1.
Marco who was diagnosed with brain tumor was
scheduled for craniotomy. In preventing the
development of cerebral edema after surgery,
the nurse should expect the use of:
Correct Answer
C. Steroids
Explanation
C. Glucocorticoids (steroids) are used for their
anti-inflammatory action, which decreases the
development of edema.
2.
Halfway through the administration of blood,
the female client complains of lumbar pain. After
stopping the infusion Nurse Hazel should:
Correct Answer
A. Increase the flow of normal saline
Explanation
A. The blood must be stopped at once, and then
normal saline should be infused to keep the line
patent and maintain blood volume.
3.
Nurse Maureen knows that the positive
diagnosis for HIV infection is made based on
which of the following:
Correct Answer
B. Positive ELISA and western blot tests
Explanation
B. These tests confirm the presence of HIV
antibodies that occur in response to the
presence of the human immunodeficiency virus
(HIV).
4.
Kenneth who has diagnosed with uremic
syndrome has the potential to develop
complications. Which among the following
complications should the nurse anticipates:
Correct Answer
A. Flapping hand tremors
Explanation
A. Elevation of uremic waste products causes
irritation of the nerves, resulting in flapping
hand tremors.
5.
A client is admitted to the hospital with benign
prostatic hyperplasia, the nurse most relevant
assessment would be:
Correct Answer
B. Distention of the lower abdomen
Explanation
B. This indicates that the bladder is distended
with urine, therefore palpable.
6.
Nurse Maureen would expect the client with
mitral stenosis would demonstrate symptoms
associated with congestion in the:
Correct Answer
D. Pulmonary
Explanation
D. When mitral stenosis is present, the left
atrium has difficulty emptying its contents into
the left ventricle because there is no valve to
prevent back ward flow into the pulmonary vein,
the pulmonary circulation is under pressure.
7.
The following are lipid abnormalities. Which of
the following is a risk factor for the development
of atherosclerosis and PVD?
Correct Answer
A. High levels of low density lipid (LDL)
cholesterol
Explanation
A. An increased in LDL cholesterol concentration
has been documented at risk factor for the
development of atherosclerosis. LDL cholesterol
is not broken down into the liver but is
deposited into the wall of the blood vessels.
8.
Nurse Josie should instruct the client to eat
which of the following foods to obtain the best
supply of Vitamin B12?
Correct Answer
A. Dairy products
Explanation
A. Good source of vitamin B12 are dairy
products and meats.
9.
Karen has been diagnosed with aplastic anemia.
The nurse monitors for changes in which of the
following physiologic functions?
Correct Answer
C. Bleeding tendencies
Explanation
C. Aplastic anemia decreases the bone marrow
production of RBC’s, white blood cells, and
platelets. The client is at risk for bruising and
bleeding tendencies.
10.
Marie with acute lymphocytic leukemia suffers
from nausea and headache. These clinical
manifestations may indicate all of the following
except
Correct Answer
D. Gastric distension
Explanation
D. Acute Lymphocytic Leukemia (ALL) does not
cause gastric distention. It does invade the
central nervous system, and clients experience
headaches and vomiting from meningeal
irritation.
11.
A client has been diagnosed with Disseminated
Intravascular Coagulation (DIC). Which of the
following is contraindicated with the client?
Correct Answer
B. Administering Coumadin
Explanation
B. Disseminated Intravascular Coagulation (DIC)
has not been found to respond to oral
anticoagulants such as Coumadin.
12.
Which of the following findings is the best
indication that fluid replacement for the client
with hypovolemic shock is adequate?
Correct Answer
A. Urine output greater than 30ml/hr
Explanation
A. Urine output provides the most sensitive
indication of the client’s response to therapy for
hypovolemic shock. Urine output should be
consistently greater than 30 to 35 mL/hr.
13.
Which of the following signs and symptoms
would Nurse Maureen include in teaching plan
as an early manifestation of laryngeal cancer?
Correct Answer
C. Hoarseness
Explanation
C. Early warning signs of laryngeal cancer can
vary depending on tumor location. Hoarseness
lasting 2 weeks should be evaluated because it is
one of the most common warning signs.
14.
A female client is receiving IV Mannitol. An
assessment specific to safe administration of the
said drug is:
Correct Answer
C. Urine output hourly
Explanation
C. The osmotic diuretic mannitol is
contraindicated in the presence of inadequate
renal function or heart failure because it
increases the intravascular volume that must be
filtered and excreted by the kidney.
15.
Patricia a 20 year old college student with
diabetes mellitus requests additional
information about the advantages of using a pen
like insulin delivery devices. The nurse explains
that the advantages of these devices over
syringes include:
Correct Answer
A. Accurate dose delivery
Explanation
A. These devices are more accurate because
they are easily to used and have improved
adherence in insulin regimens by young people
because the medication can be administered
discreetly.
16.
A male client’s left tibia is fractures in an
automobile accident, and a cast is applied. To
assess for damage to major blood vessels from
the fracture tibia, the nurse in charge should
monitor the client for:
Correct Answer
C. Prolonged reperfusion of the toes after
blanching
Explanation
C. Damage to blood vessels may decrease the
circulatory perfusion of the toes, this would
indicate the lack of blood supply to the
extremity.
17.
While performing a physical assessment of a
male client with gout of the great toe,
NurseVivian should assess for additional tophi
(urate deposits) on the:
Correct Answer
B. Ears
Explanation
B. Uric acid has a low solubility, it tends to
precipitate and form deposits at various sites where blood flow is least active, including
cartilaginous tissue such as the ears.
18.
Nurse Katrina would recognize that the
demonstration of crutch walking with tripod gait
was understood when the client places weight
on the:
Correct Answer
B. Palms of the hand
Explanation
B. The palms should bear the client’s weight to
avoid damage to the nerves in the axilla.
19.
Mang Jose with rheumatoid arthritis states, “the
only time I am without pain is when I lie in bed
perfectly still”. During the convalescent stage,
the nurse in charge with Mang Jose should
encourage:
Correct Answer
A. Active joint flexion and extension
Explanation
A. Active exercises, alternating extension,
flexion, abduction, and adduction, mobilize
exudates in the joints relieves stiffness and pain.
20.
Marina with acute renal failure moves into the
diuretic phase after one week of therapy. During
this phase the client must be assessed for signs
of developing:
Correct Answer
A. Hypovolemia
Explanation
A. In the diuretic phase fluid retained during the
oliguric phase is excreted and may reach 3 to 5
liters daily, hypovolemia may occur and fluids
should be replaced.
21.
Nurse Judith obtains a specimen of clear nasal
drainage from a client with a head injury. Which
of the following tests differentiates mucus from
cerebrospinal fluid (CSF)?
Correct Answer
C. Glucose
Explanation
C. The constituents of CSF are similar to those of
blood plasma. An examination for glucose
content is done to determine whether a body
fluid is a mucus or a CSF. A CSF normally contains
glucose.
22.
Randy has undergone kidney transplant, what
assessment would prompt Nurse Katrina to
suspect organ rejection?
Correct Answer
C. Hypertension
Explanation
Answer: (C) Hypertension
Rationale: Hypertension, along with fever,
and tenderness over the grafted kidney,
reflects acute rejection.
23.
The immediate objective of nursing care for an
overweight, mildly hypertensive male client with
ureteral colic and hematuria is to decrease:
Correct Answer
A. Pain
Explanation
Answer: (A) Pain
Rationale: Sharp, severe pain (renal colic)
radiating toward the genitalia and thigh is
caused by uretheral distention and
smooth muscle spasm; relief form pain is
the priority.
24.
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:
Correct Answer
D. Decrease the size and vascularity of the
thyroid gland.
Explanation
Answer: (D) Decrease the size and
vascularity of the thyroid gland.
Rationale: Lugol’s solution provides
iodine, which aids in decreasing the
vascularity of the thyroid gland, whichlimits the risk of hemorrhage when
surgery is performed.
25.
Ricardo, was diagnosed with type I diabetes. The
nurse is aware that acute hypoglycemia also can
develop in the client who is diagnosed with:
Correct Answer
A. Liver disease
Explanation
Answer: (A) Liver Disease
Rationale: 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.
26.
Tracy is receiving combination chemotherapy for
treatment of metastatic carcinoma. Nurse Ruby
should monitor the client for the systemic side
effect of:
Correct Answer
C. Leukopenia
Explanation
Answer: (C) Leukopenia
Rationale: Leukopenia, a reduction in
WBCs, is a systemic effect of
chemotherapy as a result of
myelosuppression.
27.
Norma, with recent colostomy expresses
concern about the inability to control the
passage of gas. Nurse Oliver should suggest that
the client plan to:
Correct Answer
C. Avoid foods that in the past caused
flatus.
Explanation
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.
28.
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:
Correct Answer
B. Keep the irrigating container less than
18 inches above the stoma.”
Explanation
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.
29.
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:
Correct Answer
A. Administer Kayexalate
Explanation
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.
30.
Terence suffered from burn injury. Using the rule
of nines, which has the largest percent of burns?
Correct Answer
D. Upper trunk
Explanation
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%.
31.
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:
Correct Answer
C. Bleeding from ears
Explanation
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.
32.
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?
Correct Answer
D. May engage in contact sports
Explanation
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.
33.
The nurse is ware that the most relevant
knowledge about oxygen administration to a
male client with COPD is
Correct Answer
A. Oxygen at 1-2L/min is given to maintain
the hypoxic stimulus for breathing.
Explanation
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.
34.
Tonny has undergo 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:
Correct Answer
B. Facilitate ventilation of the left lung.
Explanation
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.
35.
Kristine is scheduled for a bronchoscopy. When
teaching Kristine what to expect afterward, the
nurse's highest priority of information would be:
Correct Answer
A. Food and fluids will be withheld for at
least 2 hours.
Explanation
Answer: (A) Food and fluids will be
withheld for at least 2 hours.
Rationale: 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.
36.
Ms. X has just been diagnosed with condylomata
acuminata (genital warts). What information is
appropriate to tell this client?
Correct Answer
A. This condition puts her at a higher risk
for cervical cancer; therefore, she should
have a Papanicolaou (Pap) smear
annually.
Explanation
Answer: (A) This condition puts her at a
higher risk for cervical cancer; therefore,
she should have a Papanicolaou (Pap)
smear annually.
Rationale: 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.
37.
Maritess was recently diagnosed with a
genitourinary problem and is being examined in
the emergency department. When palpating her
kidneys, the nurse should keep which anatomical
fact in mind?
Maritess was recently diagnosed with a
genitourinary problem and is being examined in
the emergency department. When palpating her
kidneys, the nurse should keep which anatomical
fact in mind?
Correct Answer
A. The left kidney usually is slightly higher
than the right one.
Explanation
Answer: (A) The left kidney usually is
slightly higher than the right one.
Rationale: 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.
38.
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:
Correct Answer
C. Blood urea nitrogen (BUN) 100 mg/dl
and serum creatinine 6.5 mg/ dl.
Explanation
Answer: (C) Blood urea nitrogen (BUN)
100 mg/dl and serum creatinine 6.5mg/dl.
Rationale: 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%.
39.
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?
Correct Answer
D. Alteration in the size, shape, and
organization of differentiated cells.
Explanation
Answer: (D) Alteration in the size, shape,
and organization of differentiated cells
Rationale: 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.
40.
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?
Correct Answer
D. Kaposi's sarcoma
Explanation
Answer: (D) Kaposi's sarcoma
Rationale: 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.
41.
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:
Correct Answer
A. Auscultate bowel sounds.
Explanation
Answer: (A) Auscultate bowel sounds.
Rationale: 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.
42.
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?
Correct Answer
B. Lying on the left side with knees bent
Explanation
Answer: (B) Lying on the left side with
knees bent
Rationale: 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.
43.
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?
Correct Answer
A. Blood supply to the stoma has been
interrupted.
Explanation
Answer: (A) Blood supply to the stoma has
been interrupted
Rationale: 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.
44.
Anthony suffers burns on the legs, which nursing
intervention helps prevent contractures?
Correct Answer
A. Applying knee splints
Explanation
Answer: (A) Applying knee splints
Rationale: 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 rangeof-motion
exercises
can
prevent
contractures
in the
shoulders,
but
not
in
the
legs.
45.
. 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?
Correct Answer
B. Urine output of 20 ml/hour.
Explanation
Answer: (B) Urine output of 20 ml/hour.
Rationale: 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.
46.
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:
Correct Answer
A. Turn him frequently.
Explanation
Answer: (A) Turn him frequently.
Rationale: 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.
47.
Nurse Nikki knows that laboratory results
supports the diagnosis of systemic lupus
erythematosus (SLE) is:
Correct Answer
C. Pancytopenia, elevated antinuclear
antibody (ANA) titer
Explanation
Answer: (C) Pancytopenia, elevated
antinuclear antibody (ANA) titer
Rationale: 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.
48.
Arnold, a 19-year-old client with a mild
concussion is discharged from the emergency
department. Before discharge, he complains of a
headache. When offered acetaminophen, his
mother tells the nurse the headache is severe
and she would like her son to have something
stronger. Which of the following responses by
the nurse is appropriate?
Correct Answer
C. “Narcotics are avoided after a head
injury because they may hide a
worsening condition.”
Explanation
Answer: (C) Narcotics are avoided after a
head injury because they may hide a
worsening condition. Rationale: 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.
49.
When prioritizing care, which of the following
clients should the nurse Olivia assess first?
Correct Answer
B. A 33-year-old client with a recent
diagnosis of Guillain-Barre syndrome
Explanation
Answer: (B) A 33-year-old client with a
recent diagnosis of Guillain-Barre
syndrome
Rationale: 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.
50.
Norma asks for information about osteoarthritis.
Which of the following statements about
osteoarthritis is correct?
Correct Answer
C. Osteoarthritis is the most common form
of arthritis
Explanation
Answer: (C) Osteoarthritis is the most
common form of arthritis
Rationale: Osteoarthritis is the most
common form of arthritis and can be
extremely debilitating. It can afflict people
of any age, although most are elderly.