NCLEX Practice Test For Medical Surgical Nursing 3 (Exam Mode) By Rnpedia.Com
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Joey asks the nurse why he is receiving the injection of Morphine after he was hospitalized for severe anginal pain. The nurse replies that it:
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Will help prevent erratic heart beats
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Relieves pain and decreases level of anxiety
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Decreases anxiety
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Dilates coronary blood vessels
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Mark the letter of the letter of choice then click on the next button. Score will be posted as soon as the you are done with the quiz. You got 90 minutes to finish the exam. Good luck!
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- 2.
Myra is ordered laboratory tests after she is admitted to the hospital for angina. The isoenzyme test that is the most reliable early indicator of myocardial insult is:
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SGPT
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LDH
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CK-MB
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AST
Correct Answer
A. CK-MBExplanation
The cardiac marker, Creatinine phosphokinase (CPK) isoenzyme levels, especially the MB sub-unit which is cardio-specific, begin to rise in 3-6 hours, peak in 12-18 hours and are elevated 48 hours after the occurrence of the infarct. They are therefore most reliable in assisting with early diagnosis. The cardiac markers elevate as a result of myocardial tissue damage.Rate this question:
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- 3.
A client undergoes below the knee amputation following a vehicular accident. Three days postoperatively, the client is refusing to eat, talk or perform any rehabilitative activities. The best initial nursing approach would be to:
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Emphasize repeatedly that with as prosthesis, he will be able to return to his normal lifestyle
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Appear cheerful and non-critical regardless of his response to attempts at intervention
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Give him explanations of why there is a need to quickly increase his activity
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Accept and acknowledge that his withdrawal is an initially normal and necessary part of grieving
Correct Answer
A. Accept and acknowledge that his withdrawal is an initially normal and necessary part of grievingExplanation
The withdrawal provides time for the client to assimilate what has occurred and integrate the change in the body image. Acceptance of the client’s behavior is an important factor in the nurse’s intervention.Rate this question:
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- 4.
The laboratory results of the client with leukemia indicate bone marrow depression. The nurse should encourage the client to:
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Increase his activity level and ambulate frequently
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Sleep with the head of his bed slightly elevated
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Drink citrus juices frequently for nourishment
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Use a soft toothbrush and electric razor
Correct Answer
A. Use a soft toothbrush and electric razorExplanation
Suppression of red bone marrow increases bleeding susceptibility associated with thrombocytopenia, decreased platelets. Anemia and leucopenia are the two other problems noted with bone marrow depression.Rate this question:
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- 5.
In dealing with a dying client who is in the denial stage of grief, the best nursing approach is to:
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Agree with and encourage the client’s denial
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Reassure the client that everything will be okay
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Allow the denial but be available to discuss death
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Leave the client alone to discuss the loss
Correct Answer
A. Allow the denial but be available to discuss deathExplanation
This does not take away the client’s only way of coping, and it permits future movement through the grieving process when the client is ready. Dying clients move through the different stages of grieving and the nurse must be ready to intervene in all these stages.Rate this question:
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- 6.
Before a post- thyroidectomy client returns to her room from the OR, the nurse plans to set up emergency equipment, which should include:
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A crash cart with bed board
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A tracheostomy set and oxygen
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An airway and rebreathing mask
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Two ampules of sodium bicarbonate
Correct Answer
A. A tracheostomy set and oxygenExplanation
Acute respiratory obstruction in the post-operative period can result from edema, subcutaneous bleeding that presses on the trachea, nerve damage, or tetany.Rate this question:
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- 7.
After the acute phase of congestive heart failure, the nurse should expect the dietary management of the client to include the restriction of:
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Magnesium
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Sodium
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Potassium
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Calcium
Correct Answer
A. SodiumExplanation
Restriction of sodium reduces the amount of water retention that reduces the cardiac workloadRate this question:
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- 8.
In the evaluation of a client’s response to fluid replacement therapy, the observation that indicates adequate tissue perfusion to vital organs is:
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Urinary output is 30 ml in an hour
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Central venous pressure reading of 2 cm H2O
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Pulse rates of 120 and 110 in a 15 minute period
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Blood pressure readings of 50/30 and 70/40 within 30 minutes
Correct Answer
A. Urinary output is 30 ml in an hourExplanation
A rate of 30 ml/hr is considered adequate for perfusion of kidney, heart and brain.Rate this question:
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- 9.
The most significant initial nursing observations that need to be made about a client with myasthenia include:
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Ability to chew and speak distinctly
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Degree of anxiety about her diagnosis
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Ability to smile an to close her eyelids
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Respiratory exchange and ability to swallow
Correct Answer
A. Respiratory exchange and ability to swallowExplanation
Muscle weakness can lead to respiratory failure that will require emergency intervention and inability to swallow may lead to aspirationRate this question:
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- 10.
To promote continued improvement in the respiratory status of a client following chest tube removal after a chest surgery for multiple rib fracture, the nurse should:
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Encourage bed rest with active and passive range of motion exercises
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Encourage frequent coughing and deep breathing
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Turn him from side to side at least every 2 hours
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Continue observing for dyspnea and crepitus
Correct Answer
A. Encourage frequent coughing and deep breathingExplanation
This nursing action prevents atelectasis and collection of respiratory secretions and promotes adequate ventilation and gas exchange.Rate this question:
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- 11.
The nurse knows that a client with Pernicious Anemia understands the teaching regarding the vitamin B12 injections when she states that she must take it:
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When she feels fatigued
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During exacerbations of anemia
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Until her symptoms subside
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For the rest of her life
Correct Answer
A. For the rest of her lifeExplanation
Since the intrinsic factor does not return to gastric secretions even with therapy, B12 injections will be required for the remainder of the client’s life.Rate this question:
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- 12.
Larry is diagnosed as having myelocytic leukemia and is admitted to the hospital for chemotherapy. Larry discusses his recent diagnosis of leukemia by referring to statistical facts and figures. The nurse recognizes that Larry is using the defense mechanism known as:
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Reaction formation
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Sublimation
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Intellectualization
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Projection
Correct Answer
A. IntellectualizationExplanation
People use defense mechanisms to cope with stressful events. Intellectualization is the use of reasoning and thought processes to avoid the emotional upsets.Rate this question:
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- 13.
The key factor in accurately assessing how body image changes will be dealt with by the client is the:
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Extent of body change present
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Suddenness of the change
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Obviousness of the change
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Client’s perception of the change
Correct Answer
A. Client’s perception of the changeExplanation
It is not reality, but the client’s feeling about the change that is the most important determinant of the ability to cope. The client should be encouraged to his feelings.Rate this question:
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- 14.
In the early postoperative period following a transurethral surgery, the most common complication the nurse should observe for is:
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Sepsis
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Hemorrhage
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Leakage around the catheter
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Urinary retention with overflow
Correct Answer
A. HemorrhageExplanation
After transurethral surgery, hemorrhage is common because of venous oozing and bleeding from many small arteries in the prostatic bed.Rate this question:
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- 15.
Rene, age 62, is scheduled for a TURP after being diagnosed with a Benign Prostatic Hyperplasia (BpH). As part of the preoperative teaching, the nurse should tell the client that after surgery:
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Urinary control may be permanently lost to some degree
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Urinary drainage will be dependent on a urethral catheter for 24 hours
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Frequency and burning on urination will last while the cystotomy tube is in place
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His ability to perform sexually will be permanently impaired
Correct Answer
A. Urinary drainage will be dependent on a urethral catheter for 24 hoursExplanation
An indwelling urethral catheter is used, because surgical trauma can cause urinary retention leading to further complications such as bleeding.Rate this question:
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- 16.
Ana, 55 years old, is admitted to the hospital to rule out pernicious anemia. A Schilling test is ordered for Ana. The nurse recognizes that the primary purpose of the Schilling test is to determine the client’s ability to:
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Store vitamin B12
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Digest vitamin B12
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Absorb vitamin B12
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Produce vitamin B12
Correct Answer
A. Absorb vitamin B12Explanation
Pernicious anemia is caused by the inability to absorb vitamin B12 in the stomach due to a lack of intrinsic factor in the gastric juices. In the Schilling test, radioactive vitamin B12 is administered and its absorption and excretion can be ascertained through the urine.Rate this question:
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- 17.
Jude develops GI bleeding and is admitted to the hospital. An important etiologic clue for the nurse to explore while taking his history would be:
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The medications he has been taking
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Any recent foreign travel
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His usual dietary pattern
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His working patterns
Correct Answer
A. The medications he has been takingExplanation
Some medications, such as aspirin and prednisone, irritate the stomach lining and may cause bleeding with prolonged useRate this question:
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- 18.
The initial nursing goal for a client with myasthenia gravis during the diagnostic phase of her hospitalization would be to:
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Develop a teaching plan
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Facilitate psychologic adjustment
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Maintain the present muscle strength
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Prepare for the appearance of myasthenic crisis
Correct Answer
A. Maintain the present muscle strengthExplanation
Until diagnosis is confirmed, primary goal should be to maintain adequate activity and prevent muscle atrophyRate this question:
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- 19.
Joy, an obese 32 year old, is admitted to the hospital after an automobile accident. She has a fractured hip and is brought to the OR for surgery. After surgery Joy is to receive a piggy-back of Clindamycin phosphate (Cleocin) 300 mg in 50 ml of D5W. The piggyback is to infuse in 20 minutes. The drop factor of the IV set is 10 gtt/ml. The nurse should set the piggyback to flow at:
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25 gtt/min
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30 gtt/min
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35 gtt/min
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45 gtt/min
Correct Answer
A. 25 gtt/minExplanation
To get the correct flow rate: multiply the amount to be infused (50 ml) by the drop factor (10) and divide the result by the amount of time in minutes (20)Rate this question:
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- 20.
Eddie, a plane crash victim, undergoes endotracheal intubation and positive pressure ventilation. The most immediate nursing intervention for him at this time would be to:
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Facilitate his verbal communication
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Maintain sterility of the ventilation system
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Assess his response to the equipment
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Prepare him for emergency surgery
Correct Answer
A. Assess his response to the equipmentExplanation
It is a primary nursing responsibility to evaluate effect of interventions done to the client. Nothing is achieved if the equipment is working and the client is not respondingRate this question:
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- 21.
Forty-eight hours after a burn injury, the physician orders for the client 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:
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18 gtt/min
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28 gtt/min
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32 gtt/min
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36 gtt/min
Correct Answer
A. 28 gtt/minExplanation
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)Rate this question:
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- 22.
A client jokes about his leukemia even though he is becoming sicker and weaker. The nurse’s most therapeutic response would be:
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“Your laugher is a cover for your fear.”
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“He who laughs on the outside, cries on the inside.”
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“Why are you always laughing?”
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“Does it help you to joke about your illness?”
Correct Answer
A. “Does it help you to joke about your illness?”Explanation
This non-judgmentally on the part of the nurse points out the client’s behavior.Rate this question:
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- 23.
Helen is diagnosed with myasthenia gravis and pyridostigmine bromide (Mestinon) therapy is started. The Mestinon dosage is frequently changed during the first week. While the dosage is being adjusted, the nurse’s priority intervention is to:
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Administer the medication exactly on time
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Administer the medication with food or mild
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Evaluate the client’s muscle strength hourly after medication
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Evaluate the client’s emotional side effects between doses
Correct Answer
A. Evaluate the client’s muscle strength hourly after medicationExplanation
Peak response occurs 1 hour after administration and lasts up to 8 hours; the response will influence dosage levels.Rate this question:
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- 24.
A client with a history of recurrent GI bleeding is admitted to the hospital for a gastrectomy. Following surgery, the client has a nasogastric tube to low continuous suction. He begins to hyperventilate. The nurse should be aware that this pattern will alter his arterial blood gases by:
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Increasing HCO3
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Decreasing PCO2
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Decreasing pH
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Decreasing PO2
Correct Answer
A. Decreasing PCO2Explanation
Hyperventilation results in the increased elimination of carbon dioxide from the blood that can lead to respiratory alkalosis.Rate this question:
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- 25.
A client with multiple injury following a vehicular accident is transferred to the critical care unit. He begins to complain of increased abdominal pain in the left upper quadrant. A ruptured spleen is diagnosed and he is scheduled for emergency splenectomy. In preparing the client for surgery, the nurse should emphasize in his teaching plan the:
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Complete safety of the procedure
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Expectation of postoperative bleeding
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Risk of the procedure with his other injuries
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Presence of abdominal drains for several days after surgery
Correct Answer
A. Presence of abdominal drains for several days after surgeryExplanation
Drains are usually inserted into the splenic bed to facilitate removal of fluid in the area that could lead to abscess formation.Rate this question:
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- 26.
Dennis receives a blood transfusion and develops flank pain, chills, fever and hematuria. The nurse recognizes that Dennis is probably experiencing:
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An anaphylactic transfusion reaction
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An allergic transfusion reaction
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A hemolytic transfusion reaction
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A pyrogenic transfusion reaction
Correct Answer
A. A hemolytic transfusion reactionExplanation
This non-judgmentally on the part of the nurse points out the client’s behavior.This results from a recipient’s antibodies that are incompatible with transfused RBC’s; also called type II hypersensitivity; these signs result from RBC hemolysis, agglutination, and capillary plugging that can damage renal function, thus the flank pain and hematuria and the other manifestations.Rate this question:
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- 27.
Lucy is admitted to the surgical unit for a subtotal thyroidectomy. She is diagnosed with Grave’s Disease. When assessing Lucy, the nurse would expect to find:
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Lethargy, weight gain, and forgetfulness
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Weight loss, protruding eyeballs, and lethargy
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Weight loss, exopthalmos and restlessness
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Constipation, dry skin, and weight gain
Correct Answer
A. Weight loss, exopthalmos and restlessnessExplanation
Classic signs associated with hyperthyroidism are weight loss and restlessness because of increased basal metabolic rate. Exopthalmos is due to peribulbar edema.Rate this question:
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- 28.
When doing colostomy irrigation at home, a client with colostomy should be instructed to report to his physician :
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Abdominal cramps during fluid inflow
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Difficulty in inserting the irrigating tube
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Passage of flatus during expulsion of feces
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Inability to complete the procedure in half an hour
Correct Answer
A. Difficulty in inserting the irrigating tubeExplanation
Difficulty of inserting the irrigating tube indicates stenosis of the stoma and should be reported to the physician. Abdominal cramps and passage of flatus can be expected during colostomy irrigations. The procedure may take longer than half an hour.Rate this question:
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- 29.
Mr. Ong is admitted to the hospital with a diagnosis of Left-sided CHF. In the assessment, the nurse should expect to find:
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Crushing chest pain
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Dyspnea on exertion
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Extensive peripheral edema
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Jugular vein distention
Correct Answer
A. Dyspnea on exertionExplanation
Pulmonary congestion and edema occur because of fluid extravasation from the pulmonary capillary bed, resulting in difficult breathing. Left-sided heart failure creates a backward effect on the pulmonary system that leads to pulmonary congestion.Rate this question:
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- 30.
Twenty four hours after admission for an Acute MI, Jose’s temperature is noted at 39.3 C. The nurse monitors him for other adaptations related to the pyrexia, including:
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Shortness of breath
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Chest pain
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Elevated blood pressure
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Increased pulse rate
Correct Answer
A. Increased pulse rateExplanation
Fever causes an increase in the body’s metabolism, which results in an increase in oxygen consumption and demand. This need for oxygen increases the heart rate, which is reflected in the increased pulse rate. Increased BP, chest pain and shortness of breath are not typically noted in fever.Rate this question:
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- 31.
The meal pattern that would probably be most appropriate for a client recovering from GI bleeding is:
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Three large meals large enough to supply adequate energy.
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Regular meals and snacks to limit gastric discomfort
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Limited food and fluid intake when he has pain
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A flexible plan according to his appetite
Correct Answer
A. Regular meals and snacks to limit gastric discomfortExplanation
Presence of food in the stomach at regular intervals interacts with HCl limiting acid mucosal irritation. Mucosal irritation can lead to bleeding.Rate this question:
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- 32.
The nurse applies mafenide acetate (Sulfamylon cream) to Clara, who has second and third degree burns on the right upper and lower extremities, as ordered by the physician. This medication will:
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Inhibit bacterial growth
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Relieve pain from the burn
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Prevent scar tissue formation
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Provide chemical debridement
Correct Answer
A. Inhibit bacterial growthExplanation
Sulfamylon is effective against a wide variety of gram positive and gram negative organisms including anaerobesRate this question:
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- 33.
The nurse is assisting in planning care for a client with a diagnosis of immune deficiency. The nurse would incorporate which of the ff. as a priority in the plan of care?
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Providing emotional support to decrease fear
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Protecting the client from infection
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Encouraging discussion about lifestyle changes
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Identifying factors that decreased the immune function
Correct Answer
A. Protecting the client from infectionExplanation
Immunodeficiency is an absent or depressed immune response that increases susceptibility to infection. So it is the nurse’s primary responsibility to protect the patient from infection.Rate this question:
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- 34.
Jose, who had a myocardial infarction 2 days earlier, has been complaining to the nurse about issues related to his hospital stay. The best initial nursing response would be to:
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Allow him to release his feelings and then leave him alone to allow him to regain his composure
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Refocus the conversation on his fears, frustrations and anger about his condition
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Explain how his being upset dangerously disturbs his need for rest
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Attempt to explain the purpose of different hospital routines
Correct Answer
A. Refocus the conversation on his fears, frustrations and anger about his conditionExplanation
This provides the opportunity for the client to verbalize feelings underlying behavior and helpful in relieving anxiety. Anxiety can be a stressor which can activate the sympathoadrenal response causing the release of catecholamines that can increase cardiac contractility and workload that can further increase myocardial oxygen demand.Rate this question:
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- 35.
Routine postoperative IV fluids are designed to supply hydration and electrolyte and only limited energy. Because 1 L of a 5% dextrose solution contains 50 g of sugar, 3 L per day would apply approximately:
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400 Kilocalories
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600 Kilocalories
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800 Kilocalories
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1000 Kilocalories
Correct Answer
A. 600 KilocaloriesExplanation
Carbohydrates provide 4 kcal/ gram; therefore 3L x 50 g/L x 4 kcal/g = 600 kcal; only about a third of the basal energy need.Rate this question:
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- 36.
An early finding in the EKG of a client with an infarcted mycardium would be:
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Disappearance of Q waves
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Elevated ST segments
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Absence of P wave
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Flattened T waves
Correct Answer
A. Elevated ST segmentsExplanation
This is a typical early finding after a myocardial infarct because of the altered contractility of the heart. The other choices are not typical of MI.Rate this question:
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- 37.
Ana is diagnosed to have Pernicious anemia. The physician orders 0.2 mg of Cyanocobalamin (Vitamin B12) IM. Available is a vial of the drug labeled 1 ml= 100 mcg. The nurse should administer:
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0.5 ml
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1.0 ml
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1.5 ml
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2.0 ml
Correct Answer
A. 2.0 mlExplanation
First convert milligrams to micrograms and then use ratio and proportion (0.2 mg= 200 mcg) 200 mcg : 100 mcg= X ml : ml 100 X= 200 X = 2 ml. Inject 2 ml. to give 0.2 mg of Cyanocobalamin.Rate this question:
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- 38.
Lucy undergoes Subtotal Thyroidectomy for Grave’s Disease. In planning for the client’s return from the OR, the nurse would consider that in a subtotal thyroidectomy:
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The entire thyroid gland is removed
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A small part of the gland is left intact
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One parathyroid gland is also removed
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A portion of the thyroid and four parathyroids are removed
Correct Answer
A. A small part of the gland is left intactExplanation
Remaining thyroid tissue may provide enough hormone for normal function. Total thyroidectomy is generally done in clients with Thyroid Ca.Rate this question:
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- 39.
When observing an ostomate do a return demonstration of the colostomy irrigation, the nurse notes that he needs more teaching if he:
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Stops the flow of fluid when he feels uncomfortable
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Lubricates the tip of the catheter before inserting it into the stoma
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Hangs the bag on a clothes hook on the bathroom door during fluid insertion
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Discontinues the insertion of fluid after only 500 ml of fluid has been instilled
Correct Answer
A. Hangs the bag on a clothes hook on the bathroom door during fluid insertionExplanation
The irrigation bag should be hung 12-18 inches above the level of the stoma; a clothes hook is too high which can create increase pressure and sudden intestinal distention and cause abdominal discomfort to the patient.Rate this question:
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- 40.
Mr. Ong weighs 210 lbs on admission to the hospital. After 2 days of diuretic therapy he weighs 205.5 lbs. The nurse could estimate that the amount of fluid he has lost is:
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0.5 L
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1.0 L
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2.0 L
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3.5 L
Correct Answer
A. 2.0 LExplanation
One liter of fluid weighs approximately 2.2 lbs. Therefore a 4.5 lbs weight loss equals approximately 2 Liters.Rate this question:
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- 41.
Clara is a 37-year old cook. She is admitted for treatment of partial and full-thickness burns of her entire right lower extremity and the anterior portion of her right upper extremity. Her respiratory status is compromised, and she is in pain and anxious. Performing an immediate appraisal, using the rule of nines, the nurse estimates the percent of Clara’s body surface that is burned is:
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4.5%
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9%
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18 %
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22.5%
Correct Answer
A. 22.5%Explanation
The entire right lower extremity is 18% the anterior portion of the right upper extremity is 4.5% giving a total of 22.5%Rate this question:
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- 42.
The nurse teaches Joy, an obese client, the value of aerobic exercises in her weight reduction program. The nurse would know that this teaching was effective when Joy says that exercise will:
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Increase her lean body mass
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Lower her metabolic rate
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Decrease her appetite
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Raise her heart rate
Correct Answer
A. Increase her lean body massExplanation
Increased exercise builds skeletal muscle mass and reduces excess fatty tissue.Rate this question:
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- 43.
The nurse would know that dietary teaching had been effective for a client with colostomy when he states that he will eat:
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Food low in fiber so that there is less stool
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Everything he ate before the operation but will avoid those foods that cause gas
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Bland foods so that his intestines do not become irritated
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Soft foods that are more easily digested and absorbed by the large intestines
Correct Answer
A. Everything he ate before the operation but will avoid those foods that cause gasExplanation
There is no special diets for clients with colostomy. These clients can eat a regular diet. Only gas-forming foods that cause distention and discomfort should be avoided.Rate this question:
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- 44.
Jane, a 20- year old college student is admiited to the hospital with a tentative diagnosis of myasthenia gravis. She is scheduled to have a series of diagnostic studies for myasthenia gravis, including a Tensilon test. In preparing her for this procedure, the nurse explains that her response to the medication will confirm the diagnosis if Tensilon produces:
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Brief exaggeration of symptoms
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Prolonged symptomatic improvement
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Rapid but brief symptomatic improvement
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Symptomatic improvement of just the ptosis
Correct Answer
A. Rapid but brief symptomatic improvementExplanation
Tensilon acts systemically to increase muscle strength; with a peak effect in 30 seconds, It lasts several minutes.Rate this question:
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- 45.
The nurse performs full range of motion on a bedridden client’s extremities. When putting his ankle through range of motion, the nurse must perform:
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Flexion, extension and left and right rotation
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Abduction, flexion, adduction and extension
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Pronation, supination, rotation, and extension
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Dorsiflexion, plantar flexion, eversion and inversion
Correct Answer
A. Dorsiflexion, plantar flexion, eversion and inversionExplanation
These movements include all possible range of motion for the ankle jointRate this question:
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- 46.
Clara, a burn client, receives a temporary heterograft (pig skin) on some of her burns. These grafts will:
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Debride necrotic epithelium
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Be sutured in place for better adherence
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Relieve pain and promote rapid epithelialization
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Frequently be used concurrently with topical antimicrobials.
Correct Answer
A. Relieve pain and promote rapid epithelializationExplanation
The graft covers nerve endings, which reduces pain and provides a framework for granulation that promotes effective healing.Rate this question:
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- 47.
The transurethral resection of the prostate is performed on a client with BpH. Following surgery, nursing care should include:
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Changing the abdominal dressing
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Maintaining patency of the cystotomy tube
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Maintaining patency of a three-way Foley catheter for cystoclysis
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Observing for hemorrhage and wound infection
Correct Answer
A. Maintaining patency of a three-way Foley catheter for cystoclysisExplanation
Patency of the catheter promotes bladder decompression, which prevents distention and bleeding. Continuous flow of fluid through the bladder limits clot formation and promotes hemostasisRate this question:
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- 48.
When a post-thyroidectomy client returns from surgery the nurse assesses her for unilateral injury of the laryngeal nerve every 30 to 60 minutes by:
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Observing for signs of tetany
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Hecking her throat for swelling
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Asking her to state her name out loud
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Palpating the side of her neck for blood seepage
Correct Answer
A. Asking her to state her name out loudExplanation
If the recurrent laryngeal nerve is damaged during surgery, the client will be hoarse and have difficult speaking.Rate this question:
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- 49.
The nurse recognizes that a client understood the demonstration of crutch walking when she places her weight on:
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The palms and axillary regions
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Both feet placed wide apart
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The palms of her hands
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Her axillary regions
Correct Answer
A. The palms of her handsExplanation
The palms should bear the client’s weight to avoid damage to the nerves in the axilla (brachial plexus)Rate this question:
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