserted too far and traveled down the right main stem bronchus where it could cause a tension pneumothorax. n C-D—while all of these are relative to the intubated patient, it is most important to assess breath sounds before doing any of these. 10. C—while some of the other tests are certainly indicative of DIC, the FDP and D-Dimer are specific to DIC and these levels would indicate a positive finding of DIC. n A, B, D—while these could indicate DIC, they are less specific for DIC

11. B—Propofol is a lipid solution. This patient is receiving a 10% lipid solution in addition to the propofol. This is more than the body’s fat requirement. n A--The patient is on propofol, a medication that will assist with reducing anxiety. While this may be an appropriate diagnosis it is not the priority at this time. (2 of 9)10/6/2005 10:20:37 AM Daytona Beach Community College

C—We do not have information regarding patient weight trends, intake and output. This information would be required to determine if the patient is receiving too much fluid. n D—While being on TPN places the patient at a greater risk for infection, this is not the priority (it is a risk not an actual problem). 12. B—When the pacemaker fires but the heart produces no response, this is considered a failure to capture. n A—this condition occurs when the pacemaker does not fire producing pauses. Note that the patient does not have this condition when the pacer does not fire for the heart’s natural rhythm. n C—This condition occurs when the pacemaker ignores the underlying rhythm producing pacer spikes throughout the pqrs. n D—This condition occurs when the pacemaker does not fire and the heart does not produce a rhythm…a lack of any electrical activity. 13. D—The nurse should first check the written physician order to ensure that no transcription error has taken place regardless of the actual orders…suspicion should be aroused by the order for heparin sodium for a hemorrhagic stroke patient. n A—The nurse must check the written order against the medication administration record before signing her name indicating that the orders are correct. n B—Heparin sodium could be dangerous to the hemorrhagic stroke patient causing further intracranial bleeding

C—The nurse should ensure that the order was transcribed correctly before calling the physician to question the order. This should be done if the written order is correct (refer to B). 14. B—Even though it is important to give the medication quickly, the nurse should never use broken equipment as it could harm either the nurse or the patient. This step can be taken quickly by delegating another staff member to pick up the pump or by going to central supply to obtain the pump. Less that 10 minutes would be lost. n A—never use a broken piece of electrical equipment it could cause electrocution. n C—Never use a broken piece of electrical equipment it could cause electrocution. Fixing the problem with tape may not work. n D—The nursing supervisor will not be able to obtain the appropriate equipment more quickly. Notification of this authority is not necessary. 15. A—These signs and symptoms indicate a negative reaction to the transfusion and the patient could quickly deteriorate. Observing for theses signs and symptoms during the first 15 minutes of the transfusion takes priority in this situation. n B—This patient information is nice but not essential…transfusions also may take up to 4 hours. n C—Documentation is certainly important but takes lower priority than observation for a transfusion reaction n D—Assessment of vital signs at the END of the transfusion is important but the priority would be from start to finish. 16. C—The patient with a chest tube is likely to avoid coughing and deep breathing due to the discomfort caused by the chest tube. This may lead to many complications therefore it is very
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important for the nurse to take an active role in pulmonary toilet. n A—fluctuation in the suction chamber even in a wet chest drainage system is unimportant. You are thinking about the water seal chamber which should have fluctuations but no bubbling. n B—Nursing requires an order to clamp a chest tube. Clamping negates the function of the chest drainage system. n D—While the nurse may milk the tubing if there is a large amount of drainage, the stem of the question does not indicate this condition so C&DB would take priority. 17. D—Modified trendelenberg allows full respiratory excursion by slightly elevating the head and increasing venous return by elevating the feet. Full respiratory excursion is crucial to assume maximum ventilation capacity. The client going into shock needs all the air he can get. n A&B—Promote respiratory excursion but do not improve venous return n C—Promotes venous return but does not aid respiratory excursion. 18. B—to prevent atmospheric air from rushing into the thoracic cavity, the nurse should instruct the client to take a deep breath then hold it. n A&C would allow air to enter the thoracic cavity. n D the valsalva maneuver is helpful when removing the chest tube. 19. A—restlessness and increased respirations may indicate hemorrhage n B—introducing water into the stomach may cause metabolic alkalosis from the loss of chloride or hydrogen ions n C—the balloon holds the tube in place and should not be deflated before removal n D—the balloon controls esophageal bleeding and should be kept inflated at all times even though pressure checks should be included in the plan of care. 20. B—angioedema is a severe allergic reaction which should be reported to the physician immediately. n A—while angioedema can cause edema of the larynx and difficulty breathing, the first

action should be to notify the physician and request orders to treat the condition n C—nothing in the stem of the question gives information noting that the patient is experiencing cardiac arrest. CPR on a patient with adequate vital signs will cause harm to the patient n D—While the nurse may anticipate giving epinephrine to the patient to counteract the allergic reaction, a physician’s order is needed for this action and 2 ampules is a nonspecific dose. 21. B—the client’s blood gas results and slight fever indicate postoperative hypoventilation and atelectasis. Vigorous deep breathing can correct these problems n A—administration of oxygen is not helpful because the client is hypoventilating, not hypoxic n C—Sputum analysis will not help the client’s respiratory status at this time but may be helpful in diagnosing any respiratory infections if coughing and deep breathing do not work. n D—is not warranted because the blood gas results do not indicate respiratory acidosis. 22. B—Peanut butter provides the protein and fat needed by the burn patient with raisins providing the iron required by the burn patient (4 of 9)10/6/2005 10:20:37 AM Daytona Beach Community College

A--provides adequate nutrients but too much fat n C&D—do not provide enough protein or iron 23. B—shock causes tissue hypoxia. The first action should be to start the oxygen to promote tissue oxygenation. n A—is appropriate after oxygen therapy is initiated n C—the nurse would need further data before implementing n D—is important but does not take precedence over starting oxygen. 24. C—Mannitol is an osmotic diuretic which causes increased urine output. n A, B, D—none of these are side effects of mannitol.

25. D—An elevated serum potassium level (hyperkalemia) is common in acute renal failure putting the client at risk for life-threatening cardiac arrythmias. n A—although hypocalcemia may occur in acute renal failure it does not cause tetany due to the acidosis that occurs with renal failure keeping calcium in its ionized form n B—Damaged renal tubules cannot conserve sodium n C—this option suggests shock which is not identified as a complication of ARF 26. A—an assessment is vital before intervention can be planned n B—After the assessment it would be important to find out the client’s anxiety level n C—After the assessment it would be important to analyze what triggered the event n D—This intervention would be a part of long term planning 27. D—by decreasing sodium ions, holding onto hydrogen ions and secreting nahco3, the kidneys regulate pH n A-C—these answers are wrong or incomplete. 28. D—Hemorrhage or blood in the CSF within the brain, ventricles or subarachnoid space is irritating to the meninges and causes headache and nuchal rigidity. n A-C—the signs and symptoms in the stem do not indicate any of these conditions specifically. 29. A—Kidney diseases such as acute renal failure interfere with the metabolism and excretion of Quinidine resulting in higher drug concentrations in the body. These higher levels of the drug can depress myocardial excitability causing cardiac arrest. The nurse should withhold the drug and call the physician to clarify the order. n B—with the threat of cardiac arrest, the nurse should not administer the medication just because it was ordered n C—the second dose would be too early to measure quinine levels in the blood n D—bradycardia and cardiac arrest are more likely than hypotension in this case but

hypotension may follow prolonged periods of severe bradycardia. 30. B—A halo or ring will appear around the blood if drainage from the nose or ear of a head injured patient contains cerebrospinal fluid. n A&C—the collection of any type of culture or laboratory value using a swab or suction is contraindicated because brain tissue may be inadvertently removed at the same time or other tissue damage may result. n D—packing the nose is not indicated if CSF is present in the drainage. The nurse should first check the drainage before other action and await physician orders after notification of result. (5 of 9)10/6/2005 10:20:37 AM Daytona Beach Community College

31. B—Hypercapnia causes vasodilation which will increase intracranial pressure. n A&C-- Vigorous coughing or suctioning when not necessary will cause a rise in the intracranial pressure. n D—keeping the head of the bed flat will raise intractainial pressure by not permitting free flow of venous return out of the intracranial cavity. 32. A—A restrictive band 2-3 inches above the bite is most effective in containing the venom and minimizing lymphatic and superficial venous return. n B-D--Elevation or immobilization of the limb would not be effective. Although you may lay the victim supine to counteract effects of shock, this would not be effective in minimizing tissue damage. 33. D—Nervous control of the diaphragm (phrenic nerve) occurs at level C 3 or C 4. 34. C—Crutchfield tongs are a form of traction to hyperextend the neck and decompress the spine. During their use, the cervical spine is very unstable. It is important to continue to turn the patient to avoid the complications of immobility but turning should be no greater than a 15 degree

elevation while supporting the back and neck to avoid twisting movement. n A—the weights on the traction make it impossible for the client to sit up. Instability of the cervical spine places the client at risk for further injury to the spinal cord. n B—The head of the bed should be no more than 30 degrees with the use of the Crutchfield tongs n D—this places the client at risk for impaired skin integrity and ineffective airway clearance. 35. D--In the post operative course of care the nurse should assess for complications, bleeding having the highest priority. To evaluate for bleeding the nurse should assess the area for frank blood, and assess for tachycardia. n A—This is an important part of the plan of care but does not include the life threatening component of airway, breathing, and circulation n B—This is an important part of the plan of care but while the patient may require treatment for pain, it does not outweigh potential hemorrhage in importance. n C—This will be a part of the plan of care to determine evidence of infection throughout the client’s hospital course but it does not take priority over potential for hemorrhage. 36. A—frequent walks are permissible but strenuous activity should be avoided for a few weeks until the client has consent from the physician. n Brisk walking is a strenuous activity which should be avoided for a few weeks until the client has permission from the health care provider n Eating is contraindicated before activity shunting blood to the GI tract precluding adequate blood flow to the legs and heart n Nitroglycerine is a medication only used for active chest pain and must be ordered by the physician. 37. A—furosemide is a loop diuretic which increases potassium excretion in the distal loop.

Hypokalemia is a cause of toxic reactions in the person taking digoxin. Potassium loss is exacerbated with the concomitant use of both drugs. Orange juice increases potassium levels while the other foods do not. 38. A—the swishing sound or ‘bruit’ heard indicates that blood is flowing through the graft and is (6 of 9)10/6/2005 10:20:37 AM Daytona Beach Community College

expected. n B—the arm with the graft should never be used for blood pressure checks or drawing blood n C—This is not indicated for this normal finding n D—the graft is patent, further testing is not required. 39. B—it is important to support the client prior to and during any procedures to allay anxieties. n A—the nurse has an order, the hemoglobin falls within the range. No further order check is warranted at this time n C—this step is important but will be done by 2 RN’s once the blood is obtained from the laboratory n D—the laboratory would notify the nurse upon receiving the order if no blood of the patient’s type were available 40. D—the client who has expressive aphasia knows what he wants to say but cannot verbalize the appropriate words. Pictures of common objects and needs gives him an opportunity to indicate what he would like n A—speaking above normal voice level is not indicated as the patient’s hearing is not damaged n B—supplying the correct words readily will decrease the patient’s motivation to regain normal speech n C—correcting speech may frustrate the patient and make them unwilling to try to speak.

Many times the patient is unaware of involuntary use of profane or vulgar language and is embarrassed. 41. D—The symptoms this patient is complaining about are similar to lupus erythematosus and are seen in patients who have been on large doses for over one year. The patient should notify the physician immediately. n A—the dosage would not routinely be increased n B—while aspirin may relieve some of the symptoms, it is not the nurse’s role to make this recommendation. It would not solve the problem, only mask it. n C—this situation needs immediate attention and the symptoms are unlikely to subside. 42. C—after a heavy meal, blood is diverted to the GI tract. Increased cardiac workload increases the risk of underperfusion of the coronary arteries. n A—the client should lie on their back while the partner kneels to take some of the weight from the client and reduce myocardial oxygen demand n B—This is not an appropriate recommendation for this client. n D—Uncomplicated MI patients may usually resume sexual activity in about 5-8 weeks. An index of readiness is the ability to walk up two flights of stairs without becoming dyspneic. 43. D—apple juice is low in phosphorous, sodium, potassium and protein which are nutrients that the damaged kidney cannot clear. n A—bananas are high in potassium causing dangerous levels n B—Redmeats contain protein and phosphorus n C—Legumes contain phosphorus 44. B—Nausea, warmth, facial flushing, nd a salty taste in the mouth are all expected sensations. (7 of 9)10/6/2005 10:20:37 AM Daytona Beach Community College

A—Severe dyspnea could indicate a beginning anaphylactic reaction or perforation of the vessels, heart or lungs by the catheter n C—generalized itching is a sign of allergic reaction to the dye

D—The client who is cool and clammy may be experiencing hypovolemic shock, neurogenic shock, or anxiety 45. B—cyclosporine is an immunosuppresant that is a t-lymphocyte inhibitor n A—acyclovir is an antiviral agent n C—hydromorphone is a narcotic analgesic n D—Megestrol is a hormone to treat breast or endometrial cancer 46. C—vigorous bubbling in the water seal chamber indicates an air leak between the patient and the water seal. The first intervention would be to check all connections for any potential air leaks. n A—This would have no impact on the water seal chamber n B—This may be done later after the problem is found or cannot be corrected n D—this would be performed after the leak in the system is corrected 47. D—a major priority during seizure activity is to protect the airway. The sidelying position promotes drainage of secretions and prevents aspiration during the seizure n A—Restraints may cause additional injury and are not indicated n B—In this scenario the seizure has already begun. It will not be possible to force a tongue blade into the client’s mouth and the nurse would risk personal injury or injury to the client if attempted. n C—holding the client down may cause additional injury and is not indicated. 48. A—the appropriate action to combat the antibody response is to stop the transfusion of foreign protein in the form of the red blood cells. n B—while you may do this quickly in the regime of treatment, this requires a physician order n C—It will be important to send the blood and a patient blood sample to the lab and to fill out transfusion reaction paperwork but it is not your priority. You must first stop the transfusion n D—You will notify the physician but not before stopping the transfusion

49. B—the seventh cranial nerve closes the eyelid. Without a patch, the cornea is subject to damage. n A—suction is not necessary to prevent complication n C—Water temperature does not make a difference. n D—The client need not remain in high fowlers position although the head of the bed should remain at 30 degrees promote cerebral blood flow. 50. B—Edema is due to insufficient nitrogen for synthesis. When this occurs it leads to a change in the body’s osmotic pressure resulting in oozing of fluids out of the vascular space. This phenomena results in the formation of edema in the abdomen and flanks. 51. B—The nurse is responsible for supervision of all tasks delegated to the unlicensed Assistive personnel. n A—this statement is not true because the unlicensed personnel require supervision n C—While supervision is required, uap’s are accountable for their own actions n D—UAP’s receive varied degrees of education before they are permitted to work with clients on the nursing unit. (8 of 9)10/6/2005 10:20:37 AM Daytona Beach Community College

52. D—administration of a stool softener prevents straining at stool which may cause the patient to use the valsalva’s maneuver. Intra abdominal pressure such as that used when defecating increases intracranial pressure. n A—this intervention is questionable but according to the stem of the question there is no evidence of dehydration and this is not a common side effect post SDH evacuation n B—Suctioning is directly contraindicated as it raises ICP n C—Increasing the head of bed to ninety degrees will cause an increase in ICP 53. C—Until the cervical x-rays indicate a spinal injury, the patient should be treated as though spinal injury has occurred. To prevent twisting, turning or increased injury, the patient should be

kept supine with the head of bed flat. Logrolling the patient all in one motion is acceptable. 54. D—all of these findings are normal. The most significant for a patient with guillian barre` is respiration. These patients lose muscular control in a progressive fasion so the nurse must be diligent in assessing respiration. (9 of 9)10/6/2005 10:20:37 AM

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