Board Exam Nursing Test III NLE (Practice Mode)

1. Mr. Stewart is in sickle cell crisis and complaining pain in the joints and difficulty of breathing. On the assessment of the nurse, his temperature is 38.1 ºC. The physician ordered Morphine sulfate via patient-controlled analgesia (PCA), and oxygen at 4L/min. A priority nursing diagnosis to Mr. Stewart is risk for infection. A nursing intervention to assist in preventing infection is:

Using standard precautions and medical asepsis

Enforcing a “no visitors” rule

Using moist heat on painful joints

Monitoring a vital signs every 2 hour

Vigilant implementation of standard precautions and medical asepsis is an effective means of preventing infection

Explanation

Vigilant implementation of standard precautions and medical asepsis is an effective means of preventing infection

2. A client is scheduled to have an inguinal herniorraphy in the outpatient surgical department. The nurse is providing health teaching about post surgical care to the client. Which of the following statement if made by the client would reflect the need for more teaching?

“I should call the physician if I have a cough or cold before surgery”

“I will be able to drive soon after surgery”

“I will not be able to do any heavy lifting for 3-6 weeks after surgery”

“I should support my incision if I have to cough or turn”

The client should not drive for 2 weeks after surgery to avoid stress on the incision. This reflects a need for additional teaching.

Explanation

The client should not drive for 2 weeks after surgery to avoid stress on the incision. This reflects a need for additional teaching.

3. The postoperative gastrectomy client is scheduled for discharge. The client asks the nurse, “When I will be allowed to eat three meals a day like the rest of my family?”. The appropriate nursing response is:

“You will probably have to eat six meals a day for the rest of your life.”

“Eating six meals a day can be a bother, can’t it?”

In response to the question of the client, the nurse needs to provide brief, accurate information. Some clients who have had gastrectomies are able to tolerate three meals a day before discharge from the hospital. However, for the majority of clients, it takes 6-12 months before their surgically reduced stomach has stretched enough to accommodate a larger meal.

Explanation

In response to the question of the client, the nurse needs to provide brief, accurate information. Some clients who have had gastrectomies are able to tolerate three meals a day before discharge from the hospital. However, for the majority of clients, it takes 6-12 months before their surgically reduced stomach has stretched enough to accommodate a larger meal.

4. The nurse encourages the client to wear compression stockings. What is the rationale behind in using compression stockings?

Compression stockings promote venous return

Compression stockings divert blood to major vessels

Compression stockings decreases workload on the heart

Compression stockings improve arterial circulation

Compression stockings promote venous return and prevent peripheral pooling.

Explanation

Compression stockings promote venous return and prevent peripheral pooling.

5. Mr. Whitman is a stroke client and is having difficulty in swallowing. Which is the best nursing intervention is most likely to assist the client?

Placing food in the unaffected side of the mouth

Increasing fiber in the diet

Asking the patient to speak slowly

Increasing fluid intake

Placing food in the unaffected side of the mouth assists in the swallowing process because the client has sensation on that side and will have more control over the swallowing process.

Explanation

Placing food in the unaffected side of the mouth assists in the swallowing process because the client has sensation on that side and will have more control over the swallowing process.

6. Mrs. Moore, 62-year-old, with diabetes is in the emergency department. She stepped on a sharp sea shells while walking barefoot along the beach. Mrs. Moore did not notice that the object pierced the skin until later that evening. What problem does the client most probably have?

Nephropathy

Macroangiopathy

Carpal tunnel syndrome

Peripheral neuropathy

Peripheral neuropathy refers to nerve damage of the hands and feet. The client did not notice that the object pierced the skin.

Explanation

Peripheral neuropathy refers to nerve damage of the hands and feet. The client did not notice that the object pierced the skin.

7. What effective precautions should the nurse use to control the transmission of methicillin-resistant Staphylococcus aureus (MRSA)?

Use gloves and handwashing before and after client contact

Do nasal cultures on healthcare providers

Place the client on total isolation

Use mask and gown during care of the MRSA client

Contact isolation has been advised by the Centers for Disease Control and Prevention (CDC) to control transmission of MRSA, which includes gloves and handwashing.

Explanation

Contact isolation has been advised by the Centers for Disease Control and Prevention (CDC) to control transmission of MRSA, which includes gloves and handwashing.

8. What would be the recommended diet the nurse will implement to a client with burns of the head, face, neck and anterior chest?

Serve a high-protein, high-carbohydrate diet

Encourage full liquid diet

Serve a high-fat diet, high-fiber diet

Monitor intake to prevent weight gain

A positive nitrogen balance is important for meeting metabolic needs, tissue repair, and resistance to infection. Caloric goals may be as high as 5000 calories per day.

Explanation

A positive nitrogen balance is important for meeting metabolic needs, tissue repair, and resistance to infection. Caloric goals may be as high as 5000 calories per day.

9. A client is admitted and has been diagnosed with bacterial (meningococcal) meningitis. The infection control registered nurse visits the staff nurse caring to the client. What statement made by the nurse reflects an understanding of the management of this client?

Speech pattern may be altered

Respiratory isolation is necessary for 24 hours after antibiotics are started

Perform skin culture on the macular popular rash

Expect abnormal general muscle contractions

After a minimum of 24 hours of IV antibiotics, the client is no longer considered communicable. Evaluation of the nurse’s knowledge is needed for safe care and continuity of care.

Explanation

After a minimum of 24 hours of IV antibiotics, the client is no longer considered communicable. Evaluation of the nurse’s knowledge is needed for safe care and continuity of care.

10. Mr. Bean, a 70-year-old client is admitted in the hospital for almost one month. The nurse understands that prolonged immobilization could lead to decubitus ulcers. Which of the following would be the least appropriate nursing intervention in the prevention of decubitus?

Giving backrubs with alcohol

Use of a bed cradle

Frequent assessment of the skin

Encouraging a high-protein diet

Alcohol is extremely drying and contributes to skin break down. An emollient lotion should be used.

Explanation

Alcohol is extremely drying and contributes to skin break down. An emollient lotion should be used.

11. A 18-year-old male client had sustained a head injury from a motorbike accident. It is uncertain whether the client may have minimal but permanent disability. The family is concerned regarding the client’s difficulty accepting the possibility of long term effects. Which nursing diagnosis is best for this situation?

Nutrition, less than body requirements

Injury, potential for sensory-perceptual alterations

Impaired mobility, related to muscle weakness

Anticipatory grieving, due to the loss of independence

Stem of the question supports this choice by stating that the client has difficulty accepting the potential disability.

Explanation

Stem of the question supports this choice by stating that the client has difficulty accepting the potential disability.

12. The nurse is planning of care to a client with peptic ulcer disease. To avoid the worsening condition of the client, the nurse should carefully plan the diet of the client. Which of the following will be included in the diet regime of the client?

Eating mainly bland food and milk or dairy products

Reducing intake of high-fiber foods

Eating small, frequent meals and a bedtime snack

Eliminating intake of alcohol and coffee

These substances stimulate the production of hydrochloric acid, which is detrimental in peptic ulcer disease.

Explanation

These substances stimulate the production of hydrochloric acid, which is detrimental in peptic ulcer disease.

13. The physician prescribed digoxin 0.125 mg PO qd to a client and instructed the nurse that the client is on high-potassium diet. High potassium foods are recommended in the diet of a client taking digitalis preparations because a low serum potassium has which of the following effects?

Potentiates the action of digoxin

Promotes calcium retention

Promotes sodium excretion

Puts the client at risk for digitalis toxicity

Potassium influences the excitability of nerves and muscles. When potassium is low and the client is on digoxin, the risk of digoxin toxicity is increased.

Explanation

Potassium influences the excitability of nerves and muscles. When potassium is low and the client is on digoxin, the risk of digoxin toxicity is increased.

14. The nurse is assigned to care to a client who undergone thyroidectomy. What nursing intervention is important during the immediate postoperative period following a thyroidectomy?

Assess extremities for weakness and flaccidity

Support the head and neck during position changes

Position the client in high Fowler’s

Medicate for restlessness and anxiety

Stress on the suture line should be avoided. Prevent flexion or hyperextension of the neck, and provide a small pillow under the head and neck. Neck muscles have been affected during a thyroidectomy, support essential for comfort and incisional support.

Explanation

Stress on the suture line should be avoided. Prevent flexion or hyperextension of the neck, and provide a small pillow under the head and neck. Neck muscles have been affected during a thyroidectomy, support essential for comfort and incisional support.

15. A client is diagnosed with detached retina and scheduled for surgery. Preoperative teaching of the nurse to the client includes:

No eye pain is expected postoperatively

Semi-fowler’s position will be used to reduce pressure in the eye.

Eye patches may be used postoperatively

Return of normal vision is expected following surgery

Use of eye patches may be continued postoperatively, depending on surgeon preference. This is done to achieve >90% success rate of the surgery.

Explanation

Use of eye patches may be continued postoperatively, depending on surgeon preference. This is done to achieve >90% success rate of the surgery.

16. A client with gangrenous foot has undergone a below-knee amputation. The nurse in the nursing care unit knows that the priority nursing intervention in the immediate post operative care of this client is:

Elevate the stump on a pillow for the first 24 hours

Encourage use of trapeze

Position the client prone periodically

Apply a cone-shaped dressing

The elevation of the stump on a pillow for the first 24 hours decreases edema and increases venous return.

Explanation

The elevation of the stump on a pillow for the first 24 hours decreases edema and increases venous return.

17. A client with multiple fractures of both lower extremities is admitted for 3 days ago and is on skeletal traction. The client is complaining of having difficulty in bowel movement. Which of the following would be the most appropriate nursing intervention?

Administer an enema

Perform range-of-motion exercise to all extremities

Ensure maximum fluid intake (3000ml/day)

Put the client on the bedpan every 2 hours

The best early intervention would be to increase fluid intake, because constipation is common when activity is decreased or usual routines have been interrupted.

Explanation

The best early intervention would be to increase fluid intake, because constipation is common when activity is decreased or usual routines have been interrupted.

18. John is diagnosed with Addison’s disease and admitted in the hospital. What would be the appropriate nursing care for John?

Reducing physical and emotional stress

Providing a low-sodium diet

Restricting fluids to 1500ml/day

Administering insulin-replacement therapy

Because the client’s ability is to react to stress is decreased, maintaining a quiet environment becomes A nursing priority. Dehydration is a common problem in Addison’s disease, so close observation of the client’s hydration level is crucial. To promote optimal hydration and sodium intake, fluid intake is increased, particularly fluid containing electrolytes, such as broths, carbonated beverages, and juices.

Explanation

Because the client’s ability is to react to stress is decreased, maintaining a quiet environment becomes A nursing priority. Dehydration is a common problem in Addison’s disease, so close observation of the client’s hydration level is crucial. To promote optimal hydration and sodium intake, fluid intake is increased, particularly fluid containing electrolytes, such as broths, carbonated beverages, and juices.

19. A client with AIDS is scheduled for discharge. The client tells the nurse that one of his hobbies at home is gardening. What will be the discharge instruction of the nurse to the client knowing that the client is prone to toxoplasmosis?

Wash all vegetables before cooking

Wear gloves when gardening

Wear a mask when travelling to foreign countries

Avoid contact with cats and birds

Toxoplasmosis is an opportunistic infection and a parasite of birds and mammals. The oocysts remain infectious in moist soil for about 1 year.

Explanation

Toxoplasmosis is an opportunistic infection and a parasite of birds and mammals. The oocysts remain infectious in moist soil for about 1 year.

20. A client is placed on digoxin, high potassium foods are recommended in the diet of the client. Which of the following foods will the nurse give to the client?

Whole grain cereal, orange juice, and apricots

Turkey, green bean, and Italian bread

Cottage cheese, cooked broccoli, and roast beef

Fish, green beans and cherry pie

These foods are high in potassium

Explanation

These foods are high in potassium

21. A client with acute bronchitis is admitted in the hospital. The nurse assigned to the client is making a plan of care regarding expectoration of thick sputum. Which nursing action is most effective?

Place the client in a lateral position every 2 hour

Splint the patient’s chest with pillows when coughing

Use humified oxygen

Offer fluids at regular intervals

Fluids liquefy secretions and therefore make it easier to expectorate

Explanation

Fluids liquefy secretions and therefore make it easier to expectorate

22. Mr. Park is 32-year-old, a badminton player and has a type 1 diabetes mellitus. After the game, the client complains of becoming diaphoretic and light-headedness. The client asks the nurse how to avoid this reaction. The nurse will recommend to:

Allow plenty of time after the insulin injection and before beginning the match

Eat a carbohydrate snack before and during the badminton match

Drink plenty of fluids before, during, and after bed time

Take insulin just before starting the badminton match

Exercise enhances glucose uptake, and the client is at risk for an insulin reaction. Snacks with carbohydrates will help.

Explanation

Exercise enhances glucose uptake, and the client is at risk for an insulin reaction. Snacks with carbohydrates will help.

23. Mrs. Maupin is a professor in a prestigious university for 30 years. After lecture, she experience blurring of vision and tiredness. Mrs. Maupin is brought to the emergency department. On assessment, the nurse notes that the blood pressure of the client is 139/90. Mrs. Maupin has been diagnosed with essential hypertension and placed on medication to control her BP. Which potential nursing diagnosis will be a priority for discharge teaching?

Sleep Pattern disturbance

Impaired physical mobility

Noncompliance

Fluid volume excess

Noncompliance is a major problem in the management of chronic disease. In hypertension, the client often does not feel ill and thus does not see a need to follow a treatment regimen.

Explanation

Noncompliance is a major problem in the management of chronic disease. In hypertension, the client often does not feel ill and thus does not see a need to follow a treatment regimen.

24. The nurse in the nursing care unit is assigned to care to a client who is Immunocompromised. The client tells the nurse that his chest is painful and the blisters are itchy. What would be the nursing intervention to this client?

Call the physician

Give a prn pain medication

Clarify if the client is on a new medication

Use gown and gloves while assessing the lesions

The client may have herpes zoster (shingles), a viral infection. The nurse should use standard precautions in assessing the lesions. Immunocompromised clients are at risk for infection.

Explanation

The client may have herpes zoster (shingles), a viral infection. The nurse should use standard precautions in assessing the lesions. Immunocompromised clients are at risk for infection.

25. Following nephrectomy, the nurse closely monitors the urinary output of the client. Which assessment finding is an early indicator of fluid retention in the postoperative period?

Periorbital edema

Increased specific gravity of urine

A urinary output of 50mL/hr

Daily weight gain of 2 lb or more

Daily weights are taken following nephrectomy. Daily increases of 2 lb or more are indicative of fluid retention and should be reported to the physician. Intake and output records may also reflect this imbalance.

Explanation

Daily weights are taken following nephrectomy. Daily increases of 2 lb or more are indicative of fluid retention and should be reported to the physician. Intake and output records may also reflect this imbalance.

26. A male client visits the clinic for check-up. The client tells the nurse that there is a yellow discharge from his penis. He also experiences a burning sensation when urinating. The nurse is suspecting of gonorrhea. What teaching is necessary for this client?

Sex partner of 3 months ago must be treated

Women with gonorrhea are symptomatic

Use a condom for sexual activity

Sex partner needs to be evaluated

If infected, the sex partner must be evaluated and treated

Explanation

If infected, the sex partner must be evaluated and treated

27. A client is diagnosed with peptic ulcer. The nurse caring for the client expects the physician to order which diet?

NPO

Small feedings of bland food

A regular diet given frequently in small amounts

Frequent feedings of clear liquids

Bland feedings should be given in small amounts on a frequent basis to neutralize the hydrochloric acid and to prevent overload

Explanation

Bland feedings should be given in small amounts on a frequent basis to neutralize the hydrochloric acid and to prevent overload

28. The nurse is caring for a client who is transferred from the operating room for pneumonectomy. The nurse knows that immediately following pneumonectomy; the client should be in what position?

Supine on the unaffected side

Low-Fowler’s on the back

Semi-Fowler’s on the affected side

Semi-Fowler’s on the unaffected side

This position allows maximum expansion, ventilation, and perfusion of the remaining lung.

Explanation

This position allows maximum expansion, ventilation, and perfusion of the remaining lung.

29. The client with acute pancreatitis and fluid volume deficit is transferred from the ward to the ICU. Which of the following will alert the nurse?

Decreased pain in the fetal position

Urine output of 35mL/hr

CVP of 12 mmHg

Cardiac output of 5L/min

C = the normal CVP is 0-8 mmHg. This value reflects hypervolemia. The right ventricular function of this client reflects fluid volume overload, and the physician should be notified.

Explanation

C = the normal CVP is 0-8 mmHg. This value reflects hypervolemia. The right ventricular function of this client reflects fluid volume overload, and the physician should be notified.

30. The nurse in the morning shift is making rounds in the ward. The nurse enters the client’s room and found the client in discomfort condition. The client complains of stiffness in the joints. To reduce the early morning stiffness of the joints of the client, the nurse can encourage the client to:

Sleep with a hot pad

Take to aspirins before arising, and wait 15 minutes before attempting locomotion

Take a hot tub bath or shower in the morning

Put joints through passive ROM before trying to move them actively

A hot tub bath or shower in the morning helps many patients limber up and reduces the symptoms of early morning stiffness. Cold and ice packs are used to a lesser degree, though some clients state that cold decreases localized pain, particularly during acute attacks.

Explanation

A hot tub bath or shower in the morning helps many patients limber up and reduces the symptoms of early morning stiffness. Cold and ice packs are used to a lesser degree, though some clients state that cold decreases localized pain, particularly during acute attacks.

31. The physician has given instruction to the nurse that the client can be ambulated on crutches, with no weight bearing on the affected limb. The nurse is aware that the appropriate crutch gait for the nurse to teach the client would be:

Tripod gait

Two-point gait

Four-point gait

Three-point gait

The three-point gait is appropriate when weight bearing is not allowed on the affected limb. The swing-to and swing-through crutch gaits may also be used when only one leg can be used for weight bearing

Explanation

The three-point gait is appropriate when weight bearing is not allowed on the affected limb. The swing-to and swing-through crutch gaits may also be used when only one leg can be used for weight bearing

32. Ms Jones is brought to the emergency room and is complaining of muscle spasms, numbness, tremors and weakness in the arms and legs. The client was diagnosed with multiple sclerosis. The nurse assigned to Ms. Jones is aware that she has to prevent fatigue to the client to alleviate the discomfort. Which of the following teaching is necessary to prevent fatigue?

Avoid extremes in temperature

Install safety devices in the home

Attend support group meetings

Avoid physical exercise

Extremes in heat and cold will exacerbate symptoms. Heat delays transmission of impulses and increases fatigue.

Explanation

Extremes in heat and cold will exacerbate symptoms. Heat delays transmission of impulses and increases fatigue.

33. Following a needle biopsy of the kidney, which assessment is an indication that the client is bleeding?

Slow, irregular pulse

Dull, abdominal discomfort

Urinary frequency

Throbbing headache

An accumulation of blood from the kidney into the abdomen would manifest itself with these symptoms

Explanation

An accumulation of blood from the kidney into the abdomen would manifest itself with these symptoms

34. A 70-year-old client is brought to the emergency department with a caregiver. The client has manifestations of anorexia, wasting of muscles and multiple bruises. What nursing interventions would the nurse implement?

Talk to the client about the caregiver and support system

Complete a gastrointestinal and neurological assessment

Check the lab data for serum albumin, hematocrit and hemoglobin

Complete a police report on elder abuse

Assessment and more data collection are needed. The client may have gastrointestinal or neurological problems that account for the symptoms. The anorexia could result from medications, poor dentition, or indigestion, the bruises may be attributed to ataxia, frequent falls, vertigo, or medication.

Explanation

Assessment and more data collection are needed. The client may have gastrointestinal or neurological problems that account for the symptoms. The anorexia could result from medications, poor dentition, or indigestion, the bruises may be attributed to ataxia, frequent falls, vertigo, or medication.

35. A client is rushed to the emergency room due to serious vehicle accident. The nurse is suspecting of head injury. Which of the following assessment findings would the nurse report to the physician?

CVP of 5mmHa

Glasgow Coma Scale score of 13

Polyuria and dilute urinary output

Insomnia

These are symptoms of diabetes insipidus. The patient can become hypovolemic and vasopressin may reverse the Polyuria.

Explanation

These are symptoms of diabetes insipidus. The patient can become hypovolemic and vasopressin may reverse the Polyuria.

36. A client with AIDS is admitted in the hospital. He is receiving intravenous therapy. While the nurse is assessing the IV site, the client becomes confused and restless and the intravenous catheter becomes disconnected and minimal amount of the client’s blood spills onto the floor. Which action will the nurse take to remove the blood spill?

Promptly clean with a 1:10 solution of household bleach and water

Promptly clean up the blood spill with full-strength antimicrobial cleaning solution

Immediately mop the floor with boiling water

Allow the blood to dry before cleaning to decrease the possibility of cross-contamination

A 1:10 solution of household bleach and water is recommended by the Centers for Disease Control and Prevention to kill the human immunodeficiency virus (HIV).

Explanation

A 1:10 solution of household bleach and water is recommended by the Centers for Disease Control and Prevention to kill the human immunodeficiency virus (HIV).

37. The nurse on the night shift is making rounds in the nursing care unit. The nurse is about to enter to the client’s room when a ventilator alarm sounds, what is the first action the nurse should do?

Assess the lung sounds

Suction the client right away

Look at the client

Turn and position the client

A quick look at the client can help identify the type and cause of the ventilator alarm. Disconnection of the tube from the ventilator, bronchospasm, and anxiety are some of the obvious reasons that could trigger an alarm.

Explanation

A quick look at the client can help identify the type and cause of the ventilator alarm. Disconnection of the tube from the ventilator, bronchospasm, and anxiety are some of the obvious reasons that could trigger an alarm.

38. Before surgery, the physician ordered pentobarbital sodium (Nembutal) for the client to sleep. The night before the scheduled surgery, the nurse gave the pre-medication. One hour later the client is still unable to sleep. The nurse review the client’s chart and note the physician’s prescription with an order to repeat. What should the nurse do next?

Rub the client’s back until relaxed

Prepare a glass of warm milk

Give the second dose of pentobarbital sodium

Explore the client’s feelings about surgery

Given the data, presurgical anxiety is suspected. The client needs an opportunity to talk about concerns related to surgery before further actions (which may mask the anxiety).

Explanation

Given the data, presurgical anxiety is suspected. The client needs an opportunity to talk about concerns related to surgery before further actions (which may mask the anxiety).

39. The nurse is going to replace the Pleur-O-Vac attached to the client with a small, persistent left upper lobe pneumothorax with a Heimlich Flutter Valve. Which of the following is the best rationale for this?

Promote air and pleural drainage

Prevent kinking of the tube

Eliminate the need for a dressing

Eliminate the need for a water-seal drainage

The Heimlich flutter valve has a one-way valve that allows air and fluid to drain. Underwater seal drainage is not necessary. This can be connected to a drainage bag for the patient’s mobility. The absence of a long drainage tubing and the presence of a one-way valve promote effective therapy

Explanation

The Heimlich flutter valve has a one-way valve that allows air and fluid to drain. Underwater seal drainage is not necessary. This can be connected to a drainage bag for the patient’s mobility. The absence of a long drainage tubing and the presence of a one-way valve promote effective therapy

40. A male client with cirrhosis is complaining of belly pain, itchiness and his breasts are getting larger and also the abdomen. The client is so upset because of the discomfort and asks the nurse why his breast and abdomen are getting larger. Which of the following is the appropriate nursing response?

“How much of a difference have you noticed”

“It’s part of the swelling your body is experiencing”

“It’s probably because you have been less physically active”

“Your liver is not destroying estrogen hormones that all men produce”

This allows the client to elaborate his concern and provides the nurse a baseline of assessment

Explanation

This allows the client to elaborate his concern and provides the nurse a baseline of assessment

41. After a right lower lobectomy on a 55-year-old client, which action should the nurse initiate when the client is transferred from the post anesthesia care unit?

Notify the family to report the client’s condition

Immediately administer the narcotic as ordered

Keep client on right side supported by pillows

Encourage coughing and deep breathing every 2 hours

Coughing and deep breathing are essential for re-expansion of the lung

Explanation

Coughing and deep breathing are essential for re-expansion of the lung

42. The nurse is providing a discharge instruction about the prevention of urinary stasis to a client with frequent bladder infection. Which of the following will the nurse include in the instruction?

Drink 3-4 quarts of fluid every day

Empty the bladder every 2-4 hours while awake

Encourage the use of coffee, tea, and colas for their diuretic effect

Teach Kegel exercises to control bladder flow

Avoiding stasis of urine by emptying the bladder every 2-4 hours will prevent overdistention of the bladder and future urinary tract infections.

Explanation

Avoiding stasis of urine by emptying the bladder every 2-4 hours will prevent overdistention of the bladder and future urinary tract infections.

43. The physician ordered a low-sodium diet to the client. Which of the following food will the nurse avoid to give to the client?

Orange juice.

Whole milk.

Ginger ale.

Black coffee.

Whole milk should be avoided to include in the client’s diet because it has 120 mg of sodium in 8 0z of milk.

Explanation

Whole milk should be avoided to include in the client’s diet because it has 120 mg of sodium in 8 0z of milk.

44. A client with a diagnosis of gastric ulcer is complaining of syncope and vertigo. What would be the initial nursing intervention by the nurse?

Monitor the client’s vital signs

Keep the client on bed rest

Keep the patient on bed rest

Give a stat dose of Sucralfate (Carafate)

The priority is to maintain client’s safety. With syncope and vertigo, the client is at high risk for falling.

Explanation

The priority is to maintain client’s safety. With syncope and vertigo, the client is at high risk for falling.

45. A nurse is completing an assessment to a client with cirrhosis. Which of the following nursing assessment is important to notify the physician?

Expanding ecchymosis

Ascites and serum albumin of 3.2 g/dl

Slurred speech

Hematocrit of 37% and hemoglobin of 12g/dl

Clients with cirrhosis have already coagulation due to thrombocytopenia and vitamin K deficiency. This could be a sign of bleeding

Explanation

Clients with cirrhosis have already coagulation due to thrombocytopenia and vitamin K deficiency. This could be a sign of bleeding

46. The client is transferred to the nursing care unit from the operating room after a transurethral resection of the prostate. The client is complaining of pain in the abdomen area. The nurse suspects of bladder spasms, which of the following is the best nursing action to minimize the pain felt by the client?

Advising the client not to urinate around catheter

Intermittent catheter irrigation with saline

Giving prescribed narcotics every 4 hour

Repositioning catheter to relieve pressure

The client needs to be told before surgery that the catheter causes the urge to void. Attempts to void around the catheter cause the bladder muscles to contract and result in painful spasms.

Explanation

The client needs to be told before surgery that the catheter causes the urge to void. Attempts to void around the catheter cause the bladder muscles to contract and result in painful spasms.

47. A nurse is providing a discharge instruction to the client about the self-catheterization at home. Which of the following instructions would the nurse include?

Wash the catheter with soap and water after each use

Lubricate the catheter with Vaseline

Perform the Valsalva maneuver to promote insertion

Replace the catheter with a new one every 24 hour

The catheter should be washed with soap and water after withdrawal and placed in a clean container. It can be reused until it is too hard or too soft for insertion. Self-care, prevention of complications, and cost-effectiveness are important in home management.

Explanation

The catheter should be washed with soap and water after withdrawal and placed in a clean container. It can be reused until it is too hard or too soft for insertion. Self-care, prevention of complications, and cost-effectiveness are important in home management.

48. The nurse is going to assess the bowel sound of the client. For accurate assessment of the bowel sound, the nurse should listen for at least:

5 minutes

60 seconds

30 seconds

2 minutes

Physical assessment guidelines recommend listening for atleast 2 minutes in each quadrant (and up to 5 minutes, not at least 5 minutes).

Explanation

Physical assessment guidelines recommend listening for atleast 2 minutes in each quadrant (and up to 5 minutes, not at least 5 minutes).

49. The nurse is going to insert a Miller-Abbott tube to the client. Before insertion of the tube, the balloon is tested for patency and capacity and then deflated. Which of the following nursing measure will ease the insertion to the tube?

Positioning the client in Semi-Fowler’s position

Administering a sedative to reduce anxiety

Chilling the tube before insertion

Warming the tube before insertion

Chilling the tube before insertion assists in relieving some of the nasal discomfort. Water-soluble lubricants along with viscous lidocaine (Xylocaine) may also be used. It is usually only lightly lubricated before insertion

Explanation

Chilling the tube before insertion assists in relieving some of the nasal discomfort. Water-soluble lubricants along with viscous lidocaine (Xylocaine) may also be used. It is usually only lightly lubricated before insertion

50. Mr. Smith is scheduled for an above-the-knee amputation. After the surgery he was transferred to the nursing care unit. The nurse assigned to him knows that 72 hours after the procedure the client should be positioned properly to prevent contractures. Which of the following is the best position to the client?

Side-lying, alternating left and right sides

Sitting in a reclining chair twice a day

Lying on abdomen several times daily

Supine with stump elevated at least 30 degrees

At about 48-72 hours, the client must be turned onto the abdomen to prevent flexion contractures.

Explanation

At about 48-72 hours, the client must be turned onto the abdomen to prevent flexion contractures.