1.
Following spinal injury, the nurse should encourage the client to drink
fluids to avoid:
Correct Answer
A. Urinary tract infection.
Explanation
Clients in the early stage of spinal cord damage experience an atonic bladder, which is characterized by the absence of muscle tone, an enlarged capacity, no feeling of discomfort with distention, and overflow with a large residual. This leads to urinary stasis and infection. High fluid intake limits urinary stasis and infection by diluting the urine and increasing urinary output.
2.
The client is transferred from the operating room to recovery room after an open-heart surgery. The nurse assigned is taking the vital signs of the client. The nurse notified the physician when the temperature of the client rises to 38.8 ºC or 102 ºF because elevated temperatures:
Correct Answer
D. Increase the cardiac output.
Explanation
The temperature of 102 ºF (38.8ºC) or greater lead to an increased metabolism and cardiac workload.
3.
After radiation therapy for cancer of the prostate, the client experienced irritation in the bladder. Which of the following sign of bladder irritability is correct?
Correct Answer
B. Dysuria
Explanation
Dysuria, nocturia, and urgency are all signs an irritable bladder after radiation therapy.
4.
A client is diagnosed with a brain tumor in the occipital lobe. Which of the following will the client most likely experience?
Correct Answer
A. Visual hallucinations.
Explanation
The occipital lobe is involve with visual interpretation.
5.
A client with Addison’s disease has a blood pressure of 65/60. The nurse understands that decreased blood pressure of the client with Addison’s disease involves a disturbance in the production of:
Correct Answer
C. Mineralocorticoids
Explanation
Mineralocorticoids such as aldosterone cause the kidneys to retain sodium ions. With sodium, water is also retained, elevating blood pressure. Absence of this hormone thus causes hypotension.
6.
The nurse is planning to teach the client about a spontaneous pneumothorax. The nurse would base the teaching on the understanding that:
Correct Answer
B. There is greater negative pressure within the chest cavity.
Explanation
As a person with a tear in the lung inhales, air moves through that opening into the intrapleural and causes partial or complete collapse of the lungs.
7.
During an assessment, the nurse recognizes that the client has an increased risk for developing cancer of the tongue. Which of the following health history will be a concern?
Correct Answer
A. Heavy consumption of alcohol.
Explanation
Heavy alcohol ingestion predisposes an individual to the development of oral cancer.
8.
The client in the orthopedic unit asks the nurse the reason behind why compact bone is stronger than cancellous bone. Which of the following is the correct response of the nurse?
Correct Answer
D. Compact bone is stronger than cancellous bone because of its greater density.
Explanation
The greater the density of compact bone makes it stronger than the cancellous bone. Compact bone forms from cancellous bone by the addition of concentric rings of bones substances to the marrow spaces of cancellous bone. The large marrow spaces are reduced to haversian canals.
9.
The nurse is reviewing the laboratory results of the client. In reviewing the results of the RBC count, the nurse understands that the higher the red blood cell count, the :
Correct Answer
A. Greater the blood viscosity.
Explanation
Viscosity, a measure of a fluid’s internal resistance to flow, is increased as the number of red cells suspended in plasma.
10.
The physician advised the client with Hemiparesis to use a cane. The client asks the nurse why cane will be needed. The nurse explains to the client that cane is advised specifically to:
Correct Answer
C. Maintain balance and improve stability.
Explanation
Hemiparesis creates instability. Using a cane provides a wider base of support and, therefore greater stability.
11.
The nurse is conducting a discharge teaching regarding the prevention of further problems to a client who undergone surgery for carpal tunnel syndrome of the right hand. Which of the following instruction will the nurse includes?
Correct Answer
D. Do manual stretching exercise during breaks.
Explanation
Manual stretching exercises will assist in keeping the muscles and tendons supple and pliable, reducing the traumatic consequences of repetitive activity.
12.
A female client is admitted because of recurrent urinary tract
infections. The client asks the nurse why she is prone to this
disease. The nurse states that the client is most susceptible because
of:
Correct Answer
C. The length of the urethra.
Explanation
The length of the urethra is shorter in females than in males; therefore microorganisms have a shorter distance to travel to reach the bladder. The proximity of the meatus to the anus in females also increases this incidence.
13.
A 55-year-old client is admitted with chest pain that radiates to the
neck, jaw and shoulders that occurs at rest, with high body temperature,
weak with generalized sweating and with decreased blood pressure. A myocardial
infarction is diagnosed. The nurse knows that the most accurate
explanation for one of these presenting adaptations is:
Correct Answer
D. Inflammation in the myocardium causes a rise in the systemic body temperature.
Explanation
Temperature may increase within the first 24 hours and persist as long as a week.
14.
Following an amputation of a lower limb to a male client, the nurse
provides an instruction on how to prevent a hip flexion contracture.
The nurse should instruct the client to:.
Correct Answer
C. Lie on the abdomen 30 minutes every four hours.
Explanation
The hips are in extension when the client is prone; this keeps the hips from flexing.
15.
The physician scheduled the client with rheumatoid arthritis for the
injection of hydrocortisone into the knee joint. The client asks the
nurse why there is a need for this injection. The nurse explains that
the most important reason for doing this is to:
Correct Answer
C. Reduce inflammation.
Explanation
Steroids have an anti-inflammatory effect that can reduce arthritic pannus formation.
16.
The nurse is assigned to care for a 57-year-old female client who had a
cataract surgery an hour ago. The nurse should:
Correct Answer
A. Advise the client to refrain from vigorous brushing of teeth and hair.
Explanation
Activities such as rigorous brushing of hair and teeth cause increased intraocular pressure and may lead to hemorrhage in the anterior chamber.
17.
A client with AIDS
develops bacterial pneumonia is admitted in the emergency department.
The client’s arterial blood gases is drawn and the result is PaO2
80mmHg. then arterial blood gases are drawn again and the level is
reduced from 80 mmHg to 65 mmHg. The nurse should;
Correct Answer
C. Notify the pHysician.
Explanation
This decrease in PaO2 indicates respiratory failure; it warrants immediate medical evaluation.
18.
An 18-year-old college student is brought to the emergency department
due to serious motor vehicle accident. Right above-knee-amputation is
done. Upon awakening from surgery the client tells the nurse, “What
happened to me? I cannot remember anything?” Which of the following
would be the appropriate initial nursing response?
Correct Answer
C. “You were in a car accident this morning.”
Explanation
This is truthful and provides basic information that may prompt recollection of what happened; it is a starting point.
19.
A 38-year-old client with severe hypertension is hospitalized. The
physician prescribed a Captopril (Capoten) and Alprazolam (Xanax) for
treatment. The client tells the nurse that there is something wrong
with the medication and nursing care. The nurse recognizes this
behavior is probably a manifestation of the client’s:
Correct Answer
D. Fear of the health problem.
Explanation
Clients adapting to illness frequently feel afraid and helpless and strike out at health team members as a way of maintaining control or denying their fear.
20.
Before discharge, the nurse scheduled the client who had a colostomy for
colorectal
cancer for discharge instruction about resuming activities. The
nurse should plan to help the client understands that:
Correct Answer
C. With counseling and medical guidance, a near normal lifestyle, including complete sexual function is possible.
Explanation
There are few physical restraints on activity postoperatively, but the client may have emotional problems resulting from the body image changes.
21.
A client is scheduled for bariatric surgery. Preoperative teaching is
done. Which of the following statement would alert the nurse that
further teaching to the client is necessary?
Correct Answer
B. “I’m going to have a figure like a model in about a year.”
Explanation
Clients need to be prepared emotionally for the body image changes that occur after bariatric surgery. Clients generally experience excessive abdominal skin folds after weight stabilizes, which may require a panniculectomy. Body image disturbance often occurs in response to incorrectly estimating one’s size; it is not uncommon for the client to still feel fat no matter how much weight is lost.
22.
The client who had transverse colostomy asks the nurse about the
possible effect of the surgery on future sexual relationship. What
would be the best nursing response?
Correct Answer
D. The client will be able to resume normal sexual relationships.
Explanation
Surgery on the bowel has no direct anatomic or physiologic effect on sexual performance. However, the nurse should encourage verbalization.
23.
A 75-year-old male client tells the nurse that his wife has osteoporosis
and asks what chances he had of getting also osteoporosis like his
wife. Which of the following is the correct response of the nurse?
Correct Answer
C. “You might think about having a bone density test,”
Explanation
Osteoporosis is not restricted to women; it is a potential major health problem of all older adults; estimates indicate that half of all women have at least one osteoporitic fracture and the risk in men is estimated between 13% and 25%; a bone mineral density measurement assesses the mass of bone per unit volume or how tightly the bone is packed.
24.
An older adult client with acute pain is admitted in the hospital. The
nurse understands that in managing acute pain of the client during the
first 24 hours, the nurse should ensure that:
Correct Answer
A. Ordered PRN analgesics are administered on a scheduled basis.
Explanation
Around-the-clock administration of analgesics is recommended for acute pain in the older adult population; this help to maintain a therapeutic blood level of pain medication.
25.
A nurse is caring to an older adult with presbycusis. In formulating
nursing care plan for this client, the nurse should expect that hearing
loss of the client that is caused by aging to have:
Correct Answer
C. Difficulty hearing women’s voices.
Explanation
Generally, female voices have a higher pitch than male voices; older adults with presbycusis (hearing loss caused by the aging process) have more difficulty hearing higher-pitched sounds.
26.
The nurse is reviewing the client’s chart about the ordered
medication. The nurse must observe for signs of hyperkalemia when
administering:
Correct Answer
D. Spironolactone (Aldactone)
Explanation
Aldactone is a potassium-sparing diuretic; hyperkalemia is an adverse effect.
27.
The physician prescribed Albuterol (Proventil) to the client with severe
asthma. After the administration of the medication the nurse should
monitor the client for:
Correct Answer
A. Palpitation
Explanation
Albuterol’s sympathomimetic effect causes cardiac stimulation that may cause tachycardia and palpitation.
28.
A client is receiving diltiazem (Cardizem). What should the nurse
include in a teaching plan aimed at reducing the side effects of this
medication?
Correct Answer
D. Change positions slowly.
Explanation
Changing positions slowly will help prevent the side effect of orthostatic hypotension.
29.
A client is receiving simvastatin (Zocor). The nurse is aware that
this medication is effective when there is decrease in:
Correct Answer
A. The triglycerides
Explanation
Therapeutic effects of simvastatin include decreased serum triglyceries, LDL and cholesterol.
30.
A client is taking nitroglycerine tablets, the nurse should teach the
client the importance of:
Correct Answer
C. Making certain the medication is stored in a dark container.
Explanation
Nitroglycerine is sensitive to light and moisture ad must be stored in a dark, airtight container.
31.
The physician prescribes Ibuprofen
(Motrin) and hydroxychloroquine sulfate (Plaquenil) for a 58-year-old
male client with arthritis. The nurse provides information about
toxicity of the hydroxychloroquine. The nurse can determine if the
information is clearly understood if the client states:
Correct Answer
A. “I will contact the pHysician immediately if I develop blurred vision.”
Explanation
Visual disturbance are a sign of toxicity because retinopathy can occur with this drug.
32.
The client with an acute myocardial
infarction is hospitalized for almost one week. The client
experiences nausea and loss of appetite. The nurse caring for the
client recognizes that these symptoms may indicate the:
Correct Answer
B. Adverse effects of digoxin (Lanoxin)
Explanation
Toxic levels of Lanoxin stimulate the medullary chemoreceptor trigger zone, resulting in nausea and subsequent anorexia.
33.
A client with a partial occlusion of the left common carotid artery is
scheduled for discharge. The client is still receiving Coumadin. The
nurse provided a discharge instruction to the client regarding adverse
effects of Coumadin. The nurse should tell the client to consult with
the physician if:
Correct Answer
B. Blood appears in the urine.
Explanation
Warfarin derivatives cause an increase in the prothrombin time and INR, leading to an increased risk for bleeding. Any abnormal or excessive bleeding must be reported, because it may indicate toxic levels of the drug.
34.
Levodopa is
ordered for a client with Parkinson’s disease.
Before starting the medication, the nurse should know that:
Correct Answer
B. Levodopa may cause the side effects of orthostatic hypotension.
Explanation
Levodopa is the metabolic precursor of dopamine. It reduces sympathetic outflow by limiting vasoconstriction, which may result in orthostatic hypotension.
35.
In making a diagnosis of myasthenia gravis Edrophonium HCI (Tensilon) is
used. The nurse knows that this drug will cause a temporary increase
in:
Correct Answer
A. Muscle strength
Explanation
Tensilon, an anticholinesterase drug, causes temporary relief of symptoms of myasthenia gravis in client who have the disease and is therefore an effective diagnostic aid.
36.
The nurse can determine the effectiveness of carbamazepine (Tegretol) in
the management of trigeminal neuralgia by monitoring the client’s:
Correct Answer
D. Pain relief
Explanation
Carbamazepine ( Tegretol) is administered to control pain by reducing the transmission of nerve impulses in clients with trigeminal neuralgia.
37.
Administration of potassium iodide solution is ordered to the client
who will undergo a subtotal thyroidectomy. The nurse understands that
this medication is given to:
Correct Answer
C. Decrease the size and vascularity of the thyroid.
Explanation
Potassium iodide, which aids in decreasing the vascularity of the thyroid gland, decreases the risk for hemorrhage.
38.
A client with Addison’s disease is scheduled for discharge. Before the
discharge, the physician prescribes hydrocortisone and fludrocortisone.
The nurse expects the hydrocortisone to:
Correct Answer
C. Prevent hypoglycemia and permit the client to respond to stress.
Explanation
Hydrocortisone is a glucocorticoid that has anti-inflammatory action and aids in metabolism of carbohydrate, fat, and protein, causing elevation of blood glucose. Thus it enables the body to adapt to stress.
39.
A client with diabetes insipidus is taking Desmopressin acetate
(DDAVP). To determine if the drug is effective, the nurse should
monitor the client’s:
Correct Answer
D. Intake and output
Explanation
DDAVP replaces the ADH, facilitating reabsorption of water and consequent return of normal urine output and thirst.
40.
A client with recurrent urinary tract infections is to be discharged.
The client will be taking nitrofurantoin (Macrobid) 50 mg po every
evening at home. The nurse provides discharge instructions to the
client. Which of the following instructions will be correct?
Correct Answer
B. Increase fluid intake.
Explanation
To prevent crystal formation, the client should have sufficient intake to produce 1000 to 1500 mL of urine daily while taking this drug.
41.
A client with cancer of
the lung is receiving chemotherapy. The physician orders antibiotic
therapy for the client. The nurse understands that chemotherapy
destroys rapidly growing leukocytes in the:
Correct Answer
A. Bone marrow
Explanation
Prolonged chemotherapy may slow the production of leukocytes in bone marrow, thus suppressing the activity of the immune system. Antibiotics may be required to help counter infections that the body can no longer handle easily.
42.
The physician reduced the client’s Dexamethasone (Decadron) dosage
gradually and to continue a lower maintenance dosage. The client asks
the nurse about the change of dosage. The nurse explains to the client
that the purpose of gradual dosage reduction is to allow:
Correct Answer
A. Return of cortisone production by the adrenal glands.
Explanation
Any hormone normally produced by the body must be withdrawn slowly to allow the appropriate organ to adjust and resume production.
43.
The nurse is assigned to care for a client with diarrhea.
Excessive fluid loss is expected. The nurse is aware that fluid
deficit can most accurately be assessed by:
Correct Answer
B. A change in body weight
Explanation
Dehydration is most readily and accurately measured by serial assessment of body weight; 1 L of fluid weighs 2.2 pounds.
44.
Which of the following is the most important electrolyte of
intracellular fluid?
Correct Answer
A. Potassium
Explanation
The concentration of potassium is greater inside the cell and is important in establishing a membrane potential, a critical factor in the cell’s ability to function.
45.
Which of the following client has a high risk for developing
hyperkalemia?
Correct Answer
B. End-Stage renal disease
Explanation
The kidneys normally eliminate potassium from the body; hyperkalemia may necessitate dialysis.
46.
The nurse is reviewing the laboratory result of the client. The
client’s serum potassium level is 5.8 mEq/L. Which of the following is
the initial nursing action?
Correct Answer
C. Take the client’s vital signs and notify the pHysician
Explanation
Vital signs monitor cardiorespiratory status; hyperkalemia causes serious cardiac dysrhythmias.
47.
Potassium chloride, 20 mEq, is ordered and to be added in the IV
solution of a client in a diabetic ketoacidosis. The primary reason for
administering this drug is:
Correct Answer
A. Replacement of excessive losses
Explanation
Once treatment with insulin for diabetic ketoacidosis is begun, potassium ions reenter the cell, causing hypokalemia; therefore potassium, along with the replacement fluid, is generally supplied.
48.
A female client is brought to the emergency unit. The client is
complaining of abdominal cramps. On assessment, client is experiencing
anorexia and weight is reduced. The physician’s diagnosis is colitis.
Which of the following symptoms of fluid and electrolyte imbalance
should the nurse report immediately?
Correct Answer
C. Extreme muscle weakness and tachycardia
Explanation
Potassium, the major intracellular cation, functions with sodium and calcium to regulate neuromuscular activity and contraction of muscle fibers, particularly the heart muscle. In hypokalemia these symptoms develop.
49.
The client is to receive an IV piggyback medication. When preparing the
medication the nurse should be aware that it is very important to:
Correct Answer
A. Use strict sterile technique
Explanation
Because IV solutions enter the body’s internal environment, all solutions and medications utilizing this route must be sterile to prevent the introduction of microbes.
50.
The nurse is reviewing the laboratory result of the client. An arterial
blood gas report indicates the client’s pH is 7.20, PCO2 35 mmHg and
HCO3 is 19 mEq/L. The results are consistent with:
Correct Answer
A. Metabolic acidosis
Explanation
A low pH and bicarbonate level are consistent with metabolic acidosis.