1.
Which of the following factors can cause hepatitis A?
Correct Answer
C. Eating contaminated shellfish
Explanation
Eating contaminated shellfish can cause hepatitis A because shellfish, such as oysters and clams, can filter and concentrate the hepatitis A virus from contaminated water. When these shellfish are consumed raw or undercooked, the virus can be transmitted to humans and cause infection. Other factors listed, such as contact with infected blood, blood transfusions with infected blood, and sexual contact with an infected person, may cause other types of hepatitis but not specifically hepatitis A.
2.
After a person experiences a closure of the epiphyses, which of the following is true?
Correct Answer
D. No further increase in bone length occurs.
Explanation
After a person experiences a closure of the epiphyses, which is the point where the bone stops growing in length, there is no further increase in bone length. This is because the epiphyses are responsible for bone growth in length, and once they close, the bone can no longer elongate. However, bone can still increase in thickness through a process called remodeling, where old bone is replaced by new bone. Therefore, the correct answer is that no further increase in bone length occurs.
3.
Which intervention is appropriate for the nurse caring for a client in severe pain receiving a continuous I.V. infusion of morphine?
Correct Answer
D. Obtaining baseline vital signs before administering the first dose
Explanation
Obtaining baseline vital signs before administering the first dose is an appropriate intervention for a nurse caring for a client in severe pain receiving a continuous I.V. infusion of morphine. Baseline vital signs provide a reference point for comparison and help the nurse monitor the client's response to the medication. This is important because morphine can cause respiratory depression, hypotension, and other adverse effects. By obtaining baseline vital signs, the nurse can identify any changes or abnormalities in the client's condition and take appropriate action.
4.
Every morning a client with type 1 diabetes receives 15 units of Humulin 70/30. What does this type of insulin contain?
Correct Answer
C. 70% NPH insulin and 30% regular insulin
Explanation
Humulin 70/30 is a mixture of 70% NPH (neutral protamine Hagedorn) insulin and 30% regular insulin. NPH insulin is an intermediate-acting insulin that provides a basal level of insulin throughout the day, while regular insulin is a short-acting insulin that helps control blood sugar spikes after meals. This combination is commonly used to provide both basal and prandial (mealtime) insulin coverage for individuals with type 1 diabetes.
5.
The electrocardiogram (ECG) tracing shown below, excluding the seventh beat, has a normal QRS complex, one premature atrial contraction (PAC), and what other attributes?
Correct Answer
C. P wave is identifiable, PR interval is 0.16 second, and sinus rhythm is at 95 beats/minute
Explanation
The correct answer is that the P wave is identifiable, the PR interval is 0.16 seconds, and the sinus rhythm is at 95 beats/minute. This means that the electrical activity of the atria is normal, as indicated by the presence of a visible P wave. The PR interval, which represents the time it takes for the electrical signal to travel from the atria to the ventricles, is within the normal range. Additionally, the sinus rhythm, which indicates that the heart is beating in a regular pattern, is at a rate of 95 beats per minute.
6.
The nurse is teaching the client how to use a cane. Which of the following statements is most inaccurate?
Correct Answer
A. The client should hold the cane on the involved side.
Explanation
The client should hold the cane on the uninvolved side, not the involved side. Holding the cane on the uninvolved side provides better support and stability while walking.
7.
For a client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume?
Correct Answer
C. Increased urine osmolarity
Explanation
Increased urine osmolarity is the best assessment finding that supports a nursing diagnosis of Deficient fluid volume in a client with hyperglycemia. Hyperglycemia leads to increased blood glucose levels, which causes the kidneys to excrete more glucose in the urine. This increased excretion of glucose in the urine leads to increased urine osmolarity, indicating a loss of fluid volume. Therefore, increased urine osmolarity is a significant finding that supports the nursing diagnosis of Deficient fluid volume in this client.
8.
A client with osteoarthritis tells the nurse she is concerned that the disease will prevent her from doing her chores. Which suggestion should the nurse offer?
Correct Answer
C. "Pace yourself and rest frequently, especially after activities."
Explanation
The suggestion to pace oneself and rest frequently, especially after activities, is the most appropriate response for a client with osteoarthritis. This approach allows the client to manage their symptoms and prevent excessive strain on their joints. By pacing themselves, the client can avoid overexertion and minimize the risk of exacerbating their pain and stiffness. Resting frequently after activities also helps to reduce fatigue and allows the body to recover. This suggestion promotes self-care and encourages the client to find a balance between maintaining their independence and managing their symptoms effectively.
9.
After abdominal surgery, which factor would predispose a client to deep vein thrombosis?
Correct Answer
D. The client will be immobile during and shortly after surgery.
Explanation
After abdominal surgery, immobility is a major risk factor for deep vein thrombosis (DVT). Immobility can lead to blood pooling in the legs, which increases the risk of clot formation. Walking and physical activity help to promote blood flow and prevent clotting. The client's height, weight, and pregnancy history are not directly related to the risk of DVT in this scenario.
10.
A female patient complains of abdominal discomfort. The watery stool has been leaking from her rectum. This could be a sign of:
Correct Answer
C. Fecal impaction
Explanation
Fecal impaction can be serious. When constipation is not resolved, stool becomes hardened and unable to pass. Liquid stool may pass around the impaction. Patients may complain of feeling bloated; having the urge to push; nausea or vomiting; not wanting to eat. The impaction may need to be manually removed. Patient education should include increasing liquids and fiber, as well as regular physical activity.