Nursing Comprehensive Exam 2

1. A client began receiving a unit of blood 30 minutes ago. The client rings the call bell and complains of breathing difficulty, itching and a tight sensation in the chest. Which of the following is the first action of the nurse?

Recheck the unit of blood for compatibility

Check the client’s temperature

Stop the transfusion

Call the physician

The symptoms reported by the client are compatible with transfusion reaction. The first action of the nurse when a transfusion reaction is suspected is to discontinue the transfusion. The IV line is kept open with normal saline. The Physician is notified. Depending on agency protocol, the nurse may then obtain a urine specimen for urinalysis, draw a sample of blood, and return the unit of blood and tubing to the blood bank. The nurse also institutes supportive care for the client, which may include administration of antihistamines, crystalloids, epinephrine or vasopressors as prescribed.

Explanation

The symptoms reported by the client are compatible with transfusion reaction. The first action of the nurse when a transfusion reaction is suspected is to discontinue the transfusion. The IV line is kept open with normal saline. The Physician is notified. Depending on agency protocol, the nurse may then obtain a urine specimen for urinalysis, draw a sample of blood, and return the unit of blood and tubing to the blood bank. The nurse also institutes supportive care for the client, which may include administration of antihistamines, crystalloids, epinephrine or vasopressors as prescribed.

2. An anxious client enters the emergency department seeking the treatment for a laceration of the finger that occurred when using a power tool. The client's vital signs are pulse (P) 96 beats/min, blood pressure (BP) 148/88 mm Hg, and respirations (R) 24 breaths/min. After cleansing the injury and reassuring the client, the nurse rechecks the vital signs and notes P 82 beats/min,BP 130/80 mm Hg, and R 20 breaths/min. The change in vital signs is caused by:

Reduced stimulation of the sympathetic nervous system

The cooling effects of the cleansing solution

The body's physical adaptation to the air conditioning

Possible impending cardiovascular collapse

Physical or emotional stress triggers a symphatetic nervous system response. Responses that are reflected in the vital signs include an increased pulse, increased blood pressure,and increased respiratory rate. Stress reduction, then, returns these parameters to baseline. Option B, C, and D are unrelated to the changes in vital signs.

Explanation

Physical or emotional stress triggers a symphatetic nervous system response. Responses that are reflected in the vital signs include an increased pulse, increased blood pressure,and increased respiratory rate. Stress reduction, then, returns these parameters to baseline. Option B, C, and D are unrelated to the changes in vital signs.

3. A nurse is assisting with transferring a client from the operating room table to a stretcher. To provide safety for the client, the nurse:

Moves the client rapidly from the table to the stretcher

Uncovers the client completely before transferring to the stretcher

Secures the client with safety belts after transferring to the stretcher

Instructs the client to move himself or herself from the table to the stretcher

During the transfer of a client after a surgical procedure is complete, the nurse should avoid exposure of the client because of the risk for potential heat loss. Hurried movements and rapid changes in position should be avoided, since these predispose the client to hypotension. At the time of the transfer from the surgery table to the stretcher, the client is still affected by the effects of anesthesia, therefore the client should not move himself or herself. Safety belts can prevent the client from falling off the stretcher.

Explanation

During the transfer of a client after a surgical procedure is complete, the nurse should avoid exposure of the client because of the risk for potential heat loss. Hurried movements and rapid changes in position should be avoided, since these predispose the client to hypotension. At the time of the transfer from the surgery table to the stretcher, the client is still affected by the effects of anesthesia, therefore the client should not move himself or herself. Safety belts can prevent the client from falling off the stretcher.

4. A nurse instructs the client about the procedure to perform the Breast Self-Examination (BSE). Which client statement indicates a need for further instructions?

"I don’t need to do that, I'm too old for that."

"I do BSE 7 days after I get my period."

"I examine my breasts in the shower."

"I lie on my back to examine my breast."

BSE should still be done even after menopause. No one is “too old” to get breast cancer. Option B, C and D identify correct components of performing BSE.

Explanation

BSE should still be done even after menopause. No one is “too old” to get breast cancer. Option B, C and D identify correct components of performing BSE.

5. A nurse is caring for a client receiving total parental nutrition (TPN). The nurse implements which action to decrease the risk of infection?

Assessing vital signs at 4-hour intervals

Instructing the client to perform a Valsalva maneuver during intravenous tubing changes

Administer acetaminophen (Tylenol) before changing the central line dressing

Using aseptic technique in handling the TPN solution and tubing

Clients receiving TRN are at high risk for developing infection. Concentrated glucose are an excellent medium for bacterial growth. Using aseptic technique in handling all equipment and solutions is paramount to prevention. Option A will detect sings of an infection but is not associated with prevention. Option B and C are unrelated to decreasing the risk of infection.

Explanation

Clients receiving TRN are at high risk for developing infection. Concentrated glucose are an excellent medium for bacterial growth. Using aseptic technique in handling all equipment and solutions is paramount to prevention. Option A will detect sings of an infection but is not associated with prevention. Option B and C are unrelated to decreasing the risk of infection.

6. A client with a burn injury is transferred to the nursing unit, and a regular diet has been prescribed. Which dietary items should the nurse encourage the client to eat in order to promote wound healing?

Veal, potatoes, Jell - O, Orange juice

Peanut butter and jelly, cantaloupe, tea

Chicken breast, Broccoli, Strawberries, Milk

Spaghetti with tomato sauce, Garlic bread, Ginger ale

Protein and vitamin C are necessary for wound healing. Poultry and milk are good sources of protein. Broccoli and strawberries are good sources of vitamin C. Peanut butter is a source of niacin. Jell - O and jelly have no nutrient value. Spaghetti is a complex carbohydrate.

Explanation

Protein and vitamin C are necessary for wound healing. Poultry and milk are good sources of protein. Broccoli and strawberries are good sources of vitamin C. Peanut butter is a source of niacin. Jell - O and jelly have no nutrient value. Spaghetti is a complex carbohydrate.

7. A nurse provides medication instructions to a home health care client. To ensure safe administration of medication in the home, the nurse:

Demonstrates the proper procedure for taking prescribed medications

Allows the client to verbalize and demonstrate correct administration procedures

Instructs the client that it is OK to double up on medications if a dose has been missed

Conducts pill counts on each home visit

To ensure safe administration of medication, the nurse allows the client to verbalize and demonstrate correct procedure and administration of medications. Demonstrating the proper procedure for the client does not ensure that the client can safely perform this procedure. It is not acceptable to double up on medication, and conducting a pill count on each visit is not realistic or appropriate.

Explanation

To ensure safe administration of medication, the nurse allows the client to verbalize and demonstrate correct procedure and administration of medications. Demonstrating the proper procedure for the client does not ensure that the client can safely perform this procedure. It is not acceptable to double up on medication, and conducting a pill count on each visit is not realistic or appropriate.

8. A nurse is checking a unit of blood from the blood bank and notes the presence of gas bubbles in the bag. The nurse should take which of the following actions?

Add 10 mL of normal saline solution to the bag

Agitate the bag gently to mix contents

Add 100 units of heparin to the bag

Return the blood to the blood bank

The nurse should return the unit of blood to the blood bank. The presence of gas bubbles in the bag indicates possible bacterial growth, and the unit is considered contaminated. Options A B, and C, are incorrect actions.

Explanation

The nurse should return the unit of blood to the blood bank. The presence of gas bubbles in the bag indicates possible bacterial growth, and the unit is considered contaminated. Options A B, and C, are incorrect actions.

9. A nurse notes redness, warmth, and a purulent drainage at the insertion site of a central venous catheter in a client receiving total parenteral nutrition (TPN). The nurse notifies the physician of this finding because:

Infections of the central catheter site can lead to septicemia

The client is experiencing an allergy to the TPN solution

The TPN solution has infiltrated and must be stopped

The client is allergic to the dressing material covering the site

Redness, warmth, and purulent drainage are signs of an infection, not allergic reaction. Infiltration causes the surrounding tissue to become cool and pale.

Explanation

Redness, warmth, and purulent drainage are signs of an infection, not allergic reaction. Infiltration causes the surrounding tissue to become cool and pale.

10. A nurse is caring for a client following craniotomy who has a supratentorial incision. The nurse places a sign above the client's bed stating that the client should be maintained in which of the following positions?

Semi fowler

Dorsal recumbent

Prone

Supine

Following supratentorial surgery ( surgery above the brain's tentorium ), the client's head is usually elevated 30 degrees to promote venous outflow through the jugular veins. Options B, C and D are incorrect positions following this surgery.

Explanation

Following supratentorial surgery ( surgery above the brain's tentorium ), the client's head is usually elevated 30 degrees to promote venous outflow through the jugular veins. Options B, C and D are incorrect positions following this surgery.

11. A nurse is caring for a client with a nursing diagnosis of Altered Oral Mucous Membranes. The nurse would avoid using which of the following items when giving mouth care of this client?

Nonalcoholic mouthwash

Soft toothbrush

Lip moistener

Lemon-glycerin swabs

The nurse avoids using lemon-glycerin swabs for the client with altered oral mucous membrane because they dry the membranes further and could cause pain. Items that are helpful include a soft toothbrush to prevent trauma, lip moistener to prevent lip cracking, and soothing cleansing rinses, such as nonalcoholic mouthwash

Explanation

The nurse avoids using lemon-glycerin swabs for the client with altered oral mucous membrane because they dry the membranes further and could cause pain. Items that are helpful include a soft toothbrush to prevent trauma, lip moistener to prevent lip cracking, and soothing cleansing rinses, such as nonalcoholic mouthwash

12. A physician's order reads "acetaminophen ( Tylenol ) liquid, 450mg PO every 4 hours PRN for pain." The medication label reads "160mg / 5mL." The nurse prepares how many milliliters to administer one dose?

10ml

12ml

13ml

14ml

Use the following formula for calculating medication dosages: Desired divided by Available, multiplied by Volume = ml/dose; 450 mg divided 160 mg, multiplied by 5 ml = 14 ml

Explanation

Use the following formula for calculating medication dosages: Desired divided by Available, multiplied by Volume = ml/dose; 450 mg divided 160 mg, multiplied by 5 ml = 14 ml

13. A multi disciplinary team has been working with a home care client who has an end-stage liver failure and has been teaching the spouse interventions for the management of pain. Which statement by the spouse indicates the need for further teaching?

" If the pain increases, I must let the nurse know immediately."

"I should have my husband try the breathing exercises to control the pain."

"This narcotic will cause very deep sleep, which is what my husband needs."

"If constipation is a problem, increased fluids will help."

Changes in level of consciousness are a potential indicator of narcotic overdose, as well as an indicator of fluid, electrolyte, and oxygenation deficits. It is important to teach the spouse the differences between sleep related to relief of pain and changes in neurological status related to a deficit. Options A, B, and D all are indicative of an understanding of appropriate steps to be taken in management of pain.

Explanation

Changes in level of consciousness are a potential indicator of narcotic overdose, as well as an indicator of fluid, electrolyte, and oxygenation deficits. It is important to teach the spouse the differences between sleep related to relief of pain and changes in neurological status related to a deficit. Options A, B, and D all are indicative of an understanding of appropriate steps to be taken in management of pain.

14. A client has an order for "enemas until clear" before major bowel surgery. After preparing the equipment and the solution, the nurse assists the client into which of the following positions to administer the enema?

Left - lateral Sims' position

Right - lateral Sims' position

Left side - lying with the head of the bed elevated 45 degrees

Right side - lying with the head of the bed elevated 45 degrees

For administration of an enema, the client is placed in a left - lateral Sims' position so that the enema solution can flow by gravity in the natural direction of the colon. The head of the bed is not elevated in the Sims' position.

Explanation

For administration of an enema, the client is placed in a left - lateral Sims' position so that the enema solution can flow by gravity in the natural direction of the colon. The head of the bed is not elevated in the Sims' position.

15. A nurse employed in a long- term care facility is planning the client assignments for the shift. Which of the following clients would the nurse most appropriately assign to the nursing assistant (NA)?

A client requiring BID dressing changes

A client requiring frequent ambulation

A client on a bowel management program requiring rectal suppositories and a daily enema

A client with diabetes mellitus requiring daily insulin and reinforcement of dietary measures

Assignment of tasks needs to be implemented based on the job description of the NA, the level of clinical competence; and state law. Options A, C and D involve care that requires the skill of a licensed nurse.

Explanation

Assignment of tasks needs to be implemented based on the job description of the NA, the level of clinical competence; and state law. Options A, C and D involve care that requires the skill of a licensed nurse.

16. A nurse is caring for a client who has as order to receive an intravenous intralipid infusion. Which of the following actions does the nurse takes as part of proper procedure before hanging the infusion?

Add 100 mL of normal saline solution to the bottle

Attach an in-line filter

Remove the bottle from the refrigerator

Check the solution for separation or an oily appearance

Intralipid solutions should not be refrigerated. There should be no additive to be placed in the bottle because this could affect the stability of the solution. The solution should be checked for separation or an oily appearance. If found, it should not be used. An in-line filter is not used because it could disturb the flow of solution or become clogged.

Explanation

Intralipid solutions should not be refrigerated. There should be no additive to be placed in the bottle because this could affect the stability of the solution. The solution should be checked for separation or an oily appearance. If found, it should not be used. An in-line filter is not used because it could disturb the flow of solution or become clogged.

17. A nurse participating in a Nurse Managed Clinic wants to set up a diabetic teaching seminar. The nurse understands that to meet the needs of the clients, the nurse must first:

Assess the clients’ functional abilities

Ensure that the insurance documentation is up-to-date

Discuss the focus of the seminar multidisciplinary team

Include everyone who come into the clinic in the teaching sessions

The focus of Nurse Managed Clinic is on individualized disease prevention and health promotion and maintenance. Therefore, the nurse must first assess the clients and their needs to effectively plan the seminar. Options B, C and D do not address to the needs of the clients.

Explanation

The focus of Nurse Managed Clinic is on individualized disease prevention and health promotion and maintenance. Therefore, the nurse must first assess the clients and their needs to effectively plan the seminar. Options B, C and D do not address to the needs of the clients.

18. A nurse is caring a client with cancer. The client tells the nurse that a lawyer will be arriving today to prepare a living will. The client asks the nurse to act as one of the witnesses for the will. The most appropriate nursing action is to:

Agree to act as a witness

Refuse to help the client

Inform the client that a nurse caring for a client cannot serve as a witness to a living will

Call the physician

Living wills address the withdrawal or withholding of life sustaining interventions that unnaturally prolong life. It identifies the person who will make care decisions if the client is unable to take action. It is witnessed and signed by two people who are unrelated to the client. Nurses or employees of a facility in which the client is receiving care, and beneficiaries of the client, must not serve as a witness. There is no reason to call the physician.

Explanation

Living wills address the withdrawal or withholding of life sustaining interventions that unnaturally prolong life. It identifies the person who will make care decisions if the client is unable to take action. It is witnessed and signed by two people who are unrelated to the client. Nurses or employees of a facility in which the client is receiving care, and beneficiaries of the client, must not serve as a witness. There is no reason to call the physician.

19. A client is admitted to the hospital in metabolic acidosis caused by diabetic ketoacidosis (DKA). The nurse prepares to administer which of the following medications as a primary initial treatment for this problem?

Sodium bicarbonate

Calcium gluconate

Potassium

Insulin

The primary treatment for any acid-base imbalance is treatment of the underlying disorder caused the problem. In this case the underlying cause of the metabolic acidosis is anaerobic metabolism resulting from lack of ability to use circulating glucose. Administration of insulin corrects this problem. Potassium may be added to the treatment regimen if serum potassium levels indicate its need. Option A and B would not be used to treat this disorder.

Explanation

The primary treatment for any acid-base imbalance is treatment of the underlying disorder caused the problem. In this case the underlying cause of the metabolic acidosis is anaerobic metabolism resulting from lack of ability to use circulating glucose. Administration of insulin corrects this problem. Potassium may be added to the treatment regimen if serum potassium levels indicate its need. Option A and B would not be used to treat this disorder.

20. A nurse is preparing to administer an intramuscular injection to a 2-year-old child. The best site to select for the injection is the:

Ventral gluteal muscle

Dorsal gluteal muscle

Deltoid muscle

Vastus lateralis muscle

The vastus lateralis muscle is well developed at birth. It is the best choice for all age groups but should always be used in children younger than 3 years of age. This muscle is able to tolerate larger volumes and is not located near vital structures such as nerves and blood vessels.

Explanation

The vastus lateralis muscle is well developed at birth. It is the best choice for all age groups but should always be used in children younger than 3 years of age. This muscle is able to tolerate larger volumes and is not located near vital structures such as nerves and blood vessels.

21. A home care nurse is working with a family to assist them in caring for a newborn with congenital tracheosophageal fistula who is receiving enteral feeding. A woman identifying herself as a family friend telephones the nurse to inquire if there is anything she can do to assist the parents. The best nursing action is to:

Request that the friend come to the client’s home where she can be taught to administer the feedings.

Inform the friend to directly contact the family and offer her assistance to them

Report the friend’s telephone call to the nurse manager for referral to the client’s social worker

A nurse must uphold the client’s rights and does not give any information regarding a client’s care needs to anyone not directly involved in the client’s care. To request that the friend come for teaching is a direct violation of the client’s right to privacy. There is no information in the question to indicate that the family desires assistance from the friend. To refer call to the nurse manager and social worker again assumes that the friend’s assistance and involvement is desired by the family. By informing the friend that the nurse is visiting daily is providing information that is considered confidential. Option B directly refers the friend to the family.

Explanation

A nurse must uphold the client’s rights and does not give any information regarding a client’s care needs to anyone not directly involved in the client’s care. To request that the friend come for teaching is a direct violation of the client’s right to privacy. There is no information in the question to indicate that the family desires assistance from the friend. To refer call to the nurse manager and social worker again assumes that the friend’s assistance and involvement is desired by the family. By informing the friend that the nurse is visiting daily is providing information that is considered confidential. Option B directly refers the friend to the family.

22. A physician asks a nurse to discontinue the feeding tube in a client who is in a chronic vegetative state. The physician tells the nurse that the request was made by the client's spouse and children. The nurse understands the legal basis for carrying out the order and first checks the client's record for documentation of:

A court approval to discontinue the treatment

A written order by the physician to remove the tube

Authorization by the family to discontinue the treatment

Approval by the institutional ethics committee

The family or a legal guardian can make treatment decisions for the client who is unable to do so. Once the decision is made, the physician writes the order. Generally the family makes decisions in collaboration with physicians, other health care workers, and other trusted advisors.

Explanation

The family or a legal guardian can make treatment decisions for the client who is unable to do so. Once the decision is made, the physician writes the order. Generally the family makes decisions in collaboration with physicians, other health care workers, and other trusted advisors.

23. In a client receiving total parenteral nutrition (TPN), chest pain, dyspnea, tachycardia, cyanosis, and decreased level of consciousness suddenly develop. The nurse suspects which complication of TPN?

Hyperglycemia

Catheter-related sepsis

Allergic reaction to the TPN catheter

Air embolism

Symptoms of air embolism include decreased level of consciousness, tachycardia, dyspnea, anxiety, feelings of impending doom, chest pain, cyanosis, and hypotension. Option a, B, and C are unrelated to the symptoms identified in the question.

Explanation

Symptoms of air embolism include decreased level of consciousness, tachycardia, dyspnea, anxiety, feelings of impending doom, chest pain, cyanosis, and hypotension. Option a, B, and C are unrelated to the symptoms identified in the question.

24. A nurse is administering continuous tube feedings to a client. The nurse takes which of the following actions as part of routine for this client?

Checks the residual every 4 hours

Changes the feeding bag and tubing every 12 hours

Pours additional feeding into the bag when 25 ml are left

Holds the feeding if greater than 200 mL are aspirated.

The nasogastric feeding tube is checked at least every 4 hours for residual when administering continuous tube feedings. It is checked before each bolus with intermittent feedings. The feeding should be withheld for 30 to 60 minutes if the residual is greater than the 30 mL, or per agency policy. The bag and tubing are completely changed every 24 hours. The bag should be rinsed before adding new formula to the bag that is hanging.

Explanation

The nasogastric feeding tube is checked at least every 4 hours for residual when administering continuous tube feedings. It is checked before each bolus with intermittent feedings. The feeding should be withheld for 30 to 60 minutes if the residual is greater than the 30 mL, or per agency policy. The bag and tubing are completely changed every 24 hours. The bag should be rinsed before adding new formula to the bag that is hanging.

25. A nurse is preparing to access an implanted vascular port to administer chemotherapy. The nurse:

Anchors the port with the dominant hand

Palpates the port to locate the center of the septum

Places a warm pack over the area for several minutes to alleviate possible discomfort

Cleans the area with alcohol working from the outside inward

Before accessing an implanted port, the nurse must palpate the port to locate the center of the septum. The port should then be anchored with the nondominant hand. Cool compresses over the site can help to alleviate pain upon entry. The site should be cleansed with alcohol working from the inside out to prevent introducing germs into the access site.

Explanation

Before accessing an implanted port, the nurse must palpate the port to locate the center of the septum. The port should then be anchored with the nondominant hand. Cool compresses over the site can help to alleviate pain upon entry. The site should be cleansed with alcohol working from the inside out to prevent introducing germs into the access site.

26. A nurse has an order to infuse a unit of blood. The nurse checks the client's intravenous line to make sure that the gauge of the intravenous catheter is at least:

14

19

22

24

An intravenous line used to infuse blood should be 19-gauge or larger. This allows infusion of the blood elements without clogging the line or the IV access site

Explanation

An intravenous line used to infuse blood should be 19-gauge or larger. This allows infusion of the blood elements without clogging the line or the IV access site

27. A nurse has assisted the physician with a liver biopsy that was done at the bedside. On completion of the procedure, the nurse assists the client into which of the following positions?

Left side - lying with a small pillow or towel under the puncture site

Right side - lying with a small pillow or towel under the puncture site

Left side - lying with the right arm elevated above the head

Right side - lying with the left arm elevated above the head

Following a liver biopsy, the client is assisted to assume a right side - lying position with a small pillow or folded towel under the puncture site for 2 hours. This position compresses the liver against the chest wall at the biopsy site.

Explanation

Following a liver biopsy, the client is assisted to assume a right side - lying position with a small pillow or folded towel under the puncture site for 2 hours. This position compresses the liver against the chest wall at the biopsy site.

28. A home care nurse finds a client in the bedroom, unconscious, with pill bottle in hand. The pill bottle contained the selective serotonin reuptake inhibitor (SSRI) sertraline (Zoloft). The nurse immediately assess the client's:

Blood pressure

Respirations

Pulse

Urinary output

In an emergency situation, the nurse should determine breathlessness first, then pulselessness. Blood pressure would be assessed after these assessments were determined. Urinary output is also important, but not the priority at this point.

Explanation

In an emergency situation, the nurse should determine breathlessness first, then pulselessness. Blood pressure would be assessed after these assessments were determined. Urinary output is also important, but not the priority at this point.

29. A client has returned to the nursing unit following an abdominal hysterectomy. The client is lying supine. To completely assess the client for postoperative bleeding, the nurse should do which of the following?

Check the abdominal dressing

Check the perineal pad

Ask the client about a sensation of moistness

Roll the client to one side after checking the perineal pad and the abdominal dressing

The nurse should roll the client to one side after checking the perineal pad and the abdominal dressing. This allows the nurse to check the rectal area, where blood may pool by gravity if the client is lying supine. Asking the client about a sensation of moistness is not a complete assessment.

Explanation

The nurse should roll the client to one side after checking the perineal pad and the abdominal dressing. This allows the nurse to check the rectal area, where blood may pool by gravity if the client is lying supine. Asking the client about a sensation of moistness is not a complete assessment.

30. A nurse plans to carry out a multidisciplinary research project on the effects of immobility on clients' stress levels. The nurse understands that which principle is most important when planning this project?

Collaboration with other disciplines is essential to the successful practice of nursing

The corporate nurse executive should be consulted, because the project will take nursing time

All clients have the right to refuse to participate in research using human subjects

The cooperation of the physicians on staff must be ensured for the project to succeed

The proposed project is research and includes human subjects. Although options A, B, and D need to be considered, they are all secondary to the overriding principle of the legal and ethical practice of nursing that any client has the right to refuse to participate in research using human subjects.

Explanation

The proposed project is research and includes human subjects. Although options A, B, and D need to be considered, they are all secondary to the overriding principle of the legal and ethical practice of nursing that any client has the right to refuse to participate in research using human subjects.

31. A client is unable to expectorate to yield a sputum sample and the nurse decides to use the saline inhalation method to obtain the sample. The nurse instructs the client to inhale the warm saline vapor via nebulizer by:

Holding the nebulizer under the nose

Keeping the lips closed lightly over the mouthpiece

Keeping the lips closely tightly over the mouthpiece

Alternating one vapor breath with one breath from room air

The inhalation of heated vapor helps the client cough productively because the vapor condenses on the tracheobronchial mucosa and stimulates the production of secretions and a cough reflex. The client is told to lightly cover the mouthpiece with the lips and not to form a tight seal. The client inhales vaporized saline until coughing results.

Explanation

The inhalation of heated vapor helps the client cough productively because the vapor condenses on the tracheobronchial mucosa and stimulates the production of secretions and a cough reflex. The client is told to lightly cover the mouthpiece with the lips and not to form a tight seal. The client inhales vaporized saline until coughing results.

32. A client is admitted to the hospital for a bowel resection following a diagnosis of a bowel tumor. During the admission assessment, the client tells the nurse that a living will was prepared three years ago. The client asks the nurse if this document is still effective. The most appropriate nursing response is which of the following?

Yes it is.

You will have to ask your lawyer

It should be reviewed yearly with your physician.

I have no idea.

The client should discuss living will with the physician and it should be reviewed annually to ensure that it contains the client's present wishes and desires. Option A is incorrect. Option D is not all helpful to the client and is in fact a communication block. Although a lawyer would need to be consulted if the living will needed to be changed, the most appropriate and accurate nursing response would be to inform the client that the living will should be reviewed annually.

Explanation

The client should discuss living will with the physician and it should be reviewed annually to ensure that it contains the client's present wishes and desires. Option A is incorrect. Option D is not all helpful to the client and is in fact a communication block. Although a lawyer would need to be consulted if the living will needed to be changed, the most appropriate and accurate nursing response would be to inform the client that the living will should be reviewed annually.

33. A client has a serum sodium level of 129 mEq/L as a result of hypervolemia. The nurse consults with the physician to determine whether which of the following most appropriate measures should be instituted?

Providing a 2-g sodium diet

Providing a 4-g sodium diet

Fluid restriction

Administering intravenous hypertonic saline

Hyponatremia is defined as a serum sodium level of less than 135 mEq/L. When it is caused by hypervolemia, it may be treated with fluid restriction. The low serum sodium value is due to hemodilution. Intravenous hypertonic saline is reserved for hyponatremia when the serum sodium level is lower than 125 mEq/L. A 4-gram sodium diet is a no-added-salt diet. A 2 –gram sodium restriction would not raise the sodium level.

Explanation

Hyponatremia is defined as a serum sodium level of less than 135 mEq/L. When it is caused by hypervolemia, it may be treated with fluid restriction. The low serum sodium value is due to hemodilution. Intravenous hypertonic saline is reserved for hyponatremia when the serum sodium level is lower than 125 mEq/L. A 4-gram sodium diet is a no-added-salt diet. A 2 –gram sodium restriction would not raise the sodium level.

34. A client is diagnosed with respiratory alkalosis induced by gram-negative sepsis. The nurse carries out which of the following prescribed measures as the most effective means to treat the problem?

Administers prescribed antibiotics

Administers PRN antipyretics

Has the client breathe into a paper bag

Requests an order for a partial rebreather oxygen mask

The most effective way to treat the acid-base disorders is to treat the underlying cause of the disorder. In this case the problem is sepsis, which is most effectively treated with antibiotic therapy. Antipyretics will control fever secondary to sepsis but do nothing to treat the acid-base balance. The paper bag and partial rebreather mask will assist the client to rebreathe exhaled carbon dioxide, but again, these do not treat the primary cause of the imbalance.

Explanation

The most effective way to treat the acid-base disorders is to treat the underlying cause of the disorder. In this case the problem is sepsis, which is most effectively treated with antibiotic therapy. Antipyretics will control fever secondary to sepsis but do nothing to treat the acid-base balance. The paper bag and partial rebreather mask will assist the client to rebreathe exhaled carbon dioxide, but again, these do not treat the primary cause of the imbalance.

35. A home care visits a client recently discharge from the hospital following an acute myocardial infraction. The client tells the nurse that a living will was prepared and asks the nurse where a copy of the will can be obtained. The nurse tells the client that which area will not have a copy?

Lawyer’s office

Physician’s office

Medical record and hospital

Hospital emergency room files

Copies of living will should be kept with the record at the physician office and in the home of the client. The emergency room does not maintain these documents in their files.

Explanation

Copies of living will should be kept with the record at the physician office and in the home of the client. The emergency room does not maintain these documents in their files.

36. A nurse has an order to obtain a sputum from a client admitted to the hospital with a diagnosis of pneumonia. The nurse avoids which action when obtaining the specimens?

Placing the lid of the culture container face down on the bedside table

Obtaining the specimen early in the morning

Having the client brush teeth before expectoration

Instructing the client to take deep breaths before coughing

Placing the lid face down on the bedside table contaminates the lid and could result in inaccurate findings. The specimen is obtained early in the morning whenever possible, because increase amounts of sputum collect in the airways during sleep. The client should rinse the mouth or brush the teeth before specimen collection to avoid contaminating the specimen. The client should take deep breaths before expectoration for best sputum production.

Explanation

Placing the lid face down on the bedside table contaminates the lid and could result in inaccurate findings. The specimen is obtained early in the morning whenever possible, because increase amounts of sputum collect in the airways during sleep. The client should rinse the mouth or brush the teeth before specimen collection to avoid contaminating the specimen. The client should take deep breaths before expectoration for best sputum production.

37. Before administering a tube feeding, a nurse aspirates 40 mL of undigested formula from a client's nasogastric tube. The nurse understands that before administering the tube feeding, the 40 mL of gastric aspirate should be:

Discarded properly and recorded as output on the client’s I&O record.

Poured into the nasogastric tube through a syringe with the plunger removed

Mixed with the formula and poured into the nasogastric tube through a syringe without a plunger

Diluted with water and injected into the nasogastric tube by putting pressure on the plunger

After checking residual feeding contents, the nurse reinstills the gastric contents into the stomach removing the syringe bulb or plunger and pouring the gastric contents via syringe into the nasogastric tube. Gastric contents should de reinstilled to maintain client’s electrolyte balance. It does not need to be mixed with water, nor should it be discarded or mixed with formula.

Explanation

After checking residual feeding contents, the nurse reinstills the gastric contents into the stomach removing the syringe bulb or plunger and pouring the gastric contents via syringe into the nasogastric tube. Gastric contents should de reinstilled to maintain client’s electrolyte balance. It does not need to be mixed with water, nor should it be discarded or mixed with formula.

38. A client diagnosed with leukemia asks the nurse question about preparing a living will. The nurse informs the client that the initial step in preparing this document is to:

Consult with the American Cancer Society

Talk to the hospital chaplain

Contact a lawyer

Discuss the request with the physician

The client should discuss the request for a living will with the physician. The client should also discuss this desire with the family. Wills should be prepared with legal council and should identify the executor of the state, address distribution and use of property, and the specific plans for burial. Options A, and B maybe helpful, their contact would not be the initial step. The lawyer would be contacted following discussion with the physician and family.

Explanation

The client should discuss the request for a living will with the physician. The client should also discuss this desire with the family. Wills should be prepared with legal council and should identify the executor of the state, address distribution and use of property, and the specific plans for burial. Options A, and B maybe helpful, their contact would not be the initial step. The lawyer would be contacted following discussion with the physician and family.

39. A nurse is scheduling multiple diagnostic procedures for a client with activity intolerance. The procedures ordered include an echocardiogram, chest x-ray examination, and a computed axial tomography (CT) scan. The nurse schedules the procedure in which sequence to best meet the needs of this client?

Chest x-ray examination and echocardiogram together in the morning, and the CT scan in the afternoon of the same day

Echocardiogram in the morning, and the chest x-ray examination and CT scan together in the afternoon of the same day

CT scan in the morning, and the chest x-ray examination and echocardiogram on the following morning

Echocardiograms can be done at the beside. Chest x-ray examinations and CT scans are performed in the radiology department (unless a portable chest x-ray examination is ordered). The best sequence would be to have the client to go a procedure in another department in the morning (when most rested); have a rest period; have another procedure on the unit in the afternoon (when more fatigue); and go off the nursing unit again the next morning (when rested again). A client who has activity intolerance will do best when activities are spaced.

Explanation

Echocardiograms can be done at the beside. Chest x-ray examinations and CT scans are performed in the radiology department (unless a portable chest x-ray examination is ordered). The best sequence would be to have the client to go a procedure in another department in the morning (when most rested); have a rest period; have another procedure on the unit in the afternoon (when more fatigue); and go off the nursing unit again the next morning (when rested again). A client who has activity intolerance will do best when activities are spaced.

40. A nurse has an order to discontinue the nasogastric tube of an assigned client. After explaining to the client, the nurse raises the bed to semi-Fowlers position, places a towel across the chest, clear the tube with normal saline, clamps the tube, and removes the tube

During inspiration

During expiration

After inspiration, but before expiration

After expiration, but before inspiration

A nasogastric tube is removed during expiration, so that air and tube are moving at the same direction. Options A, C, and D are incorrect.

Explanation

A nasogastric tube is removed during expiration, so that air and tube are moving at the same direction. Options A, C, and D are incorrect.

41. A nurse has inserted a nasogastric tube (NG) into the stomach of a client and prepares to check for accurate tube placement. The nurse avoids which least reliable method for checking the tube placement?

Aspirating the tube with a 50-mL syringe to obtain gastric contents

Measuring the pH of gastric aspirate

Placing the end of the tube in water to check for bubbling

Instilling 10 to 20 mL of air into the tube while auscultating over the stomach

The least reliable method for determining accurate placement of the NG tube is to place the end of the tube in water to observe for bubbling. However, the best method for determining tube placement is to verify placement by x-ray films.

Explanation

The least reliable method for determining accurate placement of the NG tube is to place the end of the tube in water to observe for bubbling. However, the best method for determining tube placement is to verify placement by x-ray films.

42. The nurse suspects the occurrence of an air embolism in a client with a triple-lumen catheter. If an air embolism is present, the nurse would most likely note which of the following?

Hypertension

Diminished breath sounds

A churning sound heard over the right ventricle on auscultation

Rales heard in the lung bases on auscultation

All clients with IV lines are at risk for air embolism. Because an air embolism can be fatal, it is essential that the nurse monitor for the presence of chest pain, coughing, hypotension, cyanosis, and hypoxia. In addition, if the client does have an air embolism, auscultation over the right ventricle may reveal a churning, windmill type of sound. Options B and D are not characteristics of an air embolism.

Explanation

All clients with IV lines are at risk for air embolism. Because an air embolism can be fatal, it is essential that the nurse monitor for the presence of chest pain, coughing, hypotension, cyanosis, and hypoxia. In addition, if the client does have an air embolism, auscultation over the right ventricle may reveal a churning, windmill type of sound. Options B and D are not characteristics of an air embolism.

43. A nurse plans to administer a medication by IV bolus through the IV primary line. The nurse notes that the medication is incompatible with the primary IV solution. The most appropriate nursing action to safely administer the medication is to:

Call the physician for an order to change the route of the medication

Start a new IV line for the medication

Flush the tubing before and after the medication with normal saline

Flush the tubing before and after the medication with sterile water

When giving a medication by IV bolus, if the medication is incompatible with the IV solution, the tubing is flushed before and after the bolus with infusions of normal saline solution. Option A is inappropriate. Option B is premature and not necessary. Sterile water is not used for an IV flush.

Explanation

When giving a medication by IV bolus, if the medication is incompatible with the IV solution, the tubing is flushed before and after the bolus with infusions of normal saline solution. Option A is inappropriate. Option B is premature and not necessary. Sterile water is not used for an IV flush.

44. A nurse suspects that an air embolism has occurred in a client receiving total parenteral nutrition(TPN) through a central nervous catheter when the central line disconnects from the IV tubing. The nurse immediately turns the client to the:

Left side with the head higher than the feet

Right side with the head higher than the feet

Left side with the feet higher than the head

Right side with the feet higher than the head

If the client experiences air embolism, the immediate action is to place the client on the left side with the feet higher than the head. This position traps air in the right atrium. If necessary, the air can then be directly removed by intracardiac aspiration. Option A, B, and D are incorrect positions.

Explanation

If the client experiences air embolism, the immediate action is to place the client on the left side with the feet higher than the head. This position traps air in the right atrium. If necessary, the air can then be directly removed by intracardiac aspiration. Option A, B, and D are incorrect positions.

45. When administering an intramuscular injection in the gluteal muscle, the nurse places the client in which best position to relax the muscle?

On their side with the knee of the uppermost leg flexed

On their side with the knee of the lowermost leg flexed

Prone with a toe-in position

Sims’ with a toe-in position

A prone toe-in position will promote internal rotation of the hips, which will relax the muscle and make the injection less painful. Options A, B and D will not relax the muscle.

Explanation

A prone toe-in position will promote internal rotation of the hips, which will relax the muscle and make the injection less painful. Options A, B and D will not relax the muscle.

46. A physician had just inserted a Cantor tube in a client with bowel obstruction. When the procedure is complete, the nurse assists the client into which of the following positions initially to maximize the effect of the tube?

Right side

Left side

Prone

Supine

The cantor tube is a single - lumen, mercury - weighted tube. The weight of the mercury carries the tube by gravity. Following insertion, to facilitate movement of the tube, the client is positioned for 2 hours on the right side, 2 hours on the back with the head elevated, and then 2 hours on the left.

Explanation

The cantor tube is a single - lumen, mercury - weighted tube. The weight of the mercury carries the tube by gravity. Following insertion, to facilitate movement of the tube, the client is positioned for 2 hours on the right side, 2 hours on the back with the head elevated, and then 2 hours on the left.

47. A nurse has completed tracheostomy care for a client whose tracheostomy tube has a nondisposable inner cannula. The nurse reinserts the inner cannula into the tracheostomy immediately after:

Suctioning the client's airway

Rinsing it with sterile water

Tapping it against a sterile surface to dry it

Drying it thoroughly with a sterile gauze

After washing and rinsing the inner cannula, the nurse dries it by tapping it against a sterile surface. The nurse then inserts the cannula into the tracheostomy and turns it clockwise to lock it into place. Option A, B, and D are inaccurate actions.

Explanation

After washing and rinsing the inner cannula, the nurse dries it by tapping it against a sterile surface. The nurse then inserts the cannula into the tracheostomy and turns it clockwise to lock it into place. Option A, B, and D are inaccurate actions.

48. A client has a pH of 7.51 with a bicarbonate level of 29 mEq/L. The nurse prepares to administer which of the following medications that would be ordered to treat this acid-base disorder?

Sodium bicarbonate

Furosemide (Lasix)

Acetazolamide (Diamox)

Spiranolactone (Aldactone)

Acetazolamide is a diuretic used in the treatment of metabolic alkalosis. This medication causes excretion of sodium, potassium, bicarbonate, and water by inhibiting the action of carbonic anhydrase. Administration of sodium bicarbonate would aggravate the already existing condition and is contraindicated. Furosemide and spironolactone are loop and potassium sparing diuretics, respectively. These have no value when excretion of bicarbonate is needed.

Explanation

Acetazolamide is a diuretic used in the treatment of metabolic alkalosis. This medication causes excretion of sodium, potassium, bicarbonate, and water by inhibiting the action of carbonic anhydrase. Administration of sodium bicarbonate would aggravate the already existing condition and is contraindicated. Furosemide and spironolactone are loop and potassium sparing diuretics, respectively. These have no value when excretion of bicarbonate is needed.

49. A nurse is assisting in positioning a client for a surgical procedure. The nurse knows that the respiratory system is most vulnerable to which of the following positions?

Lithotomy

Supine

Lateral

Sims

The thoracic cage normally expands in all directions except posteriorly. In the lithotomy position, the expansion of the lungs is restricted at the ribs or sternum, and there is a reduction in the ability of the diaphragm to push down against the abdominal muscles. Respiratory function is impaired because of this interference with normal movements. The volume of air that can be inspired is reduced.

Explanation

The thoracic cage normally expands in all directions except posteriorly. In the lithotomy position, the expansion of the lungs is restricted at the ribs or sternum, and there is a reduction in the ability of the diaphragm to push down against the abdominal muscles. Respiratory function is impaired because of this interference with normal movements. The volume of air that can be inspired is reduced.

50. A nurse is performing a bladder catheterization and is inserting an indwelling Foley catheter. The nurse understands that which of the following represents an incorrect action when performing this procedure?

Inflating the balloon to test patency before catheter insertion

Advancing the catheter just until urine appears in the catheter tubing

Inflating the balloon with 4 to 5 mL more than the balloon capacity

Placing the bag lower than bladder level, with no kinks in the tubing

The catheter should be advanced for 1 to 2 more inches beyond the point where the flow of urine is first noted. This ensures that the balloon is fully in the bladder before it is inflated. Each of the other options represents correct procedure.

Explanation

The catheter should be advanced for 1 to 2 more inches beyond the point where the flow of urine is first noted. This ensures that the balloon is fully in the bladder before it is inflated. Each of the other options represents correct procedure.